NUR 202 Module D quizes

The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." The nurse recalls that rabies can be described as:

*An acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system*

A 5-year-old child who is HIV positive is taken to the health department for immunizations before the start of school. The CD4 count shows severe immunosuppression. What immunizations can the child be given safely at this time?

* Hepatitis A, Polio vaccine (IPV), and Diphtheria, tetanus, pertussis (DTaP)* The varicella and MMR vaccines should not be administered in the presence of severe immunosuppression because they are live vaccines.

When a 12-year-old boy who sustained several tick bites on a camping trip becomes ill, he is told that he may have Lyme disease. He asks the nurse, "What is Lyme disease?" What is the best response by the nurse?

*"The tick bites gave you an infection. There is medication that will treat it."*

After treatment for Lyme disease, a child expresses fear of going camping again because of the ticks. What is the best response by the nurse?

*"Checking yourself frequently for ticks will help prevent another infection."* Explaining the usefulness of frequent checks for ticks identifies the concern and presents an appropriate protective intervention. Detection and prompt removal of ticks decreases the chances of the spread of Lyme disease to human beings

An older female client with diarrhea is admitted to the hospital from a nursing home. A stool specimen confirms a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The daughter of the client asks why her mother has been placed in a room with another client who is on isolation. How should the nurse respond?

*"It is safe to place people with the same infection in one room."*

Acyclovir (Zovirax) 0.8 g by mouth is prescribed for a client with herpes zoster. The oral suspension contains 200 mg/5 mL. How much solution should the nurse administer? Record your answer using a whole number. ___mL

*20 mL*

A client with systemic lupus erythematosus (SLE) is at 39 weeks' gestation. What does the nurse anticipate regarding this client?

*A need to discontinue the client's salicylate therapy* Salicylate therapy (Aspirin therapy) is used because clients with SLE have an increased risk of thrombus formation; as the time of birth approaches salicylate therapy should be discontinued to reduce the possibility of bleeding in the newborn.

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?

*Administer the medication with meals or a snack.* Doxycycline or minocycline can be administered with or without food; it has no impact on absorption. 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%. Citrus juice has no influence on this drug. Antacids will interfere with absorption.

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions?

*Airborne, contact, and standard.* Contact precautions are used for patients with known or suspected infections transmitted by direct contact or contact with items in the environment. Airborne precautions are used for clients known or suspected to have infections transmitted by the airborne transmission route. Varicella can be transmitted by airborne and contact. Standard precautions are used with every client. Nurses should treat all body excretions, secretions, and moist membranes/tissues, excluding perspiration, as potentially infectious. Contact and airborne precautions must be used.

A 1-year-old infant is receiving zidovudine (AZT) for management of HIV infection. The nurse determines that the infant is exhibiting signs of life-threatening zidovudine toxicity. What clinical finding supports this conclusion?

*Bruises over the body.* Zidovudine (AZT) can cause life-threatening blood dyscrasias, including thrombocytopenia. With zidovudine toxicity the infant will demonstrate agitation, restlessness, and insomnia.

An 18-month-old toddler who stepped on a rusty nail 4 days ago shows signs of generalized tetanus, including neck and jaw stiffness and facial muscle spasms. The toddler is receiving intravenous diazepam (Valium) as a muscle relaxant every 4 hours. What response to the medication does the nurse anticipate?

*Control of hypertonicity and prevention of seizures* Diazepam is commonly used to manage generalized muscular spasms. Laryngospasm and nuchal rigidity are responses to the exotoxin and are treated with tetanus immune globulin.

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?

*Cover the infected site with a dressing*

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 posttherapeutic neuralgia?

*Damage to the nerves* After the original infection has healed, the virus remains quiescent, or it may return. Posttherapetic neuralgia, which occurs in some individuals, results from damage to the nerves caused by the varicella-zoster virus; the neuralgia may last for months.

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

*Decreasing 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.

A nurse is making a home visit to a young male client manifesting chronic symptoms of AIDS. The nurse assesses the client for signs of altered mental health function associated with AIDS.

*Delusions, paranoid thinking, hopelessness, and memory loss.*

A client with acquired immunodeficiency syndrome (AIDS) is receiving a treatment protocol that includes a protease inhibitor. When assessing the client's response to this drug, which common side effect should the nurse expect?

*Diarrhea* Diarrhea, nausea, and vomiting are common side effects; clients should take these medications with a meal or light snack. These drugs may cause hyperglycemia, not hypoglycemia.

A 16-year-old male student who was injured while skateboarding arrives in the emergency department with a deep laceration of his leg. He does not remember when he received his last tetanus immunization. The nurse explains that tetanus immunoglobulin (TIG) and tetanus toxoid are required because:

*Different mechanisms are used to stimulate the immune response* TIG provides immediate protection, whereas the tetanus toxoid initiates an active immune response. Each is effective alone, but the combination is preferred. They do not confer lifelong immunity. After the initial routine immunizations and boosters, it is recommended that the tetanus toxoid be administered every 10 years. TIG does not carry major side effects because it is derived from human serum.

