EAQ'S Week 2

A nurse is teaching a client about human immunodeficiency virus (HIV). What are the various ways HIV is transmitted? Select all that apply.

Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites or dry kissing.

What is a manifestation of tertiary syphilis?

Gummas which are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and condylomata lata occur during secondary syphilis.

What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection?

Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a drug-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a drug-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.

Which is the first antibody formed after exposure to an antigen?

IgM (immunoglobulin M) is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.

A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action?

Immobilization of the spine is most important to minimize additional injury while the child is being assessed. Placing a pillow under the head is contraindicated because the vertebral column and spinal cord might move, resulting in additional damage to the spinal cord. Log-rolling is unsafe without prior immobilization of the spine, as is moving the child.

A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client?

Personal protective equipment (disposable hats, masks, gowns, and gloves) are essential for the prevention of infection in clients with the open method of treatment. Hydrotherapy in a large tank tub may be used to clean burn wounds. Dressings are not used with the open method. Clients are more comfortable with a room temperature of 85° F (29.4° C).

A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse's priority goal when providing pin care?

Pin sites provide a direct avenue for organisms into the bone. Pin care will not ease pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.

A nurse explains to the parents of a 6-year-old child with a pinworm infestation how pinworms are transmitted. What statement indicates that the teaching has been understood?

Pinworm infestation is transferred by way of the oral-anal route, and effective hand washing is the best way to prevent transmission. Cats do not transmit pinworms. The hands should be kept away from the nose and mouth; the child should be taught to cough into a tissue or the inside elbow of the arm. Cleaning the cafeteria is not an effective means of preventing the transmission of pinworms.

A nurse teaches the mother of a child with a pinworm infestation how pinworms are transmitted. Which statement indicates that the teaching has been effective?

Pinworms are transferred by way of the anal-oral route; hand washing is the most effective method for preventing transmission. Cats do not transmit pinworms. It is unnecessary to disinfect the toilet seat because pinworms are found in the rectum or colon and travel to the perianal area only when the person sleeps. Dirty toilet seats are not the usual mode of transmission.

A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client?

Scabies is caused by the itch mite (Sarcoptes scabiei), the female of which burrows under the skin to deposit eggs. It is intensely pruritic and is transmitted by direct contact or in a limited way by soiled sheets or undergarments. It is not caused by a fungus. Scabies is an acute infestation; there are no remissions and exacerbations. It is a disease unrelated to allergies.

A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be prevented. What is the nurse's response?

Scratching can break the integrity of the skin, leaving it vulnerable to infection. Dermatitis is a response to an allergen; it is not contagious. Scratching will not cause the dermatitis to spread. There are no data to indicate that scratching or dermatitis is a precursor to skin cancer.

A school nurse is planning to teach the importance of hand washing to the children in first grade. What is the most effective approach for this age group?

Six-year-old children are still in the perceptual phase of cognitive development. They base judgments on what they see rather than on what they reason; reasoning begins around age 7. These children are at the developmental stage when they want to show off their accomplishments; just watching the technique without feedback is not sufficient at this age. These children are too young to understand the abstract concepts involved in a discussion of the cause and effect regarding pathogens or to understand why hand washing is so important in preventing illness.

Which stage of HIV would a client with a CD4+ T-cell count of 325 cells/mm 3 be classified?

Stage 2 describes a client with a CD4+ T-cell count between 200 and 499 cells/mm 3. Stage 1 describes a client with a CD4+ T-cell count of greater than 500 cells/mm 3. Stage 3 describes a client with a CD4+ T-cell count of less than 200 cells/mm 3. Stage 4 describes a client with a confirmed HIV infection but no information regarding CD4+ T-cell counts is available.

The parent of a 2-year-old calls a nurse who is a neighbor and reports that the child just ate several multivitamins with iron. What should the nurse say to the parent?

