Exhibits

A nurse is providing care for a preschooler who has acute gastroenteritis. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A. A client who has a history of MRSA will need antibiotics: Not all clients with a history of MRSA require antibiotics; treatment is only necessary if there is an active infection. Prophylactic antibiotics are not indicated solely based on past MRSA colonization or infection.

B. A client who has a history of MRSA can develop immunity to the infection: There is no immunity conferred by a past MRSA infection. Clients can be colonized or reinfected, and immunity does not prevent future transmission or infection.

C. A client who has a history of MRSA requires a protective environment: Protective environment precautions are used for immunocompromised clients to prevent them from acquiring infections, not for clients with MRSA history. MRSA requires standard and contact precautions, not protective isolation.

D. A client who has a history of MRSA can still transmit the infection: Clients with a history of MRSA may remain colonized and can transmit the bacteria to others, even if asymptomatic. Adhering to contact precautions and proper hand hygiene is essential to prevent spread within healthcare settings.

A. Heart rate 56/min: Bradycardia is not typical during severe alcohol withdrawal. Instead, clients often exhibit tachycardia due to autonomic hyperactivity and increased sympathetic nervous system stimulation.

B. Dry skin: While skin changes can occur, dry skin is not a hallmark of alcohol withdrawal. Other findings such as diaphoresis, tremors, and pallor are more commonly observed.

C. Temperature 38.6°C (101.5°F): Fever is a common sign of severe alcohol withdrawal, reflecting the hypermetabolic state and autonomic hyperactivity associated with withdrawal. Elevated temperature, along with tachycardia, hypertension, and diaphoresis, indicates a more severe withdrawal process that requires close monitoring and intervention.

D. Drowsiness: Severe alcohol withdrawal typically presents with hyperalertness, agitation, and insomnia rather than drowsiness. Lethargy may suggest other complications, but it is not a typical manifestation of acute withdrawal.