imunization

While on a hike, a rusty nail pierces the sole of an adolescent's foot and the adolescent is brought to the emergency department of a local hospital. Tetanus immune globulin is prescribed because the adolescent does not know when the last tetanus immunization was received. The nurse administers the prescribed dose of tetanus immune globulin and explains that it provides:

Immediate passive short-term immunity

Which disease is caused by protozoa

Malaria Malaria is caused by sporozoa, which is a type of protozoa, Plasmodium malariae. Leprosy is caused by spirochetes. Fungi cause oral thrush. Varicella zoster virus causes chickenpox.

When taking the blood pressure of a client who has acquired immunodeficiency syndrome (AIDS), the nurse must:

Wash the hands thoroughly

A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. The priority nursing care is:

Administering prescribed antibiotics

Which test result should a nurse review to determine if the antibiotic prescribed for the client will be effective?

Sensitivity test

What is the incubation period for an infectious disease?

The interval between entrance of pathogen into body and appearance of first symptoms

A nurse is assessing clients who are to be given the smallpox vaccination. Which client should the nurse remove from the immunization line for medical counseling?

45-year-old woman with breast cancer

A primary health care provider prescribes airborne precautions for a client with tuberculosis. After being taught about the details of airborne precautions, the client is seen walking down the hall to get a glass of juice from the kitchen. The most effective nursing intervention is to:

Explore what the precautions mean to the client

A client is admitted to the hospital for general paresis as a complication of syphilis. Which therapy should the nurse anticipate will most likely be prescribed for this client?

Penicillin therapy parental benzyl-penicillin (Penicillin G) remain the treatment of choice for all stages of syphilis

A client cannot understand how syphilis was contracted because there has been no sexual activity for several days. Which length of time associated with the incubation of syphilis should the nurse include in the teaching plan?

Two to six weeks Although the usual incubation period of syphilis is about three weeks, clinical symptoms may appear as early as nine days or as long as three months after exposure. The usual incubation period is 21 days.

A client with tuberculosis asks the nurse about the communicability of the disease. Which is the best response by the nurse?

"Untreated active tuberculosis is communicable." The statement that untreated active tuberculosis is communicable is an accurate statement; treatment is necessary to stop communicability. The statement that tuberculosis is not communicable at this time is false reassurance; untreated active tuberculosis is communicable. Tuberculosis is not communicable when there is no active infection; the primary complex refers to the presence of a primary (Ghon) tubercle and enlarged lymph nodes and is the initial response to exposure; active disease may or may not occur. Tuberculosis is a communicable disease; close contacts should be screened via a skin test.

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client?

Hyperthermia Splenomegaly A high fever (hyperthermia) results from the disease process. Parasites invade the erythrocytes, subsequently dividing and causing the cell to burst. The spleen enlarges from the sloughing of red blood cells. Oliguria, not polyuria, occurs in malaria-induced kidney failure. Leukopenia does not occur. Erythrocytosis does not occur.

Before the nurse can be an advocate for a client who is homosexual who has acquired immunodeficiency syndrome (AIDS), the nurse needs to do what?

Identify personal attitudes and feelings about homosexuality Before nurses can be client advocates, they must understand themselves, particularly regarding issues that may affect clients; this is the first step toward providing nonjudgmental care. It is not necessary for the nurse to discuss the nurse's sexual identity to clients. Although it is beneficial for nurses to examine themselves, this does not mean that the care will be nonjudgmental. Although having a commitment to treat all patients equally is important, the nurse should first thoroughly self assess attitudes, values, and beliefs. Although truthfulness is important in a therapeutic relationship, the nurse should attempt to be nonjudgmental.

The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia?

Tachypnea Increased pulse rate Fever causes an increase in the body's metabolism, which results in an increase in oxygen consumption, causing tachypnea. Fever causes an increase in the body's metabolism, which results in an increase in oxygen consumption; this need for oxygen is met by an increased heart rate, which is reflected in an increased pulse rate. Although the respiratory rate may increase slightly, fever will not cause dyspnea. Chest pain is not related to the fever unless its cause is respiratory in nature. An increase in blood pressure does not accompany necessarily a fever.

A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should:

The appropriate response is to delay the administration of the vaccine until the client is healthy. Vaccines should not be administered during a febrile illness. Administering an aspirin is a dependent function of the nurse and requires a health care provider's prescription. Although holding the vaccine and administering it after the fever and cough are resolved is appropriate, notifying the health care provider is not necessary.

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?

Use standard precautions. The Centers for Disease Control states that standard precautions should be used for all clients; these precautions include wearing of gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact and discouraging long visits from family members will unnecessarily isolate the client.

