A nurse is caring for a client who has a prescription for warfarin.

Which of the following laboratory tests should the nurse monitor?

Choice A Reason:

Removing personal protective equipment (PPE) after leaving the client's room is correct, but it should be done in a way that minimizes the risk of contamination. Proper doffing of PPE is essential to prevent self-contamination.

Choice B Reason:

Wear a gown when assisting the client with personal hygiene. When caring for a client with methicillin-resistant Staphylococcus aureus (MRSA) in a long-term care facility, wearing a gown when assisting the client with personal hygiene is an important infection control measure. MRSA can be transmitted through direct contact with contaminated surfaces or skin, so wearing a gown can help prevent the spread of the bacteria from the client to the healthcare provider's clothing.

Choice C Reason:

Ensuring that negative air pressure is active for the client's room is not typically necessary for MRSA precautions. Negative air pressure rooms are often used for clients with airborne infectious diseases, such as tuberculosis.

Choice D Reason:

Restricting the client's visitors may be necessary in some cases, especially if there is a concern about the potential spread of MRSA to vulnerable individuals. However, visitor restrictions should be implemented based on the facility's policies and guidelines, and they should be communicated clearly to visitors and family members.

Choice A Reason:

Abnormal Involuntary Movement Scale is correct. The Abnormal Involuntary Movement Scale (AIMS) is a standardized tool used to assess and identify tardive dyskinesia, a side effect of antipsychotic medications. Tardive dyskinesia involves involuntary, repetitive movements, typically involving the face, mouth, and sometimes other body parts. Regular monitoring using the AIMS helps healthcare providers detect and evaluate the severity of these abnormal movements, allowing for appropriate management and intervention as needed.

Choice B Reason:

Mental Status Examination (MSE) is incorrect. The MSE is a comprehensive assessment of a person's mental state and cognitive function. While it is valuable for assessing a person's overall mental health and cognitive status, it is not specific for identifying tardive dyskinesia, which is a specific movement disorder.

Choice C Reason:

Brief Psychiatric Rating Scale (BPRS) is incorrect. The BPRS is a tool used to assess the severity of psychiatric symptoms and their changes over time. It is not specific for identifying the physical movements associated with tardive dyskinesia.

Choice D is incorrect:

Patient Health Questionnaire (PHQ) is incorrect. The PHQ is a self-report tool used to screen for symptoms of depression and anxiety. It is not designed for identifying movement disorders like tardive dyskinesia, which are characterized by abnormal physical movements.