EAQ 5: Protection and Movement

The nurse instills an antibiotic ophthalmic ointment into a newborn's eyes. The nurse would explain to the mother that the medication prevents which condition? 1 Ophthalmia neonatorum 2 Herpetic ophthalmia 3 Retinopathy of prematurity 4 Hemorrhagic conjunctivitis

1 Ophthalmia neonatorum is caused by gonorrheal and/or chlamydial infections present in the vaginal tract. It is preventable with the prophylactic use of an antibiotic ophthalmic ointment applied to the neonate's eyes. Herpes affects the neonate systemically. Retinopathy of prematurity (formerly retrolental fibroplasia) occurs as a result of prolonged exposure to a too-high oxygen concentration. Hemorrhagic conjunctivitis is usually caused by rapid expulsion of the fetus's head from the vagina.

Which characteristic is common in clients with Sjögren syndrome (SS)? 1 Dry eyes 2 Muscle cramping 3 Urinary tract infection 4 Elevated blood pressure

1 SS is a group of problems that often appear with other autoimmune disorders. Problems include dry eyes, which are caused by autoimmune destruction of the lacrimal glands. Muscle cramping, urinary tract infection, and elevated blood pressure are not common characteristics of SS.

Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply. One, some, or all responses may be correct. 1 Asthma 2 Hay fever 3 Sarcoidosis 4 Myasthenia gravis 5 Rheumatoid arthritis 00:00:01 Question Answer Confidence ButtonsJust a guessPretty sureNailed it

1, 2 Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions mediated by a reaction between IgE antibodies with antigens. Type I hypersensitivities result in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis are a result of reactions between sensitized T cells and antigens. Myasthenia gravis results from a type II hypersensitivity reaction due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction resulting in inflammation from the formation of immune complexes between antigens and antibodies.

Which worker(s) would the nurse consider to be at high risk of developing dermatitis? Select all that apply. One, some, or all responses may be correct. 1 Dry cleaners 2 Dye workers 3 Lathe operators 4 Hospital workers 5 Agricultural workers

1, 2 Dry cleaners and dye workers are at high risk of developing dermatitis due to exposure to substances such as solvents and dye stuffs. Lathe operators are at high risk of developing cancer. Hospital workers are at greater risk of latex allergies. Agricultural workers are at high risk of skin cancer.

To reduce the incidence of human immunodeficiency virus (HIV) transmission, which basic strategies would the nurse teach a health class? Select all that apply. One, some, or all responses may be correct. 1 Using condoms 2 Using separate toilets 3 Practicing sexual abstinence 4 Preventing direct casual contacts 5 Sterilizing the household utensils

1, 3 HIV is found in body fluids such as blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, and cerebrospinal fluid. A client should use condoms to prevent contact between the vaginal mucous membranes and semen. Practicing sexual abstinence is the best method to prevent transmission of the virus. The HIV virus is not transmitted by sharing the same toilet facilities, casual contacts such as shaking hands and kissing, or by sharing the same household utensils.

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. Which score on the Lovett scale would be given to this client? 1 Fair (F) 2 Good (G) 3 Trace (T) 4 Normal (N)

2 According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as G (good). F (fair) can be given if the client exhibits a full range of motion with no resistance. T (trace) score is given when the client exhibits slight contractility with no movement. N (normal) on the Lovett scale indicates full range of motion against gravity with full resistance.

Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery? 1 Maintain muscle strength 2 Reduce leg discomfort 3 Prevent clot formation 4 Improve wound healing

3 Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. Although isotonic exercises do promote muscle strength, that is not the purpose of these exercises at this time. These isotonic exercises are being performed on the unaffected extremity; there should be no discomfort. Active ROM exercises will not improve wound healing.

