A nurse is assisting with the admission of a child who has measles. Which of the following isolation precautions should the nurse initiate?
Contact
Airborne
Protective environment
Droplet
The Correct Answer is B
Choice A: Contact isolation is not appropriate for a child who has measles, which is a highly contagious viral infection that causes fever, rash, cough, runny nose, and red eyes. Contact isolation is used for patients who have infections that can be spread by direct or indirect contact with the patient or their environment, such as wound infections, scabies, or Clostridioides difficile. Contact isolation requires wearing gloves and gowns and using dedicated equipment.
Choice B: Airborne isolation is appropriate for a child who has measles, as it is used for patients who have infections that can be spread by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, chickenpox, or measles. Airborne isolation requires wearing a respirator mask and placing the patient in a negative pressure room with the door closed.
Choice C: Protective environment isolation is not appropriate for a child who has measles, as it is used for patients who have compromised immune systems and are at high risk of acquiring infections from others, such as transplant recipients, cancer patients, or patients receiving immunosuppressive therapy. Protective environment isolation requires wearing gloves, gowns, masks, and eye protection and placing the patient in a positive pressure room with high-efficiency particulate air (HEPA) filters.
Choice D: Droplet isolation is not appropriate for a child who has measles, as it is used for patients who have infections that can be spread by large droplets that can travel up to 6 feet from the source, such as influenza, pertussis, or meningitis. Droplet isolation requires wearing a surgical mask and eye protection and placing the patient in a private room or cohorting with other patients with the same infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Oliguria is a condition of reduced urine output, which can indicate dehydration, kidney failure, or urinary tract obstruction. It is not associated with a CNS infection, which affects the brain and spinal cord.
Choice B: A negative Brudzinski sign is a normal finding that indicates no meningeal irritation. It is elicited by flexing the neck of a supine patient and observing no involuntary flexion of the hips and knees. A positive Brudzinski sign, on the other hand, is a sign of meningitis, which is a type of CNS infection.
Choice C: A bulging fontanel is an abnormal finding that indicates increased intracranial pressure, which can be caused by a CNS infection, such as meningitis or encephalitis. A fontanel is a soft spot on the skull of an infant that allows for brain growth and development.
Choice D: Jaundice is a condition of yellowing of the skin and eyes, which can indicate liver disease, hemolytic anemia, or neonatal hyperbilirubinemia. It is not associated with a CNS infection, which affects the brain and spinal cord.
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect because bradycardia is not a common finding in a child who is in a sickle cell crisis. Bradycardia is a condition in which the heart rate is slower than normal (less than 60 beats per minute). It may be caused by various factors such as hypothermia, hypothyroidism, or medication side effects, but it does not indicate a sickle cell crisis.
Choice B reason: This choice is incorrect because constipation is not a common finding in a child who is in a sickle cell crisis. Constipation is a condition in which the bowel movements are infrequent, hard, or difficult to pass. It may be caused by various factors such as dehydration, a low-fiber diet, or lack of physical activity, but it does not indicate a sickle cell crisis.
Choice C reason: This choice is correct because pain is a common finding in a child who is in a sickle cell crisis. Sickle cell crisis is a condition in which the red blood cells become sickle-shaped and clump together, blocking the blood flow and oxygen delivery to the organs and tissues. It may cause severe pain in the chest, abdomen, joints, or bones, as well as symptoms such as pallor, jaundice, fatigue, or shortness of breath.
Choice D reason: This choice is incorrect because high fever is not a specific finding in a child who is in a sickle cell crisis. High fever may indicate infection, inflammation, or dehydration, but it does not indicate sickle cell crisis. However, the infection can trigger or worsen the sickle cell crisis, so it should be treated promptly with antibiotics and fluids.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today