Giddens, Concept 25 - Infection
Which of the following clinical manifestations does the nurse associate with rubeola? 1 Macular rash 2 Paroxysmal cough 3 Enlarged parotid glands 4 Generalized vesicular lesions
1 Rubeola (measles) starts with a discrete maculopapular rash on the face that spreads downward, eventually becoming confluent. A paroxysmal cough occurs with whooping cough. Enlarged parotid glands occur with mumps. Generalized vesicular lesions occur with chickenpox.
Which are examples of actively acquired specific immunity? Select all that apply. 1 Recovery from measles 2 Recovery from chickenpox 3 Maternal immunoglobulin in the neonate 4 Immunization with live or killed vaccines 5 Injection of human gamma immunoglobulin
1, 2, 4 Naturally acquired active-type immunity is seen in a client who has recovered from measles or chickenpox or who has been immunized with a live- or killed-virus vaccine. Maternal immunoglobulin in a neonate and an injection of human gamma immunoglobulin into a client are examples of passively acquired specific immunity.
A client with tuberculosis is prescribed rifampin. What does the nurse teach the client about this medication? Select all that apply. 1 "Avoid drinking alcohol while you are on this drug." 2 "Report immediately if you find a yellow appearance to the skin." 3 "Wear a protective clothing and sunscreen when going out in sunlight." 4 "Your soft contact lenses will become permanently stained with this drug." 5 "Immediately consult your physician if you find reddish orange tinge in your urine."
1, 2, 4 Rifampin is an antitubercular drug that kills slow-growing organisms residing in the caseating granulomas. Rifampin may cause liver damage, so alcohol should be avoided as it potentiates liver damage. Yellow appearance to the skin is a sign of liver failure. Therefore, a client on rifampin therapy is taught to report the presence of any yellowing of the skin. Rifampin permanently stains soft contact lenses and therefore the client is made aware to avoid wearing them while on the medication. Pyrazinamide causes photosensitivity reactions and therefore a client on that drug therapy is advised to wear protective clothing and sunscreen when going outdoors. The nurse should inform the client that rifampin changes the color of body secretions, which is normal and harmless.
A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness? 1 Hepatitis A 2 Rheumatic fever 3 Spinal meningitis 4 Rheumatoid arthritis
2 Rheumatic fever Antibodies produced against group A beta-hemolytic streptococci sometimes interact with antigens in the heart's valves, causing damage and symptoms of rheumatic heart disease; early recognition and treatment of streptococcal infections have limited the occurrence of rheumatic heart disease. Hepatitis A, an inflammation of the liver, is caused by the hepatitis A virus (HAV), not by bacteria. The most common causes of meningitis, an infection of the membranes surrounding the brain and spinal cord, include Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Rheumatoid arthritis is believed to be an autoimmune disorder; it is not caused by microorganisms.
The nurse is caring for four clients in the medical unit. Which nursing instruction indicates a need for correction? 1 Client A Abnormal vaginal bleeding. Avoid super absorbent tampons 2 Client B Diarrhea. Wash hands frequently 3 Client C AIDS. Never share your eating utensils. 4 Client D Tuberculosis. Wear a mask during transport to other areas.
3 Client C Human immunodeficiency virus leads to acquired immunodeficiency syndrome. The virus in client C cannot be transmitted through sharing eating utensils, hugging, dry kissing, shaking hands, and using toilet seats. The nurse should advise client A to use sanitary pads rather than superabsorbent tampons to prevent toxic shock syndrome due to Staphylococcus aureus infection. Client B with diarrhea should wash hands frequently to reduce the transmission of the disease. The nurse should advise client D with tuberculosis to wear a mask to prevent the transmission of Mycobacterium tuberculosis from small droplets when being transported.
When assessing the oral cavity of a newly admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies areas of white plaque on the client's tongue and palate. What is the nurse's initial response? 1 Instruct the client to perform meticulous oral hygiene at least once daily. 2 Scrape an area of one of the lesions and send the specimen for a biopsy. 3 Document the presence of the lesions, describing their size, location, and color. 4 Consider that these lesions are universally found in clients with AIDS and require no treatment.
