A nurse is planning care for a toddler who has measles. Which of the following isolation precautions should the nurse initiate?

Rationale

A. Acceptance: Acceptance is the stage of grief in which the client comes to terms with their prognosis and makes peace with the situation. Choosing comfort care over further treatment reflects understanding of their terminal condition and a focus on quality of life rather than curative measures. Documentation should reflect the client’s informed decision and readiness to embrace this stage.

B. Denial: Denial involves refusal to acknowledge the reality of the illness or prognosis. The client in this scenario is aware of their condition and is making conscious choices, indicating they are not in denial. Recognizing denial helps identify when clients may need additional support or education.

C. Bargaining: Bargaining involves attempting to negotiate for more time or a different outcome, often through “if only” statements or promises. The client is not seeking alternative treatments or making deals to extend life, so bargaining is not applicable in this case.

D. Depression: Depression is characterized by deep sadness, hopelessness, or withdrawal in response to loss. While the client may experience emotional responses, the statement indicates acceptance rather than pervasive despair. Distinguishing between acceptance and depression ensures accurate documentation of the client’s emotional stage.

Rationale

A. Infection: Infection at an IV site usually presents with redness, warmth, pain, and possibly purulent drainage. Taut and edematous skin without these signs is more consistent with fluid leakage rather than infection.

B. Phlebitis: Phlebitis involves inflammation of the vein, often causing redness, warmth, swelling, and tenderness along the vein. Taut, edematous skin around the site without vein inflammation points to a different complication.

C. Air embolism: An air embolism presents with sudden respiratory distress, hypotension, and chest pain. Localized swelling at the IV site is not a typical manifestation of an air embolism.

D. Infiltration: Infiltration occurs when IV fluid leaks into the surrounding tissue, causing swelling, tautness, pallor, and cool skin around the insertion site. This complication matches the observed findings and requires prompt intervention to prevent tissue damage.