Influenza
A nurse is caring for a client with a new diagnosis of the flu. The nurse should realize this client was exposed to the virus how long ago? A) 18-72 hours B) 10-14 days ago C) 5-7 days ago D) 12-24 hours ago
18-72 hours ago The incubation period is the timeframe between when the client was exposed to the virus and the time when the symptoms appeared. For the flu, this time period is only 18-72 hours, which is approximately the amount of time that has passed since the client was exposed to the virus.
The nurse is reviewing diagnostic and laboratory studies performed for a client with influenza. Which result should the nurse recognize as being consistent with influenza? A) Decreased white blood cell count. B) Increased BUN C) Decreased sodium level D) Fluid-filled lungs on chest X-ray
A) Decreased white blood cell count The white blood cell count of a client with influenza will typically be decreased. Laboratory tests for BUN and sodium levels are not usually associated with influenza. Unless the client with influenza develops complications, the chest x-ray is clear.
Because of the way the influenza virus is transmitted from person to person, nurses who are working with clients with influenza should implement: A) Droplet precautions B) Isolation precautions C) Airborne precautions D) Contact precautions
A) Droplet precautions Influenza is spread through droplets when the client sneezes or coughs. Therefore, droplet precautions should be used. Isolation precautions limit the number of people who come in contact with the client and are used only for severe or life-threatening infections. Airborne precautions are used for tuberculosis and other infections that are airborne. Contact precautions are used when the nurse is at risk of contacting infected body fluids such as stool or wound drainage.
The nurse is caring for an older adult client with influenza. At which timefrae does the nurse identify the client to be at greatest risk of developing viral pneumonia? A) The first 48 hours after the onset B) Within 24 hours after recovery C) The first 24 hours after the onset D) Within 48 hours after recovery
A) The first 48 hours after onset Older adult clients, especially those with preexisting heart valve or pulmonary disease, are at higher risk of developing viral pneumonia. Viral pneumonia typically develops within 48 hours after onset of the influenza infection
What should the nurse recommend for a pregnant client who is concerned about a recent flu outbreak? A) The nurse should recommend that the client receive the influenza vaccination. B) The nurse should recommend that the client stay home until the influenza outbreak has ended. C) The nurse should recommend that the client take amantadine (Symmetrel) prophylactically. D) The nurse should recommend that the client eat foods that boost the immune system.
A) The nurse should recommend that the client receive the influenza vaccination. The influenza vaccine is the client's best method of preventing influenza infection, and it has no indication of harm to the unborn child. Amantadine is a Category C drug and should not be given during pregnancy to prevent influenza. Although eating foods that boost the immune system is a good recommendation, it will not be as effective at preventing influenza in an exposed individual as the influenza vaccine. Recommending the client stay home for several weeks is not a practical method of prevention
The nurse is caring for a client with acute malaise, muscle aches, and fever. Which additional assessment findings should the nurse recognize as consistent with influenza? SATA A) No history of vaccinations with the past 12 months. B) Nonproductive cough C) Hypotension D) Difficulty urinating E) Dizziness
A, B A) No history of vaccinations within past 12 months. B) Nonproductive cough. Based on the presenting symptoms, the nurse would ask whether the client has had a seasonal flu shot or recently been exposed to the flu. Usually, the cough of a client with influenza is nonproductive. A productive cough may indicate a different diagnosis. Insufficient voiding, hypotension, and dizziness are not routine manifestations of influenza.
The nurse is working in a primary care setting. Which clients should the nurse identify as being at high risk for influenza or its complications? SATA A) A 25-year-old pregnant woman at 20 weeks gestation. B) A 65-year-old woman C) A 3-year-old with cystic fibrosis. D) A 35-year-old man with a severe allergy to eggs. E) A 20-year-old healthcare worker.
A, B, C, E People at increased risk of influenza or its complications include infants, young children, pregnant women, and anyone age 50 or older. Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary diseases, are more susceptible as well. Healthcare workers have increased risk of exposure to influenza. A man with an allergy to eggs is not at increased risk for influenza or its complications.
