C7 - NUR1023C Exam 1
Active acquired immunity
(Acquired or specific) Immunity acquired by immunization/vaccination or naturally being exposed to infectious pathogens like chicken pox.
Innate Immunity
(Nonspecific) Also referred to as natural or native; is the immunity present at birth; The body's first response to harmful foreign substances
Systemic infection (Signs and Symptoms)
(i.e., infections that infiltrate the bloodstream) can cause fever, increases in heart and respiratory rates, lethargy, anorexia, and tenderness or enlargement of lymph nodes.
1 cc
1 mL = ________
If 2 or more warning signs are showing, Primary Immunodeficiency is diagnosed. 1. Four or more new ear infections within 1 year 2. Two or more serious sinus infections within 1 year 3. Two or more months of taking antibiotics with little effect 4. Two or more pneumonias within 1 year 5. Failure of an infant to gain weight or grow normally 6. Recurrent, deep skin, or organ abscesses 7. Persistent thrush in mouth or fungal infection on skin 8. Need for intravenous antibiotics to clear infections 9. Two or more deep-seated infections, including septicemia 10. A family history of PI.
10 Warning Signs of (PI)
Formal operational stage
11 years and up; The person refines one's ability to think logically; is capable of abstract thought. (Piaget)
Preoperational stage
2-7 years old; The child begins to use images and symbols to represent the world but is still unable to repeat mentally what the child can do physically. (Piaget)
Concrete operational stage
7-11 years old; Logical reasoning gradually replaces intuitive thought. (Piaget)
C. Identity vs. role confusion Rationale: This child's statement indicates a struggle to establish a sense of identity, which is characteristic of the identity vs. role confusion stage. The intimacy vs. isolation stage is characterized by establishing intimate bonds of love and friendship. Looking back over one's life and accepting its meaning are observed in the ego integrity vs. despair stage of psychosocial development. The generativity vs. stagnation stage is seen in middle adulthood, where fulfilling life goals that involve family, career, and society plays an important role.
A 13-year-old child states, "I don't know if I want to go to college or start working after high school." Which stage of psychosocial development is indicated by this child's uncertainty? A. Intimacy vs. isolation B. Ego integrity vs. despair C. Identity vs. role confusion D. Generativity vs. stagnation
C. A patient with Varicella (chicken pox) will be in airborne and contact precautions.
A 6 year old female is diagnosed with Varicella. What type of isolation precautions will be initiated for this patient? A. Droplet B. Airborne C. Airborne and Contact D. Droplet and Contact
Skin
A barrier that is impermeable to most infectious microorganisms.
3-6 years old
A child having an imaginary friend or companion is perceived as normal at this age/stage of childhood development; Should be encouraged.
D. neutropenic CT immunosuppressed should be placed in a private room and use good hand washing before touching the client and any belongings. Limit number of nurses caring for client. No fresh plants or flower. No fresh fruits or veggies. Avoid catheterization. PPE. Visitor restriction.
A client is admitted to the hospital with a temp of 101 F and WBC of 3000/mm3. Which precaution should be used? A. contact B. airborne C. droplet D. neutropenic
A. Determine the client's allergies
A client is admitted with cellulitis of the left leg and a temperature of 103° F (39.4° C). The primary healthcare provider prescribes intravenous (IV) antibiotics. Which action is the priority before administering the antibiotics? A. Determine the client's allergies B. Apply a warm, moist dressing over the cellulitis C. Measure the amount of swelling in the client's left leg D. Obtain the results of the culture and sensitivity tests
"Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics."
A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. What would be the best response from the nurse?
6 -12 months This does depend on risk factors such as (in prison, healthcare workers, communal living, HIV+, etc.).
A client with tuberculosis asks the nurse how long treatment will be continued. What is the nurse's most accurate reply?
Humoral Immunity
A defense system that involves WBC's (B lymphocytes) that produce antibodies in response to antigens or pathogens circulating in the lymph and blood.
Clostridioides difficile (C.diff)
A germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon).
Normal flora
A group of microorganisms that live in or on the body (bacteria, fungi, protozoa) but do not cause disease.
Inflammation is defined as
A local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration. Signs include redness, swelling, heat, pain, and loss of function.
D. Vector Vector-borne diseases are carried from one host to another. Part of the life cycle of the pathogen occurs in the body of the fly, mosquito, or tick.
A mosquito or a fly carries an organism that infects another living organism. What is this mode of transmission of infection? A. Common vehicle B. Direct excretion C. Ingestion D. Vector
Standard precautions
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client? Standard or transmission precautions
B. Sweat The sweat glands excrete an antimicrobial enzyme.
A nurse is discussing the body's first and second lines of defense against infection with a community group. What does the body's first line of defense include? A. Teeth B. Sweat C. White blood cells D. T lymphocytes
D. Regard the outer 1 inch of the sterile field as contaminated. Considering the outer 1 inch of the sterile field as contaminated is a principle of sterile technique. Moisture contaminates the sterile field. Sneezing or coughing would contaminate the sterile glove and necessitate replacing the contaminated glove with a new sterile one. The hand used to clean the wound would not be used to apply a dry dressing. The hand would have to be regloved.
A nurse is preparing to change a sterile dressing and has put on a pair of sterile gloves. To maintain surgical asepsis, what else must the nurse do? A. Keep the amount of splashes on the sterile field to a minimum. B. If a sneeze is imminent, cover the nose and mouth with a gloved hand. C. With a moist saline sponge, use the dominant hand to clean the wound and then apply a dry dressing. D. Regard the outer 1 inch of the sterile field as contaminated.
