# Situation: The father, 40, a construction worker, has bacteriologically confirmed pulmonary tuberculosis (TB) and started treatment 2 months ago at the Rural Health Unit (RHU), 12 km from home. The family of five lives in a one-room house with small windows that are kept closed. The children are 3, 7, and 12 years old. A barangay health station (BHS) with a midwife is within walking distance of the home. Which set of interventions should the nurse include in the family's care plan? 1. Screen all household contacts for TB 2. Start TB preventive treatment for the 3-year-old today, before any screening 3. Teach cough etiquette and safe disposal of sputum 4. Keep the young children from sharing his sleeping area until he is declared no longer infectious > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=627250 > language: ko > subject: Nursing Practice I — Community Health Nursing ## 문제 Situation: The father, 40, a construction worker, has bacteriologically confirmed pulmonary tuberculosis (TB) and started treatment 2 months ago at the Rural Health Unit (RHU), 12 km from home. The family of five lives in a one-room house with small windows that are kept closed. The children are 3, 7, and 12 years old. A barangay health station (BHS) with a midwife is within walking distance of the home. Which set of interventions should the nurse include in the family's care plan? 1. Screen all household contacts for TB 2. Start TB preventive treatment for the 3-year-old today, before any screening 3. Teach cough etiquette and safe disposal of sputum 4. Keep the young children from sharing his sleeping area until he is declared no longer infectious ## 보기 1. 1, 2 and 4 2. 1, 3 and 4 **✔ 정답** 3. 1, 2 and 3 4. 2, 3 and 4 **정답: 2** ## 해설 All household contacts are screened, and TB preventive treatment is given to eligible contacts only after active TB has been excluded, because preventive treatment alone would undertreat active disease. Cough etiquette, safe sputum disposal, and limiting close contact with young children until the doctor declares him no longer infectious reduce spread at home. ## 심화 해설 Question Analysis The father has bacteriologically confirmed pulmonary TB and has been on treatment for 2 months. The household is crowded, poorly ventilated, and includes three young children. The nurse must select interventions that protect the family while following the correct clinical sequence for TB contact management. The correct answer is 2 (1, 3, and 4): screen all household contacts, teach cough etiquette and safe sputum disposal, and keep young children from sharing his sleeping area until he is declared no longer infectious. TB preventive treatment (TPT) is given only after active TB has been excluded through screening, because giving preventive therapy alone to a child who already has active disease would undertreat the infection. This is why intervention 2 is incorrect as stated: starting TPT for the 3-year-old today, before any screening, violates the mandatory sequence of ruling out active TB first. --- Why Each Correct Intervention Matters 1. Screen all household contacts for TB Household contacts of a bacteriologically confirmed pulmonary TB case are at substantially elevated risk for both TB infection and progression to active disease. Contact investigation is the entry point for identifying children who need either treatment for active TB or preventive therapy for latent infection. The systematic review and individual-participant meta-analysis by Martinez et al. demonstrated that children with close exposure to a TB case have a meaningful risk of developing incident TB, underscoring the importance of systematic screening rather than waiting for symptoms to appear [1]. Screening must precede any preventive treatment decision. A child with active TB who receives only TPT will not receive the multi-drug regimen required to cure active disease, and the infection may progress while the family falsely believes the child is protected. The cluster-randomized trial in South Africa showed that household contact tracing with intensified screening improved TB-free survival, reinforcing that active case-finding among contacts is a core intervention [3]. 3. Teach cough etiquette and safe disposal of sputum The father has been on treatment for 2 months, but smear or culture conversion is not guaranteed at this point. Cough hygiene and safe sputum disposal reduce the concentration of infectious droplet nuclei in the shared living space, which is especially important in a one-room house with closed windows. Covering the mouth when coughing, disposing of sputum in a covered container with appropriate disinfection, and hand hygiene after contact with respiratory secretions are practical measures that interrupt airborne transmission at the source. The household environment described here—small windows kept closed—means that airborne bacilli can accumulate. Teaching the family to open windows when feasible and to practice cough etiquette directly addresses the environmental risk factor that increases transmission intensity. 