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?

*Document the presence of the lesions, describing their size, location, and color.*

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include?

*Eat foods high in vitamin C, Take your temperature daily, and Balance periods of rest and activity.* Vitamin C should be encouraged because it is essential for the biosynthesis of collagen. A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not necessary. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.

An adolescent has been admitted with symptoms of fatigue, intermittent fever, weight loss, and arthralgia, and the diagnosis is systemic lupus erythematosus. The nurse knows that the best intervention at this time is:

*Education about diet, rest, and exercise* Client education about the integrative interventions of diet, rest, and exercise will be of the most help to the adolescent client with newly diagnosed lupus. These are interventions that the client has some control over, and this is important to the adolescent

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

*Facial rash, Joint pain, And 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.

nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use?

*Gloves, gown and goggles.* Standard personal protective equipment (PPE), which should be used for performing colostomy care in a client positive for MRSA, includes gloves, gown, and goggles. A combination mask/eye shield may be used when caring for this client; however, a mask is not necessary.

A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client:

*Has a CD4+ T lymphocyte level of less than 200 cells/µL.* AIDS is diagnosed when an individual with HIV develops one of the following: a CD4+ T lymphocyte level of less than 200 cells/µL, wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flu-like syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain), one to three weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.

A nurse is counseling the family of an infant who is HIV positive. Where is the best place for this infant to receive long-term care?

*Home environment* Unless there is an episode of acute illness, home is the best place for the infant; this prevents hospital-acquired infection and promotes family interaction.

A client with human immunodeficiency virus (HIV)-associated Pneumocystis jiroveci pneumonia is to receive pentamidine isethionate (Pentam 300) intravenously (IV) once daily. The nurse should monitor the client for the side effect of:

*Hypoglycemia* Pentamidine isethionate can cause either hypoglycemia or hyperglycemia even after therapy is discontinued, and therefore blood glucose levels should be monitored. Hypotension, occurs with pentamidine isethionate. Hyperkalemia, occurs with pentamidine isethionate. Hypocalcemia, occurs with pentamidine isethionate.

A construction worker sustains a puncture from a rusty nail. It is unknown when the worker had the last immunization for tetanus and the primary health care provider prescribes tetanus immune globulin. What protection does this type of immunization offer?

*Immediate passive short term immunity* Tetanus immune globulin contains ready-made antibodies and confers short-term passive immunity. Passive immunity lasts a short time,

A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first?

*Increase the oxygen flow rate per facility protocol* This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation. Most facilities have a protocol to increase the oxygen flow rate to keep oxygen saturation greater than 92%.

A school nurse teaches a 13-year-old child with hay fever that the prescribed phenylephrine (Neo-Synephrine) nasal spray must be used exactly as directed. What complication may occur if the nasal spray is used incorrectly?

*Increased nasal congestion* Frequent and continued use of phenylephrine (Neo-Synephrine) can cause rebound congestion of mucous membranes. Hypotension, tachycardia, and tingling of the extremities may occur

A nurse is caring for a client who is human immunodeficiency virus (HIV) positive. For which complication associated with this diagnosis is it most important for the nurse to teach prevention strategies?

*Infection*

The significant other of a client who is dying of AIDS tells the nurse, "Life is not worth living without my partner." What should the nurse plan to do to help the significant other cope with the impending death?

*Involve the significant other's support system.* Involving the support system will decrease the person's feelings of isolation. Anticipatory grieving does not involve psychotic thoughts. Suggesting a bereavement group to the significant other is premature. The concern is about loss and loneliness, not self-image.

A client who has recently been found to be infected with HIV comments to the nurse, "There are so many terrible people around. Why couldn't one of them get HIV instead of me?" What is the best response by the nurse?

*It seems unfair that you should have this disease.* The client is in the anger or "why me" stage of grieving; encouraging the client to express feelings will help the client resolve them while moving toward acceptance.

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome?

*Malaise and Swollen lymph glands* Development of HIV-specific antibodies (seroconversion) is accompanied by a flulike syndrome called acute retroviral syndrome. This syndrome includes malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle/joint pain, or a diffuse rash. It occurs one to three weeks after infection and may continue for several months. Acute retroviral syndrome over time is followed by the early-chronic, intermediate-chronic, and late-chronic stages of HIV infection. Development of HIV-specific antibodies, accompanied by flulike syndrome, includes swollen lymph glands. Confusion is associated with the intermediate-chronic and late-chronic stages of HIV infection when the individual develops AIDS-dementia complex or opportunistic infection that affects the neurologic system. Diarrhea, not constipation, is associated with this syndrome. Oropharyngeal candidiasis occurs during the intermediate-chronic stage of HIV infection.

A client is suspected of having rabies after being bitten by a raccoon. For which clinical indicators should the nurse assess the client?

