Ch. 33 infectious resp. probs

A 70-year-old client has a complicated medical history including chronic obstructive pulmonary disease (COPD). Which client statement indicates the need for further teaching about the disease? A. "I am here to receive the yearly pneumonia shot again." B. "I am here to get my yearly flu shot again." C. "I should avoid large gatherings during cold and flu season." D. "I should cough into my upper sleeve instead of my hand."

"I am here to receive the yearly pneumonia shot again."

The nurse has taught the client about influenza infection control. Which client statement indicates the need for further teaching? A. "Handwashing is the best way to prevent transmission." B. "I should avoid kissing and shaking hands." C. "It is best to cough and sneeze into my upper sleeve." D. "The intranasal vaccine can be given to everybody in the family."

"The intranasal vaccine can be given to everybody in the family."

The client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? A. "You are not contagious unless you stop taking your medication." B. "You will not be contagious to the people you have been living with." C. "You will have to take these medications for at least 1 year." D. "Your sputum may turn a rust color as your condition gets better."

"You will not be contagious to the people you have been living with."

Inhalation anthrax

(respiratory anthrax) is a bacterial infection caused by the gram-positive organism Bacillus anthracis, which lives as a spore in contaminated soil. Infection with this organism occurs through the skin, the intestinal tract, or the lungs. Inhalation anthrax is a rare natural occurrence in the United States and is nearly 100% fatal without treatment. It is not spread by person-to-person contact.

How does the process of TB infections occur?

1. The granulomatous inflammation created by the tubercle bacillus in the lung becomes surrounded by collagen, fibroblasts, and lymphocytes. 2. Caseation necrosis, which is necrotic tissue being turned into a granular mass, occurs in the center of the lesion. If this area shows on x-ray, it is called Ghon's tubercle, or the primary lesion.

An older client presents to the emergency department (ED) with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? A. A bronchodilator would not be beneficial for this client. B. A bronchodilator would help decrease the bronchospasm. C. It would clear up the density in the bases of the client's lungs. D. It would decrease the client's pain on inspiration.

A bronchodilator would help decrease the bronchospasm.

Empyema

A collection of pus in the pleural cavity

Pulmonary empyema

A collection of pus in the pleural space.

Tuberculosis (TB)

A highly communicable disease caused by Mycobacterium tuberculosis. It is the most common bacterial infection worldwide. The organism is transmitted via aerosolization (i.e., an airborne route) Far more people are infected with the bacillus than actually develop active TB.

Lung Abscess

A lung abscess is a localized area of destruction caused by liquefaction necrosis, which is usually related to pyogenic bacteria. Patients with an abscess often have a history of pneumonia, aspiration of stomach contents, or obstruction as a result of a tumor or foreign body. Multiple abscesses and cavities form in patients with tuberculosis (TB) or fungal infections of the lung.

Pleuritic chest pain

A stabbing pain upon taking a deep breath

Severe acute respiratory syndrome (SARS)

An easily spread respiratory infection first identified in China in November 2002. At first appearing as an atypical pneumonia, it is caused by a new, more virulent form of coronavirus, and there is no known effective treatment. It infects cells of the respiratory tract, triggering inflammatory responses, and stays in the respiratory passageways rather than spreading into the blood. The virus is easily spread by airborne droplets from infected people through sneezing, coughing, and talking. People at greatest risk for SARS are those in close direct contact with an infected person. The portals of entry are the mucous membranes of the eyes, nose, and mouth.

Pneumonia

An excess of fluid in the lungs resulting from an inflammatory process.

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin addicted. Which action will be most effective in ensuring that the client completes treatment? A. Arrange for a health care worker to watch the client take the medication. B. Give the client written instructions about how to take prescribed medications. C. Have the client repeat medication names and side effects. D. Instruct the client about the possible consequences of nonadherence.

Arrange for a health care worker to watch the client take the medication.

An older adult resident in a long-term care facility becomes confused and agitated, telling the nurse "Get out of here! You're going to kill me!" Which action will the nurse take first? A. Check the resident's oxygen saturation. B. Do a complete neurologic assessment. C. Give the prescribed PRN lorazepam (Ativan). D. Notify the resident's primary care provider.

Check the resident's oxygen saturation.

What is the most common diagnostic test for pneumonia?

Chest x-ray continues to be the most common diagnostic test for pneumonia but may not show changes until 2 or more days after manifestations are present. It usually appears on chest x-ray as an area of increased density. It may involve a lung segment, a lobe, one lung, or both lungs. In the older adult, the chest x-ray is essential for early diagnosis because pneumonia symptoms are often vague.

