A nurse is caring for a client who states, "I smoke because I have a lot of anxiety." The nurse should recognize the client's statement as which of the following defense mechanisms?

Rationale:

• Client rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications. The client’s pain has worsened from 4/10 despite pain medication, indicating the current pain management approach is ineffective, and the wound may not be healing as expected.
• Mild purulent drainage noted: The presence of purulent drainage is a sign of infection, further indicating that the wound vac therapy has not been successful in preventing or managing infection at the wound site.
• Left knee wound is 3 cm by 2 cm with 1 cm depth, compared to 2 cm by 2 cm with 1 cm depth one week ago: The increase in wound sizefrom 2cm by 2 cm to 3 cm by 2 cm suggests that the wound vac therapy is not promoting healing effectively, leading to a failure of wound closure.

Rationale for Incorrect Choices:

• Wound bed vascular with some approximation of the edges: The wound bed being vascular with some approximation of the edges indicates that there is some healthy tissue and the edges of the wound are coming together. This suggests that some healing is occurring, although it may be slower than expected.

A. Provide a mask for the client when they are outside their room: The client has a positive influenza test, it is important to prevent the spread of the virus to others by wearing a mask when outside their room to minimize the risk of transmission through respiratory droplets.

B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room. While hand sanitizer is appropriate for influenza, droplet precautions, the client also has Clostridium difficile, which requires contact precautions, specifically hand hygiene with soap and water. Alcohol-based hand sanitizers are not effective against C. diff spores.

C. Don a gown when entering the client's room: The client is positive for C. difficile, which requires contact precautions. Wearing a gown when entering the room is necessary to protect healthcare workers from coming into contact with potentially contaminated surfaces or materials.

D. When removing personal protective equipment, remove gloves first: When removing personal protective equipment gloves should be removed first to avoid contamination of other surfaces. This is the recommended sequence for safe removal of PPE in contact precautions.

E. Place the client in a room with positive air flow: A room with positive air flow is necessary for airborne precautions (e.g., for tuberculosis or varicella), but it is not required for C. difficile or influenza, which are both managed through contact and droplet precautions.