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 ["B","C","E"]
Explanation
Choice A Reason:
A negative Chvostek’s sign is not expected in a client with hypocalcemia. The Chvostek’s sign is a clinical indicator of hypocalcemia, where tapping the facial nerve triggers facial muscle twitching. A positive Chvostek’s sign indicates neuromuscular irritability due to low calcium levels. Therefore, a negative Chvostek’s sign would not be consistent with hypocalcemia.
Choice B Reason:
A positive Trousseau’s sign is a classic indicator of hypocalcemia. This sign is elicited by inflating a blood pressure cuff on the upper arm to a level above the systolic pressure for several minutes. The resultant carpopedal spasm (involuntary contraction of the hand and wrist muscles) is a positive Trousseau’s sign, indicating neuromuscular irritability due to low calcium levels.
Choice C Reason:
Muscle cramps are a common syptom of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to involuntary muscle contractions and cramps. These cramps can occur in various muscle groups, often causing significant discomfort.
Choice D Reason:
Abdominal distention is not typically associated with hypocalcemia. While abdominal distention can result from various gastrointestinal issues, it is not a direct symptom of low calcium levels. Hypocalcemia primarily affects neuromuscular function rather than causing abdominal distention.
Choice E Reason:
Tingling sensation around the lips, also known as perioral tingling, is a common symptom of hypocalcemia. This occurs due to increased neuromuscular irritability caused by low calcium levels, leading to sensations of tingling or numbness around the mouth.
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.