A local hunter is admitted to the intensive care unit with a diagnosis of inhalational anthrax. Which of the following medications will the RN anticipate as a physician request? A. Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours B. Ceftriaxone (Rocephin) 2 g IV every 8 hours C. Ciprofloxacin (Cipro) 400 mg IV every 12 hours D. Pyrazinamide (PZA) 1000 to 2000 mg orally every day

Ciprofloxacin (Cipro) 400 mg IV every 12 hours

The medical-surgical unit has one negative airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A. Client with bacterial pneumonia and a cough productive of green sputum B. Client with neutropenia and pneumonia caused by Candida albicans C. Client with possible pulmonary tuberculosis who currently has hemoptysis D. Client with right empyema who has a chest tube and a fever of 103.2° F

Client with possible pulmonary tuberculosis who currently has hemoptysis

Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? A. Client with group A beta-hemolytic streptococcal pharyngitis who has stridor B. Client with pulmonary tuberculosis who is receiving multiple medications C. Client with sinusitis who has just arrived after having endoscopic sinus surgery D. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

Client with pulmonary tuberculosis who is receiving multiple medications

The client is homeless and has been living in shelters for the past 6 months. The client asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? Select all that apply. A. Combination drug therapy is effective in preventing transmission. B. Combination drug therapy is the most effective method of treating tuberculosis (TB). C. Combination drug therapy will decrease the length of required treatment to 2 months. D. Multiple drug regimens destroy organisms as quickly as possible. E. The use of multiple drugs reduces the emergence of drug-resistant organisms.

Combination drug therapy is effective in preventing transmission. Combination drug therapy is the most effective method of treating tuberculosis (TB). Multiple drug regimens destroy organisms as quickly as possible. The use of multiple drugs reduces the emergence of drug-resistant organisms.

Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply. A. Administering antibiotic prophylaxis B. Continuous removal of subglottic secretions C. Elevating the head of the bed at least 30 degrees whenever possible D. Handwashing before and after contact with the client E. Placing a nasogastric tube F. Placing the client in a negative airflow room

Continuous removal of subglottic secretions Elevating the head of the bed at least 30 degrees whenever possible Handwashing before and after contact with the client

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which physician order should the nurse implement first? A. Administer levofloxacin (Levaquin) 500 mg IV. B. Draw aerobic and anaerobic blood cultures. C. Give lorazepam (Ativan) as needed for agitation. D. Refer to social worker for alcohol counseling.

Draw aerobic and anaerobic blood cultures.

Which method is the best way to prevent outbreaks of pandemic influenza? A. Avoiding public gatherings at all times B. Early recognition and quarantine C. Vaccinating everyone with pneumonia vaccine D. Widespread distribution of antiviral drugs

Early recognition and quarantine

The oxygen saturation monitor of the client recovering from an empyema indicates periodic decreased perfusion, yet the client is talking and laughing with a visitor. The client's respirations are even and unlabored, and the nail beds are pink. What does the nurse do first? A. Auscultates breath sounds B. Calls Respiratory Therapy C. Ensures that the pulse oximetry probe is in place D. Instructs the client to breathe deeply

Ensures that the pulse oximetry probe is in place

A client is taking INH, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? A. Ethambutol B. INH C. Pyrazinamide D. Rifampin

Ethambutol

Which symptom of pneumonia may present differently in the older adult than in the younger adult? A. Crackles on auscultation B. Fever C. Headache D. Wheezing

Fever

What are some important assessment findings regarding pulmonary empyema?

Important history findings include recent febrile illness (including pneumonia), chest pain, dyspnea, cough, and trauma. Observe and document the character of the sputum. Chest wall motion may be reduced on physical examination. If a pleural effusion is present, fremitus may be decreased or absent on palpation, percussion may sound flat, and breath sounds are decreased on auscultation. With compression of lung tissue near the effusion, abnormal breath sounds include bronchial breath sounds, egophony, and whispered pectoriloquy. Ask about fever, chills, night sweats, and weight loss. The patient may be hypotensive because of a mediastinal deviation placing pressure on the heart. Palpate the point of maximal impulse (PMI) because it may be displaced.

What are the stages of inhalation anthrax illness?

Inhalation anthrax is a two-stage illness—prodromal and fulminant. The prodromal stage is early and difficult to distinguish from influenza or pneumonia. Manifestations include fever, fatigue, mild chest pain, and a dry, harsh cough. A special feature of inhalation anthrax is that it is not accompanied by upper respiratory manifestations of sore throat or rhinitis. Usually the patient starts to feel better and symptoms improve in 2 to 4 days. The fulminant stage begins after the patient feels a little better. Usually there is a sudden onset of breathlessness. This sensation rapidly progresses to severe respiratory distress, dyspnea, diaphoresis, stridor, and cyanosis. The patient has a high fever. Mediastinitis and pleural effusions develop. As the disease spreads through the blood, causing septic shock and meningitis, death often occurs within 24 to 36 hours even if antibiotics are started in this stage.

