ADN Nursing Level 3, Test 5: Immunity (Tuberculosis, SLE, RA, IBD, MS)

Antecedents of End of Life

- Terminal Illness/Advanced Disease - Meets criteria for hospice - Time defined aspect of care

Recommended diagnostic criteria guidelines for clinical diagnosis of brain death in adults

- coma or unresponsiveness - absence of brainstem reflexes - apnea

Stages in the Silver Hour Model

1) Dying 2) Death 3) Dead

Attributes of End of Life Concept

1) Holistic care addressing the needs of the patient and family 2) Quality of life vs Quantity 3) Care vs Cure

What options are there for the treatment of latent TB infection?

1) Isoniazid (INH) daily for 9 months. 2) A combination regimen of isoniazid (INH) and rifapentine (RPT) given in 12 once-weekly doses under directly observed therapy (DOT). 3) Rifampin (RIF) given daily for 4 months In some cases, rifabutin (RBT) may be substituted when rifampin (RIF) cannot be used.

Goals of End of Life Care

1) Provide comfort and supportive care during the dying process 2) Improve the quality of the patient's remaining life 3) Help ensure a dignified death 4) Provide emotional support to the family

What are the 5 components of a medical evaluation for TB disease?

1. Medical history 2. Physical exam 3. Test for TB infection (TST or IGRA) 4. Chest X-Ray 5. Bacteriological examination

Autoimmune diseases increase with aging. This is consistent with which of the following theories of aging? A) immune theory of aging B) programmed theory of aging C) neuroendocrine theory of aging D) Intrinsic mutation theory of aging

A

Which one of the following is correct? A. Patients with symptoms of TB disease should always be evaluated for TB disease, regardless of their TST or IGRA results. B. A positive TST or IGRA result can confirm whether or not a patient has TB disease. C, A chest x-ray can confirm whether or not a patient has pulmonary TB disease.

A

A client with possible TB is admitted to the unit. The client complains of night sweats, coughing up sputum that is streaked with blood, and weight loss. The priority nursing action is to A. start airborne precautions. B. obtain height and weight. C. collect sputum for culturing. D. encourage fluid intake.

A The greatest risk is the spread of the infection to others, and based on the Centers for Disease Control and Prevention guidelines, airborne precautions for the client should be initiated first. Obtaining the client's baseline height and weight will provide information to compare future data with; obtaining a sputum specimen is necessary for diagnosis; and encouraging fluid intake will help maintain hydration. These actions are all important but are not the priority.

When an ethical issue arises, one of the most important nursing responsibilities in managing client care situations is which of the following? A) Be able to defend the morality of one's own actions B) Remain neutral and detached when making ethical decisions C) Ensure that a team is responsible for deciding ethical questions D) Follow the client and family's wishes exactly

A - A nurse's actions in an ethical dilemma must be defensible according to moral and ethical standards. The nurse may have strong personal beliefs but distancing oneself from the situation does not serve the client (Answer B). A team is not always required to reach decisions (Answer C). The nurse is not obligated to follow the client's wishes automatically when they may have negative consequences for self or others (Answer D).

In working with a dying client, the nurse demonstrates assisting the client to die with dignity when performing which action? A) Allows the client to make as many decisions about care as is possible B) Shares with the client the nurse's own views C) Avoids talking about dying and focuses on the present D) Relieves the client of as much responsibility for self-care as is possible

A - Assisting the client to die with dignity involves allowing the client to participate in and choose the direction of the remainder of his or her life.

Following a motor vehicle crash, the parents refuse to permit withdrawal of life support from the child with no apparent brain function. Although the nurse believes the child should be allowed to die and organ donation considered, the nurse supports their decision. Which moral principle provides the basis for the nurse's actions? A) Respect for autonomy B) Nonmaleficence C) Beneficence D) Justice

A - Autonomy is the client's (or surrogate's) right to make his or her own decision. The nurse is obliged to respect the client's or significant other's informed decision. These parents may modify their decision as time goes on and the client's condition, or their feelings, change. This situation is not clearly one of nonmaleficence (do no harm) in Answer B or beneficence (do good) in answer C since there are many aspects of both. If the child appeared to be suffering or an effective treatment was being denied, these principles might apply. Justice (fairness) generally applies when the rights of one client are being balanced against those of another client (Answer D).

During a TB contact investigation, Juan, a 55-year old man, was identified as a contact to a patient with infectious TB disease. Juan was tested for TB infection and found to have a TST result of 22 mm. Juan received further evaluation and was found to have no symptoms of TB and his chest x-ray results were normal. What is the appropriate diagnosis for Juan? A) Latent TB infection B) TB disease C) Neither

A - Juan should be diagnosed with latent TB infection. His TST result is positive for TB infection. An induration of 5mm or larger is considered positive for recent contacts of persons with infectious TB disease. Thus, Juan's result of 22mm indicates infection with M. tuberculosis. However, because Juan has no TB symptoms and his chest x-ray is normal, he is considered to have latent TB infection, not TB disease.

