Uworld-Adult Infection TB

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? 1. Isolation gown, surgical mask, goggles, and gloves[1%] 2. Isolation gown and surgical mask[4%] 3. N95 respirator mask[49%] 4. Surgical mask[45%]

Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions. (Options 1 and 2) The client on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. The other personal protective equipment is not necessary. (Option 3) The Centers for Disease Control and Prevention recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air. Educational objective:While away from the negative-pressure isolation room, all clients on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions.

An elderly client has a 17-mm induration after a tuberculin skin test (TST). Based on this result, which statement is most accurate? 1. The client has a false-positive reaction due to advanced age 2. The client has a tuberculosis (TB) infection 3. The client has active TB disease 4. The client must be isolated immediately

2 In a heathy client, an induration >15 mm indicates a positive TST; this means that the client was exposed to TB, developed antibodies to the disease, and has a TB infection. Additional tests are needed to determine if the client has latent TB infection (LTBI) or active TB disease. Clients with LTBI are asymptomatic and cannot transmit the microorganism to others. Clients with active TB disease usually are symptomatic and can transmit the microorganisms through the air. (Option 1) The elderly have decreased immunity and may be unable to develop antibodies to react to the tuberculin; this can result in a false-negative TST reaction. (Option 3) A positive reaction to TST means that the client is infected with TB bacteria. The infectious bacteria are concealed by the body's defense and do not lead to active TB disease in most individuals. When the client has a decreased immunity (eg, immunosuppression), bacteria cause an active TB disease. Additional diagnostic tests (eg, chest x-rays, bacteriologic sputum smear for acid-fast bacilli and culture) are needed to determine if this client has active TB disease. (Option 4) A positive reaction indicates a TB infection only. Further evaluation and bacteriologic testing is necessary. If active TB is suspected before testing is completed, airborne transmission precautions will then be initiated. Educational objective:A positive reaction to TST means that a client was exposed to TB, developed antibodies, and now has a TB infection. Additional testing is needed to determine if a client has LTBI or active TB disease.

The nurse assesses the site where a client received an intradermal purified protein derivative (ie, Mantoux) test 48 hours ago and notices a 16-mm area of induration. The client has no symptoms. Which action will the nurse take next? 1. Document the negative response in the client's medical record 2. Have the client return in a week to receive a second injection 3. Obtain a prescription for the client to have a chest x-ray 4. Place the client in an airborne-infection isolation room

3 The intradermal purified protein derivative (PPD) test, or Mantoux test, is administered to screen for tuberculosis (TB). The forearm is injected with 0.1 mL of the PPD, and the client returns in 48-72 hours to have the site assessed for induration (a raised area). Redness alone is not read as a positive response. An area of induration >15 mm is considered a positive response in any client (Option 1). However, a positive PPD test does not mean that the client has active TB infection but rather that the client has been exposed to TB and has developed an immune response. Positive sputum cultures, chest x-rays, and the presence of symptoms confirm that the client has active disease(Option 3). (Option 2) A second injection is not needed when the client has a positive PPD. (Option 4) Placing the client in airborne precautions before confirming the presence of active TB is premature. Only clients with active TB (eg, symptoms, positive chest x-ray or sputum stain/culture) require isolation. Educational objective:A positive purified protein derivative (ie, Mantoux) response alone does not indicate active tuberculosis (TB). Confirmation of active TB will be made by positive sputum samples, chest x-ray, and the presence of symptoms.

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply. 1. Gown 2. Goggles or face shield 3. Hand washing 4. N95 particulate respirator 5. Surgical mask

3,4 Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. (Options 1 and 2) Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis). (Option 5) For client care involving airborne precautions, a class N95 or higher respirator must be used in lieu of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation. Educational objective:Tuberculosis requires airborne precautions. Clients suspected of having tuberculosis should be given a surgical mask to wear on entering any health care setting. Clients are placed in negative-pressure isolation rooms. Nurses must use a class N95 or higher particulate respirator.

A home health nurse is giving an infection control presentation on pulmonary tuberculosis (TB) disease to a group of home health aides. Which statement made by a home health aide indicates an understanding about the mode of transmission of pulmonary TB? 1. "It is spread by contact with the client's blood or urine." 2. "It is spread by contact with the client's soiled clothing and bed linens." 3. "It is spread by contact with the client's soiled eating utensils." 4. "It is spread by small droplets that the client coughs or sneezes into the air."

