A nurse is caring for a 24-year-old female client who fell while horseback riding in the accident emergency unit.

Exhibits

A nurse is preparing the client for surgery. Based on the provided data, which of the following are the most critical to address before proceeding with the exploratory laparotomy? Select all that apply.

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.

Rationale for correct answers

Neglect: The client’s condition and living situation indicate neglect. The client is frail, has poor hygiene, unkempt hair, dry skin, and visible pressure injuries. The daughter, who is the primary caregiver, admits to being overwhelmed and neglecting the client’s needs, such as hygiene and repositioning. Neglect is defined as the failure to provide necessary care, assistance, and supervision to a dependent individual, leading to harm or potential harm.

Adult Protective Services: As a mandated reporter, the nurse must report the signs of elder mistreatment to Adult Protective Services (APS). APS is responsible for investigating reports of abuse, neglect, and exploitation of elderly or disabled adults. Reporting to APS ensures that the client receives the necessary intervention and support to address the neglect and improve her quality of life.

Rationale for incorrect answers

Abandonment: Abandonment refers to deserting an elderly person, leaving them without the necessary care and support. In this case, the client has not been deserted; her daughter is present and attempting to provide care, although she is overwhelmed and neglectful. Therefore, abandonment is not the correct answer.

Physical abuse: Physical abuse involves the intentional use of physical force that results in bodily injury, pain, or impairment. There is no evidence of physical abuse in this case. The client’s condition is due to neglect, not physical harm inflicted by another person.

Self-neglect: Self-neglect occurs when an individual fails to meet their own basic needs, such as personal hygiene, nutrition, or medical care. In this scenario, the client is dependent on her daughter for care and unable to provide for herself due to limited mobility. The neglect is not self-imposed but rather due to the caregiver's inability to meet her needs.