NUR255: MyLab ch. 35, Influenza Questions

a patient is demonstrating signs of acute rhinitis. which question should the nurse ask the patient?

"Are you having nasal drainage?" rationale: A thin, watery nasal discharge is a symptom of acute rhinitis which occurs as a result of a viral infection, such as the common cold, or an allergic reaction. Allergies that cause nasal discharge often produce itchy eyes, sore throats, or headaches.

The nurse is working with students in the classroom. Which action by a student should cause the nurse intervene?

A child placing a lightly used tissue back in the desk rationale: When using a tissue, students should be instructed to use disposable tissues and dispose of them promptly. Holding on to used tissues can increase the risk of transmission to others. Students should be advised to wash the hands after blowing the nose or sneezing/coughing and before eating.

a pt w/ viral URI is starting an antihistamine. which should the nurse emphasize to this pt?

"Do not drive or engage in dangerous activity until the drug's effects are known." rationale: lol it just said BYE U DON'T GET IT

a pt prescribed an antihistamine is instructed to avoid driving until the effects of the meds are known. which reason should the nurse provide for the instruction?

"it may cause drowsiness or dizziness" rationale: Antihistamines may cause drowsiness or dizziness. For safety reasons, the patient should refrain from driving or engaging in dangerous activities until the effects of the drug are known. Antihistamines are not known to cause blurred vision, intensify sound, or trigger diarrhea.

a pt w/ seasonal allergic rhinitis is prescribed an intranasal corticosteroid. which effect should the nurse include about this med?

"it reduces tissue edema" rationale: Intranasal corticosteroids are applied directly to the nasal mucosa to prevent symptoms of allergic rhinitis. They reduce tissue edema, decrease the release of inflammatory mediators, and produce a mild vasoconstriction that opens air passages. Intranasal corticosteroids must be used for 1-3 weeks for peak response to occur.

the nurse is caring for a group of pt at the outpatient clinic. there are limited # of influenza vaccines available. which pt should the nurse consider a priority for receiving the vaccine?

20 year old pt in chemotherapy for leukemia rationale: Immunocompromised patients, such as those diagnosed with AIDS, receiving treatment for cancer, or taking immunosuppressive drugs are at the highest risk for complications due to influenza. The patient who is receiving chemotherapy is at the greatest risk and should receive the vaccine. Thoughthis disease nearly everyone is recommended to get a flu vaccine, a healthy 18-year-old or 16-year-old is better able to deal with potential complications than is the patient receiving treatment for cancer. The pregnant woman is at the beginning of their pregnancy and should receive the vaccine, but the patient receiving cancer treatment is at a higher risk.

a pt w/ influenza is producing thick mucus secretions that are difficult to cough up. which intervention should the nurse make the priority for this pt?

attaching a humidifier to a face mask rationale: If the patient is having thick and viscous pulmonary secretions that are difficult to remove, the nurse should provide humidified air and increase fluids to help thin secretions. A cough suppressant will only worsen the patient's secretions. Administering an analgesic may help with discomfort but it won't address the problem. Droplet precautions may be necessary but does not address the patient's concern.

the nurse is teaching a community group about influenza. which symptoms should the nurse include?

chills, fever, muscle aches, and cough rationale: The symptoms of influenza infection include chills, fever, malaise, muscle aches, headache, cough, and sore throat. Symptoms of Guillain-Barré syndrome include paralysis of the muscles, including the muscles of respiration. Symptoms of Reye syndrome include persistent vomiting, seizures, altered consciousness, and personality changes.

a pt reports increasing difficulty breathing and numbness in the feet. the pt has a very recent hx of flu. which condition should the nurse be most concerned about?

guillain-barre syndrome rationale: Guillain-Barré syndrome is a rare complication of influenza that causes progressive paralysis of the muscles in the body, including the muscles of respiration (responsible for the patient's difficulty in breathing). The symptoms of viral pneumonia may include fever, cough, and chest pain but definitely not numbness in the feet. Reye syndrome causes vomiting, listlessness, and seizures. Bronchitis may cause a cough but will not cause numbness or tingling in the feet.

the nurse is caring for a young adult w/ influenza. which dietary intervention should the nurse initiate?

increasing fluid intake rationale: The most important dietary intervention is the increase of fluid intake, whether it is water, electrolyte solutions, or soup. The patient should be encouraged to eat what is comfortable and tolerated. There is no need for a pureed diet, increased protein or fat intake, or reduction of dairy intake.

a pt tells the nurse that she has been "feeling under the weather" for the past 3 or 4 days and originally thought it was just a cold. she reports that about 2 days ago, she began having a fever, muscle aches, and headache. which is the most likely cause of the pt symptoms?

