A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?
Assign the client to a room with other clients who require droplet precautions.
Modify the protocol for donning and removing personal protective equipment before entering or leaving the client's room.
Have staff and visitors wear gowns, masks, and gloves while in the client's room.
Place the client in a private room with a special ventilation system.
The Correct Answer is D
Rationale:
A. Clients with active tuberculosis should not be placed in a room with other clients, even if they require droplet precautions, as TB requires airborne precautions.
B. While PPE protocols are important, the most critical precaution for TB is ensuring the client is in the correct environment to prevent airborne transmission.
C. Wearing gowns, masks, and gloves is important, but the most essential measure is the room's ventilation system.
D. Active tuberculosis is an airborne infectious disease, so the client should be placed in a private room with a negative pressure ventilation system to prevent the spread of the bacteria through the air.
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Correct Answer is B
Explanation
Rationale:
A. Anabolic steroids are associated with mood swings and aggressive behavior but are less likely to cause the acute symptoms of paranoia, hallucinations, and severe agitation described here.
B. Hallucinogens, such as LSD or PCP, can cause intense paranoia, hallucinations, and erratic behavior, as seen in the client’s symptoms. These substances often lead to altered perceptions of reality, including visual and auditory hallucinations.
C. Stimulants like cocaine or methamphetamines can cause paranoia and hyperactivity but are less likely to cause the vivid hallucinations described.
D. Opioids typically cause drowsiness, respiratory depression, and a sense of euphoria rather than hallucinations and severe agitation.
Correct Answer is ["B","C","E"]
Explanation
Rationale:
A. Nylon socks are generally not considered a risk for self-harm and can be safely kept with the client.
B. A glass-framed picture presents a risk as the glass could be broken and used for self-harm. This item should be taken home.
C. Lace-up tennis shoes have long laces that could be used for self-harm, making them unsafe for a client at risk of suicide.
D. Cotton underwear does not pose a significant risk for self-harm and can be kept with the client.
E. A necklace could be used for self-harm, such as strangulation, and should be taken home to ensure the client's safety.