What information shold the nurse include when teaching parents of pediatric clients about ways to decrease the spread of influenza? SATA A) "Cover your cough" education. B) An explanation of appropriate hand hygiene. C) Methods for safe food preparation and storage D) Where to obtain the influenza vaccine E) The importance of withholding immunization for children with compromised immune systems.
A, B, D A) "Cover your cough" education. B) An explanation of appropriate hand hygiene. D) Where to obtain the influenza vaccine. Teaching children to wash their hands and to use respiratory etiquette helps control the growth and spread of microorganisms. The influenza vaccine can decrease each child's susceptibility to influenza infection. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children.
Which interventions should the nurse anticipate carrying out to promote effective breathing in a client with respiratory manifestations of the flu? SATA A) Maintain adequate hydration B) Teach the client coughing and deep breathing C) Prepare the client for the possibility of a tracheotomy tube. D) Keep the head of the bed elevated E) Administer antitussives during the day.
A, B, D A) Maintain adequate hydration B) Teach the client coughing and deep breathing D) Keep the head of the bed elevated. Keeping the head of the bed elevated improves lung excursion and reduces the work of breathing. Coughing and deep breathing are essential for achieving airway clearance. Hydration thins the mucus and also aids in clearing the airway. Insertion of a tracheostomy and oxygen are not primary treatments for ineffective airway clearance. Antitussives should be administered at night to promote sleep but should not be administered during the day to promote airway clearance through coughing.
A nurse is considering implementing a community-wide program to increase vaccination rates among schoolchildren. Who should the nurse consider collaborating with? SATA A) School nurses at nearby schools B) Local community businesses C) The local health department D) A pediatric health clinic E) Local internal medicine physicians
A, C, D Initiating a community-wide vaccination education program requires the input of many different organizations. The local elementary schools are helpful in targeting the population the nurse would be trying to reach. The local health department can assist in providing education and vaccination supplies. The pediatric clinic would also be helpful in reaching potential targets. Internal medicine physicians only care for adults, not children. Local businesses may not be the best way to attract children in the community.
A nurse is caring for a client with severe cough and nasal congestion. Which nursing diagnosis should the nurse use to guide this client's care? SATA A) Airway clearance, ineffective B) Swallowing, Impaired C) Breathing Pattern, Ineffective D) Infection, Risk for E) Fatigue
A, C, D The client's cough and nasal congestion means that the client's nursing diagnoses should include Airway Clearance, Ineffective; and Breathing Pattern, Ineffective. Ineffective airway clearance requires an additional nursing diagnosis of Infection, Risk for, because the accumulation of pulmonary secretions increases the client's risk of infection. There is no evidence in the question to indicate that the client's nursing diagnosis should include Fatigue or Swallowing, Impaired.
The nurse advises a client with the flu to rest in bed. Which is the reason the nurse made this recommendation? SATA A) To prevent spread of infection B) To reduce cough C) To boost immune system D) To prevent dehydration E) To reduce malaise
A, C, E Bedrest reduces malaise, boosts the immune system, and prevents the spread of infection. Bedrest does not prevent dehydration or reduce cough.
