A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

Select words from the choices below to fill in each blank in the following sentence.

The nurse should identify that

_______

and

__________

indicate manifestations of borderline personality disorder.

A. Place the client in a negative pressure room: Negative pressure rooms are used for airborne diseases like tuberculosis or measles, where pathogens are airborne. VRE is a contact-transmitted infection, not airborne, so a negative pressure room is not necessary.

B. Wear a gown and gloves during client interactions and care: VRE is spread through direct contact with contaminated surfaces or bodily fluids. Wearing a gown and gloves provides the necessary precautions to prevent the spread of the infection through contact transmission.

C. Wear a surgical mask during client interactions and care: A surgical mask is primarily used for droplet precautions (e.g., influenza), not for contact precautions like VRE. A mask is not necessary unless the client has a respiratory infection or if there is a risk of splashing bodily fluids.

D. Place the client in a room with high-efficiency particulate air (HEPA) filtration for incoming air: HEPA filtration is used for airborne infections such as tuberculosis. Since VRE is not an airborne pathogen, this measure is unnecessary for preventing the spread of VRE.

• Placenta previa: Placenta previa occurs later in pregnancy and is characterized by painless bright red vaginal bleeding without abdominal tenderness. The client is only 6 weeks pregnant, and placenta previa is not a concern this early in gestation.
• abruptio placentae: Abruptio placentae involves painful bleeding and a rigid uterus, usually occurring after 20 weeks' gestation. The client’s gestational age and presenting symptoms are more consistent with an early pregnancy complication rather than abruptio placentae.
• ectopic pregnancy: This occurs when a fertilized egg implants outside the uterus. The client’s missed period, positive pregnancy test, right lower quadrant tenderness, and dark red vaginal spotting are classic signs of ectopic pregnancy. Ectopic pregnancy is a life-threatening emergency if rupture occurs, requiring prompt identification and management.
• acute asthma attack: While the client has a history of asthma and slight inspiratory wheezing, her respiratory status is stable with normal oxygen saturation and no signs of acute respiratory distress. Therefore, an asthma attack is not the primary concern.
• pyelonephritis: Pyelonephritis typically presents with fever, chills, flank pain, and urinary symptoms. The client’s presentation of right lower quadrant tenderness and vaginal spotting does not align with the typical findings of pyelonephritis.
• respiratory rate: The client’s respiratory rate is normal at 16/min, indicating stable respiratory function. Respiratory rate does not explain the primary concern related to abdominal pain and vaginal bleeding.
• history of regular menstrual period: While this supports that the client is late in her cycle, it is not the most direct or critical finding pointing toward the diagnosis. The focus should be on current clinical signs like abdominal tenderness.
• temperature: The client’s temperature is within normal range at 37.3°C (99.1°F), making infection less likely and not the primary concern related to her current symptoms.
• right lower quadrant abdominal tenderness: Localized tenderness in the right lower quadrant combined with vaginal spotting strongly suggests an ectopic pregnancy. This is a hallmark finding that supports the diagnosis as the growing embryo can cause irritation, stretching, or rupture of the fallopian tube.
• hyperactive bowel sounds: Hyperactive bowel sounds are nonspecific and can occur due to anxiety, mild gastrointestinal upset, or pain, but they are not diagnostic for ectopic pregnancy. The abdominal tenderness is the more significant finding.