I should remove extra blankets, toys, and pillows from my baby's crib
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?
Wear a particulate respirator when caring for the client.
A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. What precautions should the nurse take?
C. Vehicle Contaminated food is a vehicle for transmitting an infection. Direct contact requires close proximity between the susceptible host and an infected person. A vector is a nonhuman carrier, such as an insect or animal. In airborne transmission, the organism is carried through the air on a small droplet or dust particles.
A patient develops food poisoning from contaminated food. What is the means of transmission for the infectious organism? A. Direct contact B. Vector C. Vehicle D. Airborne
Sputum test
A patient expels sputum by coughing and the sputum is analyzed for bacterial content.
B. "Babies are born with immunoglobulin E (IgE), an antibody that crosses the placenta, but it only briefly protects the baby." Infants acquire antibodies from the mother, but they only last a few months.
A patient in early labor says to the nurse, "I will pass on protection from diseases, and the baby will not ever need any shots." What is the best response by the nurse? A. "Babies are born with innate (natural) immunity at birth." B. "Babies are born with immunoglobulin E (IgE), an antibody that crosses the placenta, but it only briefly protects the baby." C. "Yes, immediate antibody immunity from the mother is the first line of defense against disease for babies." D. "Yes, the mother passes on cell-mediated immunity."
A. Contact Patients with Hepatitis A are placed in contact precautions IF the patient is diapered or incontinent of stool. Remember Hep A is spread through stool.
A patient is diagnosed with Hepatitis A and is incontinent of stool. What type of precautions would be initiated? A. Contact B. Standard C. Droplet D. Contact and Droplet
D. It is caused by a long-term antibiotic therapy. Superinfections such as Clostridium difficile infections are caused by long-term antibiotic therapy, which kills all the natural flora of the bowel and causes diarrhea.
A patient with the diagnosis of Clostridium difficile infection asks what has caused the diarrhea. What is the best response by the nurse? A. It is caused by a protozoal infection. B. It is caused by a fecal-oral contamination. C. It is caused by an inflammatory response. D. It is caused by a long-term antibiotic therapy.
Human Immunodeficiency Virus (HIV)
A retrovirus that causes a gradual deterioration of the immune system by systematically destroying the CD4 Helper/Inducer T-cells.
B. Asthma Fungi are principle allergens that can trigger respiratory allergic responses such as asthma.
A school nurse starts a clean-up campaign at a local elementary school in an effort to combat allergens. What is the most common allergic response disorder? A. Anaphylaxis B. Asthma C. Contact dermatitis D. Urticaria
Correct: 1, 2, 4, 5, 3
According to Freud's theory, in what order do the stages of child development occur? 1. Oral 2. Anal 3. Genital 4. Oedipal 5. Latency
D. Middle childhood Rationale: Logical thinking is a characteristic of middle childhood, which is 6 to 12 years of age. The use of symbols and egocentric behavior is seen in preschoolers. Adolescence is characterized by abstract thinking. Early childhood is characterized by a preoperational period during which thinking using symbols and egocentric behavior are observed.
According to Piaget, which developmental stage is characterized by logical thinking? A. Preschool B. Adolescence C. Early childhood D. Middle childhood
A. Administer oxygen. The first intervention should be to supply oxygen. Notification of the charge nurse and the administration of fluids to combat hypovolemia will come afterward. Covering with blankets would increase the vasodilation and increase the shock.
After receiving an injection of penicillin, a patient undergoes an anaphylactic reaction. What should the nurse do first? A. Administer oxygen. B. Prepare fluids to combat shock. C. Notify the charge nurse. D. Cover with several blankets.
Identity vs. role confusion
Age: 12-18 years; Erikson's 5th Stage of Development; Teens develop of sense of who they are (individuality); Decisions about their education/career choices along with physical changes occur at this stage. If needs are not met at this stage self doubt emerges.
Autonomy vs. Shame and Doubt
Age: 18 months - 3 years; Erikson's 2nd stage of Development; Child strive to make decisions for themselves; Providing guidance, safety and security; Overly restrictive parents will cause the child to feel shame and doubt in their own abilities
Intimacy vs. Isolation
Age: 18-40; Erikson's 6th Stage of Development; Young adults have achieved a sense of identity and have set a path for where they are going. The main task of this phase is to develop an intimate and trusting relationship with another person (Physical and emotional intimacy); People who fail at developing such a relationship may retreat into isolation.
Initiative vs. Guilt
Age: 3-6 years old; Child explores the world and their abilities; Positive reinforcement leads to a sense of purpose.
Generativity vs. Stagnation
Age: 40-65; Erikson's 7th Stage of Development; More concerned with leaving behind a legacy that'll continue after their death; If the person fails to grow during this phase, the result may be stagnation with self-absorption (egocentric behavior) and self-indulgence. Depression
Industry vs. Inferiority
Age: 6-12 years; Erikson's 4th Stage of Development; Refining previously acquired skills and developing a peer social network; Develops a sense of self-worth based on accomplishments while avoiding feelings of failure.
Integrity vs. Despair
Age: 65-Death; It is either they are happy with their life, or they are upset about it? Person reviews life events and accepts the finality of death.
D. By focusing on simple anatomical diagrams Rationale: According to Piaget, an 8-year-old child's level of development is in the stage of concrete operations; the child will benefit from simple, concrete examples. The preschooler and younger child, not the school-age child, require repetition. Therapeutic needle play is more appropriate if and when the child is to receive an injection. The child who is in the period of concrete operations cannot think in the abstract; the ability to do this develops during adolescence.
