A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident.

Exhibits

Which of the following assessment findings should the nurse attend to right away?

Choice A rationale

A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) requires a negative airflow room and airborne precautions. This is to prevent the spread of tuberculosis (TB), an infectious disease that can be transmitted through airborne particles. The use of a particulate respirator mask by healthcare personnel is essential in protecting themselves from inhaling infectious aerosols. Implementing these precautions is critical in controlling the spread of TB within healthcare settings and ensuring patient and staff safety.

Choice B rationale

A client with genital herpes simplex II lesions does not require a negative airflow room or airborne precautions. Herpes simplex virus (HSV) is primarily transmitted through direct contact with infected lesions or body fluids. Standard precautions, including contact precautions when dealing with lesions, are adequate to prevent the spread of HSV. Negative airflow rooms and airborne precautions are not necessary for managing this condition.

Choice C rationale

Scarlet fever, complicated with pneumonia, primarily requires standard and droplet precautions rather than airborne precautions. Scarlet fever is caused by group A Streptococcus, which is spread through respiratory droplets. While pneumonia can increase the severity of the infection, negative airflow rooms and particulate respirators are not typically required. Droplet precautions, such as wearing masks and maintaining distance, are sufficient to prevent transmission.

Choice D rationale

Scabies is a parasitic infestation that spreads through direct skin-to-skin contact or contact with contaminated items such as bedding and clothing. Negative airflow rooms and airborne precautions are not necessary for managing scabies. Standard and contact precautions, including wearing gloves and gowns and thoroughly cleaning and disinfecting contaminated items, are adequate to prevent the spread of the mites causing scabies. The use of a particulate respirator mask is not required.

Choice A rationale: Acute appendicitis is most likely based on the history of sudden onset of severe abdominal pain localized to the right lower quadrant, nausea, vomiting with green bile, and tenderness on physical examination. The ultrasound findings of right lower quadrant tenderness further support this diagnosis. The client's vital signs, including tachycardia and tachypnea, are consistent with the stress and pain caused by acute appendicitis.

Choice B rationale: Ectopic pregnancy is less likely as the client has a negative pregnancy test and reports regular menstrual cycles with her last period occurring one week ago. Additionally, her symptoms are more typical of appendicitis.

Choice C rationale: Ovarian cyst rupture would typically present with sudden onset of pelvic pain, often associated with menstrual irregularities or a history of ovarian cysts. However, the client's presentation and diagnostic results strongly point towards acute appendicitis.

Choice D rationale: Acute gastritis generally presents with epigastric pain, nausea, and vomiting. However, the localization of pain to the right lower quadrant and the ultrasound findings make appendicitis a more likely diagnosis in this case.