*Nuchal rigidity and Pharyngeal spasm* Rabies, an acute infectious disease affecting the central nervous system (CNS), causes stiffness of the back of the neck (nuchal rigidity). Painful pharyngeal spasms when swallowing or even looking at water are responsible for the use of the term hydrophobia to refer to rabies.

A client scheduled for surgery has a history of methicillin-resistant Staphylococcus aureus (MRSA) since developing an infection in a surgical site nine months ago. The site is healed and the client reports having received antibiotics for the infection. What should the nurse do to determine if the infecting organism is still present?

*Obtain an order to culture the client's blood.*

A school-aged child who has just arrived from Africa has been exposed to diphtheria, and a nurse in the pediatric clinic is to administer the antitoxin. Which type of immunity does the antitoxin confer?

*Passive artificial* In the creation of passive artificial immunity an antibody is produced in another organism and then injected into the infected or presumed infected person to provide immediate immunity against the invading organism. Active natural immunity takes too much time to develop; this child needs immediate protection. Passive natural immunity is acquired from the mother and is effective only during the first few months of life. Active artificial immunity takes too much time to develop; the child needs immediate protection.

What should be a priority of nursing care for a client with a dementia resulting from AIDS?

*Providing basic intellectual stimulation* Providing basic intellectual stimulation maintains, for as long as possible, the client's remaining intellectual functions by providing an opportunity to use them.

A nurse is caring for clients with various health problems. These problems include scarlet fever, otitis media, bacterial endocarditis, rheumatic fever, and glomerulonephritis. What common factor linking these diseases should the nurse consider?

*Result from streptococcal infections that enter via the upper respiratory tract* Streptococcal organisms are present on the skin, in the mucous membranes, and in the environment at all times. The most frequent portals of entry are the respiratory tract and breaks in the skin; once in the body, the organisms can be transmitted to the heart and kidneys via the circulation. All are caused by streptococci.

A client has been admitted to the hospital with a diagnosis of methicillin-resistant Staphylococcus aureas (MRSA) in the urine. The client has a urinary catheter in place. No private rooms are available. Which of the following room assignments would be most appropriate for this client?

*Roommate has MRSA in the urine. The roommate is ambulatory, but confused.*

A nurse is counseling the family of a child with AIDS. What is the most important concern that the nurse should discuss with the parents?

*Susceptibility to infection* Children with AIDS have a dysfunction of the immune system (depressed or ineffective T lymphocytes, B lymphocytes, and immunoglobulins) and are susceptible to opportunistic infections.

A client is experiencing an exacerbation of systemic lupus erythematosus. To reduce the frequency of exacerbations, what would be important for the nurse to include in the client's teaching plan?

*Techniques to reduce stress* Systemic lupus erythematosus is an autoimmune disorder and physical and emotional stresses have been identified as contributing factors to the occurrence of exacerbations

A nurse is caring for a 26-year-old client recently diagnosed with human immunodeficiency virus (HIV). The client needs an update on immunizations and asks which ones are needed. Which vaccines are required to comply with the recommended immunization schedule for a client with HIV?

*Tetanus, hepatitis B, influenza, and pneumococcal vaccines*

A nurse is caring for a 26-year-old client recently diagnosed with human immunodeficiency virus (HIV). The client needs an update on immunizations and asks which ones are needed. Which vaccines are required to comply with the recommended immunization schedule for a client with HIV?

*Tetanus, hepatitis B, influenza, and pneumococcal vaccines* According to recent recommendations, adults with HIV should receive tetanus, influenza, hepatitis B, and pneumococcal vaccines. Live pathogen vaccines (MMR, varicella) are contraindicated for individuals who are immunosuppressed. Currently there is no immunization for hepatitis C and the diphtheria vaccine is not recommended.

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 Center 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.

A 26-year-old homosexual client is diagnosed with acquired immune deficiency syndrome (AIDS). The primary nurse reports to the nursing team that the client cried when told of the diagnosis. One of the nursing assistants responds, "I don't feel sorry for him. He made his bed, and now he can lie in it." To best help the nursing assistant, the nurse manager must first identify that this comment most likely is a result of the nursing assistant's:

*Values and beliefs about sexual lifestyles*

A child who is known to be infected with HIV is admitted to the hospital with the diagnosis of Pneumocystis jiroveci pneumonia. The nurse administers the prescribed trimethoprim/sulfamethoxazole (Bactrim). Which common side effects should the nurse anticipate? Select all that apply.

*Vomiting and a hypersensitivity reaction* Nausea and vomiting may occur as a result of gastrointestinal irritation. Hypersensitivity reactions such as skin rash, erythema, fever, and pruritus occur with much greater frequency in children and adults with AIDS.

A hospitalized client is on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). Which statement by an unlicensed assistive personnel (UAP) indicates a need for further teaching?

"I will remove the gown, then the gloves, before washing my hands."

What statement by the nursing student indicates understanding of the precautions needed in the provision of care to a 7-year-old child who is HIV positive?

"I'll put on gloves, if I'm to be in contact w/bodily fluids.*