The nurse is serving on the hospital ethics committee which is considering the ethics of a proposal for the nursing staff to search the room of a client diagnosed with substance abuse while he is off the unit and without his knowledge. Which of the following should be considered concerning the relationship of ethical and legal standards of behavior? a) Ethical standards are generally higher than those required by law. b) Ethical standards are equal to those required by law. c) Ethical standards bear no relationship to legal standards for behavior. d) Ethical standards are irrelevant when the health of a client is at risk.

A - Some behavior that is legally allowed might not be considered ethically appropriate. Legal and ethical standards are often linked, such as in the commandment "Thou shalt not kill." Ethical standards are never irrelevant, though a client's safety or the safety of others may pose an ethical dilemma for health care personnel. Searching a client's room when they are not there is a violation of their privacy. Room searches can be done with a primary health care provider's order and generally are done with the client present.

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? a) Instruct the client to breathe into a paper bag. b) Offer the client fluids frequently. c) Administer ordered supplemental oxygen. d) Administer an ordered decongestant.

A - The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.

A client with possible TB is admitted to the unit. The client complains of night sweats, coughing up sputum that is streaked with blood, and weight loss. The priority nursing action is to A) start airborne precautions B) obtain height and weight C) collect sputum for culturing D) encourage fluid intake

A - The greatest risk is the spread of infection to others, and based on CDC guidelines, airborne precautions for the client should be initiated first.

The client with tuberculosis is prescribed isoniazid (INH). Which diet selection indicates the client needs more teaching? A) Tuna fish sandwich on white bread, potato chips, and iced tea. B) Pot roast, mashed potatoes with brown gravy, and a light beer. C) Fried chicken, potato salad, corn on the cob, and white milk. D) Caesar salad with chicken noodle soup and water.

A - Tuna, foods with yeast extracts, aged cheese, red wine, and soy sauce contain tyramine and histamine, which interact with INH and result in a headache, flushing, hypotension, lightheadedness, palpitations, and diaphoreses. Red wine, not beer, can cause a reaction with INH (B). Fried foods and whole milk may not be a healthy diet, but they are not contraindicated with INH (C). Soup is high in sodium content, but it is not contraindicated in clients taking INH (D).

Sharon, a 48-year old woman, goes to the public health clinic because she has not been feeling well. When she meets with the clinician, she complains of weight loss, fever, and a cough that has lasted for about one month. Sharon also reports that she occasionally injects heroin. Which of the following is an appropriate next step for the clinician? Select all that apply. A. Obtain a sputum sample for smear and culture. B. Give Sharon a face mask and send her to the radiology department for a chest x-ray. C. Immediately diagnose Sharon with latent TB infection and prescribe her with a one month supply of isoniazid.

A and B. Patients with symptoms of TB should always be evaluated for TB disease. Additionally, b/c Sharon may be infectious, it is appropriate to give her a face mask to help prevent the spread of TB to others.

What does a bacteriological examination consist of?

A bacteriological examination consists of five parts: 1. Specimen collection 2. Examination of acid-fast bacilli (AFB) smears 3. Direct identification of specimen (nucleic acid amplification) 4. Specimen culturing and identification 5. Drug susceptibility testing

Ann is a 25-year old graduate student from Southeast Asia. She goes to the clinic complaining of a cough lasting 3 weeks, fever, and weight loss. The clinic evaluates her for TB. The results of her medical evaluation are: • Tuberculin skin test (TST): Positive • Chest x-ray: Cavity in lung • Sputum smear: Positive for acid-fast bacilli (AFB) • Nucleic acid amplification test (NAAT): Positive for M. tuberculosis • Culture: Pending • Drug susceptibility tests: Pending • HIV test: Negative Based on her medical evaluation results, Ann is presumed to have TB. She is started on the standard initial TB disease treatment regimen. Which of the following drugs should be included in Ann's initial treatment regimen? Select all that apply. A) Isoniazid (INH) B) Rifampin (RIF) C) Levofloxacin D) Pyrazinamide (PZA) E) Ethambutol (EMB) F) Linezolid

A) Isoniazid (INH) B) Rifampin (RIF) D) Pyrazinamide (PZA) E) Ethambutol (EMB) The standard initial treatment for treating TB disease should include these 4 drugs. When drug susceptibility results are available, the treatment regimen may be changed accordingly.

Which of the following statements are correct? Select all that apply. A. TB disease should be suspected in patients with unexplained weight loss and a cough of more than 3 weeks. B. HIV testing and counseling should be offered to all patients being evaluated for TB disease. C. A physical examination is an essential step in the diagnosis of TB disease

A, B, and C are correct.