The Poison Control Center will provide the best guidance for treatment of excess ingestion of a substance; enemas, lavage, or chelation therapy with deferoxamine (Desferal), a heavy metal antagonist, may be recommended, depending on the amount ingested and the child's age and response. Orange juice will enhance absorption of the iron and will create a greater risk for toxicity. Iron is the most toxic substance in multivitamins. Although signs and symptoms may not be evident for several hours, treatment should be initiated before a problem develops. Emetics are not used for poisonings; they are not effective in removing the toxic substance, and causing the child to vomit creates a risk for aspiration.

A school nurse is asked to develop a program for teachers about infection control, especially focusing on hand washing technique. What is the most effective way for the nurse to evaluate what the teachers have learned?

The best way to evaluate learning is by feedback demonstration of precautions related to infection control, such as hand washing techniques. This method is observable and must meet objective criteria. Although observing a lecture, giving a written exam, or sharing what has been learned in a seminar are all evaluation techniques that may be used, none of these methods are as objective and definitive as observing an actual psychomotor demonstration of techniques.

A child becomes cyanotic during a generalized tonic-clonic seizure. What is the most appropriate action by the nurse?

The child's status and the progression of the seizure should be monitored; the child will not breathe until the seizure is over, and cyanosis should subside at that time. Attempting to open a clenched jaw may result in injury to the child. Oxygen is useless until the child breathes when the seizure is over. The practitioner may be notified later; provisions for the child's safety and observation are the priorities.

Which hospital department plays a primary role in disaster preparedness?

The emergency department plays a primary role in emergency disaster preparedness. While all departments in the hospital contribute to disaster planning, the only department that plays a primary role is the emergency department.

A nurse is planning to teach the four-point alternate crutch gait to a 9-year-old child with cerebral palsy. How does the nurse explain this choice to the parents?

The four-point alternate crutch gait is a simple, slow, stable gait because there are always three points of support on the floor, with equal but partial weight bearing on each limb. The child has the ability to move, but the movement in the lower extremities is uncoordinated. The four-point gait provides for three points of support, not two, at all times. A four-point gait divides weight bearing equally among the limbs.

A school nurse is teaching a health class of 12-year-olds about hepatitis C. Which statement by a student indicates an understanding of the origin of the disease?

The hepatitis C virus (HCV) is a blood-borne pathogen; it can be acquired during the application of a tattoo with equipment that is contaminated with the hepatitis C virus. Hepatitis C is not transmitted by close contact in crowded spaces; HCV is a blood-borne pathogen. HCV is not transmitted by casual contact; it is a blood-borne pathogen. The fecal-oral route of transmission is associated with hepatitis A, not hepatitis C.

Which of these age groups has the highest incidence of lead poisoning?

The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and because of their increased level of oral activity, put objects into their mouths. Adults have a greater risk of cardiovascular or pulmonary disease. Drowning and motor vehicle accidents are more common among adolescents. Bicycle accidents are more common among school-aged children.

What is it imperative for a mental health nurse to prevent clients from doing?

The physical safety of the client and others is the priority. Although it is important for clients to avoid breaking contracts, it is not imperative and cannot always be prevented. The nurse cannot control clients' thinking and perceptions.

A 2-year-old toddler requires close supervision to protect against potential accidents. The nurse teaches a class for parents about the learning style of toddlers. How do toddlers learn self-protection?

The toddler is developing autonomy, is curious, and learns self-protection from experience. Toddlerhood play is parallel play, not interactive, play. The struggle for autonomy at this age limits learning from siblings, even though the toddler attempts to copy their behavior. The toddler is still learning from experiences, not from others. The toddler is still attempting to distinguish the self as separate from the parents; the struggle for autonomy limits learning from parents. Toddlers learn gross and fine motor skills as they play with their toys, not self-protection.

The nurse is providing instruction to a parent of a child with influenza. Which statement by the parent indicates the need for further instruction?