An 8-year-old child is being prepared for surgery the next day. How should the nurse present preoperative instructions to this child? A. By repeating instructions often B. By providing time for needle play C. By using several abstract examples D. By focusing on simple anatomical diagrams
Respirations TB is a infection that primarily targets the patients lungs.
An important nursing intervention for a pt. with TB would be to monitor the pts. vital signs. What VS would be the most important in a patient with TB?
Pathogen
An infectious agent that causes disease.
Medication error
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.
Intimate Partner Violence
Any violence occurring between intimate partners who are living together or separated.
18-40 years old
At which age would assessment of lifestyle including sensitive issues such as sexual orientation, safe-sex practices, sexually transmitted diseases (STDs), pregnancy prevention, domestic and intimate partner violence, and substance use and abuse be appropriate?
A. Sensorimotor Rationale: During the sensorimotor period, the child understands that objects continue to exist even when they cannot be seen, heard, or touched. This is called object permanence. During the preoperational phase, children learn to think with the use of symbols and mental images. Egocentricity is observed in the formal operations period. Children are able to perform mental operations during the concrete operations period.
At which phase does a child develop the sense of object permanence according to Jean Piaget? A. Sensorimotor B. Preoperational C. Formal operations D. Concrete operations
Suicide
Between ages 12-19 (adolescents); _______________ may be the result of feelings of inadequacy, depression over bullying or breaking up with a boyfriend or girlfriend, or mental illness; _____________ is more common in this age group because their impulse control has not fully developed; thus, they may act on an impulse without considering the consequences.
Sensorimotor Stage
Birth - 2 years old; The child explores the environment by using the senses. (Piaget)
Aminoglycosides
Can cause ototoxicity or nephrotoxicity in high doses...
Localized infection (Signs and Symptoms)
Can cause redness, swelling, warmth, pain, tenderness, drainage, numbness or tingling, and loss of function to the affected area.
Vaccines
Can help protect against certain diseases by imitating an infection. This type of imitation infection, helps teach the immune system how to fight off a future infection. Help your immune system fight infections faster and more effectively. Sparks your immune response, helping your body fight off and remember the germ so it can attack it if the germ ever invades again. (Does not always prevent infection from occuring.)
Fungal infections
Candidiasis (yeast infection), Aspergillosis (infection from mold, typically resulting in respiratory infection), tinea pedis (athlete's foot)
Urinary tract infections in the Elderly
Caused by incomplete emptying of the bladder, decreased sphincter control, bladder outlet obstruction due to an enlarged prostate gland, pelvic floor relaxation because of estrogen depletion, and reduced renal blood flow
6-12 years old
Child is now entering school, bones lengthening and slimming down. Children start participating more frequently in sports and activities.
Infection
Defined as the invasion and multiplication of pathogens in body tissues.
How many times do you get up too urinate at night and how much? When was your last prostate exam?
For men aged 40-65, what are some important questions to ask during a health assessment?
Healthcare Associated Infection (HAI)
Formerly referred to as nosocomial infections, are infections acquired while the patient is receiving treatment in a health care facility such as a hospital, long-term care facility, clinic, or primary care office.
Steroidal agents
Glucocorticoids used to suppress the immune system and thus inflammatory response (prednisone); effective for swelling.
HIV
Highly Active Antiretroviral Therapy (HAART) is typically used to treat patients with?
C. Allowing the child limited choices The toddler's need for autonomy can best be supported by allowing the child choices within limits. Parents consistently meet the child's needs during the infant period. In later developmental stages, imaginative play is encouraged, and experimentation is promoted to determine cause and effect.
How is the toddler's need for autonomy best met? A. The parents' consistently meeting the child's needs B. Encouraging imaginative play C. Allowing the child limited choices D. Promoting experimentation to determine cause and effect
A. Place the needle in a specially marked, puncture-proof container. To avoid needlestick injuries, the nurse should place the uncapped needle, pointing downward, directly into a specially marked, puncture-proof container. Recapping the needle should only be done when no other feasible alternative is available. When recapping is necessary, use an acceptable technique such as the one-handed scoop technique in which the nurse places the needle cap on a sterile surface and, using one hand, scoops up the cap with the needle. Placing the needle in an improper container (biohazard bag) that could be punctured by the contaminated needle places other staff members at risk. Safe Practice: Never recap a dirty or used needle because doing so increases the risk for exposure to blood-borne pathogens.
How should the nurse dispose of the syringe with needle after administering an injection? A. Place the needle in a specially marked, puncture-proof container. B. Recap the needle, and carefully place it in the trash can. C. Place the needle in a biohazard bag with other contaminated supplies. D. Recap the needle, and place it in a puncture-proof container.
Excretion
How the drug leaves the body
First-line drugs
INH, rifampin, pyrazinamide, and ethambutol—are considered more effective and less toxic than drugs used in the treatment of drug-resistant TB
Vastus lateralis
Identify the following injection site.
Ventrogluteal
Identify the following injection site.
Antibodies
Immunoglobin molecules that recognize foreign invaders.
Droplet precautions
In addition to standard precautions, wear a surgical mask when within 3 feet (6 feet for smallpox) of persons known or suspected of having diseases spread by droplets (Large particles.)
Susceptible Host
Individual that may have a trait that affects the susceptibility or severity of the disease. (Age, immune deficiency, surgery, burns, diabetes)
Penicillin
Introduced in WWII, derived from a fungus/mold. This is the classification that produces the most allergic reactions.