Which of the following are considered serious adverse reactions to the medications used to treat TB disease? Select all that apply. A) Vomiting B) Orange urine, saliva, or tears C) Fever for 3 or more days D) Skin rash E) Increased sun sensitivity

A, C, D.

Which of the following are regimens that can be used to treat latent TB infection? Select all that apply. A) Isoniazid (INH) daily for 9 months B) Isoniazid (INH) daily for 1 month C) Isoniazid (INH) and rifapentine (RPT) given in 12 once-weekly doses under directly observed therapy (DOT) D) Rifampin (RIF) daily for 4 months

A, C, D. (B) Isoniazid (INH) daily for 1 month is NOT a regimen that can be used to treat latent TB infection.

With treatment, Ann's symptoms begin to go away. Additionally, her bacteriology results have become available. Ann's specimen is culture positive and the drug susceptibility test shows that her TB is drug-susceptible to all of the drugs used in the standard treatment regimen. Why is it important to order drug susceptibility testing with the initial sputum culture? A) Early drug susceptibility test results help clinicians modify the drug treatment regimen if drug resistance is found. B) The patient will not have to return to the clinic for another test. C) Drug susceptibility results help to determine the infectiousness of the patient.

A. Drug susceptibility testing helps clinicians choose appropriate drugs for treating patients. Treatment success depends upon using TB drugs that can kill the TB bacteria. If patients are given drugs to which their TB is resistant, they will still be sick with TB and potentially develop further drug resistance.

Means "answerable to oneself and others for one's own actions"

Accountability

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager? a) Review the nurse's malpractice insurance policy. b) Address the nurse's omissions as negligent behavior. c) Ask the nurse whether the client refused the assessments. d) Reprimand the nurse for being forgetful.

Address the nurse's omissions as negligent behavior. Correct Explanation: Negligence refers to careless acts on the part of an individual who is not exercising reasonable or prudent judgment. It also refers to the failure to do something that a reasonable person (another nurse) would do.

A general term used to describe documents that give instructions about future medical care and treatments and who should make them in the event the person is unable to communicate

Advance directive

Written statements of a person's wishes regarding medical care

Advance directives

Greatest risk factor for TB Disease

Altered Immune Function

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? a) The client had a liver transplant 2 years ago. b) The client has never traveled outside of the country. c) The client sees his physician for a check-up yearly. d) The client works in a health care insurance office.

Answer = A A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized

Most common distress symptom near the end of life

Anxiety

Moral principle that refers to the right to make one's own decisions

Autonomy

How long does treatment for drug-susceptible TB disease typically last? A) 1 to 3 months B) 6 to 9 months C) 10 to 12 months More than 24 months

B

Why is latent TB infection treated? A) To reduce the infectiousness of the patient B) To prevent progression from latent TB infection to TB disease C) To improve the patient's symptoms

B

A client with stage 1 Alzheimer's disease is diagnosed with terminal lung cancer. He asks the nurse what he should do when he "reaches the end." How should the nurse respond? a) "Have you considered putting together a living trust that states your desires?" b) "An advance directive will help to make sure that your wishes are carried out." c) "You need to discuss this issue with your family; they will help you decide what to do." d) "An advance directive will allow others to make decisions about your care."

B - The client's Alzheimer's is in an early stage and his question indicates awareness of his situation. Providing information about how an advance directive can be used to carry out his wishes may help relieve some of his anxieties. Telling the client that an advance directive will allow others to make decisions about his care and asking if he's considered establishing a living trust provide inaccurate information and don't address his real need for assurance. A health care power of attorney, not an advance directive, gives others power to make decisions about a client's medical care. A living trust, which concerns property ownership, wouldn't address the client's concerns. Discussing the client's needs with family is important, but this suggestion doesn't address the client's concerns or respond to his request for the nurse's professional advice.

The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question? a) Notify the surgeon of the client's question. b) Arrange for a person with an ostomy to visit the client preoperatively. c) Have the client talk with a member of the clergy about these concerns. d) Tell the client to worry about those concerns after surgery.

B - If the client agrees, having a visit by a person who has successfully adjusted to living with an ileostomy would be the most helpful measure. This would let the client actually see that typical activities of daily living can be pursued postoperatively. Someone who has felt some of the same concerns can answer the client's questions. A visit from the clergy may be helpful to some clients but would not provide this client with the information sought. Disregarding the client's concerns is not helpful. Although the physician should know about the client's concerns, this in itself will not reassure the client about life after an ileostomy.