influenza

the visiting nurse is evaluating a pt in their home. which action by a pt should cause the nurse to intervene?

placing a lightly used tissue back on the table rationale: When using a tissue, patients should be instructed to use disposable tissues and dispose of them promptly. Holding on to used tissues can increase the risk of transmission to others. Patients should be advised to wash the hands after blowing the nose or sneezing/coughing and before eating.

a pt is demonstrating symptoms of hay fever. which allergen should the nurse suspect is responsible for the pt symptoms?

pollen rationale: Hay fever is the term given to allergic rhinitis caused by pollen, an outdoor allergen. Allergic rhinitis caused by indoor allergens is known as perennial allergic rhinitis. Indoor allergens include dust mites, animal dander, and mold.

a pt has an upper respiratory infection. which should be expected when the nose is examined w/ a speculum?

red mucosa rationale: Swollen and red nasal mucosa is a symptom of an upper respiratory infection. Nasal mucosa that is pale and boggy or swollen is associated with chronic allergies. A history of a fractured nose may cause a deviated septum. Nasal polyps are found in patients with chronic allergies.

the nurse discusses the use of decongestants for the treatment of allergic rhinitis. which should the nurse identify as a goal of treatment?

temporary relief of symptoms rationale: The therapeutic goal of decongestants is the immediate temporary relief of acute symptoms of allergic rhinitis. No drugs exist to cure the condition, prevent complications, or aid in the diagnosis.

the nurse notes that a pt's throat swab was positive for influenza virus A/Taiwan/89. which should the nurse realize the 89 represents in this lab report?

the year the strain was identified rationale: New strains of influenza virus are named according to the strain, geographic origin, and year the strain was identified. In this case, the strain was discovered in 1989. It does not stand for the percentage of the vaccine's effectiveness, number of people dying, or number of places in which it was found.

which condition contributes to sleep apnea in a pt who sleeps on their back?

tongue relaxes and falls backward rationale: The tongue may relax and fall backward in those lying on their backs, which leads to the airway narrowing or blockage. Lying on the back does not impact the chest wall or nasal passages. Abdominal pressure may decrease the ability to take a deep breath, but sleeping in this position does not contribute to sleep apnea.

The nurse is caring for a patient with the flu. Which information should the nurse include when teaching the patient about this health problem?

"Avoid cough suppressants during the day because you won't clear out mucus." rationale: Using cough suppressants during the day is not recommended because coughing helps to clear the airway of excess mucus. The patient should be encouraged to rest when tired and increase fluid intake, not protein or fat intake. The patient should take deep breaths and practice therapeutic coughing to help clear the airway.

The nurse is caring for a young mother who was just diagnosed with the flu. Which advice should the nurse provide so the patient can recover sooner?

"Have someone watch the baby for a little bit so you can rest." rationale: The young mother may need someone to help watch the baby so that they can rest. The patient may be too tired to get out and walk; plus, they run the risk of exposing others to the flu, especially the baby. Rest and increased fluids are of high importance for someone with the flu. The patient should be encouraged to drink more fluids, not restrict them. Antivirals won't interfere with her ability to care for the children.

The nurse prepares to complete a health history with a patient experiencing symptoms of the flu. Which question should the nurse include?

"Have you traveled outside of the United States recently?" rationale: International travel has increased the risk of an influenza pandemic being brought to the United States. It is important for the nurse to inquire about recent international travel and potential interactions with infectious people. Domestic travel, current pets, and place of employment are less important questions to ask.

the clinical nurse specialist is teaching a group of staff nurses about surgical treatment that may be included in the care of pt who are diagnosed w/ obstructive sleep apnea. which statement should the nurse include?

"Surgery is usually only considered if continuous positive airway pressure (CPAP) therapy is not tolerated." rationale: For patients with obstructive sleep apnea, surgical treatment may be an option, especially if the obstruction is caused by the tonsils (tonsillectomy) or adenoids (adenoidectomy). However, surgery is usually only considered if CPAP therapy is not tolerated. In children, an adenotonsillectomy may be performed to treat obstructive sleep apnea. Another procedure that may be performed to help treat obstructive sleep apnea is partial surgical removal of the soft palate, uvula, and posterior lateral pharyngeal wall (uvulopalatopharyngoplasty [UPPP]).

a young adult w/ influenza asks why a runny nose occurs. which response by the nurse is accurate?

"The cold or influenza virus causes the cells in the nose to swell and die, which lets all of the fluid in the cells escape." rationale: Flu virus infects the respiratory system, which causes inflammation and replication of neighboring cells. These cells necrose, which eventually allows extracellular fluid to escape and produce a runny nose. The cold or flu virus does not produce extra fluid in the respiratory tract, and neither do the immune cells fighting the infection. Rhinorrhea is not caused by fluid that comes up from the lungs when coughing.