Cellular immunity
Involves defense by WBCs against microorganisms that the body does not recognize.
Denver II Test
Is a screening test to determine whether children are meeting their developmental milestones.
Superinfection
Is an infection that occurs during antimicrobial treatments for another infection. (MRSA, C. Diff, treatment-resistant fungal infections, VRE (people can carry without knowing)
Chronic inflammation
Is an inflammatory reaction that lasts for weeks to years. Tissue is repeatedly destroyed and repaired.
Tuberculosis (TB)
Is caused by a bacterium called Mycobacterium tuberculosis.
Bioavailability
Is how much of the actual drug reaches the circulation.
Distribution
Is how the drug becomes available to the body.
Absorption
Is how the drug gets into the body fluids.
Acute inflammation
Is the first line of protection against injury. Immediate response to tissue injury and is in short duration (minutes to days)
Secondary Immunodeficiency
Is the loss of immune functioning (in which the person was previously with normal immune functioning) as a result of an illness or treatment. (Ex: Depressed system may be created with meds in order to avoid rejection in transplanted tissue, or it may be induced as a result of treatment or various types of cancer. Leukemia and the destruction of bone marrow is necessary before healthy stem cells can be reintroduced and reestablish a healthy immune system.)
Recombinant DNA/monoclonal antibodies
MRNA vaccines, generated in vitro using synthetic genes to treat diseases (covid vaccine)
Birth to 6 months old
Makes reflex movements like sucking and startling.
NSAIDs
Manage pain, fever and inflammation (Ibuprofen or naproxen).
Systemic inflammation
May result from many diseases or may be a consequence of disease processes.
500-1200 cells/mm3
Normal CD4 T-cells are between
5,000 to 10,000 WBCs per microliter
Normal WBC levels are between?
Passive acquired immunity
Occurs by the introduction of preformed antibodies—either from an artificial route, such as a transfusion of immunoglobulin (Ig), or from a natural route (from mother to baby through the placenta or breastfeeding)
Trust vs. Mistrust
Occurs from Birth to 18 months; Erikson's 1st stage of Development; Caregiver must provide basic needs. To resolve this stage needs must be met.
Primary Immunodeficiency (PI)
Occurs when the entire immune defense is missing some or all components for complete immune response. Individuals with this are more susceptible to infections.
A,B, C Purulent drainage, tenderness, localized pain, and redness or warmth are results of the inflammatory response to an infection. Well-approximated edges are a desired outcome of wound healing. The normal white blood count for adults is 5000 to 10,500 cells/mm3.
Of the following assessment findings, which cues indicate to a nurse that a patient has a surgical site infection? (Select all that apply.) A. Redness or warmth at the affected site B. Purulent drainage at the incision site C. Tenderness and localized pain D. Wound with well-approximated edges E. White blood cell count 6500 cells/mm3
B. A 40-year-old who has an indwelling urinary catheter in place Hospital-acquired infections are associated with indwelling urinary catheters. A normal white blood cell count, smoking cigarettes, or being a vegetarian has not been associated with hospital-acquired infections.
Of the following hospitalized patients, who is most at risk for acquiring a health care-associated infection? A. A 60-year-old who smokes two packs of cigarettes per day B. A 40-year-old who has an indwelling urinary catheter in place C. A 65-year-old who is a vegetarian and slightly underweight D. A 60-year-old who has a white blood cell count of 6000
C. Superinfection response to the antibiotic medication Antibiotics frequently wipe out good bacteria and cause other bacteria to overgrow, causing vaginitis.
On a visit to administer the fifth in a series of 10 antibiotic doses, a home health nurse is told that the patient is now complaining about a bothersome vaginal discharge. The nurse communicates the problem and arranges for medication. What is the most likely cause of the vaginal discharge? A. Poor genital hygiene—not changing underwear often enough B. Allergy to the soap or soap products used in the genital area C. Superinfection response to the antibiotic medication D. Sexual contact with another infected person
Intravenously
Only drugs given __________________ are 100% bioavailable.
Infectious Agent > Source (Reservoir) > Portal of Exit > Mode of Transmission > Portal of Entry > Susceptible Host
Order of the "Chain of Infection"
Protozoa Protozoa cause the opportunistic pulmonary infection of PCP.
Persons with human immunodeficiency virus (HIV) have acquired Pneumocystis Pneumonia (PCP), a serious pulmonary infection caused by _____.
Immunity
Physiological process that provides an individual with protection or defense from disease. Can be active or passive.
Reservoir
Place where the infectious agent grows and lives (People, water, food, and animals)
- Individuals in close contact with the infected patient is at the highest risk of becoming infected. - Immunocompromised (e.g., patients with HIV, diabetes, and renal failure and those taking certain medications, such as cortisol), - People living or working in high-risk residential settings (e.g., nursing homes, shelters, correctional facilities), - Those who inject illegal drugs, and health care workers who serve high‑risk patients
Populations at risk for TB:
Contact precautions
Precautions when in contact with individuals known or suspected of having diseases spread by direct or indirect contact.
Medical Asepsis
Procedures include handwashing, wearing gloves, gowning, and environmental disinfecting.
Respite Care
Provides parents and other caregivers with short-term child care services that offer temporary relief, improve family stability, and reduce the risk of abuse or neglect. Important for the "Sandwich Generation".
Secondary immune response
Reaction when the immune system reacts following subsequent exposure. Explanation: Same antigen, at a later time therefore a faster response because memory cells are activated.
