Practice Test Assessment Performance

A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, “Why do you have to wear a gown and mask when you are in my room?” How should the nurse respond? Rationale Reverse isolation precaution implement measures to protect the client from exposure to microorganisms from others. Although microbes are prevalent in all environments, informing the child about germs in hospital does not adequately answer the child's question. Reverse isolation should be implemented until the client's white blood cell increases. Neutropenia in this child does not place others at risk for infection. A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide? Rationale Due to the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is 5 to 7 days after menstruation stops because physiologic alterations in breast size and activity reach their minimal level after menses. One week before menses and midway between menses can vary from month to month and does not provide a consistent day of the month for the client to remember to do BSE. The first day of menses is commonly the day of the menstrual cycle that the breast are most affected by hormonal influence. "There are many forms of bacteria and germs in the hospital." "To protect you because you can get an infection very easily." "After taking medication for 24 hours a gown and mask won't be needed." "Your condition could be spread to staff and other clients in the hospita