4 TB disease is spread from person to person via inhalation of airborne droplets containing tubercle bacilli bacteria. These droplets are coughed, sneezed, or exhaled (eg, breathing, singing, talking, laughing) into the air by an individual with active TB disease. The probability of becoming infected is related to sharing airspace and the amount of time spent with the client. All health care workers caring for clients with TB disease must follow standard and airborne transmission precautions and wear high-efficiency particulate or N95 respirator masks. (Options 1, 2, and 3) Pulmonary TB is not spread via contact with the client's blood, urine, or soiled clothing, bed linens, or eating utensils. Educational objective:Mycobacterium tuberculosis microorganisms from a client with active pulmonary TB disease are transmitted to another person via airborne droplets.

A client is admitted to the hospital for evaluation of suspected pulmonary tuberculosis (TB). The nurse assesses for which characteristic presenting signs and symptoms associated with TB disease? Select all that apply. 1. Dysuria 2. Jaundice 3. Low back pain 4. Night sweats 5. Purulent or blood-tinged sputum 6. Weight loss

4,5,6 Mycobacterium tuberculosis is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). TB, regardless of location, commonly presents with constitutional symptoms, including: Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes: Cough Purulent or blood-tinged sputum Shortness of breath Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in immunocompromised clients and the elderly. (Option 1) Dysuria is a symptom of extrapulmonary genitourinary TB. (Option 2) Jaundice can be present in disseminated TB with liver involvement. It can also be a side effect associated with drugs used to treat pulmonary TB (eg, isoniazid). (Option 3) Back pain indicates spinal TB. Educational objective:The characteristic signs and symptoms associated with pulmonary TB disease include cardinal (major) signs (eg, cough, sputum production, dyspnea) and constitutional (minor) signs (eg, anorexia, weight loss, fatigue, fever, night sweats).

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priority for a private room assignment? 1. Client who is a known IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C 2. Client with chronic obstructive pulmonary disease who has a latent tuberculosis infection 3. Client with diabetes mellitus and HIV infection who is in diabetic ketoacidosis 4. Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture

A client with a positive nose swab for methicillin-resistant Staphylococcus aureus (MRSA) is colonized and can transmit the bacteria to others. If signs of infection are absent, treatment is not required. Colonized clients are at increased risk for infection with MRSA; if signs (eg, fever, wound drainage, purulent mucus) are present, treatment is required. The Centers for Disease Control and Prevention (CDC) recommends placing a colonized client on contact precautions and in a private room. The CDC also recommends that the highest priority be given to placing a colonized client who may transmit the bacteria through body secretions or excretions (eg, sputum, wound drainage) in a private room. Therefore, the client with pneumonia should be placed in the private room. (Options 1 and 3) The CDC recommends standard precautions for clients with hepatitis C and those who are HIV positive. A private room is not necessary for a client who has osteomyelitis or diabetic ketoacidosis. (Option 2) A client with a latent tuberculosis infection (LTBI) has a positive tuberculin skin test, has no symptoms of infection, and is not contagious. Immunosuppressant drugs, chemotherapy, and debilitating disease can convert a LTBI to active disease. At this time, the client requires only standard precautions. Educational objective:The Centers for Disease Control and Prevention recommends contact precautions and private room placement for a client who is colonized with methicillin-resistant Staphylococcus aureus, especially if the client can transmit the bacteria through body secretions or excretions.

The client with suspected active pulmonary tuberculosis (TB) has a positive tuberculin skin test (TST). Which prescription from the health care provider does the nurse anticipate will confirm the diagnosis in this client? 1. Collect 2 blood cultures from different intravenous sites after cleansing with a chlorhexidine swab 2. Collect 2 early morning nose specimens (swabs) from each nare using sterile culturettes 3. Collect an early morning sterile sputum specimen on 3 consecutive days 4. Collect blood for the QuantiFERON-TB test after cleansing the site with a chlorhexidine swab

