Level: Foundational
Difficulty: Easy
Subtopic: Suicide risk
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for expressions of hopelessness. As…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for expressions of hopelessness. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. Which infection-prevention action is essential?
Question
A. Wear gloves only and skip hand hygiene when leaving the room.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Skip precautions if the client has no fever.
D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Skip precautions if the client has no fever.
D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
Rationale
Correct answer: D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
Rationale: Infection control matches the pathogen route: hand hygiene plus appropriate precautions for contact, droplet, or airborne transmission.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Infection control matches the pathogen route: hand hygiene plus appropriate precautions for contact, droplet, or airborne transmission.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.