The parent of a newborn asks the nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. Which response would the nurse provide? 1 "A newborn's spleen can't produce efficient antibodies." 2 "Infants younger than 2 months are rarely exposed to infectious disease." 3 "The immunization will attack the infant's immature immune system and cause the disease." 4 "Maternal antibodies interfere with the development of active antibodies by the infant when immunized."

4 Passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases. The spleen does not produce antibodies. Young infants often are exposed to infectious diseases. The viruses in immunizations are inactivated or attenuated; they may cause irritability and fever but will not cause the related disease.

When teaching a client about their disease process, which term would the nurse use to describe bone loss greater than normal but less than that caused by osteoporosis? 1 Osteopenia 2 Osteomyelitis 3 Osteomalacia 4 Osteoarthritis

1 The definition of osteopenia is bone loss that is more than normal but not yet at the level for a diagnosis of osteoporosis. Osteomyelitis is infection of bone or bone marrow. Osteomalacia is softening of bones due to calcium or vitamin D deficiency. Osteoarthritis is cartilage deterioration in the joints.

Which medication treats hay fever by preventing leukotriene synthesis? 1 Zileuton 2 Cromolyn sodium 3 Chlorpheniramine 4 Diphenhydramine

1 Zileuton is a leukotriene antagonist medication; this substance prevents the synthesis of leukotrienes and helps in managing and preventing hay fever. Cromolyn sodium stabilizes mast cells and prevents the opening of mast cell membranes in response to allergens binding to immunoglobulin E. Chlorpheniramine and diphenhydramine are antihistamines and prevent the binding of histamine to receptor cells and decrease allergic manifestations.

Which are barrier methods of contraception? Select all that apply. One, some, or all responses may be correct. 1 Condom 2 Diaphragm 3 Lea's shield 4 Spermicidal foam 5 Coitus interruptus 00:00:01 Question Answer Confidence ButtonsJust a guessPretty sureNailed it

1, 2, 3 A condom is considered a barrier method of contraception because it prevents the entrance of sperm into the vagina. Lea's shield is a reusable vaginal contraceptive made of silicone. A diaphragm is a cervical covering used to prevent sperm from reaching the egg. Spermicidal foams are a chemical method of contraception. Coitus interruptus is a withdrawal contraceptive method.

Why is an infection caused by Neisseria gonorrhoeae particularly troublesome for a female client? 1 The medication is expensive. 2 The infection is difficult to treat with antibiotics. 3 Symptoms are often overlooked. 4 Treatment has many adverse effects.

3 Many female clients who contract gonorrhea are asymptomatic or overlook the minor symptoms, making possible for the bacteria to remain a source of infection. There is no evidence to support the medication to treat the infection is expensive. The infection can be treated with one intramuscular injection of ceftriaxone. There is no evidence to support the medication to treat this infection has many adverse effects.

Which medication might damage the cartilage of children? 1 Tetracycline 2 Corticosteroids 3 Quinolone antibiotics 4 Nonsteroidal anti-inflammatories

3 Quinolone antibiotics are contraindicated during the growing years because they can cause permanent or destructive arthropathy. Tetracycline, corticosteroids, and nonsteroidal anti-inflammatories do not generally damage the cartilage of children.

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is the priority? 1 Urinary output 2 Sensation to touch 3 Neurological status 4 Respiratory exchange

4 The ascending paralysis of Guillain-Barré syndrome can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurological status are important, none of them are the priority.

Which sexually transmitted infection is caused by a virus? 1 Syphilis 2 Gonorrhea 3 Genital warts 4 Chlamydial infection

3 Strains of the human papillomavirus (HPV) cause the sexually transmitted infection of genital warts. Bacteria cause syphilis, gonorrhea, and chlamydial infections.

Which would the nurse teach the parent of an infant who is at risk for infections? 1 "You must avoid placing the infant in bright sunlight." 2 "Breast-feeding will provide protection against bacteria." 3 "Use soy-based infant formulas to help prevent infection." 4 "The infant will be less susceptible to infections later in life."

