A client with active pulmonary tuberculosis (TB) and a documented history of severe alcohol use disorder is admitted to an airborne infection isolation room (AIIR). Twenty-four hours after admission, the client becomes profoundly disoriented, experiences visual hallucinations, and repeatedly attempts to leave the room, stating they must "go to work immediately." What is the safest and most appropriate initial nursing action?
- AAssign an unlicensed assistive personnel (UAP) to remain in the room and continuously assess the client's neurologic and behavioral status.
- BApply physical restraints to prevent the client from exiting the room and exposing the general unit to an airborne pathogen.
- CKeep the isolation room door partially open to allow frequent visual monitoring by the nursing staff while minimizing repeated room entries.
- Don a fit-tested N95 respirator, enter the room to implement verbal de-escalation, and prepare to administer prescribed symptom-triggered medications.Answer
Answer
The nurse should put on the required personal protective equipment (an N95 respirator), enter the room to calm the client using verbal de-escalation, and treat the underlying cause of the agitation (alcohol withdrawal) with prescribed medications.
The safest approach is to directly address the client's agitation—which is likely caused by alcohol withdrawal—using the least restrictive measures first. Donning an N95 respirator ensures the nurse is protected from tuberculosis, while verbal de-escalation and symptom-triggered medications (such as benzodiazepines) safely manage the withdrawal delirium without compromising infection control or patient rights.
Step-by-Step Solution
Key Concept
Managing behavioral emergencies in isolation environments requires addressing the root cause of agitation while strictly adhering to transmission-based precautions and safe delegation principles.
Estimated Time:1m 30s