A nurse is caring for a terminally ill client in the home. The family wants to know how to respond when the client asks if he/she is dying. Which of the following is the best response by the nurse? a) "Change the subject if dying comes up in the conversation." b) "Answer the client truthfully in a caring, gentle manner." c) "Tell the client that we are all dying in some way." d) "You should offer hope that the client will be better in a week or two."

B - It is important to be truthful in order for the client to trust the people caring for him/her. The other options are either untrue or do not allow the client to further express how the client is feeling about his/her condition.

The client diagnosed with tuberculosis is administered rifampin (Rifadin), an antitubercular medication. Which information should the nurse discuss with the client? A) Instruct the client to consume fewer dark-green, leafy vegetables. B) Explain that the client's urine and other body fluids will turn orange. C) Encourage the client to stop smoking cigarettes while taking this medication. D) Tell the client to increase fluid intake to 3000 mL a day.

B - The client should be informed that this medication turns the urine and body secretions orange and can discolor contact lenses. This is not harmful to the client. The consumption of dark-green, leafy vegetables will not affect this medication (A). The client should be encouraged to stop smoking for general health reasons, but smoking will not affect this medication (C). Increasing fluid intake has no bearing on taking this med (D).

Which of the following situations is most clearly a violation of the underlying principles associated with professional nursing ethics? A) The hospital policy permits use of internal fetal monitoring during labor. However, there is literature to both support and refute the value of this practice. B) When asked about the purpose of a medication, a nurse colleague responds, "Oh, I never look them up. I just give what is prescribed." C) The nurses on the unit agree to sponsor a fund-raising event to support a labor strike proposed by fellow nurses at another facility. D) A client reports that he didn't quite tell the doctor the truth when asked if he was following his therapeutic diet at home.

B - The nurse has an ethical responsibility to act only when actions are safe or risks minimized. This nurse is putting the client at unnecessary risk for a medication error. Many medical practices are controversial but not necessarily unethical (Answer A). The nurse should follow agency policy. Although some may view nurses' strikes as unethical, supporting others who are striking is a personal decision (Answer C). Although a client statement in confidence to a nurse may have ethical overtones, it does not automatically constitute an ethical dilemma. Since the assigned health care provider is a member of the team, principles of confidentiality do not include him or her (Answer D).

A client's family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after 6:00 PM when mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until the next day. How would the nurse best manage this situation? A) Gently explain the policy to the family and then implement it. B) Inquire of the nursing supervisor how an exception to the policy could be made. C) Call the client's primary care provider for advice. D) Move the deceased to an empty room and assign an aide to stay with the body.

B - When possible, modifications of policy that demonstrate respect for individual differences should be explored. The primary care provider is in no position to modify the implementation of hospital policy (Answer C). Utilizing an empty room and a staff member for a deceased client is an inappropriate use of resources (Answer D).

Which of the following statements are correct? Select all that apply. A. Positive AFB smears can confirm the diagnosis of TB disease. B. Some patients with negative cultures are diagnosed with TB disease based on their signs and symptoms and response to treatment. C. Drug susceptibility testing determines which drugs can kill the tubercle bacilli.

B and C

When caring for R.J., a dying patient, you prioritize meeting which patient needs? Select all that apply. A) value needs B) safety needs C) physiologic needs D) role performance needs

B and C. Meeting the patient's physiologic and safety needs is the priority. Physical care focuses on the needs for oxygen, nutrition, pain relief, mobility, elimination, and skin care. People who are dying deserve and require the same physical care as people who are expected to recover.

A home health nurse is caring for an older adult client who has active tuberculosis (TB). She lives at home with her husband who has tested negative for TB. She is prescribed the following medication regimen: Isoniazid (INH) 250 mg PO daily, Rifampin (RIF) 500 mg PO daily, Pyrazinamide (PZA) 750 mg PO daily, Ethambutol 1 g PO daily. Which of the following statements indicates her understanding of appropriate home care measures? Select all that apply. A) "I can substitute one medication for another since they all fight the infection." B) "I need to wash my hands each time I cough or sneeze." C) "I will increase my intake of citrus fruits, red meat, and whole grains." D) "I am glad that I don't have to collect any more sputum specimens." E) "I will remember to wear a mask when I am in a public place."

B, C, E. The correct statements demonstrate understanding by the client on how to prevent transmission of infection and promote nutrition. All of the medications should be taken until the provider discontinues one and sputum collection should be continued to monitor response of the disease to drug therapy.

Why are fewer drugs needed for a person with latent TB infection?

Because there are fewer TB bacteria in a person with latent TB infection, fewer drugs are needed

Moral principle that means "doing good"

Beneficence

What is the diagnosis of death based on?

Brain or cerebral death

A client recently diagnosed with TB is prescribed the medication ethambutol (EMB). Which of the following instructions should the nurse reinforce to the client? A. "Your urine may turn a dark orange." B. "The sclera's color may change to yellow." C. "Watch for any changes in vision." D. "Take a small daily dose of vitamin B6."

