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 ["C","D","E"]
Explanation
Rationale:
A. Allowing a client to skip therapy may not be promoting mental health effectively and could hinder progress.
B. Administering medications is a necessary task but does not directly relate to mental health promotion strategies.
C. Allowing the use of exercise equipment to manage anxiety supports mental health promotion by encouraging healthy coping mechanisms.
D. Assisting clients in using adaptive coping skills is a key aspect of mental health promotion, helping clients develop effective strategies to manage their condition.
E. Following suicide precautions ensures safety and is a proactive approach to mental health management.
Correct Answer is ["B","D","E","F"]
Explanation
Rationale:
A. The ECG shows persistent sinus bradycardia on both December 1 and December 15. While sinus bradycardia is common in anorexia nervosa, its persistence may not necessarily reflect a therapeutic response.
B. The respiratory rate improved from 24/min to 20/min and the respirations are described as even and unlabored on December 15. This indicates a positive response to treatment.
C. The temperature data for December 15 is not provided. However, an increase toward normal temperature would indicate a therapeutic response, but without this data, we cannot confirm.
D. The weight increased from 34.5 kg (76 lb) to 37.2 kg (82 lb), which is a significant therapeutic improvement, reflecting progress in treatment.
E. The sodium level improved from 128 mEq/L to 130 mEq/L. Although the level is still slightly below normal, the upward trend indicates improvement.
F. The creatinine level decreased from 1.2 mg/dL to 0.9 mg/dL, showing improvement in kidney function and response to treatment.