Where is an initial TB infection seen?

Initial infection is seen more often in the middle or lower lobes of the lung.

Your client has been homeless and has spent the past 6 months living in shelters. The client has been diagnosed with confirmed tuberculosis (TB). You are completing your medication teaching with this client. About which medications will the nurse teach the client? A. Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Tebrazid), ethambutol (Myambutol) B. Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) C. Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Trabrazide) D. Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)

Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Tebrazid), ethambutol (Myambutol)

The RN is caring for a client with severe acute respiratory syndrome (SARS) who is receiving mechanical ventilation. Which nursing action should the nurse delegate to a nursing assistant? A. Keeping the head of the bed elevated 30 to 45 degrees B. Monitoring the impact of the ventilator on the client's oxygenation C. Performing oral care with disinfecting rinses every 12 hours D. Suctioning the client's endotracheal tube as needed

Keeping the head of the bed elevated 30 to 45 degrees

What are clinical manifestations of pneumonia?

Many patients with pneumonia have flushed cheeks, bright eyes, and an anxious expression. The patient may have chest or pleuritic pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, dyspnea, tachypnea, hemoptysis, and sputum production. Severe chest muscle weakness also may be present from sustained coughing. Observe the patient's breathing pattern, position, and use of accessory muscles. The hypoxic patient may be uncomfortable in a lying position and will sit upright, balancing with the hands. Assess the cough and the amount, color, consistency, and odor of sputum produced. Crackles are heard with auscultation when fluid is in interstitial and alveolar areas. Wheezing may be heard if inflammation or exudate is in the airways. Bronchial breath sounds are heard over areas of density or consolidation. Fremitus is increased over areas of pneumonia, and percussion is dulled. Chest expansion may be diminished or unequal on inspiration. In evaluating vital signs, compare the results with baseline values. The patient with pneumonia is likely to be hypotensive with orthostatic changes as a result of vasodilation and dehydration, especially the older adult. A rapid, weak pulse may indicate hypoxemia, dehydration, or impending shock. Dysrhythmias may be present as a result of cardiac tissue hypoxia.

The nurse plans discharge teaching for the client who is recovering from pneumonia. When is the best time to accomplish this? A. After the client has had his bath B. In the evening C. Midmorning or midafternoon D. When visitors are present

Midmorning or midafternoon

What are noninfectious causes of pneumonia?

Noninfectious causes of pneumonia include inhalation of toxic gases, chemical fumes, and smoke and aspiration of water, food, fluid, and vomitus.

The client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? Select all that apply. A. Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B. The medications may cause nausea. The client should take them at bedtime. C. The client is generally not contagious after 2 to 3 consecutive weeks of treatment. D. These medications must be taken for 2 years. E. These medications may cause renal failure.

Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. The medications may cause nausea. The client should take them at bedtime.

A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? A. Ensure that ED staff members receive oseltamivir (Tamiflu). B. Obtain specimens for the H5 polymerase chain reaction test. C. Place the client in a negative air pressure room. D. Start an IV line and administer rehydration therapy.

Place the client in a negative air pressure room.

A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? A. Contacts the health care provider for tuberculosis (TB) medications B. Performs a TB skin test C. Places a respiratory mask on the client D. Tests all family members for TB

Places a respiratory mask on the client

What are infectious causes of pneumonia?

Pneumonia can be caused by bacteria, viruses, mycoplasmas, fungi, rickettsiae, protozoa, and helminths (worms).

What are priority problems for the patient with pneumonia?

Priority problems for the patient with pneumonia are: 1. Hypoxemia related to decreased diffusion at the alveolar-capillary membrane 2. Potential for airway obstruction related to excessive tracheobronchial secretions, fatigue, chest discomfort, muscle weakness 3. Potential for sepsis related to the presence of microorganisms in a very vascular area

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? A. Homeless people B. Hospital staff C. Politicians D. Prison staff and inmates

Prison staff and inmates

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? A. Ensures that the client is wearing a mask B. Tells the visitor that the client cannot receive visitors at this time C. Provides a particulate air respirator to the visitor D. Provides a mask to the visitor

Provides a mask to the visitor

What is secondary TB?

Secondary TB is a reactivation of the disease in a previously infected person. It is more likely when defenses are lowered, such as with older adults and people with HIV disease. The upper lobes are the most common site of reactivation and are referred to as Simon's foci.

What should you teach the patient regarding laryngitis?