C Clients taking ethambutol will need to watch for changes in vision due to optic neuritis, such as blurred vision, altered color discrimination, and constriction of visual fields. Clients receiving isoniazid should take B6 every day and observe for signs of hepatotoxicity. Clients receiving rifampin should expect their urine to turn a dark orange to brown; however, if the sclera turns yellow, this could indicate liver damage and should be reported to the provider.

A nurse is reviewing instructions for a low-residue diet with a client who has an acute exacerbation of colitis. To evaluate the client's understanding of the diet, the nurse asks the client to plan a menu. Which of the following food selections by the client indicates an understanding of a low-residue diet? a) Cream soup and crackers, peas, and orange juice b) Baked fish, macaroni with cheese, and milk c) Lean roast beef, white rice, and tea with sugar d) Stewed chicken, baked potatoes, and milk

C - A low-residue diet decreases the amount of fecal material in the lower intestinal tract. This is necessary in the acute phase of ulcerative colitis to prevent irritation of the colon. Orange juice contains cellulose, which is not absorbed and irritates the colon. Cream soup and milk contain lactose, which is irritating to the colon.

16. A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding? a) The ostomy bag should be adjusted. b) An intestinal obstruction has occurred. c) Blood supply to the stoma has been interrupted. d) This is a normal finding 1 day after surgery.

C - An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion. The nurse should interpret this finding as an indication that the stoma's blood supply is interuppted, which may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding 1 day after surgery. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.

The nurse cares for clients on a medical/surgical unit. The family of a client diagnosed with end stage liver disease has been consistently dissatisfied with the nursing care. Early 1 morning, the nurse discovers the client has died and the charge nurse notifies the family. The staff expresses concern about having to interact with the client's family. Which response by the charge nurse is most appropriate? A) "The nursing supervisor will be here when the family arrives." B) "I will notify the legal department about the family's complaints." C) "Please wash the client and place pads under the client's bottom." D) "The chaplain will greet the family."

C - Appropriate postmortem care; staff's priority is caring for the deceased client and family; charge nurse can offer staff an opportunity to express their feelings after caring for the client a- passing the buck; staff should care for the client and family b- priority is caring for the deceased client and family d- passing the buck; chaplain comes when requested by the family

A nurse who is interested in providing caring for persons with chronic illnesses should identify that most chronic illnesses are managed in A. hospice care. B. homeless shelters. C. a community setting. D. an acute care hospital.

C - Chronic illnesses (other than the acute phase or acute exacerbations) are usually managed in a community setting such as in ambulatory care, at home, in an assisted living facility, or in a skilled nursing facility. Diagnosis and the acute phase or acute exacerbations of a chronic illness are often managed in a hospital.

Ann comes to the clinic each morning to take her medication by DOT. Because of a change in her class schedule, Ann is now unable to make it to the clinic for her scheduled DOT appointments. What can be done to ensure that Ann continues her TB treatment? A) Nothing. If Ann cannot make it to the clinic for her DOT appointments, then she will not be able to complete treatment. B) The health care worker should give Ann a bottle of all of the remaining drugs in her treatment plan and follow-up with Ann at the end of treatment. C) The health care worker should speak with Ann and find a time and location for the DOT visit that is convenient for Ann.

C - DOT is the most effective strategy for ensuring adherence to treatment. DOT appointments should be made at a time and location that are convenient for the patient. This can include the home, work setting, or a local hangout.

The nurse provides care to the client who had a thoracotomy 3 days ago. The client has a chest tube in place that is connected to a suction/drainage system. The client reports having trouble breathing, and the nurse notes the client appears agitated and gasping for breath. Which action should the nurse take first? a) ask if this is a new onset of shortness of breath b) apply oxygen by nasal cannula at 10 liters/minute c) look at the tubing connected to the drainage system d) reassure the client that this is an expected clinical finding 3 days postoperative

C - Determine if the chest tube is still connected; if disconnected, could present with respiratory distress a- does not validate client condition b - rate of oxygen is inappropriate for a nasal cannula; usual administration for a nasal cannula is 1-4 liters d - significant SOB is not expected; determine cause of SOB

When developing a care plan for a client with a do-not-resuscitate (DNR) order, a nurse should: a) withhold food and fluids. b) discontinue pain medications. c) ensure access to spiritual care providers upon the client's request. d) always make the DNR client the last in prioritization of clients.

C - Ensuring access to spiritual care, if requested by the client, is an appropriate nursing action. A nurse should continue to administer appropriate doses of pain medication as needed to promote the client's comfort. A health care provider may not withhold food and fluids unless the client has a living will that specifies this action. A DNR order does not mean that the client does not require nursing care.