Inflammation
Redness, swelling (Edema), pain, loss of function are are cardinal signs of?
Asepsis
Refers to freedom from and prevention of disease-causing contamination.
Respiratory infections in the Elderly
Respiratory infections are increased due to decreased cough reflex, decreased elastic recoil of the lungs, decreased activity of the cilia, and abnormal swallowing reflex.
RICE
Rest, Ice, Compression, Elevation
Localized inflammation
Results in the formation of granulation
C, D, E, F. Measles, Varicella (chicken pox), Disseminated Varicella Zoster (shingles), and TB require airborne precautions. NOTE: Varicella and Disseminated Varicella Zoster also require contact precaution as well. Noravirus and RSV are contact precautions. Hepatitis A is contact precautions IF the patient is diapered or incontinent of stool. Whooping cough (Pertussis) and Epiglottitis are droplet precautions.
Select ALL the conditions that warrant airborne precautions: A. Noravirus B. Hepatitis A C. Measles D. Varicella E. Disseminated Varicella Zoster F. Tuberculosis G. Whooping Cough H. RSV I. Epiglottitis
B, C, E. Patients with Pertussis (Whooping Cough), Scarlet Fever, and Streptococcal Pharyngitis are to be placed in droplet precautions. Patients with TB are to placed in airborne precautions while a patient with Chicken Pox should be place in both airborne and contact precautions. Patients with C. Diff are to be placed in contact precautions.
Select ALL the patients that would be placed in droplet precautions A. A 5 year old patient with Chicken Pox. B. A 36 year old patient with Pertussis. C. A 25 year old patient with Scarlet Fever. D. A 56 year old patient with Tuberculosis. E. A 69 year old patient with Streptococcal Pharyngitis. F. A 89 year old patient with C. Diff.
False To prevent mother-to-child transmission of HIV, ART is recommended in all pregnant patients who test positive for HIV infection, regardless of virologic, immunologic, or clinical parameters
T or F: A pregnant female infected with HIV cannot transmit the virus during pregnancy, labor, and delivery and through breastfeeding.
True
T or F: HIV is found in blood and all body fluids except sweat?
False
T or F: Infection can exist without inflammation
True
T or F: Inflammation can exist without infection
True
T or F: Many older adults are still sexually active, so as a nurse you should counsel and educate on safe sex practices.
True As a result, two TB-related conditions exist latent TB infection (LTBI) and Active TB disease.
T or F: Not everyone infected with TB bacteria becomes sick.
False In fact, according to the U.S. Department of Health and Human Services (DHHS), tuberculosis is one of the world's leading causes of death due to infectious diseases in persons older than five years of age.
T or F: Tuberculosis is NOT fatal?
Six Rights of Medication Administration
The Right Patient The Right Drug The Right Dose The Right Time The Right Route The Right Documentation
Conservation
The ability to recognize that objects remain the same even if they change in appearance.
Sepsis
The body's extreme response to an infection. It is a life-threatening medical emergency. Happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to this most often start in the lung, urinary tract, skin, or gastrointestinal tract. (Blood and urine)
Normal flora, the inflammatory response, and the immune response.
The body's three main defenses against infection are:
Hepatic first-pass
The drug has absorbed from the stomach or small-intestine, sent to the liver via the portal vein where it is metabolized or broken down before going into the circ. system.
Denver Developmental Test
The importance of the Denver Developmental Test is to assess if there is a need for further evaluation and/or implement an intervention program.
Infectious Agent
The microorganisms that can cause disease or illness (Bacteria (E.coli), Fungi (mold), parasites (lice, tick), and virus (flu))
B. Bacterium The cause of an infection in the surgical wound in a hospitalized patient who has had abdominal surgery is most likely bacteria because it is present on the skin as normal flora. Fungi and spores are the focus of removal during the surgical preparation. Viruses are target specific and do not usually live on the skin.
The nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. Which agent is most likely the cause of the infection? A. Virus B. Bacterium C. Fungus D. Spore
A. Private room A private room decreases the chance of another patient contracting the infection. The other precautions (i.e., private room with negative airflow, mask worn by staff when entering the room, and mask worn by staff and patient when leaving the patient's room) are airborne precautions, which are not necessary in managing this patient.
The nurse is caring for a patient who has been diagnosed with methicillin-resistant Staphylococcus aureus located in her incision. What transmission-based precautions will the nurse implement for the patient? A. Private room B. Private, negative-airflow room C. Mask worn by the staff when entering the room D. Mask worn by the staff and the patient when leaving the patient's room
C. A disease resulting from pathogens in or on the body A disease resulting from pathogens in or on the body is the definition of an infection. An illness resulting from living in an unclean environment, from lack of knowledge about food preparation, or from trauma can lead to an infection but does not define an infection.
The nurse is providing patient education on infection prevention. Which definition of an infection does the nurse use as a teaching point? A. An illness resulting from living in an unclean environment B. A result of lack of knowledge about food preparation C. A disease resulting from pathogens in or on the body D. An acute or chronic illness resulting from traumatic injury
A. 5 years
The nurse is using Piaget's theory to assess the cognitive development in a child. What is most likely to be the age of the child who has reached a developmental milestone by grasping the concept of conservation of numbers for the first time? A. 5 years B. 7 years C. 9 years D. 12 years
B. The staff member holds onto the outer surface of the facemask while pulling mask away from face Do not touch outer surface of mask. Untie top mask string and then bottom string, pull the mask away from the face and drop into trash receptacle
The nurse observes a staff member prepare to leave the room of a client on droplet precautions. The nurse should intervene if: A. The staff member removes the gloves by pulling off inside out B. The staff member holds onto the outer surface of the facemask while pulling mask away from face C. The staff member unties the gown and removes it without touching the outside of the gown D. The nurse performs hand hygiene for 15 seconds
A. Liver The liver filters the blood and plays a part in the immune response by the production of globulins and other chemicals involved in the immune response.