A patient asks if an over-the-counter cough suppressant should be used when recovering from the flu. Which respond by the nurse is accurate?

"The drug could reduce the effectiveness of coughing during the day." rationale: The nurse is concerned about promoting airway clearance, which is helped by coughing during the day. Cough suppressants do not have any addictive qualities and do not cause drowsiness or insomnia. Also, there are not enough calories in the artificial flavoring of medicines to cause weight gain.

A pregnant patient asks if it is safe to get an annual flu vaccination. Which reply by the nurse is accurate?

"The flu shot is safe in pregnant women and is effective in preventing the flu." rationale: The Centers for Disease Control and Prevention recommends the flu shot for all pregnant women (not just in the second or third trimester) in order to prevent the flu or serious complications. There is indication that there is a risk to the unborn fetus.

a pt doesn't want to use the continuous positive airway pressure (CPAP) machine bc of discomfort and waking up w/ dry mouth. how should the nurse respond to this pt?

"i recommend you use an inline or room humidifier" rationale: The most common side effect of CPAP or bilevel positive airway pressure (BiPAP) therapy is a dry mouth and airway, so an inline or room humidifier is recommended. A mask that does not sit right will not cause a dry mouth. Adjusting the air pressure of the machine will minimize difficulty exhaling. Drinking plenty of fluid while using a CPAP mask will not remedy the dryness caused by the use of a CPAP machine.

A patient with the flu is not able to sleep at night. Which action should the nurse take to help this patient?

Administering prescribed antipyretics and analgesics shortly before bed rationale: Administering antipyretics and analgesics before bed may allow the patient to rest better during bedtime. Elevating the head of the bed promotes ventilation, not rest. Administering cough suppressants, not avoiding them, may help promote sleep. Increasing the humidity of inspired air helps to maintain airway patency, not promote sleep.

The residents and staff of a nursing home are in an area with reports of confirmed influenza cases. The nurse administrator has decided to offer antiviral medication to all staff and residents as a preventive measure. At which time should the staff and residents stop taking the medication?

After 7 days with no new flu cases rationale: After 7 days with no new flu cases, the prophylaxis can stop. That is more than 5 consecutive days of medications. An absence of reported deaths is not a signal to stop. The antivirals do not confer immunity to the flu.

A parent brings a 7-year-old child who is feeling unwell to the pediatric clinic. A diagnosis of flu is confirmed. Which teaching should the nurse provide to the parent?

Avoid using aspirin for fever or pain. rationale: Young children who take aspirin during an influenza infection are at risk for Reye syndrome, a noninflammatory encephalopathy causing liver failure and cerebral edema. Avoidance of aspirin is a crucial teaching point for these parents. The child should be encouraged to drink extra fluids, rest as much as possible, and use decongestants to clear excess secretions.

a pt is newly diagnosed w/ obstructive sleep apnea (OSA). which equipment should the nurse prepare too teach the pt about for home use?

CPAP rationale: CPAP applies continuous positive pressure on the airway to stop the obstruction of obstructive sleep apnea. ECG, EEG, and EMG are diagnostic tools used to test the impact of sleep on the body but are not used in the home to treat obstructive sleep apnea.

The nurse is teaching a hospitalized patient with the flu about dietary measures to improve flu symptoms. Which menu items selected by the patient indicates that teaching has been effective?

Chicken noodle soup with Jell-O for dessert rationale: A patient with influenza should be instructed to increase fluids. Soup and Jell-O are both high in fluids and are good choices for a patient with the flu. A salad with oil and vinegar dressing, yogurt and granola, or grilled cheese sandwiches are not high in fluids and indicate the need for additional teaching.

A nurse is teaching a mother with young children about flu. Which symptoms of the flu should the nurse include in the teaching?

Chills, fever, muscle aches, and cough rationale: The symptoms of influenza infection include chills, fever, malaise, muscle aches, headache, cough, and sore throat. Symptoms of Guillain-Barré syndrome include paralysis of the muscles, including the muscles of respiration. Symptoms of Reye syndrome include persistent vomiting, seizures, altered consciousness, and personality changes.

The nurse is caring for a patient with fever, chills, cough, muscle aches, and sore throat. The healthcare provider has ordered a chest x-ray. The nurse should understand that this test was ordered for which reason?

It rules out the presence of pneumonia. rationale: The healthcare provider has ordered a chest x-ray to rule out the presence of pneumonia or other pulmonary reasons for the patient's symptoms. It is not diagnostic for the flu or for a cold, and it is not used to evaluate Guillain-Barré syndrome.