2 Breast milk contains immunoglobulin G (IgG) that protects the infant against many bacteria, such as Escherichia coli. The nurse instructs the parent to avoid placing the infant in bright sunlight for a long period of time to prevent burns, but not to prevent infections. Soy-based infant formulas are used only if the infant is allergic to lactose in the breast milk and are not used to prevent the risk for infections. Later, susceptibility would be dependent on multiple factors, including nutrition and exposure to infections.

Which synovial joint movement is described as turning the sole away from the midline of the body? 1 Pronation 2 Eversion 3 Adduction 4 Supination

2 Eversion is a synovial joint movement that describes turning the sole outward away from the midline of the body. Pronation is a synovial joint movement that describes turning the palm downward. Adduction is a synovial joint movement that describes movement toward midline of the body. Supination is a synovial joint movement that describes turning the palm upward.

Which hypersensitivity reaction may occur in a newborn with hemolytic disease? 1 Type I 2 Type II 3 Type III 4 Type IV

2 Hemolytic disease in a pregnant woman may result in erythroblastosis fetalis, a type II hypersensitivity reaction. Type I reactions involve immunoglobulin E (IgE)-mediated reactions such as anaphylaxis and wheal-and-flare reactions. Type III reactions are immune complex reactions such as rheumatoid arthritis or systemic lupus erythematosus. Type IV reactions are delayed hypersensitivity reactions such as contact dermatitis.

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? 1 Atrophy of the sweat glands 2 Decreased subcutaneous fat 3 Stiffening of the collagen fibers 4 Degeneration of the elastic fibers

2 In older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers. Atrophy of the sweat glands will cause dry skin and decreased body odor. Stiffening of the collagen fibers and degeneration of the elastic fibers will result in the development of wrinkles.

Which medication is a newer treatment option for treating metastatic melanoma? 1 Lomustine 2 Ipilimumab 3 Carmustine 4 Temozolomide

2 Ipilimumab is a type of immunotherapy and is a monoclonal antibody. It is a newer option of medication therapy used in the treatment of metastatic melanoma. Lomustine, carmustine, and temozolomide are established chemotherapy medications in use for many years for the treatment of metastatic melanoma.

Which stage of the human immunodeficiency virus (HIV) would a client with a CD4+ T cell count of 325 cells/mm3 be classified? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4

2 Stage 2 describes a client with a CD4+ T cell count between 200 and 499 cells/mm3. Stage 1 describes a client with a CD4+ T cell count of greater than 500 cells/mm3. Stage 3 describes a client with a CD4+ T cell count of less than 200 cells/mm3. Stage 4 describes a client with a confirmed HIV infection but no information regarding CD4+ T cell counts is available.

The nurse documents the range-of-motion exercises performed on a client who had a cerebrovascular accident (CVA). Which term would the nurse use to describe the client's hand portrayed in the provided image? 1 Flexion 2 Extension 3 Adduction 4 Circumduction

2 The image presents the fingers in a flared out, extended position and in an abducted position. The fingers are neither bent nor flexed. The fingers are abducted, not adducted, from the midline of the hand. Circumduction is a circular movement of a limb that occurs at a ball-and-socket joint. The shoulder and hip joints, not the wrist or fingers, can be moved in this way.

Which issue related to antibiotic use is an increased risk for the older adult? 1 Allergy 2 Toxicity 3 Resistance 4 Superinfection

2 The older adult is at increased risk for toxicity related to antibiotic use because of reduced metabolism and excretion of medications. Allergy, resistance, and superinfection are a risk for all antibiotic recipients but not an increased risk in the older adult population.

Which element would the nurse focus on when teaching crutch-walking to a client who has a casted leg fracture? 1 Establishing a schedule for pain medication 2 Maintaining a fixed schedule of daily activities 3 Modifying the home environment to prevent accidents 4 Understanding that a more sedentary lifestyle is necessary

3 Modifications in the home may be needed to permit safe use of crutches. Pain medications should not be required on a regular basis. The client may vary the schedule of activities based on abilities and responses to activities. The client does not have to be sedentary; crutches are used for ambulation.