The organs involved in immunity include the tonsils, spleen, and lymph nodes. What other organ is involved in immunity? A. Liver B. Lungs C. Periosteum D. Pancreas
B. "I will position my baby on the back while sleeping." Rationale: Sleeping on the stomach may cause upper airway obstruction and increase the risk of SIDS. Therefore, infants should be placed on their backs to decrease this risk. Sleeping in the same bed as the baby may increase the risk of SIDS. Covering the baby with warm blankets may cause overheating or suffocation and can increase the risk of SIDS. The use of soft bedding and pillows for an infant may lead to suffocation. Therefore, the nurse will teach the mother to use a firm mattress.
The registered nurse is teaching the mother of an infant about the prevention of sudden infant death syndrome (SIDS). Which statement by the mother indicates effective learning? A. "I will sleep in the bed with my baby." B. "I will position my baby on the back while sleeping." C. "I will use warm blankets and sheets to cover my baby." D. "I will put my baby to sleep on soft bedding with pillows."
Primary immune response
The response that occurs following the first exposure to a foreign antigen. Slower response.
C. Giving grades and gifts for satisfactory performances. Rationale: During the psychosocial development of school-age children, reinforcement in the form of grades, material rewards, additional privileges, and recognition provides encouragement and stimulation. A sense of accomplishment also involves the ability to cooperate, to compete with others, and to cope effectively with people, so separating children will not promote their mental health. When the reward structure is based on evidence of mastery, children who are incapable of developing these skills are also at risk for feelings of inadequacy and inferiority. Comparison with one another can also cause some children to develop negative feelings towards themselves, and result in a sense of inferiority.
The school health nurse is teaching a group of teachers about promoting the mental health of school-age children. Which action made by the teachers promotes a sense of industry among the children? A. Separating children during tasks B. Basing a reward structure on evidence of mastery C. Giving grades and gifts for satisfactory performances D. Comparing the performances of children with one another
Portal of Exit
The way in which infectious agent leaves the reservoir (Blood or any excretions, skin, mouth, and feces)
Modes of Transmission
The way in which the infectious agent spread. (Contact, airborne, vehicle, droplet, vector-borne)
Portal of Entry
The way in which the infectious agents enters the host (Broken skin, mucous membrane, respiratory system, digestive system)
1. Reverse transcriptase 2. Integrase 3. Protease
There are three enzymes in HIV:
1. Exposure to infected blood: Needle sticks, blood transfusions, sharing of needles for drug use 2. Sexual contact: Unprotected vaginal, oral, or anal intercourse 3. Maternal: Fetal transmission in utero or during breastfeeding
There are three modes of transmission of HIV infection:
Active TB
This condition makes you sick and, in most cases, can spread to others. It can occur in the first few weeks after infection with the TB bacteria or happen years later.
Erythrocyte sedimentation rate (ESR)
This tests for autoimmune disease?
C-reactive protein (CRP)
This tests for protein in the liver?
Culture and Sensitivity Cultures that can be tested (fluid - blood, stool - not sterile, urine, sputum) Sensitivity: Using the cultures obtained, checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection.
This type of test is done to help diagnose an infection by testing cultures and what medications (antibiotics) should/can be used to treat the infection.
Antimicrobial
Treat underlying cause of infection that leading to inflammation
Immunosuppression therapy
Treatment that lowers the activity of the body's immune system. This reduces its ability to fight infections and other diseases, such as cancer (inhibits the immune response); may be used to keep a person from rejecting a bone marrow or organ transplant.
Parasites
Trichinosis, Toxoplasmosis, Malaria, Lyme Disease, and intestinal worm infestations
Bacteria, Viruses, Fungi, and Parasites.
Types of infectious agents include...
Mechanical, thermal, electrical, chemical, radiation, and biological assault
Types of injury leading to inflammation...
Object permanence
Understanding that objects still exist even when out of sight.
Analgesic
Used for pain relief (acetaminophen or aspirin)
Protective or Reverse isolation
Used for protecting vulnerable pt's with weakened immune systems. Protects them from microorganisms in the environment. Type of pt's: Transplant, Chemo, Lupus, RA (Rheumatoid Arthritis), HIV, and Septic pt's.
Second-line drugs
Used in the treatment of drug-resistant TB, in which M. tuberculosis is resistant to at least one first-line drug, or MDR TB, in which M. tuberculosis is resistant to INH and rifampin plus one other first-line drug, are used in combination with first-line drugs to treat drug-resistant M. tuberculosis.
Antipyretic
Used to reduce fever, a common response to inflammation (Acetaminophen, aspirin, NSAIDs)
Antifungals
Used to treat fungal infections (Examples are Metronidazole (Flagyl) and Fluconazole (Diflucan)
Airborne precautions
Used when contagious diseases can be transmitted via droplets or from the air. N95 respirator mask, goggles, face shield, a negative pressure room with high efficiency particulate air filtration system. (Small droplets)
Wasting syndrome (cachexia)
Weight loss, decrease in muscular strength, appetite, and mental activity; associated with AIDS
A. Good hand washing technique Surgical asepsis is sterile technique. Medical asepsis is considered a clean technique.
What is required by medical asepsis that is not required by surgical asepsis? A. Good hand washing technique B. That no nonsterile product comes into contact with the patient C. Elimination of all microorganisms D. Hand washing with antimicrobial soap for 3 minutes
Correct: 2, 1, 4, 3
What is the correct order of the different stages in Piaget's theory of cognitive development? 1. Preoperational 2. Sensorimotor 3. Formal operations 4. Concrete operations
Sterilization is a process used to destroy all microorganisms, including their spores. Disinfection is the removal of pathogenic microorganisms, destroys all pathogenic microorganisms except spores from inanimate objects.
