A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?
Perform a Mantoux skin test on the client.
Assign the client to a negative-pressure airflow room.
Wear a surgical mask when providing care to the client.
Recommend that the client's family members receive antiviral therapy.
The Correct Answer is C
The correct answer is: c. Wear a surgical mask when providing care to the client.
Choice A: Perform a Mantoux skin test on the client
The Mantoux skin test is used to screen for tuberculosis, not pertussis. Pertussis, also known as whooping cough, is a bacterial infection caused by Bordetella pertussis. The Mantoux test would not be relevant or helpful in diagnosing or managing pertussis.
Choice B: Assign the client to a negative-pressure airflow room
Negative-pressure airflow rooms are typically used for airborne infections such as tuberculosis, measles, or varicella. Pertussis is primarily spread through respiratory droplets, not airborne transmission, so a negative-pressure room is not necessary.
Choice C: Wear a surgical mask when providing care to the client
Wearing a surgical mask is appropriate when caring for a client with pertussis. Pertussis is spread through respiratory droplets, and wearing a mask helps prevent the transmission of the bacteria to healthcare workers and other patients.
Choice D: Recommend that the client’s family members receive antiviral therapy
Antiviral therapy is not effective against pertussis, which is a bacterial infection. Instead, antibiotics such as azithromycin or erythromycin are used to treat pertussis and prevent its spread. Therefore, recommending antiviral therapy would not be appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Tapping the client's facial nerve and noting any facial twitching is not a specific assessment for bacterial meningitis. This action is more related to evaluating facial nerve function and is not typically used to diagnose meningitis.
Choice B reason: Striking the client's patellar tendon with a percussion hammer and noting any increase in response is a test for reflexes, which may or may not be altered in bacterial meningitis. An increased response can be seen in various neurological conditions and is not specific to meningitis.
Choice C reason: Gently elevating the client's head and noting any nuchal rigidity is a key part of the focused assessment for bacterial meningitis. Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and is assessed by gently lifting the head and attempting to move the chin toward the chest. If the client resists due to pain or stiffness, this could indicate nuchal rigidity associated with meningitis.
Choice D reason: Running a tongue blade on the outside of the client's sole and noting any flaring of the toes, known as the Babinski sign, is used to assess for central nervous system lesions and is not specific to meningitis. While it can be part of a neurological assessment, it does not specifically indicate bacterial meningitis.
Correct Answer is A
Explanation
Choice A reason: "Your provider wouldn't prescribe this medication if it weren't necessary." This response acknowledges the client's concerns while also reinforcing the importance of the medication as part of their treatment plan.
Choice B reason: "If you don't take this medication, you will feel worse." This response may come across as threatening and may not effectively address the client's concerns or foster a trusting relationship.
Choice C reason: "Most clients feel better after taking the antibiotic." While this may be true, it does not directly address the client's individual concerns about medication necessity.
Choice D reason: "I will tell your provider that you do not want to take this medication." This response does not engage with the client's concerns and may make the client feel unheard.
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