10. A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child? a) Having a mother who did not receive prenatal care until the second trimester of her pregnancy. b) Being in the 95th percentile for height and weight. c) Being an infant. d) Being male.

C - Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system. In later childhood and adolescence, morbidity and mortality are higher in females than males. A higher-than-average weight and height would indicate that the child has had good nutrition. Poor nutrition is a risk factor for tuberculosis. Prenatal care is unrelated to tuberculosis.

Sue Vale has been working full time as a nurse with terminally ill patients for 3 years. She has been experiencing irritability and mixed emotions when expressing sadness since 4 of her patients died on the same day. To optimize the quality of her nursing care she should examine her own: a) full-time work schedule b) past feelings toward death c) patterns for dealing with grief d) demands for involvement in care

C - She should examine her own patterns for dealing with grief.

When can a health care worker determine that Ann has successfully completed treatment? A) When Ann successfully completes her initial treatment phase. B) When Ann leaves the United States after her classes are finished. C) When Ann takes all of the prescribed doses of her TB treatment. D) When Ann symptoms are gone and she feels better.

C - TB treatment completion is determined by the number of doses taken over a given period of time. This includes treatment given in both the initial and continuation treatment phase. It is important that patients take all of their prescribed doses of medication even if they feel better and their symptoms are gone to help ensure that the TB bacteria in their body is killed and that they do not develop drug resistance.

As death approaches, you need to respond appropriately to R.J.'s psychosocial manifestations at the end of life. Which interventions would be most appropriate to help R.J. deal with feelings of hopelessness? A) administer pain medication B) encourage relaxation exercises C) support patient involvement in care decisions D) encourage the patient to verbalize fears and concerns

C - support patient involvement in care decisions. Feelings of hopelessness and powerlessness are common at the end of life. Supporting the patient's involvement in decision making about care can foster a sense of control and autonomy. The other options are appropriate to decrease patient anxiety and fears.

An important nursing action helpful to a chronically ill older adult is to A) avoid discussing future lifestyle changes B) assure the patient that the condition is stable C) treat the patient as a competent manager of the disease D) encourage the patient to "fight" the disease as long as possible

C - treat the patient as a competent manager of the disease

A natural death act is an advance directive that A) is legally binding B) encourages the use of artificial means to prolong life C) allows a person to direct his or her health care in the event of terminal illness D) designates who can act for the patient when the patient is unable to do so personally

C) allows a person to direct his or her health care in the event of terminal illness

Nursing interventions directed at health promotion in the older adult are primarily focused on A) disease management B) controlling symptoms of illness C) teaching positive health behaviors D) teaching regarding nutrition to enhance longevity

C) teaching positive health behaviors

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? A. Water-seal chamber has 5 cm of water. B. No new drainage in collection chamber C. Chest tube with a loose-fitting dressing D. Small pneumothorax at CT insertion site

C. If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

Involves the use of drugs for resuscitation without the use of CPR

Chemical code

A pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing

Cheyne-Stokes respiration

A formal statement of a group's ideals and values

Code of ethics

What must be done to confirm a diagnosis of TB disease?

Culture

After recovery from her hip replacement, an elderly client wants to go home. The family wants the client to go to a nursing home. If the nurse were acting as a client advocate, the nurse would perform which of the following actions? A) Inform the family that the client has a right to decide on her own. B) Ask the primary care provider to discharge the client to home. C) Suggest the client hire a lawyer to protect her rights. D) Help the client and family communicate their views to each other.

D - A major role of the client advocate is to mediate between conflicting parties. The nurse needs to assess the situation before offering an intervention. Informing the family is an intervention without assessment (Answer A). If the primary care provider sends the client home, the nurse has not acted to assist in resolving or reducing the conflict (Answer B). If the nurse assists in resolving or reducing the conflict, the added expense of an attorney may not be needed. However, legal action should be a last resort (Answer D).

A client is admitted to the healthcare facility with active tuberculosis (TB). The nurse should include which intervention in the care plan? a) Instructing the client to wear a mask at all times b) Wearing a gown and gloves when providing direct care c) Keeping the door to the client's room open to observe the client d) Putting on an individually-fitted mask when entering the client's room

D - Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupational Safety and Health Administration (OSHA/Canadian Centre for Occupational Health and Safety) standards require an individually-fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who does not anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times

A nursing care plan includes the desired outcome of "quality of life" for a client with a chronic degenerative illness who is likely to live for many more years. Which of the following is one example that would indicate the outcome has been met? A) The client demonstrates having adequate financial resources to pay for health care for many more years. B) The client spends the majority of his or her time in spiritual reflection. C) The client has no signs or symptoms of preventive complications of the illness. D) The client verbalizes satisfaction with current relationships with other persons.

