A charge nurse has four new clients arriving on the unit for admission. Which of the following clients should the nurse place in airborne precautions?
A client who has tuberculosis.
A client who has pneumonia.
A client who has shigella.
A client who has strep throat.
The Correct Answer is A
Choice A Reason:
Tuberculosis (TB) is a highly contagious bacterial infection that primarily affects the lungs and is spread through airborne particles. When a person with active TB coughs, sneezes, or talks, they release tiny droplets containing the bacteria into the air, which can be inhaled by others1. Therefore, placing a client with TB in airborne precautions is essential to prevent the spread of the infection. This involves using a negative pressure room and requiring healthcare workers to wear N95 respirators or higher-level protection.
Choice B Reason:
Pneumonia is an infection that inflames the air sacs in one or both lungs, which can fill with fluid or pus. While pneumonia can be caused by bacteria, viruses, or fungi, it is typically spread through respiratory droplets rather than airborne particles. Therefore, droplet precautions, rather than airborne precautions, are usually sufficient for managing clients with pneumonia. This includes wearing masks and maintaining a safe distance from the infected person.
Choice C Reason:
Shigella is a bacterial infection that primarily affects the intestines and is spread through the fecal-oral route. It is not transmitted through the air, so airborne precautions are not necessary. Instead, contact precautions are recommended to prevent the spread of Shigella, which involves wearing gloves and gowns when handling the patient or their environment and practicing good hand hygiene.
Choice D Reason:
Strep throat is a bacterial infection caused by group A Streptococcus. It is spread through respiratory droplets when an infected person coughs or sneezes. Similar to pneumonia, droplet precautions are sufficient for managing clients with strep throat. This includes wearing masks and maintaining a safe distance from the infected person to prevent the spread of the bacteria.
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Correct Answer is C
Explanation
Choice A reason:
Preventive care focuses on measures taken to prevent diseases, rather than treating them. This includes vaccinations, screenings, and lifestyle counseling. Emergency care, which deals with immediate and acute medical conditions, does not fall under preventive care. Preventive care aims to reduce the incidence of diseases and conditions before they occur, whereas emergency care addresses urgent health issues that require immediate attention.
Choice B reason:
Tertiary care involves specialized consultative care, usually on referral from primary or secondary medical care personnel. It includes advanced medical investigation and treatment, such as cancer management, neurosurgery, cardiac surgery, and other complex medical and surgical interventions. Emergency care, which provides immediate treatment for acute illnesses and injuries, is not categorized under tertiary care. Tertiary care is more about long-term and specialized treatment.
Choice C reason:
Primary care is the first point of contact for individuals entering the healthcare system. It includes general health care services provided by physicians, nurse practitioners, and physician assistants. Primary care focuses on overall health maintenance, disease prevention, and the treatment of common illnesses and conditions. Emergency care, which deals with acute and urgent medical conditions, is not part of primary care. Primary care providers may refer patients to emergency care when immediate attention is needed.
Choice D reason:
Secondary care involves specialized medical services provided by specialists after referral from a primary care provider. It includes services such as cardiology, dermatology, and orthopedics. Emergency care, which provides immediate treatment for acute medical conditions, is considered part of secondary care. Emergency departments in hospitals are staffed by specialists who provide urgent and critical care to patients.
Correct Answer is A
Explanation
Choice A Reason
Eyelashes that curl slightly outward are a normal finding in an eye assessment. This natural curl helps protect the eyes from debris and sweat, and it also aids in the distribution of tears across the eye surface. Eyelashes that curl outward are typical and expected in a healthy individual.
Choice B Reason
Corneas with an opaque appearance are not a normal finding. The cornea should be clear and transparent, allowing light to pass through to the retina. An opaque cornea can indicate various conditions such as corneal edema, scarring, or infection. Therefore, this finding would be abnormal and warrant further investigation.
Choice C Reason
Eyelids that blink involuntarily 30 to 35 times per minute are not within the normal range. The average blink rate for a healthy adult is approximately 15 to 20 times per minute. A significantly higher blink rate could indicate an underlying condition such as dry eye syndrome, blepharospasm, or other neurological issues.
Choice D Reason
Pupils that are 8 to 9 mm in diameter are abnormally large. The normal pupil size ranges from 2 to 4 mm in bright light and 4 to 8 mm in dim light. Pupils that are consistently larger than this range could indicate a condition such as mydriasis, which can be caused by various factors including medications, trauma, or neurological disorders.