The use of aspirin to treat the fever associated with influenza is contraindicated; it is associated with Reye syndrome, which involves a toxic encephalopathy and hepatic dysfunction. Inactivated influenza viral vaccines are effective in the prevention of influenza. Fever may lead to dehydration; fluids help maintain hydration. The influenza virus can be spread by direct contact or through contact with surfaces contaminated with the virus; staying home prevents the spread of the disease to other students.

A parent receives a note from school reporting that a student in class has head lice. The parent calls the school nurse to ask how to check for head lice. What instruction should the nurse provide?

The white dots are nits, the eggs of head lice ( Pediculosis capitis); they can be seen on the shaft of hair along the scalp line, behind the ears, and at the nape of the neck. Asking the child where it itches is too vague; objective visualization will confirm the presence of nits. Canine ear mites are not transferable to humans. Red lines between the fingers are a sign of scabies, infestation with the Sarcoptes scabiei mite.

A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the most appropriate nursing action?

A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse should apply cold compresses to the affected area to reduce the pain in the client. A client with Candida albicans infection should keep his or her skin clean and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may suffer from cardiac, arthritic, and neurologic manifestations. Therefore the nurse has to monitor for these symptoms. Direct contact may transmit a Sarcoptes scabieiinfection; the nurse should make sure that the client's clothes are bleached to prevent the transmission of the infection.

What is an example of a type I hypersensitivity reaction?

An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A blood transfusion reaction is a type II cytotoxic reaction.

After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our child have to have restraints?" How should the nurse respond?

An explanation of how the restraints work and why they are used may reassure the parents. Touching the suture line may cause a separation of the wound edges, predisposing the infant to infection and compromised wound healing. Explaining routine use of restraints does not explain why they are being used now. Restraints are not a legal requirement; applying elbow restraints is a postoperative prescription. Stating that the nurse cannot be with the infant continuously may give the parents the feeling that their baby's needs are not being met.

An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. What should the nurse tell the girl that may help her wear the bracelet consistently?

Because adolescents have a developmental need to conform to their peers, the teenager should be able to select a bracelet of a design similar to that of those worn by her peers. Hiding the bracelet under long-sleeved clothes might be acceptable in cool weather, but not when it is warm and friends are wearing T-shirts. The bracelet should be worn at all times when the girl is not with responsible family members. Asking friends to wear a similar bracelet may be difficult, especially if the girl does not wish to tell her friends why she needs the bracelet.

A nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. How should the nurse respond?

Because of the risk for infection, the client should avoid tub baths, hot tubs, pools, and immersion in other bodies of water until after the wound has healed and these activities are approved by the primary healthcare provider. Immersion in water for a prolonged period interferes with wound healing, because water may macerate tissue. Having a friend along does not change the fact that immersion in water for a prolonged period will interfere with wound healing. The client needs to continue physical therapy after discharge whether or not the client goes swimming.

A nurse is counseling the family of a child with AIDS. What is the most important concern that the nurse should discuss with the parents?

Children with AIDS have a dysfunction of the immune system (depressed or ineffective T lymphocytes, B lymphocytes, and immunoglobulins) and are susceptible to opportunistic infections. All children are subject to injury because of their curiosity, inexperience, and lack of judgment. Although inadequate nutrition can be a problem for children with AIDS, the prevention of infection is the priority. Although children with AIDS are usually small for age, altered growth and development is not as life threatening as an infection.

A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?

Children with leukemia most often die of infection; a low neutrophil count is associated with myelosuppressant therapy. Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques are the best ways to minimize complications. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion are not appropriate measures to prevent infection resulting from neutropenia; they are appropriate for treating the anemia. Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture are not appropriate measures to prevent infection resulting from neutropenia; they are more appropriate for preventing bleeding. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes are not appropriate measures to prevent infection resulting from neutropenia; they are used to ease and treat stomatitis.

What is the most commonly reported sexually transmitted infection (STI)?

Chlamydial infections are the most commonly reported sexually transmitted infection. Syphilis and gonorrhea are not the most commonly reported STI. Herpes simplex is not a reportable infection.