D - Quality of life is determined by the client and expressed in terms of his or her satisfaction with a variety of aspects of life. Although being able to pay for care (Answer A), having apparent spiritual peace (Answer B), and absence of physiological complications (Answer C) may appear to contribute to good quality of life, only the client's expression of satisfaction can provide the data the nurse requires to evaluate the goal.

The client with active tuberculosis is prescribed antitubercular medications. Which intervention will the public health nurse implement? A) Request the client come to the public health clinic weekly for sputum cultures. B) Place the client and family in quarantine while the client takes the medication. C) Inform the neighbors and coworkers that the client has been diagnosed with TB. D) Arrange for a health-care professional to observe the client taking the medication daily.

D - TB is a communicable disease that is a detriment to the community; therefore, the client is mandated to take the antitubercular medication and will be observed daily for the duration of the regimen, which may be 9-12 months. The risk of drug resistance is extremely high if the regimen is not strictly and continuously followed. This will result in multi-drug-resistant TB in the community. The client will not have to go to the clinic weekly. Sputum cultures are done to diagnose TB and to determine when the client's illness is no longer communicable. 3 negative sputum cultures taken for 3 consecutive days 10-14 days after starting medication indicate the client's illness is no longer communicable(A). This medication will be administered for 9-12 months, and the client is quarantined for 10-14 days until negative sputum cultures are obtained. Family members are not quarantined unless they have active TB (B). The public health nurse will notify the people who have been in contact with the client during the infectious stage, but the nurse will not divulge the client's name, which would be a violation of HIPAA. The nurse will explain that the individual may have come into contact with a person recently diagnosed with TB and the person should receive a PPD skin test (C).

The nurse is evaluating whether a hospice referral is appropriate for a 69-year-old man with end-stage liver failure. What is one of the two criteria necessary for admission to a hospice program? A. The hospice medical director certifies admission to the program. B. The physician guarantees the patient has less than 6 months to live. Incorrect C. The patient has completed both advance directives and a living will. D. The patient wants hospice care and agrees to terminate curative care.

D - There are two criteria for admission to a hospice program. The first criterion is the patient must desire the services and agree in writing that only hospice care (and not curative care) can be used to treat the terminal illness. The second criterion is that the patient must be considered eligible for hospice. Two physicians must certify that the patient's prognosis is terminal with less than 6 months to live.

A written medical order that documents a patient's or family's wishes regarding resuscitation

DNR

The third phase of the Silver Hour

Dead - The third phase begins when the patient is declared dead and the body is released for transport to the next service provider.

The term for noisy, wet-sounding respirations due to mouth breathing and accumulation of mucus in the airways when approaching death

Death rattle

Low Residue Diet

Decreases amount of fecal material in lower intestinal tract, used to reduce fiber and slow bowel movements in patients with Crohn's and colitis. LO RES (Low Residue) L - Limited fat & fried foods O - Zero milk R - Real fresh fish/Unseasoned ground meat E - Eggs boiled, not fried S - Strained foods

A written physician's order instructing health care providers not to attempt CPR

Do Not Resuscitate (DNR)

A term used by some states to describe a document used for listing the person or persons to make health care decisions should a patient become unable to make informed decisions for self

Durable power of attorney for health care or Medical power or attorney

First part of the Silver Hour

Dying - the recognition of imminent death

The term currently used for issues related to death and dying, as well as services provided to address these issues

End-of-life care

Moral principle that means to be faithful to agreements and promises

Fidelity

Which moral principle is the nurse demonstrating when she says to a patient, "I'll be right back with your pain medication."

Fidelity

In which culture is it appropriate to first discuss a terminal diagnosis with the family before informing the patient?

Filipino American

What is the criteria for admission to a hospice program?

First, the patient must desire the services. Second, a physician must certify that the patient has 6 months or less to live.

Complete and total heroic measures, which may include CPR, drugs, and mechanical ventilation

Full code

The strongest known risk factor for progressing to TB disease

HIV

Usually the last sense to disappear before death

Hearing

Kinship tends to be very strong in this culture

Hispanic

When does hepatotoxicity usually appear in patients as a side effect of taking INH?

In the first 1 to 3 months of therapy, but may occur at any time during treatment

A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation? a) Notify security that the visitor viewed confidential client information. b) Confirm that the client is on the unit but offer no further details. c) Inform the other nurse that the viewed screen resulted in a breach of confidentiality. d) Validate the relationship of the visitor to the client before discussing the client's status.

Inform the other nurse that the viewed screen resulted in a breach of confidentiality. Inform the other nurse that the viewed screen resulted in a breach of confidentiality. Explanation: Nurses must protect the privacy of all client information, and this includes information on an electronic medical record. The computer screen at the nurses' station should not be in view of anyone other than the person accessing the record. The other answers are incorrect because they breach client confidentiality.