Which instruction would the nurse include when teaching episiotomy care? 1 Rest with legs elevated at least 2 times a day. 2 Avoid stair climbing for several days after discharge. 3 Perform perineal care after toileting until healing occurs. 4 Continue sitz baths 3 times a day if they provide comfort.

3 Performing perineal care after toileting until the episiotomy is healed is critical to the prevention of infection, which is at the core of episiotomy care. Resting is encouraged to promote involution and general recovery from childbirth. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort.

Which effect of povidone-iodine would the nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? 1 Avoids drying the skin 2 Preferred to alcohol swabs because it doesn't create false-positive blood alcohol results 3 Eliminates surface bacteria that may contaminate the culture 4 Provides a cooling agent to diminish the feeling from the puncture wound

3 Povidone-iodine exerts bactericidal action that helps eliminate surface bacteria that will contaminate culture results. Whether it affects blood alcohol results is irrelevant when used to obtain blood for cultures. It does dry the skin. Although povidone-iodine may provide a cool feeling, this is not a reason for its use.

Which is the priority assessment for the client who has Guillain-Barré syndrome with rapidly ascending paralysis? 1 Monitoring urinary output 2 Assessing nutritional status 3 Monitoring respiratory status 4 Assessing communication needs

3 The most serious complication of Guillain-Barré syndrome is respiratory failure caused by respiratory muscle paralysis. Urinary retention is common in Guillain-Barré, but monitoring urinary output is of lower priority than monitoring respiratory status. If ascending paralysis impairs the gag reflex, clients may require tube feedings or parenteral nutrition. Assessing nutritional status, however, is of lower priority than monitoring respiratory status. If ascending paralysis impairs cranial nerve functioning or if the client is intubated, verbal communication abilities are lost.

Which finding would the nurse document as normal for a second, postabdominoperineal resection stoma? 1 Dry, pale pink, and even with the skin 2 Moist, skin-colored, and flush with the skin 3 Moist, red, and raised above the skin surface 4 Dry, purple, and depressed below the skin surface

3 The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; elevation of the stoma beyond the skin surface usually occurs to allow drainage to go into the appliance rather than onto the skin. The stoma should be moist, not dry. Pale pink may indicate limited circulation to the stoma. Although some stomas can be flush with the skin, a raised stoma is more common. Although the stoma should be moist, a skin-colored stoma indicates limited circulation to the stoma. A purple color indicates compromised circulation.

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct. 1 Switch positions every 4 hours. 2 Use a heating pad for the first 24 hours. 3 Apply for 30-minute time intervals. 4 Place the ice pack directly to injury site. 5 Take ibuprofen every 4 hours PRN.

3 To prevent skin damage, ice and heat should only be applied for 20- to 30-minute intervals. Clients should be instructed to shift positions every hour to prevent skin breakdown. Ice should be used the first 24 to 48 hours followed by heat. Ice should never be directly applied to the skin as it can cause injury to the tissue. The client can take ibuprofen if approved by the health care provider.

The nurse at a community health care center focuses on providing primary preventive care. Which is the focus of primary preventive care? 1 Rehabilitating the client 2 Treating early stages of disease 3 Preventing complications from illness 4 Promoting health in healthy individuals

4 Primary prevention precedes disease or dysfunction and is applied to clients considered physically and emotionally healthy. Health education programs, immunizations, and physical and nutritional fitness activities are primary prevention activities. Tertiary preventive care occurs when an individual has a permanent or irreversible disability. The client undergoing rehabilitation is receiving tertiary preventive care. Secondary preventive care focuses on individuals who are experiencing health problems. Secondary preventive care involves treating clients in the early stages of disease. It also focuses on preventing complications from illness.