A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit.
What action by the nurse is best?
Ask the spouse to explain the fear of visiting in further detail.
Inform the spouse that the precautions are meant to keep other clients safe.
Show the spouse how to follow the Isolation Precautions to avoid illness.
Tell the spouse that he or she has already been exposed, so it's safe to visit.
The Correct Answer is C
Choice A rationale
While understanding the spouse's fear is important for a holistic approach, it does not directly address the underlying knowledge deficit or provide a solution to mitigate the perceived risk. The fear likely stems from a lack of understanding regarding transmission and protective measures for tuberculosis, which requires specific education to overcome.
Choice B rationale
Informing the spouse that precautions protect other clients is true but does not alleviate the spouse's personal fear of contracting the disease. The spouse's primary concern is self-preservation and protecting themselves from potential infection, which needs to be directly addressed by demonstrating safety protocols.
Choice C rationale
This action directly empowers the spouse by providing concrete education and demonstration of proper isolation techniques. Understanding and practicing these precautions, such as donning and doffing personal protective equipment and hand hygiene, significantly reduces perceived and actual transmission risk, promoting a sense of safety and control.
Choice D rationale
Stating that the spouse has already been exposed can be misleading and may not be entirely accurate, as exposure does not guarantee infection. Furthermore, it dismisses the spouse's valid anxieties about active disease transmission from a hospitalized individual, potentially fostering mistrust rather than alleviating fear and encouraging visits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A negative chest x-ray, while indicative of resolving lung pathology, does not definitively confirm the absence of viable Mycobacterium tuberculosis. Radiographic resolution can lag behind bacteriologic clearance, meaning granulomas might still be present even if the active infection has been eliminated, and thus transmissibility cannot be excluded solely based on imaging.
Choice B rationale
The absence of clinical symptoms, such as cough, fever, or weight loss, suggests clinical improvement but does not guarantee bacteriologic cure or non-infectiousness. A patient can be asymptomatic yet still shed viable mycobacteria, posing a risk of transmission to others. Bacteriological confirmation is essential.
Choice C rationale
Three negative sputum cultures, typically collected on separate days, are the gold standard for confirming that a patient with tuberculosis is no longer infectious. This indicates the absence of viable Mycobacterium tuberculosis in respiratory secretions, significantly reducing the risk of transmission to others due to the inability to aerosolize infectious particles.
Choice D rationale
A negative skin test, or tuberculin skin test (TST), indicates the absence of a delayed-type hypersensitivity reaction to M. tuberculosis antigens. It primarily reflects exposure and immune response, not active infection or infectiousness. A previously positive TST usually remains positive even after successful treatment, so a negative result in a treated patient is not a measure of non-infectiousness.
Correct Answer is C
Explanation
Choice A rationale
While queries regarding etiology eventually arise, the immediate emotional response of parents to the sudden and unexpected death of an infant from SIDS is often profound shock and a strong sense of personal culpability. The search for a "reason why" typically follows the initial surge of intense emotional distress and self-blame.
Choice B rationale
Acceptance is a much later stage in the grief process and is rarely the initial reaction to a traumatic loss like SIDS. The suddenness and unexplained nature of SIDS often lead to prolonged denial, disbelief, and a struggle to comprehend the event before any form of acceptance can begin to manifest.
Choice C rationale
Feelings of blame or guilt are almost universally the initial and most intense reactions experienced by parents following an infant's death from SIDS. The unexplained nature of the death often leads parents to scrutinize their actions, believing they somehow failed to protect their child, even when no identifiable cause is found.
Choice D rationale
Requests for an infant's belongings may occur at various points during the grieving process, representing a desire to hold onto memories or tangible connections. However, this is not typically the very first reaction, which is dominated by overwhelming emotional shock, grief, and often profound self-blame and guilt.
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