Teach the patient and family about relief measures, infection prevention, and avoidance of alcohol, tobacco, and pollutants, which can irritate the larynx. Teach about preventive strategies such as reducing tobacco and alcohol use. Emphasize the need to avoid activities that place an added strain on the larynx, such as singing, cheering, public speaking, heavy lifting, and whispering. Speech-language therapy is used when vocal cord injury occurs with laryngitis. Further evaluation is needed for recurrent bouts of laryngitis.

Calmette-Guérin (BCG) vaccine

The BCG vaccine contains attenuated tubercle bacilli and is used in many countries to produce increased resistance to TB. Anyone who has received BCG vaccine within the previous 10 years will have a positive skin test that can complicate interpretation. Usually the size of the skin response decreases each year after BCG vaccination. These patients should be evaluated for TB with a chest x-ray or the QuantiFERON-TB Gold test. The effectiveness of BCG vaccine in preventing TB is controversial, and it is not used widely for this purpose in the United States or Canada.

A client is being admitted for pneumonia. The sputum culture is positive for Streptococcus. The client asks about the length of the treatment. On what does the nurse base the answer? A. The client may be switched from IV to oral antibiotics in 2 to 3 days. B. Usually anti-infectives are used for 7 to 10 days. C. When the client has completed 6 days of therapy D. When the client is afebrile for 24 hours

The client may be switched from IV to oral antibiotics in 2 to 3 days.

How does pneumonia affect the body?

The inflammation occurs in the interstitial spaces, the alveoli, and often the bronchioles. The process begins when organisms penetrate the airway mucosa and multiply in the alveoli. White blood cells (WBCs) migrate to the area of infection, causing local capillary leak, edema, and exudate. These fluids collect in and around the alveoli, and the alveolar walls thicken. Both events seriously reduce gas exchange and lead to hypoxemia, interfering with oxygenation and possibly leading to death. Red blood cells (RBCs) and fibrin also move into the alveoli. The capillary leak spreads the infection to other areas of the lung. If the organisms move into the bloodstream, sepsis results; if the infection extends into the pleural cavity, empyema (a collection of pus in the pleural cavity) results. The fibrin and edema of inflammation stiffen the lung, reducing compliance and decreasing the vital capacity. Alveolar collapse (atelectasis) further reduces the ability of the lung to oxygenate the blood moving through it. As a result, arterial oxygen levels fall, causing hypoxemia

What are possible causes of pulmonary empyema?

The most common cause of empyema is pulmonary infection, lung abscess, or infected pleural effusion. Pneumonia or lung abscess can spread across the pleura. Lymph node obstruction can cause a retrograde (backward) flood of infected lymph into the pleural space. A liver abscess or abdominal abscess can spread through the lymphatic system into the lungs. Chest surgery or trauma can introduce bacteria directly into the pleural space, leading to empyema. Blood from trauma may collect in the pleural space, promoting infection.

What are some considerations for older adults when assessing for pneumonia?

The older adult with pneumonia has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is often present. The most common manifestation of pneumonia in the older adult patient is acute confusion from hypoxia. The WBC count may not be elevated until the infection is severe. Waiting to treat the disease until more typical manifestations appear greatly increases the risk for sepsis and death.

What are some signs of the flu?

The patient with influenza often has a severe headache, muscle aches, fever, chills, fatigue, and weakness. Adults are contagious from 24 hours before symptoms occur and up to 5 days after they begin. Patients who are immunosuppressed may be contagious for several weeks. Sore throat, cough, and watery nasal discharge generally follow the initial symptoms for a week or longer. Most patients feel fatigued for 1 to 2 weeks after the acute episode has resolved.

Coronaviruses

These viruses have ribonucleic acid (RNA) as their genetic material and have many projections that look like a halo or "corona." This family of viruses causes many forms of the common cold.

How often should clients receive the pneumococcal polysaccharide vaccine (PPV23)?

This vaccine is usually given once; however, some experts believe that older adults and those with chronic health problems could benefit from a second vaccination if more than 5 years have passed since the first vaccination.Especially encourage people older than 65 years and those with a chronic health problem to receive the PPV23.

The client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? A. Chest x-ray B. Complete blood count C. Tuberculosis (TB) skin test D. Throat culture

Throat culture

What are common manifestations of SARS?

Usually, the patient has a fever higher than 100.4° F (38.0° C), a headache, and general body aches. Mild cold symptoms of a runny nose, sore throat, and watery eyes may also be present. Within 2 to 7 days, the patient develops a dry cough and has difficulty breathing. Hypoxia, with cyanosis, low oxygen saturation, and a feeling of breathlessness, indicates more severe illness. Chest x-rays show a pattern similar to pneumonia. Diagnosis is made by the manifestations and the use of a rapid SARS test that detects SARS-CoV RNA in the blood within 2 days after symptoms begin.