Tuberculosis
The nurse is reviewing data collected during the assessment of a client with tuberculosis. Which nursing diagnosis should the nurse select for this client? (Select all that apply.) A. Fatigue B. Resilience, Impaired C. Nutrition, Imbalanced: Less than Body Requirements D. Health: Community, Deficient E. Infection, Risk for
A,C,D,E
The nurse is providing care to a client who has been diagnosed with tuberculosis. Which diagnostic test should the nurse expect to be prescribed prior to initiating antibiotic treatment? (Select all that apply.) A. Sputum smear B. Intradermal PPD (Mantoux) test C. Polymerase chain reaction (PCR) D. Tine test E. Sputum culture
A,C,E
The nurse is caring for a child diagnosed with tuberculosis infection. Which risk factor should the nurse identify that would greatly increase the risk for progression to disease? (Select all that apply.) A. Age less than 2 years B. Magnitude of the infection C. Virulence of the organism D. Presence of HIV infection E. Genetic factors
A,D
The nurse prepares educational material on the development of tuberculosis for a group of new nurses. In which order should the nurse explain the disease process develops? WBCs surround bacteria Tubercle forms and caseous necrosis occurs Droplet nuclei enter the lungs and the bacteria multiply Scar tissue forms around tubercle and the lesion calcifies Mycobacterium tuberculosis in droplet nuclei enter the air
1. Mycobacterium tuberculosis in droplet nuclei enter the air 2. Droplet nuclei enter the lungs and the bacteria multiply 3. WBCs surround bacteria 4. Tubercle forms and caseous necrosis occurs 5. Scar tissue forms around tubercle and the lesion calcifies
As the nurse reviews the history of a client admitted in labor, the nurse notes that the client has inactive tuberculosis. Which should the nurse include in the plan of care for this client? A. The client will be allowed to breastfeed the infant. B. Pharmacologic therapy for the client should be initiated immediately. C. Once delivered, the infant will be placed on prophylactic treatment. D. Direct contact should be avoided until the client is noninfectious.
A
The public health nurse is training a nurse on tuberculin skin testing. Which information about the Mantoux test should the public health nurse include in the training? (Select all that apply.) A. "Diameter of induration is recorded in millimeters." B. "The test is read within 48 to 72 hours." C. "This test is less accurate than the T-SPOT test." D. "PPD (0.1 mL) is injected intradermally into the dorsal aspect of the forearm." E. "Ten tuberculin units are injected."
A,B
The nurse is planning care for a client who is homeless. The client is prescribed four drugs to treat tuberculosis. Which action should the nurse take to ensure compliance with this medication therapy? (Select all that apply.) A. Assess the client's understanding of the disease process, and identify misperceptions and emotional reactions. B. Tailor teaching concerning the drugs to the needs of the client. C. Work collaboratively with other healthcare team members to identify barriers or challenges. D. Ask the healthcare provider to consider hospitalizing the client for initial treatment to ensure compliance. E. Reduce the number of drugs and the duration of taking the medicine to accommodate the client's transient situation.
A,B,C
The nurse is preparing teaching for a client newly diagnosed with tuberculosis. Which drug generally used in initial treatment should the nurse include in the session? (Select all that apply.) A. Rifampin B. Pyrazinamide C. Isoniazid D. Ethambutol E. Amikacin
A,B,C,D
The nurse instructs a client with tuberculosis on prescribed medication. Which finding should the nurse instruct the client to report to the healthcare provider? (Select all that apply.) A. Hemoptysis B. Chest pain C. Yellow tint to sclera D. Orange tint to sweat E. Sudden weight gain
A,B,C,E
The infection control nurse is teaching the staff at a long-term care facility after a recent outbreak of tuberculosis. Which element of infection control should the nurse include in the teaching? (Select all that apply.) A. Treatment of clients with suspected or confirmed disease B. Identification of infected individuals C. Administration of the bacille Calmette-Gurin (BCG) vaccine to residents D. Implementation of universal screening E. Use of airborne precautions
A,B,E
The nurse is identifying interventions for a client with tuberculosis. Which nursing intervention should the nurse identify to address the risk of infecting others? (Select all that apply.) A. Teaching the client why it is important to comply with prescribed treatments for the whole course of therapy B. Informing all personnel who have contact with the client of the diagnosis C. Assessing self-care abilities and support systems D. Providing verbal and written instructions about when to take the medications E. Teaching the client how to avoid transmitting the disease to others
A,B,E
The nurse in a community clinic is asked to determine which clients require tuberculosis testing. Which individual should the nurse recommend for this screening? (Select all that apply.) A. An individual infected with HIV or at high risk for HIV infection B. An individual who had the bacille Calmette-Gurin (BCG) vaccine C. An individual that has had PPD D. An individual with close contacts who already have or are suspected to have tuberculosis E. An individual who is a resident or staff member of a long-term residential facility
A,D,E
The nurse is assessing a client with tuberculosis. Which should the nurse focus on during this assessment? (Select all that apply.) A. Skin color B. Nasal congestion C. Carbon dioxide level D. Presence of cough E. Difficulty breathing
A,D,E
The nurse is preparing a plan of care for a client diagnosed with tuberculosis. Which goal and outcome should the nurse identify for this client? (Select all that apply.) A. The client with latent infection completes therapy and does not develop active tuberculosis. B. The client will demonstrate behaviors that reduce the risk of spreading the disease to others. C. The client will articulate required treatment and follow-up care. D. The client will have the resources necessary to obtain required supplies and medications. E. The client with active tuberculosis complies with prescribed therapies, symptoms resolve, and chest x-rays improve.
B,C,D
The nurse suspects that a client is at risk for tuberculosis. Which risk factor should the nurse assess in this client? (Select all that apply.) A. Sharing clothes with an infected individual B. Living in a poorly ventilated environment C. Using injection drugs D. Being an immigrant to the United States E. Having a compromised immune system
B,C,D,E
A client with tuberculosis experiences shortness of breath, hypoxia, cyanosis, and subcutaneous emphysema. Which pathophysiologic change should the nurse suspect as causing this client's symptoms? A. Encapsulation of the bacilli B. Miliary tuberculosis C. Rupture of tuberculosis lesion D. Reactivation tuberculosis
C
An older adult client experiencing a cough, hemoptysis, night sweats, anorexia, and weakness reports being told of having tuberculosis when younger. Which reason should the nurse suspect is responsible for the client's current symptoms? A. Skeletal tuberculosis B. Dormant tuberculosis C. Reactivation tuberculosis D. New-onset tuberculosis
C
The nurse visits the home of a client with tuberculosis. Which action should the nurse teach family members to take during the first 2 weeks of treatment to prevent the spread of the infection to other family members? A. Emphasize the importance of maintaining good general health through diet and exercise. B. Ensure that housemates of the client are tested and receive prophylactic treatment if indicated. C. Use disposable tissues to contain respiratory secretions. D. Be compliant with the medication regimen.
C
The nurse instructs a client with tuberculosis on the medication rifampin. Which client statement indicates teaching has been effective? (Select all that apply.) A. "I need to take pyridoxine (vitamin B6) along with the rifampin." B. "I need to monitor my vision daily by reading a newspaper." C. "I should not be frightened if my urine changes to an orange-red color; it is a normal side effect." D. "I should not take aspirin while I am taking rifampin." E. "I should take rifampin on an empty stomach."
C,D,E
A client has a 6-mm area that is slightly red and soft to the touch at the site of a PPD (Mantoux) test. Which finding should the nurse document for this client? A. Positive response B. Positive response if the client had an abnormal chest x-ray C. Indeterminate response D. Negative response
D