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). The nurse expects to find:

A decrease in CD4 T cells The human immunodeficiency virus (HIV) infects helper T-cell lymphocytes; therefore, 300 or fewer CD4 T cells per cubic millimeter of blood or CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS . The thymic hormones necessary for T-cell growth are decreased. An increase in immunoglobulin E is associated with allergies and parasitic infections. A decrease in the serum level of glucose-6-phosphate dehydrogenase is associated with drug induced hemolytic anemia and hemolytic disease of the newborn.

A client has a Mantoux test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. The nurse concludes that this response indicates that the client has:

Been exposed to the Tubercle Bacillus Induration measuring 10 mm or more in diameter is interpreted as significant; it does not indicate that active tuberculosis is present. About 90% of individuals who have significant induration do not develop the disease. Exposure to the tubercle bacillus indicates exposure; infection can be past or present. Passive immunity occurs when the body plays no part in the preparation of the antibodies; a positive Mantoux indicates the presence of antibodies, not how they were formed. Developing a resistance to the tubercle bacillus reaction indicates exposure, not resistance.

A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain one week later. What does the nurse identify as the cause of the post therapeutic neuralgia?

Damage to the nerves After the original infection has healed, the virus remains quiescent, or it may return. Post therapetic neuralgia, which occurs in some individuals, results from damage to the nerves caused by the varicella-zoster virus; the neuralgia may last for months. Untreated major depression and scarring in the area of the rash are unrelated to post therapeutic neuralgia. The rash does not cause post therapeutic neuralgia. .

What is the primary focus of nursing care for a client admitted with tetanus caused by a puncture wound?

decrease external stimuli The slightest stimulation can set off a wave of severe, painful muscle spasms involving the whole body. Nerve impulses cross the myoneural junction and stimulate muscle contraction caused by exotoxins produced by Clostridium tetani. Monitoring urinary output is not a major nursing concern for clients with tetanus. Body alignment is not an important consideration for clients with tetanus. Oral intake of fluids may not be possible because of excessive secretions and laryngospasms.

A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug?

give an hour before milk product are ingested Any product containing aluminum, magnesium, or calcium ions should not be taken in the hour before or after an oral dose, because it decreases absorption by as much as 25% to 50%. Food interferes with absorption; it should be given one hour before or two hours after meals. Citrus juice has no influence on this drug. Antacids will interfere with absorption

A client with acquired immunodeficiency syndrome (AIDS) comments to the nurse, "There are so many rotten people around. Why couldn't one of them get AIDS instead of me?" The nurse's best response is:

"It seems unfair that you should be so ill." Rationale The client is in the anger or "why me" stage; encouraging the expression of feelings will help the client resolve them and move toward acceptance. The response "It may be helpful to speak with a minister" abdicates the responsibility of talking with the client; a suggestion to speak with a minister ignores the client's need for an immediate supportive response. The response "I can understand why you're so afraid of death" does not reflect on what the client said. The judgmental response "I'm sure you really don't wish this on someone else" may precipitate feelings of guilt and block the nurse-client relationship.

Ampicillin 250 mg by mouth every six hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin?

"The medicine should be taken one hour before or two hours after meals." Ampicillin is a form of penicillin that should be given on an empty stomach; food delays absorption. The response "I should drink a glass of milk with each pill" is incorrect; opaque liquids, such as milk, delay absorption of this drug. The response "I should drink at least six glasses of water every day" is not necessary; however, it is appropriate with sulfonamides. The response "The medicine should be taken with meals and at bedtime" is incorrect; food delays absorption of this drug.

A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?

"Wash used dishes in hot, soapy water."

Which prescribed medication should the nurse expect to administer to a female client who exhibits the genital lesions presented in the illustration?

Acyclovir sodium is a treatment for herpes simplex type 2 in a female client. There is no medication that cures this disease; however, an antiviral, such as acyclovir sodium, generally is prescribed to reduce healing time and the severity of clinical findings. Zidovudine is a nucleoside analog reverse transcriptase inhibitor often prescribed to treat acquired immunodeficiency syndrome (AIDS). Metronidazole is an antimicrobial agent generally prescribed to treat gastroenteritis caused by Clostridium difficile. Ceftriaxone is an antimicrobial agent generally prescribed for gonorrhea.

A client in the emergency department states, "I was bitten by a raccoon while I was fixing a water pipe in the crawl space of my basement." Which is the most effective first-aid treatment for the nurse to use for this client?

Cleansing the wound with soap and water

A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, the nurse anticipates a prescription for:

Water-soluble forms of vitamins A and E Vitamins A, D, E, and K are known as fat-soluble vitamins because bile salts and other fat-related compounds aid their absorption. A high fat diet will not achieve the uptake of fat-soluble vitamins in this client. Supplemental cod liver oil will not achieve the uptake of fat-soluble vitamins in this client. TPN is unnecessary; a well-balanced diet is preferred. Water-miscible forms of vitamins A and E can be absorbed with water-soluble nutrients.

