A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

Place the client in a protective environment.

Clean surfaces with chlorhexidine.

Wash hands with alcohol-based hand rub.

Obtain a stool specimen with gloves.

Answer and Explanation

The Correct Answer is A

Clostridium difficile is a spore-forming bacteria that can cause severe diarrhea and other gastrointestinal symptoms. It's highly contagious and can easily spread to other patients. Alcohol-based hand rubs are not effective against spores and should not be used for hand hygiene in this case. Chlorhexidine is also not sporicidal and should not be used for environmental cleaning. A protective environment is indicated for clients who are at risk of infection from others, not for clients who are infectious to others. Gloves are important for preventing the spread of infection, but they should be used in conjunction with other infection control measures, such as handwashing and protective isolation.

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Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

A. "Are your immunizations current?" B. Do you have any household pets, such as a cat?" C. "Was anyone in your family recently exposed to a viral disease?" D. "Have you been out of the country in the past 30 days?"

Correct Answer is B

Explanation

Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii, which can be transmitted by contact with cat feces or eating undercooked meat containing cysts. The nurse should ask about the client's exposure to cats or cat litter, as this is a risk factor for acquiring toxoplasmosis, especially in immunocompromised individuals.

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A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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