A client is admitted to the medical-surgical unit with a 3-week history of a productive cough, night sweats, low-grade fever, and unexplained weight loss. The client reports feeling fatigued and has decreased appetite. Based on these assessment findings, which intervention should the nurse implement first?

Placing the client in airborne isolation

Obtaining sputum cultures

Monitoring the client's fluid intake and output

Assessing the client's temperature every 8 hours

Answer and Explanation

The Correct Answer is A

Rationale:

A. Placing the client in airborne isolation: The client’s symptoms strongly suggest pulmonary tuberculosis. Airborne isolation prevents transmission of Mycobacterium tuberculosis to healthcare workers and other clients, making infection control the first concern.

B. Obtaining sputum cultures: Sputum cultures are necessary to confirm TB diagnosis and guide treatment. However, cultures should be obtained only after the client has been placed in proper isolation to prevent potential spread of infection during the collection process.

C. Monitoring the client's fluid intake and output: While hydration status is important in clients with fever, weight loss, and decreased appetite, it is not an immediate priority compared to preventing transmission of a highly contagious airborne disease.

D. Assessing the client's temperature every 8 hours: Monitoring fever helps track infection severity but does not address the urgent risk of spreading TB. Infection control measures take precedence before routine monitoring can be performed.

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Correct Answer is D

Explanation

A. Avoiding crowded places such as public transportation during peak hours: Avoiding crowded areas can help reduce exposure to infections, but it is not the most critical aspect of self-care. Clients cannot always fully avoid public spaces, and prevention strategies must be more comprehensive.

B. Appropriate use of prophylactic antibiotics: Some clients with HIV may be prescribed prophylactic antibiotics to prevent opportunistic infections. However, this is provider-directed and not a universal measure for all clients. Teaching should emphasize broader, daily self-care practices.

C. Taking prescribed medications with food to reduce gastrointestinal upset: Taking medications with food can help manage side effects and improve adherence, but this is secondary to infection prevention. GI upset is manageable, whereas infections can quickly become life-threatening.

D. Maintaining strict personal hygiene practices: Clients with HIV are immunocompromised and highly susceptible to infections. Proper handwashing, safe food handling, and skin/mouth care are essential in reducing exposure to pathogens and preventing serious complications.

A. Place the client on seizure precautions. B. Notify the physician C. Administer Benadryl/diphenhydramine IM immediately as prescribed D. Advocate for a decrease in the antipsychotic medication

Correct Answer is C

Explanation

A. Place the client on seizure precautions: The presentation of eyes rolling back and jaw locking is consistent with an acute dystonic reaction, not seizure activity. Seizure precautions would not address the immediate pathophysiologic cause.

B. Notify the physician: Informing the provider is important, but it is not the priority. Acute dystonia is a medical emergency that requires rapid intervention to relieve painful and potentially dangerous muscle contractions before further communication with the provider.

C. Administer Benadryl/diphenhydramine IM immediately as prescribed: Diphenhydramine, an antihistamine with anticholinergic properties, rapidly relieves acute dystonia caused by antipsychotic medications. Prompt treatment prevents airway compromise and reduces client distress.

D. Advocate for a decrease in the antipsychotic medication: Medication adjustment may be needed long-term, but reducing the antipsychotic dosage does not resolve the immediate dystonic crisis. The client first requires urgent pharmacologic intervention.

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Naxlex Comprehensive Predictor Exams

A client with HIV is being discharged home and will begin receiving care in the home setting. During discharge education, which aspect of self-care should the nurse emphasize as the priority to help prevent complications?

Correct Answer is D

Explanation

The client with schizophrenia taking antipsychotic medication is conversing with the nurse when the eye's roll back in a locked position and their jaw presents to be locked in one position. Which is the priority action by the nurse?

Correct Answer is C

Explanation

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