What is the priority intervention for the nurse to enhance meeting the psychosocial needs of a client on transmissionbased precautions?
Allow the client to sleep to build up stamina
Maintain a sixfoot distance from the client
Provide a timeframe for the isolation
Provide the client with diversional activities
The Correct Answer is D
Choice A reason: Allowing the client to sleep to build up stamina is not the priority intervention, because it does not address the psychosocial needs of the client. Sleeping is a physiological need, not a psychosocial need. Sleeping may help the client recover physically, but it does not help the client cope emotionally or socially with the isolation.
Choice B reason: Maintaining a sixfoot distance from the client is not the priority intervention, because it does not enhance the psychosocial needs of the client. Maintaining a sixfoot distance from the client is a safety measure, not a psychosocial intervention. Maintaining a sixfoot distance from the client may help prevent the transmission of infection, but it does not help the client feel less lonely or isolated.
Choice C reason: Providing a timeframe for the isolation is not the priority intervention, because it does not enhance the psychosocial needs of the client. Providing a timeframe for the isolation is an informational intervention, not a psychosocial intervention. Providing a timeframe for the isolation may help the client understand the rationale and duration of the precautions, but it does not help the client feel more engaged or supported.
Choice D reason: Providing the client with diversional activities is the priority intervention, because it enhances the psychosocial needs of the client. Providing the client with diversional activities is a psychosocial intervention, not a physiological, safety, or informational intervention. Providing the client with diversional activities may help the client feel more entertained, stimulated, and connected with others, which can reduce the negative effects of isolation.
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Correct Answer is C
Explanation
Choice A reason: This is not the best action because encouraging range of motion can worsen the symptoms and cause more damage to the nerves and blood vessels. Range of motion is the movement of the joints and muscles through their normal extent. Range of motion can help to prevent stiffness, contractures, and muscle atrophy, but it can also increase the swelling and pressure in the affected area, which can impair the circulation and sensation.
Choice B reason: This is not the best action because applying heat to the affected hand can worsen the symptoms and cause more damage to the tissues. Heat is the transfer of thermal energy from a warmer object to a cooler one. Heat can help to relax the muscles, reduce the pain, and increase the blood flow, but it can also increase the inflammation and edema in the affected area, which can compromise the oxygen and nutrient delivery to the tissues.
Choice C reason: This is the best action because removing the cast can decrease the pressure and restore the circulation and sensation to the affected area. A cast is a rigid device that immobilizes and protects a fractured or injured body part. A cast can help to align the bones, prevent displacement, and promote healing, but it can also cause complications, such as compartment syndrome, infection, or nerve damage. Compartment syndrome is a condition where the pressure inside the muscles increases to dangerous levels, causing severe pain, reduced blood flow, and tissue death. The nurse should remove the cast immediately and notify the physician if the client shows signs of compartment syndrome, such as numbness, tingling, pallor, coolness, or swelling.
Choice D reason: This is not the best action because raising the arm above the level of the heart can worsen the symptoms and cause more damage to the nerves and blood vessels. Raising the arm above the level of the heart can help to reduce the swelling and pain in the affected area, but it can also reduce the blood flow and oxygenation to the area, which can lead to ischemia, necrosis, or gangrene. The nurse should elevate the arm at or below the level of the heart and monitor the pulse, color, temperature, and sensation of the fingers.
Correct Answer is B
Explanation
Choice A reason: A susceptible host is not an infectious disease, but a factor that influences the transmission of an infectious disease. A susceptible host is a person who is vulnerable to infection due to factors such as age, health status, immunization, or genetic predisposition. A susceptible host may become infected by a communicable disease, but it is not the disease itself.
Choice B reason: A communicable disease is an infectious disease that can be transmitted directly from one person to another. A communicable disease is caused by a pathogen, such as a virus, bacterium, fungus, or parasite, that can spread through contact, droplet, airborne, vector, or vehicle transmission. Examples of communicable diseases are influenza, tuberculosis, measles, malaria, and HIV/AIDS.
Choice C reason: A portal of entry to a host is not an infectious disease, but a factor that influences the transmission of an infectious disease. A portal of entry to a host is a route through which a pathogen can enter the body of a susceptible host and cause infection. A portal of entry to a host may be a break in the skin, a mucous membrane, or a body opening, such as the mouth, nose, eyes, or genitals. A portal of entry to a host may facilitate the transmission of a communicable disease, but it is not the disease itself.
Choice D reason: A portal of exit from the reservoir is not an infectious disease, but a factor that influences the transmission of an infectious disease. A portal of exit from the reservoir is a route through which a pathogen can leave the body of an infected person or animal and reach another susceptible host. A portal of exit from the reservoir may be a body fluid, such as blood, saliva, urine, or feces, or a body part, such as the skin, hair, or nails. A portal of exit from the reservoir may enable the transmission of a communicable disease, but it is not the disease itself.
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