A nurse is teaching a client about drug therapy for gonorrhea. Which fact about drug therapy should the nurse emphasize?

Cures the infection Ceftriaxone (Rocephin), followed by doxycycline (Vibramycin), is specific for Neisseria gonorrhoeae and eradicates the microorganism; other treatment regimens are available for resistant strains. If the disease progresses before the diagnosis is made, complications such as sterility, heart valve damage, or joint degeneration may occur. Transmission is not controlled; the organism is eliminated. If tubal structures, heart valves, or joints degenerate, the pathological changes will not be reversed by antibiotic therapy.

A client is diagnosed with gastroenteritis. What does the nurse determine is the basic intention underlying the unique dietary management for this client

Eliminate chemical, mechanical, and thermal irritation. Irritation of the mucosa may cause increased bleeding or perforation and therefore should be avoided. All clients' diets should be nutritionally balanced; this is not specific to this client's problem. Bulk and roughage may irritate the mucosa and should be decreased. Psychological support is not the primary goal; efforts should be made to include foods that are psychologically beneficial but eliminate foods that are irritating to the mucosa.

A mother with the diagnosis of acquired immunodeficiency disease (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine?

If the baby is breastfeeding Epidemiological evidence has identified breast milk as a source of human immunodeficiency virus (HIV) transmission. Kissing is not believed to transmit HIV. When the baby last received antibiotics is unrelated to transmission of HIV. HIV transmission does not occur from contact associated with caring for a newborn.

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit?

Joint pain Facial rash Pericarditis SLE is a chronic, autoimmune disease that affects connective tissue; joint pain is common. A butterfly rash is characteristic of SLE. Pericarditis is the most common cardiac indicator of SLE. Weight loss, not gain, is a classic sign of SLE because of gastrointestinal effects. Renal impairment with SLE may cause hypertension, not hypotension. pg 87-88

The nursing staff has a team conference on acquired immunodeficiency syndrome (AIDS) and discusses the routes of transmission of the human immunodeficiency virus (HIV). The discussion reveals that there is no risk of exposure to HIV when an individual:

Makes a donation of a pint of whole blood Equipment used in blood donation is disposable; the donor does not come into contact with anyone else's blood. The risk depends on the spouse's previous behavior. Although condoms do offer protection, they are subject to failure because of condom rupture or improper use; risks of infection are present with any sexual contact. An individual may be infected before testing positive for the antibodies; the individual can still transmit the virus.

A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to avoid to best prevent malaria?

Mosquito bites Malaria is caused by the protozoan Plasmodium falciparum, which is carried by mosquitoes. Avoiding untreated water, undercooked food, and overpopulated areas will not prevent protozoa from entering the bloodstream.

What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection?

Occurred in conjunction with treatment for an illness. Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a drug-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a drug-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.

The nurse explains to a client that a positive diagnosis for human immunodeficiency virus (HIV) infection is made based on:

Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests pg 764 Positive ELISA and Western blot tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus. Performance of high-risk sexual behaviors places someone at risk but does not constitute a positive diagnosis. Evidence of extreme weight loss and high fever do not confirm the presence of HIV; these adaptations are related to many disorders, not just HIV infection. The diagnosis of just an opportunistic infection is not sufficient to confirm the diagnosis of HIV. An opportunistic infection (included in the Center for Disease Control surveillance case definition for acquired immunodeficiency syndrome [AIDS]) in the presence of HIV antibodies indicates that the individual has AIDS.

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client?

Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions Toxins from bacilli invade nervous tissue, causing restlessness. Toxins from bacilli invade nervous tissue, causing muscle spasms and muscular rigidity . Toxins from the bacillus invade nervous tissue; respiratory spasms may result in respiratory failure. Toxins from bacilli invade nervous tissue, causing spastic contraction of voluntary muscles. Tetanus causes spasms of facial muscles, resulting in a grotesque grinning expression (risus sardonicus) and spasms of masticatory muscles (trismus), not atony of facial muscles.

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care?

With scleroderma, the skin becomes dry because of interference with the underlying sweat glands. Pruritus, inflamed areas, and skin lesions are not associated with scleroderma. Answer: Keep skin lubricated with lotion

A nurse is caring for a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV?

gloves and hand hygiene Wearing gloves protects the nurse from potential contamination. Gloves are appropriate when there is a risk of the hands coming into contact with a client's blood or body fluids. Hand hygiene is the most effective way to prevent the spread of microorganisms. Wearing a mask is necessary for procedures where splashing of body fluids is anticipated or a risk. Wearing a gown is necessary for procedures where splashing of body fluids is anticipated or a risk. Wearing a face shield is necessary for procedures where splashing of body fluids is anticipated.