A nurse is assisting in the care of a group of children on a pediatric medical surgical unit. Which of the following children should the nurse collect data from first?

A. Place the client in a negative pressure room: Negative pressure rooms are used for airborne diseases like tuberculosis or measles, where pathogens are airborne. VRE is a contact-transmitted infection, not airborne, so a negative pressure room is not necessary.

B. Wear a gown and gloves during client interactions and care: VRE is spread through direct contact with contaminated surfaces or bodily fluids. Wearing a gown and gloves provides the necessary precautions to prevent the spread of the infection through contact transmission.

C. Wear a surgical mask during client interactions and care: A surgical mask is primarily used for droplet precautions (e.g., influenza), not for contact precautions like VRE. A mask is not necessary unless the client has a respiratory infection or if there is a risk of splashing bodily fluids.

D. Place the client in a room with high-efficiency particulate air (HEPA) filtration for incoming air: HEPA filtration is used for airborne infections such as tuberculosis. Since VRE is not an airborne pathogen, this measure is unnecessary for preventing the spread of VRE.

• Frequent headaches: Phenelzine, an MAOI, can cause hypertensive crisis, with one of the earliest signs being persistent or worsening headaches. Frequent headaches must be treated as a possible warning of dangerously elevated blood pressure and require immediate provider notification.
• Elevated blood pressure (169/91 mm Hg): The significant rise in the client's blood pressure compared to baseline indicates new-onset hypertension. This is a serious adverse effect associated with MAOIs and signals the potential development of a hypertensive crisis, which must be urgently addressed.
• Difficulty sleeping: Difficulty sleeping or insomnia is a common side effect of phenelzine and other antidepressants. Although not life-threatening, insomnia can impair recovery if untreated and should be documented and discussed with the provider to adjust management if needed.
• Feeling much better: Improvement in mood and reduced fatigue are intended therapeutic outcomes of phenelzine treatment. These findings are positive signs and do not indicate an adverse reaction that needs intervention.
• Heart rate 78/min and respiratory rate 18/min: Both values are within normal ranges and do not suggest immediate concerns related to cardiovascular or respiratory function. They should continue to be monitored but do not require urgent action.