4. Keep the young children from sharing his sleeping area until he is declared no longer infectious Young children, particularly those under 5 years, are at higher risk of progression from TB infection to active disease, and the youngest child in this family is 3 years old. Prolonged close contact during sleep represents a high-intensity exposure because of the extended duration and proximity, which increases the inhaled dose of Mycobacterium tuberculosis. The meta-analysis confirmed that close exposure is a major driver of TB risk in children [1]. Separating sleeping areas reduces the cumulative exposure burden. This intervention is time-limited: it continues only until the treating clinician confirms the father is no longer infectious, typically based on clinical improvement, adherence to treatment, and negative sputum results. The nurse should explain that this is not permanent separation but a temporary protective measure. --- Why Intervention 2 Is Incorrect Watch out! The statement "Start TB preventive treatment for the 3-year-old today, before any screening" is dangerous because it reverses the correct clinical sequence. TPT is indicated for eligible contacts only after active TB has been excluded through clinical evaluation, chest radiography when indicated, and appropriate testing. A child with active pulmonary TB who receives only preventive therapy (typically isoniazid or a short rifamycin-based regimen) will be undertreated, leading to disease progression, potential dissemination, and continued transmission risk within the household. The hospital-based study by Sun et al. emphasized that screening strategies must be tailored to exposure level and that identifying children with latent TB infection requires appropriate diagnostic testing before any treatment decision . The study from Cambodia similarly highlighted that contact investigation aims to distinguish between TB disease and TB infection, because the management pathways differ fundamentally . The 3-year-old is at particularly high risk because young age is associated with both higher likelihood of infection after exposure and higher risk of rapid progression to active disease, including severe forms such as miliary TB and TB meningitis. This makes correct sequencing even more critical: screen first, then treat based on findings. --- Clinical Reasoning Summary | Intervention | Correct? | Rationale | | --- | --- | --- | | Screen all household contacts | Yes | Identifies active TB and latent infection; guides treatment decisions [1][3] | | Start TPT for 3-year-old today, before screening | No | TPT requires exclusion of active TB first; otherwise undertreats active disease | | Teach cough etiquette and safe sputum disposal | Yes | Reduces airborne bacilli in shared, poorly ventilated space | | Keep young children from sharing sleeping area until declared non-infectious | Yes | Reduces prolonged close-contact exposure in highest-risk children [1] | Key point! The unifying principle is that all household contacts must be systematically evaluated, and preventive treatment is a subsequent step reserved for those without evidence of active disease. Infection control measures at home—cough etiquette, sputum disposal, and reducing close contact—are implemented concurrently to lower ongoing transmission while the diagnostic workup proceeds.References (research sources) - [1]The risk of tuberculosis in children after close exposure: a systematic review and individual-participant meta-analysis.Meta-analysis/systematic reviewMartinez L, Cords O, Horsburgh CR, Andrews JR, Pediatric TB Contact Studies Consortium (2020) · DOI: 10.1016/S0140-6736(20)30166-5 - [3]Household Contact Tracing With Intensified Tuberculosis and Human Immunodeficiency Virus Screening in South Africa: A Cluster-Randomized Trial.RCT/clinical trialMartinson NA, Lebina L, Webb EL, Ratsela A, Varavia E, Kinghorn A (2022) · DOI: 10.1093/cid/ciab1047 ## 임상 시나리오 TB Household Contact ManagementScreen first, then prevent and protect For a household contact of bacteriologically confirmed pulmonary TB, the first step is to screen all household contacts for active TB. TB preventive treatment is given only after active TB has been excluded, because preventive therapy alone would undertreat active disease. Teach cough etiquette and safe sputum disposal to reduce airborne spread at home. Keep young children from sharing his sleeping area until the clinician declares him no longer infectious, typically after effective treatment and clinical improvement. CautionDo not start preventive treatment for a child before screening. A child with undiagnosed active TB who receives only preventive therapy is at risk of undertreatment and disease progression. ## 핵심 개념 - **TB preventive treatment (TPT)** — Treatment given to contacts with TB infection but no active disease, only after active TB has been excluded by screening. - **Contact investigation** — Systematic screening of household and close contacts of a confirmed TB case to detect active disease or latent infection. - **Cough etiquette** — Behaviors such as covering the mouth and nose when coughing to reduce airborne spread of respiratory pathogens. - **Bacteriologically confirmed TB** — Pulmonary TB proven by a positive smear, culture, or molecular test such as Xpert MTB/RIF. - **Infectious period** — The time during which a TB patient can transmit Mycobacterium tuberculosis; typically ends after effective treatment and clinical improvement. ## 같은 주제 문제 - [Situation: The public health nurse makes a home visit to a family. The father, 58, a drive…](https://mymerci.kr/pages/nclex_q.php?qn_id=627034) - [Situation: The public health nurse makes a home visit to a family. The father, 58, a drive…](https://mymerci.kr/pages/nclex_q.php?qn_id=627035) - [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627045) - [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627046) - [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627047) - [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627048) - [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627049) - [Situation: During a follow-up home visit, the nurse learns that the father, 38, lost his j…](https://mymerci.kr/pages/nclex_q.php?qn_id=627050) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._