3 Documentation of nursing findings during assessment is a nursing function; this facilitates early treatment. Scraping an area of one of the lesions and sending the specimen for a biopsy medical intervention is beyond the scope of nursing practice. Inadequate oral hygiene has not been identified as a cause of plaques; once-daily treatment is insufficient for anyone. Candida is a frequent secondary infection in clients with AIDS; it is treated when present.
An adolescent comes to the school nurse complaining of a 2-day history of low-grade fever, exhaustion, and lack of energy and appetite. He has been tardy to school twice in the past week. Which assessment should the nurse use to identify the possible origin of the problem? 1 Eliciting the Kernig sign 2 Eliciting the Brudzinski sign 3 Checking for lymphadenopathy 4 Checking the pupillary response to light and accommodation
3 Checking for lymphadenopathy Infectious mononucleosis is caused by the Epstein-Barr virus. Mononucleosis is common in people between the age of 15 and 30 years. Signs and symptoms of mononucleosis include fever, fatigue, swollen lymph glands, and enlargement of the liver and spleen. Pupillary response to light and accommodation is checked as part of a neurologic assessment. The Kernig sign (asking the child to straighten a leg that is bent at a 90-degree angle at the knee) and Brudzinski sign (asking a child who is lying flat to bend his head and try to put his chin on his chest) are elicited as part of the assessment when meningitis is suspected.
A client reports neck stiffness, severe headache, and a decreased level of consciousness. What condition does the nurse suspect? 1 Encephalitis 2 Brain abscess 3 Viral meningitis 4 Bacterial meningitis
4 Bacterial meningitis is caused by a bacterium such as Streptococcus pneumonia. Fever, severe headache, neck stiffness, photophobia, and decreased levels of consciousness are symptoms that indicate bacterial meningitis. Encephalitis is the acute inflammation of brain. Nausea and vomiting are symptoms of encephalitis. Headache, fever, nausea, and vomiting are the symptoms of brain abscess. Headache, fever, and photophobia are the symptoms of viral meningitis.
A male client with small overgrowths on the skin in the cervical region arrives at the hospital. The laboratory report reveals the presence of human papillomavirus type 16. Which condition is associated with this virus? 1 Balanitis 2 Prosthitis 3 Genital warts 4 Penile carcinoma
4 Human papillomavirus type 16 is commonly associated with penile carcinoma. Uncircumcised males may be at higher risk for infections such as balanitis and prosthitis. Human papillomavirus types 11 and 6 are commonly associated with genital warts.
A primary healthcare provider diagnoses late-stage (tertiary) syphilis in a client. Which statement made by the client supports this diagnosis? 1 "I noticed a wart on my penis." 2 "I have sores all over my mouth." 3 "I've been having a sore throat lately." 4 "I'm having trouble keeping my balance."
4 Neurotoxicity, as manifested by ataxia (balance problems), is evidence of tertiary syphilis, which may involve the central nervous system (CNS) or cardiovascular system. A wart on the penis occurs in the secondary stage of syphilis. Sores all over the mouth occur in the first and secondary stage of syphilis. Sore throat with flulike symptoms occurs in the secondary stage of syphilis.
A client with active genital herpes has a cesarean birth. The nurse teaches the mother how to limit transmission of the virus to her newborn. The nurse concludes that the instructions have been understood when the mother makes what statement? 1 "I should avoid kissing the baby on the lips." 2 "I have to wear gloves when I'm holding the baby." 3 "I should wash my clothes and my baby's clothes separately." 4 "I have to wash my hands with soap and water before handling the baby."
4 The herpes virus disintegrates rapidly on contact with soap used in meticulous hand washing. The lesion is in the genital area, not on the lips; kissing will not affect the infant. Wearing gloves when holding the infant is not necessary; nor is washing the infant's clothes separately.
