The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

A. Avoid forcing apart the teeth: Placing objects in the client’s mouth or trying to pry open the teeth can cause injury. It is important to let the seizure pass without interfering with the jaw or mouth.

B. Loosen clothing around the neck: Loosening tight clothing reduces the risk of airway obstruction or restricted breathing during a seizure. This is a correct and helpful intervention.

C. Position the head from injury: Protecting the client’s head with a soft object prevents trauma during convulsions. This is a recommended and safe practice during seizures.

D. Secure the limbs to the body: Restraining or holding down limbs can cause musculoskeletal injuries and increase agitation. Seizure safety protocols emphasize allowing movement without physical restraint.

A. Use standard precautions and wear a mask: Standard precautions are necessary for all patients, but wearing a mask is not specifically required for MRSA unless there is suspicion of respiratory involvement. The focus should be on contact precautions rather than masking.

B. Explain the purpose of a low bacteria diet: A low bacteria diet is not necessary for a client with MRSA unless the client is immunocompromised. The main focus should be on preventing MRSA transmission and managing the infection at the wound site.

C. Send wound drainage for culture and sensitivity: Sending the wound drainage for culture and sensitivity is essential for identifying the causative organism and determining appropriate antibiotic treatment for MRSA. This helps guide therapy and ensure proper management.

D. Institute contact precautions for staff and visitors: Contact precautions are critical for preventing spread of MRSA, especially in wound care situations. The nurse should ensure all staff and visitors follow these precautions to protect others and minimize transmission risk.

E. Monitor the client's white blood cell count: Monitoring the white blood cell count is important as it helps assess the client's immune response to infection. An elevated count may indicate the presence of infection, and close monitoring helps guide treatment decisions.