What is the difference between sterilization and disinfection?
D. Demonstrate and monitor a return demonstration of a good hand washing technique by the family. Good hand washing is the cornerstone of infection control.
What is the most effective method to control the spread of communicable disease? A. Isolate the infected person from all contact with noninfected persons. B. Vigorously petition the community health department to increase spraying. C. Administer prophylactic antibiotics to the rest of the family. D. Demonstrate and monitor a return demonstration of a good hand washing technique by the family.
C. Gloves, gown, wash hands, goggles, mask, and wash hands Gloves are removed before the rest of personal protective equipment because they usually are the most contaminated. Gowns are removed by untying the waist and then the neck and grasping inside the neck. Hand hygiene is performed. Protective eyewear or goggles are removed next by grasping them by the earpieces. The mask is removed last because it prevents the spread of respiratory microorganisms. Hands should be washed thoroughly after the equipment has been removed.
What is the proper order of removal of soiled personal protective equipment (PPE) when the nurse leaves the patient's room? A. Gown, goggles, mask, gloves, and exit the room B. Gloves, wash hands, remove gown, mask, and wash hands C. Gloves, gown, wash hands, goggles, mask, and wash hands D. Goggles, mask, gloves, gown, and wash hands
B. 1 mL
What is the usual maximum volume in one subcutaneous injection? A. 2 mL B. 1 mL C. 5 mL D. 3 mL
A, B, C, D
What population is at a higher risk of acute bacterial or viral infections, and a diminished immune response? (Select all that apply) A. The elderly B. Young and the frail C. Individuals with a genetic predisposition D. Someone with a compromised immune system
A decrease in blood pressure, tachycardia - as BP decreases the heart starts to pump harder to make up for the loss, urinary output drop, tachypnea, decrease in temperature (hypothermic).
What signs would you typically see in a Septic patient?
Narcan (naloxone)
When dealing with an opioid overdose, what medication should be used?
The first 24 to 48 hours after the injury is the critical period when RICE measures will be most beneficial. Typically, icing the sprain or strain for 10 minutes at a time every 2 or 3 hours is indicated.
When would the RICE method for inflammation be most beneficial?
A. Deliberately placing the thumb into the mouth The deliberate action of placing the thumb in the mouth elicits a pleasurable effect. Accidentally kicking a ball is not a deliberate action. Searching for objects and shaking a rattle occur at later stages.
Which action by a 3-month-old infant would the nurse interpret as an example of Piaget's sensorimotor stage of primary circular reaction? A. Deliberately placing the thumb into the mouth B. Accidentally kicking a ball C. Searching for an object under a blanket D. Shaking a rattle
A,B,C,E Cultural beliefs, societal values, personal beliefs and expectations, and peer influences are all factors that influence an individual's transition into adulthood. Although governmental rules may influence certain societal values
Which factor(s) is/are likely to influence the transition from adolescence to adulthood? (Select all that apply.) A. Cultural beliefs B. Societal values C. Personal beliefs and expectations D. Governmental rules E. Peer influences
A. Holds a crayon
Which fine motor skill should the nurse expect when assessing the development of an infant between 10 and 12 months of age? A. Holds a crayon B. Walks with assistance C. Stands independently D. Sits from a standing position
C. 18 gauge The smaller the gauge the larger the diameter of the needle.
Which gauge needle is the largest in diameter? A. 27 gauge B. 23 gauge C. 18 gauge D. 22 gauge
A. Sits alone without support Rationale: Infants between 6 and 8 months of age can sit alone without support. Infants can creep on their hands and knees at the age of 8 to 10 months. Infants who are 10 to 12 months of age can walk while holding onto furniture and can sit down from a standing position due to their well-developed motor skills.
Which gross motor skill can be observed in a 7-month-old infant? A. Sits alone without support B. Creeps on hands and knees C. Walks holding onto furniture D. Sits down from a standing position
B. Antibiotics
Which intervention is most likely to decrease mortality in the septic client? A. Oxygen B. Antibiotics C. Vasopressors D. Intravenous fluids
B. Transductive reasoning Rationale: Transductive reasoning is observed in the preoperational stage, in which the individual thinks that because two events occur together, they cause each other. Inductive reasoning occurs in the stage of concrete operations. Sense of cause and effect is observed in the sensorimotor stage of cognitive development. Deductive and abstract reasoning is the characteristic of formal operations.
Which is observed in the preoperational stage of Piaget's cognitive development? A. Inductive reasoning B. Transductive reasoning C. Sense of cause and effect D. Deductive and abstract reasoning
A,B,C,D,E,F
Which of the following patients would be in contact precautions? Select-all-that-apply: A. A 8 year old patient with lice. B. A 85 year old patient with CRE (Klebisella Pneumoniae). C. A 65 year old patient with Noravirus. D. A 75 year old patient with Disseminated Herpes Zoster. E. A 12 year old patient with impetigo. F. A 9 year old with RSV.