Which term describes the practice of placing clients with the same infection in a semi-private room?

Cohorting is the practice of grouping clients who are colonized or infected with the same pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to the development of an infection in the body. Cross-referencing has nothing to do with an infectious process.

What causes condylomata acuminate?

Condylomata acuminate are genital warts which are caused by the human papillomavirus (HPV). Genital warts are not caused by chlamydia, gonorrhea, or herpes simplex.

A 15-month-old child is hospitalized after ingesting toilet bowl cleaner. The mother confides that she feels guilty about leaving the cleaner where her child could get it. What is the best response by the nurse?

Describing the incident as an accident and recommending locks on closets accepts the mother's statement and helps the mother express her guilt while providing directions to safeguard her child. Poisoning is not an everyday occurrence; teaching should be incorporated to protect the child. Telling the mother that the child will get better is false reassurance; the child's condition is still in question. Calling the mother careless only increases the mother's guilt and provides nothing more than a vague suggestion of how to remedy the problem.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching?

Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.

A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child?

All nursing care should be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills, formulation of realistic ego boundaries, and opportunities to discharge energy are all important, prevention of injury is the priority.

What should the nurse encourage the parents of a child with plumbism (lead poisoning) to do?

All sources of lead must be removed from the home if the problem is to be controlled. Sources include lead-painted surfaces and old plumbing that has lead solder. Although pica must be controlled if it is present, this alone will not eliminate the environmental risks. The data do not indicate that the child is engaging in pica. Leaded gasoline is no longer used in the United States. Chelation therapy is based on the blood lead level; changes in bone take longer to evaluate.

Which pregnancy safety category shows a proven risk of fetal harm, but potential benefits of use during pregnancy may be acceptable despite its risks?

Category D drugs show a proven risk of fetal harm; however, potential benefits of its use during pregnancy are acceptable in case there is a life-threatening disease. Category A drugs pose little to no risk of fetal harm. Category X drugs have been proven to harm the fetus; the risks outweigh the possible benefits of using this drug. Category C drugs have harmed animal fetuses, but there is no conclusive evidence that the drug may harm human fetuses.

Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?

Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions.

For which illness should airborne precautions be implemented?

Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected to be transmitted by droplet include influenza and pneumonia. A disease that is known or suspected to be transmitted by direct contact is respiratory syncytial virus.

A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention?

Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.

A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What instruction should the nurse include in the accident-prevention teaching plan?

Excessively high temperatures can damage the delicate skin of an infant. Although infants are capable of putting small things in their mouths, a 3-month-old is not yet able to crawl and probably will not be placed on the floor. At 3 months of age infants are not yet able to explore the environment to the point that electric outlets pose a problem. At 3 months of age infants are still too small and have not yet developed motor capabilities to get into containers of poison.

An 8-year-old girl who is hospitalized for intravenous antibiotic therapy tells the nurse that she is bored. The nurse has a discussion with the father about appropriate activities. Which activity suggested by the father indicates a need for further teaching?

Playing with a bat and ball is an unsafe activity in a hospital setting; the IV catheter could be dislodged, and boisterous activity is dangerous to the other children on the unit. A radio and CD player, homework and school supplies, and rubber stamps and a collection box are all appropriate for the school-aged child.

A 4-year-old child is brought to the pediatric clinic for a well-child visit. While entering the examination room the child bumps into the door jamb and then tilts his head to one side. The nurse suspects that the child has strabismus. What additional clinical finding supports this conclusion?

Strabismus is a disorder in which the optic axes cannot be directed to the same object; this causes difficulty in focusing from one distance to the other. Eventually loss of vision in the eye will occur if the condition goes uncorrected. Squinting, a classic sign of strabismus, occurs because of the misalignment of the eyes. Bloodshot sclerae are associated with conjunctivitis, not strabismus. Blinking may indicate an affectation or nervous tic, not strabismus. Tearing may indicate blockage of the tear ducts, not strabismus.