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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View Related questions
Correct Answer is C
Explanation
Choice A Reason:
Instructing the client to take deep, rhythmic breaths can help in managing pain by promoting relaxation and reducing muscle tension. Deep breathing exercises are a common nonpharmacological intervention for pain relief. However, for localized back pain, this method might not be as effective as applying an ice pack directly to the affected area.
Choice B Reason:
Encouraging the client to apply a heating pad for 2 hours at a time can provide relief by increasing blood flow and relaxing muscles. However, prolonged use of heat can sometimes exacerbate inflammation, especially if the pain is due to an acute injury. Therefore, it is generally recommended to alternate between heat and cold therapy.
Choice C Reason:
Applying an ice pack to the client’s back for 1 hour is effective in reducing inflammation and numbing the pain. Cold therapy is particularly useful in the initial stages of pain management as it helps to constrict blood vessels, reducing swelling and providing immediate pain relief. This method is often recommended for acute pain and injuries.
Choice D Reason:
Removing distractions from the client’s room can create a more restful environment, which may help in overall pain management. However, this action alone is unlikely to provide significant relief for localized back pain. It is more of a supportive measure rather than a primary intervention for pain relief.
Correct Answer is B
Explanation
Choice A Reason:
A family whose only child recently died due to cancer is experiencing a significant and traumatic loss. This type of loss is categorized as a situational loss because it is unexpected and not part of the normal life cycle. Situational losses are typically sudden and can cause profound grief and disruption in the family’s life. The death of a child is one of the most devastating events a family can endure, leading to intense emotional pain and a long grieving process.
Choice B Reason:
A family whose oldest child is moving away for college is experiencing a maturational loss. Maturational losses are those that occur as part of normal life transitions and developmental stages. These losses are anticipated and expected as individuals grow and progress through different phases of life. The transition of a child moving away for college is a common maturational loss, as it signifies a significant change in the family dynamic and the child’s development into adulthood.
Choice C Reason:
A family whose house was destroyed in a fire is dealing with a situational loss. This type of loss is unexpected and can have a severe impact on the family’s sense of security and stability. The destruction of a home involves not only the loss of physical property but also the emotional attachment and memories associated with the home. Recovering from such a loss requires significant emotional and practical adjustments.
Choice D Reason:
A family whose head of household lost their job is experiencing a situational loss. Job loss can lead to financial instability and stress, affecting the entire family’s well-being. This type of loss is not part of the normal developmental process and can create significant challenges for the family as they navigate the uncertainty and potential changes in their lifestyle.