Which interventions should the nurse incorporate into the plan of care for a client diagnosed with influenza? SATA A) Placing droplet and contact precaution signs on the client's room door. B) Placing the client in a negative air flow room C) Placing a ventilator in the room. D) Notifying other departments of the diagnosis E) Using appropriate PPE
A, E A) Placing droplet and contact precaution signs on the client's room door. E) Using appropriate PPE To prevent the spread of influenza, the client is placed in a private room with signs for droplet and contact precautions. It is important for healthcare workers to use appropriate PPE for these transmission-based precautions. Placing signs on the door is the way to notify other departments of precautions; no additional notification is needed. Negative air flow rooms are for diseases such as chickenpox, measles, and severe acute respiratory syndrome
The nurse is caring for a group of clients with influenza. Which client should the nurse identify as being at greatest risk for complications? A) A 53-year-old woman B) A 72-year-old woman C) A 35-year-old woman D) A 12-year-old boy
B) A 72 year-old woman. Children under the age of 5 and older adults over the age of 65 are at highest risk of developing complications related to influenza infection. Older adults are more at risk because their immune defenses become weaker with age
A nurse is caring for a client who is unable to sleep because of a fever and other influenza symptoms. Which nursing diagnosis should the nurse make a priority for this client? A) Health Behavior, Risk-Prone B) Fatigue C) Airway Clearance, Ineffective D) Coping, Ineffective
B) Fatigue The priority nursing diagnosis for this client would be Fatigue due to the client's inability to sleep. The nursing diagnoses Coping, Ineffective; Airway Clearance, Ineffective; and Health Behavior, Risk-Prone do not apply to this client.
An adult client wants to know about the choices of OTC drugs for treating flu symptoms. Which nonprescription drug should the nurse suggest? SATA A) Antivirals B) NSAIDs C) Acetaminophen D) Antiemetics E) Aspirin
B, C, E NSAIDs, Acetaminophen, Aspirin Nonprescription drugs for treating flu symptoms include aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs. Antiemetics are used to treat nausea and vomiting. Antivirals must be prescribed by a healthcare provider.
The nurse prepares to complete a health history with a client experiencing symptoms of the flu. Which information should the nurse include when completing this history? SATA A) Recent colds B) Chronic diseases C) History of influenza D) Presence of productive cough E) History of influenza vaccination
B, D, E Some components of the health history are a history of influenza vaccination, chronic diseases, and presence of a productive cough. A history of influenza or recent colds is not a helpful fact.
Which oral antiviral drug that is commonly prescribed for influenza A and B works by preventing the release of newly formed virus? A) Rimantadine (Flumadine) B) Zanamivir (Relenza) C) Oseltamivir (Tamiflu) D) Amantadine (Symmetrel)
C) Oseltamivir (Tamiflu) Oseltamivir (Tamiflu) is an oral antiviral drug that is prescribed for influenza A and B. It works by preventing the release of newly formed virus. Zanamivir (Relenza) has a similar mechanism of action, but it is given via inhalation. Rimantadine (Flumadine) and amantadine (Symmetrel) are primarily used for prophylaxis of influenza. They are not recommended by the Centers for Disease Control and Prevention (CDC) for treatment of active influenza.
A nurse is caring for young child with Reye Syndrome who has had the flu. The nurse notes signs of rising ICP, alerts the healthcare provider, and should prepare to administer which medication? A) Antipyretic B) Antitussive C) Osmotic diuretic D) IV therapy with D5NS
C) Osmotic diuretic Reye syndrome can cause cerebral edema and increased intracranial pressure. The nurse should prepare to administer an osmotic diuretic to help alleviate some of the pressure on the brain. Intravenous therapy with D5NS, antipyretics, and antitussives would not reduce intracranial pressure
A nurse receives report that a client with a new diagnosis of Guillan-Barre will be admitted to the unit. Which equipment should the nurse place at the bedside? A) Chest tube insertion kit B) Foley kit C) Rapid intubation kit D) Central line insertion kit
C) Rapid intubation kit Clients with Guillain-Barré syndrome are at risk of respiratory failure and may need mechanical intubation emergently. The nurse should place an intubation kit at the bedside or nearby in case the need arises. Central line insertion kits, Foley catheter kits, and chest tube insertion kits are not likely to be needed emergently and do not need to be placed at the bedside.
A client with a fever caused by the flu asks when the fever will go away. How should the nurse respond? A) "The fever should have gone away by now." B) "The fever can last up to several weeks." C) "The fever can last up to a week." D) "The fever should be gone within 2-3 days after onset of the flu."
