The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?

Change bed linens on a daily basis.

Provide fresh drinking water every four hours.

Restrict visitors who have an upper respiratory infection.

Monitor intake and output every shift.

Answer and Explanation

The Correct Answer is C

C. This is the priority intervention because clients in protective isolation have compromised immune systems and are at high risk of infection. Upper respiratory infections can be transmitted easily through respiratory droplets, posing a significant risk to the client. Restricting visitors with such infections helps minimize the risk of introducing pathogens into the client's environment.

A. While maintaining cleanliness is important in any healthcare setting, changing bed linens daily may not be the highest priority in protective environment isolation unless there is a specific indication (e.g., soiled linens, contamination). It is essential to minimize unnecessary contact and potential sources of infection, but this is not the priority in the given context.

B. Hydration is important for all clients, but the frequency of providing fresh drinking water every four hours is generally a routine nursing care measure. Unless there are specific medical orders or client needs, this action is not directly related to the specialized care required in protective environment isolation.

D. Monitoring intake and output is important for assessing fluid balance and kidney function in hospitalized clients. However, in the context of protective isolation, where infection control is paramount, restricting visitors who pose a potential infectious risk takes precedence over routine monitoring tasks.

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Correct Answer is A

Explanation

A. Spiritual care is integral to holistic care. Addressing spiritual needs can provide comfort, meaning, and a sense of peace to clients, which can contribute to a reduction in suffering, both physical and emotional. Spiritual distress can exacerbate physical symptoms and affect overall well-being, so addressing these needs can lead to better outcomes.

B. While nurses play a significant role in providing holistic care, including spiritual care, they are not the sole providers. Spiritual care can be provided by chaplains, spiritual counselors, and other healthcare professionals trained in addressing spiritual needs. However, nurses often have frequent and intimate contact with patients, making them well-positioned to assess and address spiritual concerns and to collaborate with other members of the healthcare team to meet these needs.

C. While addressing spiritual needs can contribute to overall well-being and healing, physical healing does not solely depend on meeting spiritual needs. Physical healing involves medical interventions, treatments, and physiological processes. However, addressing spiritual needs can positively impact a client's emotional and psychological state, which can support the overall healing process.

D. Understanding and respecting the client's own beliefs, values, and preferences regarding spirituality is crucial. Each individual may have unique spiritual beliefs and practices that influence their health beliefs and behaviors. The nurse should approach spiritual care with cultural sensitivity and respect for diversity, ensuring that the care provided aligns with the client's beliefs and preferences.

A. strain all of the client's urine. B. inflate a blood pressure cuff 20 mmHg above systolic measurement. C. lightly percuss the client's cheek. D. obtain a baseline height and weight.

Correct Answer is C

Explanation

C. Chvostek's sign is assessed by tapping or lightly percussing the facial nerve (facial muscles) at the angle of the jaw, just in front of the earlobe. A positive Chvostek's sign is indicated by facial twitching, especially around the mouth, nose, and eye, in response to this percussion. It indicates neuromuscular irritability due to low calcium levels.

A. Straining urine is typically done to collect urine for analysis or to detect urinary stones. It does not relate to the assessment of neuromuscular irritability, which is what Chvostek's sign evaluates.

B. This option does not pertain to assessing Chvostek's sign either. Inflating a blood pressure cuff above systolic measurement is a technique used to assess for Trousseau's sign, which is another clinical indicator of hypocalcemia but involves different physiological mechanisms than Chvostek's sign.

D. This option is unrelated to assessing Chvostek's sign or hypocalcemia. Baseline height and weight are typically obtained for nutritional assessment, growth monitoring, or as part of a general health assessment. They do not help in evaluating neuromuscular irritability associated with calcium levels.

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The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?

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Naxlex Comprehensive Predictor Exams

As a part of care planning, the nurse considers the client's spiritual needs. What is the Rationale for this concern?

Correct Answer is A

Explanation

The nurse is caring for a client with a total calcium level of 7.0 mg/dL. To assess for Chvostek's sign, the nurse would:

Correct Answer is C

Explanation

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