A nurse is planning care for a client who practices Orthodox Judaism and is observing the Passover holiday. Which of the following actions should the nurse include in the plan of care?

Provide unleavened bread.

Provide chicken with a cream sauce.

Avoid serving fish with fins and scales.

Avoid serving foods containing lamb.

Answer and Explanation

The Correct Answer is A

Choice A reason: Unleavened bread (matzah) is required during Passover in Orthodox Judaism, as leavened products are prohibited. Providing it respects dietary laws, critical for cultural sensitivity, ensuring nutritional needs, and supporting client comfort, aligning with patient-centered care principles during religious observances in healthcare settings.

Choice B reason: Chicken with cream sauce is prohibited during Passover, as Orthodox Jews avoid mixing meat and dairy (kosher laws). Unleavened bread is appropriate. Serving this risks dietary violation, causing distress, critical to avoid in ensuring culturally sensitive care for clients observing Passover in healthcare settings.

Choice C reason: Fish with fins and scales is kosher and permitted during Passover, not to be avoided. Unleavened bread aligns with Passover rules. Assuming fish avoidance risks unnecessary restriction, potentially affecting nutrition, critical to prevent in supporting dietary adherence for Orthodox Jewish clients during Passover.

Choice D reason: Lamb is permitted during Passover if kosher, not universally avoided. Unleavened bread is a dietary staple. Assuming lamb avoidance risks misaligned care, potentially causing nutritional or cultural issues, critical to avoid in ensuring respectful, adherent care for Orthodox Jewish clients observing Passover.

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Correct Answer is B

Explanation

Choice A reason: Holding a debriefing is post-incident, not a priority during restraint use; observing movement ensures safety. Assuming debriefing is immediate risks neglecting client monitoring, potentially causing injury, critical to avoid in ensuring safe restraint use and client well-being in acute behavioral situations.

Choice B reason: Observing range of movement during restraints ensures proper application, preventing injury like nerve damage or circulation issues, critical for client safety. This ongoing assessment adheres to restraint protocols, essential for minimizing harm, ensuring ethical care, and supporting de-escalation in aggressive clients.

Choice C reason: Maintaining sensory stimulation is inappropriate during restraints, as it may escalate agitation; observing movement is priority. Assuming stimulation is needed risks worsening aggression, potentially prolonging restraint use, critical to avoid in ensuring calm and safe management of clients in mechanical restraints.

Choice D reason: Identifying stressors is important but secondary to ensuring physical safety by observing movement during restraints. Assuming stressors are the immediate focus risks neglecting restraint safety, potentially causing injury, critical to prevent in ensuring proper monitoring and care in aggressive client situations.

A. Ensure all gloves in the client’s room are nonlatex. B. Equip the client’s room with a HEPA filtration system. C. Place a box of surgical masks outside the client’s room. D. Assign the client to a negative pressure room.

Correct Answer is C

Explanation

Choice A reason: Nonlatex gloves are relevant for allergies, not droplet precautions, which require masks. Placing surgical masks is key. Assuming gloves are priority risks neglecting respiratory protection, potentially increasing transmission, critical to avoid in ensuring effective infection control for droplet-borne illnesses in healthcare settings.

Choice B reason: HEPA filtration is for airborne precautions, not droplet, which needs masks. Placing surgical masks is correct. Assuming HEPA is needed risks misapplying resources, potentially diverting focus from droplet transmission prevention, critical to prevent in ensuring proper infection control for clients on droplet precautions.

Choice C reason: Placing surgical masks outside the room is essential for droplet precautions, ensuring staff and visitors wear masks to prevent respiratory transmission. This is critical for infection control, reducing spread, protecting others, and adhering to CDC guidelines for managing droplet-borne infections in healthcare settings.

Choice D reason: Negative pressure rooms are for airborne precautions, not droplet, which requires masks. Assuming negative pressure is needed risks inappropriate room assignment, potentially increasing transmission, critical to avoid in ensuring correct infection control measures for clients on droplet precautions in healthcare facilities.

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A nurse is planning care for a client who practices Orthodox Judaism and is observing the Passover holiday. Which of the following actions should the nurse include in the plan of care?

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