Bacteriologic testing is performed in clients with suspected TB disease to confirm the diagnosis. A stained sputum smear is examined microscopically for the presence of Mycobacterium tuberculosis (tubercle bacillus), and a culture identifies the growth of the microorganisms. Collect an early morning sputum sterile specimen on 3 consecutive days for an acid-fast bacilli (AFB) smear and culture. Fluids and/or expectorants can be given at bedtime to help liquefy secretions. It is usually easier for clients to produce a specimen upon awakening as secretions collect in the airways during the night. (Option 1) Blood cultures that identify microorganism in the blood are not usually obtained to confirm a diagnosis of TB. (Option 2) Nose cultures are routinely performed to determine the presence of methicillin-resistant Staphylococcus aureus but are not performed to confirm a diagnosis of TB. (Option 4) The QuantiFERON-TB blood test is performed to screen for TB and can be used as an alternate to the TST. The advantages it offers include the following: there are fewer false-positive results, only a single client visit is required, and results are available in 24 hours. However, it is more expensive. Educational objective:An AFB sputum culture and smear test are performed to detect the presence of M. tuberculosis and confirm a diagnosis of TB.

A client with multidrug-resistant tuberculosis (MDR-TB) has a 1-month follow up visit after beginning medication therapy. The client states, "I've had really bad nausea and fatigue, but because my cough has already improved, I knew it would be alright to stop taking the medications." The nurse identifies which priority nursing diagnosis (ND) in this client's care plan? 1. Activity intolerance 2. Imbalanced nutrition, less than body requirements 3. Knowledge deficit of prescribed therapeutic regimen 4. Nausea

Knowledge deficit is the lack of adequate information required for health recovery, maintenance, and promotion. The priority ND is knowledge deficit of the prescribed therapeutic regimen manifested by the client's verbalization of nonadherence to the prescribed MDR-TB therapy. Medication to treat MDR-TB usually must be taken for 6 to 9 months. The length of the treatment regiment, the cost and amount of medications that must be taken, and the unpleasant side effects all contribute to clients becoming nonadherent with treatment. If clients do not properly complete the entire medication regimen, they risk reactivating the MDR-TB disease, increasing the bacteria's drug-resistance, and spreading the disease to others. The medications cannot be discontinued until therapy is complete. (Option 1) Activity intolerance is an insufficient physiological or psychological energy to complete daily activities. In this client, it is related to side effects of the medications and a deconditioned state and is manifested as fatigue or weakness. This is appropriate to include in the care plan but is not the priority ND. (Option 2) Imbalanced nutrition, less than body requirements, is an insufficient intake of nutrients to meet metabolic needs. In this client, it is related to inability to ingest foods secondary to nausea, fatigue, and anorexia and is manifested by inadequate caloric intake and a loss of appetite. This is appropriate to include in the care plan but is not the priority ND. (Option 4) In this client, nausea is related to medication side effects and is suggested by a verbal report of nausea and loss of appetite. It is appropriate to include this in the care plan but is not the priority ND. Educational objective:The ND, knowledge deficit of the prescribed therapeutic regimen, is appropriate in a client with MDR-TB who is nonadherent to the prescribed medication therapy. Nonadherence increases the risk for recurrence, development of drug-resistant organisms, and spread of TB disease to others.

The public health nurse provides care for a client on a directly observed therapy (DOT) program to treat tuberculosis (TB). Which option best describes the care the nurse provides on this program? 1. Follows the client until 3 sputum cultures are normal 2. Gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits 3. Provides and watches the client swallow every prescribed medication 4. Screens all of the client's close contacts

TB is curable if the client completes the prescribed medication regimen. Noncompliance with the treatment plan is a major problem in treating TB due to the length of time drug therapy is required (usually about 6 months) and the associated unpleasant side effects. DOT is an effective patient-centered treatment strategy developed by the World Health Organization that increases compliance with drug therapy, prevents reinfection and the development of multi-drug resistant TB strains, and controls the spread of TB disease worldwide. The public health nurse provides and watches the client swallow every prescribed medication for at least the first 2 months of antitubercular medication therapy, preferably longer. Any designated person (ie, caregiver) can provide the medications and observe the client swallow them. This can take place in any designated area (eg, clinic, home, school, workplace). (Option 1) The public health nurse follows the client throughout the treatment period until all sputum smears and cultures are normal, but not in the DOT program. (Option 2) The public health nurse gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits as incentives, but not in the DOT program. (Option 4) The public health nurse screens all of the client's close contacts for possible infection and prophylactic treatment, but not in the DOT program. Educational objective:Directly observed therapy is a patient-centered treatment strategy, implemented by a health care worker or caregiver, to ensure adherence with drug therapy.