A,B,C,E Clapping, offering praise, and giving rewards are all positive reinforcements that are likely to increase desired behavior(s). Time-out is a type of negative punishment used to discourage unwanted behavior.
Which of the following would be examples of positive reinforcers? (Select all that apply.) A. Clapping for a child who successfully used the toilet B. Offering praise for a child who behaved in a store C. Taking a child to the playground after a positive teacher report D. Placing a child in time-out for misbehavior. E. Stickers for positive play with peers.
B, D Screening for domestic violence with all patients and asking about abuse will help identify patients who may be victims. Calling the police is a step that may be taken when abuse is confirmed but is not a step in identifying victims. Taking this step will be decided on with the involvement of both health care providers and the patient. Asking for proof may cause the victim to mistrust the health care provider. Never disregard a report of abuse. Abusers often are related to or married to the victim.
Which step(s) can nurses and health care providers take to remove barriers to identifying and treating victims of domestic violence? (Select all that apply.) A. Call the police. B. Ask about abuse. C. Ask for proof of domestic violence. D. Screen for domestic violence with all patients. E. Disregard reported abuse in spouses.
A. Freud's theory
Which theory explains psychosexual development through infancy to adolescence? A. Freud's theory B. Piaget's theory C. Erikson's theory D. Kohlberg's theory
4. Droplet Precautions. Droplet Precautions are respiratory precautions used for organisms that have a limited span of transmission. Precautions include staying at least four (4) feet away from the client or wearing a standard isolation mask and gloves when coming in close contact with the client. Clients are in isolation for 24 to 1. Standard Precautions are mandated for all clients, but a client with septic meningitis will require more than the Standard Precautions. 2. Airborne Precautions are for contagious organisms that are spread on air currents and require the hospital personnel to wear an ultra-high filtration mask; these precautions would be applied for diseases such as tuberculosis. 3. Contact Precautions are for contagious organisms that are spread by blood and body fluids, such as those that occur with wounds or diarrhea.
Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? 1. Standard Precautions. 2. Airborne Precautions. 3. Contact Precautions. 4. Droplet Precautions.
D. Concrete operations Rationale: During the stage of concrete operations, the child's thought becomes more logical and coherent. The child in this stage is able to classify, sort, order, and organize facts about the world to use in problem-solving. Therefore, the child placing the pebbles in order of smallest to largest indicates that the child is in the stage of concrete operations. In the sensorimotor stage, the child develops a sense of cause and effect as they direct behavior towards objects. In the preoperational stage, thinking is concrete and tangible. The child lacks the ability to make deductions or generalizations. In formal operations, thought is characterized by adaptability and flexibility. Abstract thinking and problem-solving skills are observed in this stage.
While playing, a child takes a few pebbles and places them in order from smallest to largest. Which stage of cognitive development does the child's behavior demonstrate? A. Sensorimotor B. Preoperational C. Formal operations D. Concrete operations
B. Using soap and water After providing care to patients with C. Diff, Noravirus, or Rotavirus, you must perform hand hygiene by washing the hands with ONLY soap and water. Hand-sanitizer is not sufficent enough in killing the germs in these conditions.
You are providing care to a patient with C. Diff. After removing the appropriate PPE, you would perform hand hygiene by: A. Using hand sanitizer B. Using soap and water C. Using soap and water only if hands are soiled but can use hand sanitizer D. Using either hand sanitizer or soap and water
Latent TB
You have a TB infection in this condition, but the bacteria remain in your body in an inactive state and cause no symptoms. ____________ also called inactive TB or TB infection, isn't contagious.
B. "Patients with airborne diseases such as Meningitis require a special room with negative air pressure." This statement is FALSE because Meningitis is not a condition that requires airborne precautions but droplet precautions. However, patients with airborne diseases do require a special room with negative air pressure. However, patients with Meningitis do not.
You're providing an in-service on transmission-based precautions to a group of nursing students. Which statement made by a student warrants re-education about the topic? A. "I will make sure that any patient who is in droplet precaution wears a surgical mask when being transported." B. "Patients with airborne diseases such as Meningitis require a special room with negative air pressure." C. "I will always wear a gown and gloves when entering a room of a patient in contact precautions." D. "If I provide care to patients with C. Diff, Noravirus, and Rotavirus infections, I will always wash my hands with soap and water, not hand sanitizer."
A. Notify the receiving department and place a surgical mask on the patient.
Your patient is being transported to special procedures for a PICC line placement. The patient is in droplet precautions. What are your nursing actions to ensure proper transport of the patient? A. Notify the receiving department and place a surgical mask on the patient. B. Place an N95 mask on the patient and notify the receiving department. C. Cancel transport and notify the physician for further orders. D. Notify the receiving department and place goggles, gown, and mask on the patient.
AST (Aspartate transaminase) and ALT (Alanine transaminase)
______ and ______ should be monitored for liver function.
Viral Load
________ _________ is the number of viral particles a person has; the higher the ________ ________, the higher the viral burden. The more at risk a person is for developing full-blown AIDS or opportunistic infections.
Polypharmacy (1)
____________ is defined as the simultaneous use of multiple drugs by a single patient, for one or more conditions.
Polypharmacy (2)
_______________ is a primary cause for delirium, it is important for the nurse to thoroughly assess the patient's medication list. As a nurse it may be helpful to educate the member to keep RX's filled with the same pharmacy for fill history and RX log.
Immunization
________________ is the process by which an individual develops immunity against a specific agent; it is important in preventing the spread of communicable diseases.