The home health nurse is conducting a home assessment of a 7-month-old. When teaching the mother about how to help reduce the infant's risk of developing influenza, which information is appropriate for the nurse to include?

Making sure the child receives a yearly flu shot rationale: A yearly flu shot is recommended for all children over the age of 6 months to help prevent the flu and complications arising from it. Keeping the child at home in isolation will not prevent the flu, as other family members may come into contact with the flu outside of the house and bring the virus home. Use of pacifiers does not impact transmission of influenza virus. Breastfeeding, not bottles, helps to improve immune function in infants.

the nurse is preparing a community presentation on staying well during influenza season. which recommendation should the nurse include as the best way to prevent influenza infection?

Obtaining the annual influenza vaccination rationale: The best way to avoid getting influenza is to get a yearly flu vaccination. In addition, regular and frequent handwashing and other hygiene measures are extremely important to prevent the contraction of a cold or influenza infection. Staying indoors will not prevent influenza, nor will an increase in zinc or vitamin C intake, or regular use of anti-inflammatory drugs.

the nurse is discussing the importance of recognizing the symptoms of respiratory syncytial virus (RSV) in older adult patients. which statement should the nurse include?

RSV presents w/ symptoms similar to pneumonia in the older adult rationale: Although respiratory syncytial virus (RSV) is usually asymptomatic in patients over the age of 2, older adults, particularly those in nursing home settings, do present with symptoms of RSV infection. These symptoms tend to be more severe and consistent with those of pneumonia and other lower respiratory tract infections. RSV does not present as a common cold or with asthmatic wheezing.

The nurse is teaching a group of unlicensed volunteers helping in a community clinic during flu season with specimen testing. Which instruction regarding flu testing should the nurse include in this teaching?

Specimens should be tested as early in the disease process as possible. rationale: Rapid influenza testing should be performed as early in the disease process as possible. Nasal, throat, or nasopharyngeal swabs can be taken for culture and sensitivity, not sputum. Results are available within 10-15 minutes and there is no need to make the patient wait until the next day for results. The provider may order a chest x-ray and CBC along with the rapid influenza test.

The nurse is caring for a patient with the flu and notes that the patient had a prior nursing diagnosis of Airway Clearance, Ineffective. Which outcome indicates that the patient has had effective nursing care?

The patient reports decreased coughing. rationale: Airway Clearance, Ineffective can result when the patient is unable to clear their airway due to excess mucus production or increased cough. Decreased coughing is a sign that nursing care has been effective. Maintenance of normal fluid balance, increased energy, and normal temperature are all signals that the patient's condition is improving, but do not specifically address the nursing diagnosis of Airway Clearance, Ineffective. (NANDA-I @ 2014)

a college student w/ fatigue is awaiting the results of a lab test. which lab value should the nurse identify that supports the diagnosis of influenza?

decreased WBC count rationale: Influenza can cause a lower-than-normal white blood cell count. Changes in the CBC, including an increased hemoglobin and decreased hematocrit, would not support the diagnosis of influenza. An increased glucose level may indicate diabetes, not influenza.

a pt w/ allergic rhinitis reports an allergy to pollen. which health problem should the nurse suspect the pt is experiencing?

hay fever rationale: Some patients experience symptoms of allergic rhinitis at specific times of the year such as when pollen is at high levels in the environment. These periods are typically in the spring and fall when plants and trees are blooming and are termed seasonal allergic rhinitis. When the symptoms are caused by an outdoor allergen, the problem is called hay fever. Allergic rhinitis caused by indoor allergens is known as perennial allergic rhinitis. Indoor allergens include dust mites, animal (e.g., cat) dander, or mold. Mast cells contain histamine and help cause the allergic rhinitis symptoms. A delayed hypersensitivity reaction occurs 4-8 hours after exposure to an allergen.

the nurse is performing a physical assessment on a pt w/ a suspected case of influenza. which assessment should the nurse consider the priority for this pt?

lung sounds rationale: Lung sounds are an important part of the assessment of a patient with influenza. Without proper ventilation secondary to increased pulmonary secretions, the patient is at risk for respiratory arrest. Distal pulses, joint tenderness, and mobility are not the priority assessment factors for this patient.

an older adult pt w/ influenza is having difficulty breathing in the supine position. in which position should the nurse place the pt?

upright rationale: Sitting with the head elevated helps the lungs move more efficiently and reduces the work of breathing, which increases effective ventilation. Trendelenburg, side-lying, and prone are not positions that promote ventilation and ease breathing effort.