A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

Choice A reason: Gloves prevent MRSA spread via contact during oral care, a high-risk task. This adheres to contact precautions for infection control.

Choice B reason: Masks aren’t needed for MRSA patients; it’s not airborne. Contact precautions suffice, so this is unnecessary outside specific contexts.

Choice C reason: Negative pressure suits airborne pathogens, not MRSA, which spreads by contact. This overcomplicates room requirements for this infection.

Choice D reason: HEPA filters address air quality, irrelevant to MRSA’s contact transmission. Standard isolation, not filtration, controls this bacterial spread.

Choice A reason: Reversibility is a preschool (3-5) belief, not school-age (6-12), where permanence is grasped. Scientifically, this mismatches developmental grief stages, as school-age children understand death’s finality, making this less expected in an older sibling’s response.

Choice B reason: Alienating from peers is common in school-age grief, as sadness or guilt isolates them socially. Scientifically, this aligns with developmental psychology, where peer withdrawal reflects processing loss inwardly, a typical reaction to a sibling’s terminal illness.

Choice C reason: Bad behavior causing death is magical thinking, typical of preschoolers, not school-age kids who reason logically. Scientifically, this regresses below their cognitive stage, making it less likely than social withdrawal in grief responses.

Choice D reason: Regression (e.g., bedwetting) occurs more in younger children under stress, less in school-age. Scientifically, older kids cope via isolation or questions, not developmental backsliding, making this less characteristic than peer alienation in this age group.