A nurse is contributing to the plan of care for a client who was newly admitted and has tuberculosis. Which of the following actions should the nurse recommend Including in the plan of care?
Initiate contact precautions.
Increase the client's daily intake of vitamin D.
Perform tuberculin skin testing.
Place the client in a positive-pressure isolation room.
The Correct Answer is B
Choice A Reason:
Contact precautions are not sufficient for tuberculosis (TB), which is an airborne infection. Instead, airborne precautions should be initiated.
Choice B Reason:
Increasing the client's daily intake of vitamin D may be considered as a complementary measure to support the immune system.
Choice C Reason:
Performing tuberculin skin testing (TST) is a diagnostic test for TB but is typically not included in the plan of care for a newly admitted client with confirmed TB.
Choice D Reason:
Placing the client in a positive-pressure isolation room is not the recommended isolation method for clients with TB. Negative-pressure isolation rooms help prevent the spread of infectious airborne diseases like TB.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Determining the client's level of consciousness is correct. Delirium is characterized by a sudden change in mental status, including altered consciousness, confusion, and impaired attention. Assessing the client's level of consciousness helps the nurse understand the severity of the condition and whether the client is experiencing any immediate risks.
Choice B Reason:
Administer an anxiolytic medication is incorrect. Medication administration should not be the first action because the nurse needs to assess the client's condition first to determine if medication is appropriate. Additionally, the underlying cause of the delirium should be identified and treated if possible.
Choice C Reason:
Keep lights on in the client's room is incorrect. While maintaining proper lighting can be important for safety, it is not the first action because it doesn't address the underlying cause or assess the client's level of consciousness.
Choice D Reason:
Encouraging visits from family members is incorrect. Involving family members can provide emotional support, but it's not the first action because the client's condition should be assessed and stabilized before involving others in care.
Correct Answer is A
Explanation
Choice A Reason:
"I will get you information about some head-covering options." This response shows empathy and a willingness to provide practical support to the client. It addresses the client's concerns about hair loss and offers assistance in finding head-covering options, which can be helpful during chemotherapy. It demonstrates a proactive and caring approach to the client's needs.
Choice B Reason:
"I wouldn't worry about this right now. Let's focus on your chemotherapy." This response dismisses the client's concerns and does not provide any support or information.
Choice C Reason:
"Let's discuss this when we have more time. “This response delays addressing the client's concerns and does not offer immediate support or information.
Choice D Reason:
"I can't imagine how difficult it would be to lose my hair." This response expresses personal empathy but does not offer practical assistance or information to the client about managing hair loss.
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