The most effective, single drug for TB disease

Isoniazid (INH)

Hepatotoxicity is a serious and sometimes fatal adverse effect of INH; thus, what should the patient be carefully monitored for?

Jaundice Fatigue Loss of appetite Elevated hepatic enzymes

Which culture believes that the spirit should not be alone when it leaves the body at the time of death?

Jewish Americans

Moral principle that is frequently referred to as fairness

Justice

A lay term used frequently to describe any number of documents that give instructions about future medical care and treatments of the wish to be allowed to die without heroic or extraordinary measures should the patient be unable to communicate for self

Living will

In which extremities does the sense of touch decrease in first when approaching death?

Lower extremities, because of circulatory alterations

People in this culture use hospice care less often because they live in close-knit communities and often prefer to care for their own family members

Mexican American

TB disease that occurs when tubercle bacilli enter the bloodstream and are carried to all parts of the body, where they grow and cause disease in multiple sites

Miliary TB

Juan's result of 22 mm indicates infection with M. tuberculosis. However, because Juan has no TB symptoms and his chest x-ray is normal, he was diagnosed with latent TB infection. Is he infectious? A) Yes B) No

No, Juan is not infectious because he has latent TB infection, not TB disease. Persons with latent TB infection cannot spread TB to others.

Can a physical examination confirm or rule out TB disease?

No, but it can provide valuable information about the patient's overall health & help to identify any factors that may affect how TB disease is treated if it is diagnosed.

Does the finding of negative sputum smears exclude TB disease as a diagnosis?

No. Smear negative results do not excluse TB disease as a diagnosis because there can be acid-fast bacilli in the smear that were not seen.

Does a TST or IGRA confirm if a person has TB disease?

No. These tests help to confirm if there is infection with M. tuberculosis but cannot confirm if a person has TB DISEASE.

Moral principle that is duty to "do no harm"

Nonmaleficence

Who is at greater risk of developing hepatotoxicity while taking INH?

Older adults and those with daily alcohol consumption

People in this culture may want to kiss and touch the body after death has occurred in order to say goodbye

Puerto Rican American

Refers to "the specific accountability or liability associated with the performance of duties of a particular role"

Responsibility

The second phase of the Silver Hour

The declaration of death

What does a positive result on a TB skin test indicate?

The patient has been exposed to the antigen that was injected. It does not indicate that TB is currently present.

What does a negative result on a TB skin test indicate?

There has been no exposure or there is depression of cell-mediated immunity such as occurs in HIV infection.

Moral principle that refers to telling the truth

Veracity

Should sputum specimens be cultured even though they had a negative sputum smear?

Yes, ALL specimens should be cultured, regardless of whether the AFB smear is positive or negative. M. Tuberculosis may grow in cultures even if there are no acid-fast bacilli seen on the smear.

A patient is displaying symptoms of TB disease, but his results for the TST test come back negative. Should he still be evaluated for TB disease?

Yes. Patients with symptoms of TB disease should always be evaluated for TB Disease regardless of their test results because the TST and IGRA do not confirm if a person has TB Disease. Additionally, if a patient has symptoms of TB disease, clinicians should not wait for test results before starting other diagnostic tests.

An HIV patient has a TST done. Should the patient's TST result of 7 mm be considered a positive reaction?

Yes. The pt's TST result should be considered positive because he has an induration of 7 mm. An induration of 5 mm or larger is considered a positive reaction for persons living with HIV.

Allows the person to die with comfort measures only and without the interference of technology

a "no code" or a DNR order

a new term being used to replace "no code" or DNR

allow natural death (AND)

While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is most appropriate? a) Assist the client to ambulate back to bed b) Reconnect the tube to the water seal c) Assess the client's lung sounds with a stethoscope d) Have the client cough forcibly several times

b - The tube should be reconnected to the water seal as quickly as possible. Assisting the client back to bed and assessing the client's lung are possible actions after the system is reconnected.

cells and tissues in the body that protect the body from foreign substances

immune system

refers to the condition when a person is infected with tubercle bacilli but has not developed TB disease

latent TB infection (LTBI)

TB that is resistant to at least the drugs isoniazid and rifampin

multidrug-resistant TB (MDR TB)

For use by terminally ill patients who wish to have no heroic measures used to prolong life after they leave an acute care facility

out-of-hospital DNR

how an infection or disease develops in the body

pathogenesis

Another name for the Mycobacterium tuberculosis organisms that cause TB disease

tubercle bacilli

refers to the ability of an organism to produce a disease

virulence

When should patients be reevaluated for TB disease?

• Symptoms do not improve after 2 months of therapy • Symptoms worsen after improving initially • Culture results are still positive after 2 months of treatment • Culture results become positive after being negative