C) The fever can last up to a week. Acute symptoms of the flu tend to subside within 2-3 days, but fever can last up to a week, and a cough can persist for several weeks. The nurse should inform the client that the fever may be around for a few more days and advise the client to seek medical attention if it hasn't gone away within a week after flu symptoms began.
The nurse makes a home visit to a client recovering from influenza. Which client statements indicate that desired outcomes have been met? SATA A) "I'm eating healthy foods now." B) "I went back to work." C) "I haven't had chills since I left the hospital." D) "I slept the whole night without coughing." E) "I was able to take a walk today."
C, D C) "I haven't had chills since I Ieft the hospital." D) "I slept the whole night without coughing." Desired outcomes for a client recovering from the flu include absence of symptoms of acute infection (such as fever and chills), resolution of respiratory symptoms, and resumption of normal sleep-rest patterns. The facts that the client has returned to work, is able to walk, and is eating a healthy diet do not indicate that the client's flu has resolved.
A nurse is working in an influenza vaccination clinic. To which client should the nurse refuse to administer the vaccine? A) A woman who is 28 weeks pregnant B) A 72-year-old long-term care resident C) A young child with severe asthma D) A client with an egg allergy
D) A client with an egg allergy The influenza vaccine contains egg proteins and is contraindicated in clients with a severe egg allergy or history of severe hypersensitivity response to the vaccine. Pregnant women, residents of a long-term care facility, and young children, especially those with a chronic condition like asthma, are all at higher risk and should receive the vaccine each year.
Which assessment question is important for the nurse to ask before administering an influenza vaccination? A) "Have you had any interaction with new animals lately?" B) "Do you have a cough?" C) "Have you traveled outside of the US recently?" D) "Are you allergic to eggs?"
D) Are you allergic to eggs? People with a severe allergy to eggs or who have had a prior hypersensitivity reaction to an influenza vaccination should not receive the influenza vaccine. Asking about travel outside of the United States or interactions with potentially infectious animals can help screen for the emergence of new strains of influenza. Asking about cough is a routine part of the health history.
A client with the flu has been producing thick sputum. Which intervention should the nurse suggest? A) Taking cold showers. B) Staying on bedrest C) Taking a cough suppressant D) Increasing fluid intake
D) Increasing fluid intake Thick and viscous sputum is a sign that the client needs more fluid. The nurse should advise the client to increase fluid intake and possibly use a bedside humidifier to promote ventilation. Bedrest or cold showers do not promote clearance of secretions. Use of cough suppressants will only worsen cough and sputum because cough is the body's way of clearing excess respiratory secretions
Necrosis of respiratory epithelial cells and shedding of serous and ciliated cells of the respiratory tract produce which common symptom of influenza? A) Malaise B) Coryza C) Cough D) Rhinorrhea
D) Rhinorrhea Shedding of serous and ciliated cells of the respiratory tract leads to rhinorrhea, or a runny nose. Serous cells are replaced more rapidly than ciliated cells, leading to continued cough and coryza. Malaise is a general symptom of influenza and is not directly related to the shedding of cells from the respiratory tract.
The nurse is establishing goals for a client with poor airway clearance. Which outcome should the nurse identify for this client? A) The client maintains a good oxygen saturation B) The client ambulates as tolerated C) The client drinks 2 liters of fluid per day D) The client maintains an oxygen saturation above 95%
D) The client maintains an oxygen saturation above 95% Nursing goals should be as clear as possible and measurable—for example, this would mean stating that oxygen saturation "will remain above 95%" instead of stating that oxygen saturation is "good." Drinking 2 liters of fluid each day and ambulating as tolerated are not reflective of the client's ability to clear the airway
The nurse reviews medications prescribed for a client with the flu. Which antiviral drug should the nurse recognize is recommended by the CDC for the treatment or prophylaxis of influenza? SATA A)Ribavirin B) Rimantadine C) Amantadine D) Oseltamivir E) Zanamivir
D, E Oseltamivir Zanamivir The CDC currently recommends zanamivir and oseltamivir for the flu. The other antiviral drugs are not recommended by the CDC.