week 2 cc

The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What are the appropriate nursing responses? Select all that apply. "We have to do this treatment to help your wound heal." "Medical maggots are sterilized before they are introduced to the wound." "I understand your concern; let's talk further about your thoughts about this treatment." "If you do not have this debridement, you will get septicemia and possibly die." "The choice regarding whether to have or decline this treatment is yours."

"Medical maggots are sterilized before they are introduced to the wound." "I understand your concern; let's talk further about your thoughts about this treatment." "The choice regarding whether to have or decline this treatment is yours."

The parents of a 4-month-old diagnosed with sepsis tell the nurse that the physician explained sepsis to them but they don't really understand it. The parents state, "Could you please explain it to us?" What is the best response by the nurse? "Sepsis results in systemic inflammatory response syndrome (SIRS) due to infection." "The pathophysiology of sepsis is complex." "The infection your child has causes the release of toxins into the system, which can lead to impaired function in the lungs, liver, and kidneys." "The pathogens cause an overproduction of proinflammatory cytokines. These cytokines are responsible for the clinically observable effects of the sepsis."

"The infection your child has causes the release of toxins into the system, which can lead to impaired function in the lungs, liver, and kidneys."

A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room? A room with a 12-month-old infant with a urinary tract infection A room with an 8-month-old infant with failure to thrive A private room near the nurses' station A two-bed room in the middle of the hall

A private room near the nurses' station

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is A young female adolescent who developed shock from tampon use during menses An older adult man with end-stage renal disease and an infected dialysis access site An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection A middle-aged woman with metastatic breast cancer and a BMI of 26

An older adult man with end-stage renal disease and an infected dialysis access site

An older adult client is diagnosed with acute pancreatitis. Using what the nurse understands about gerontologic considerations related to acute pancreatitis, what concept does the nurse understand? Select all that apply. As the client ages, there is an increased risk for the development of acute pancreatitis. As the client ages, there is an increased mortality rate for acute pancreatitis. As the client ages, there is an increased risk for the development of multiple organ dysfunction syndrome. As the client ages, the pattern of complications related to acute pancreatitis changes. As the client ages, the size of the pancreas decreases, increasing the risk of developing acute pancreatitis.

As the client ages, there is an increased mortality rate for acute pancreatitis.

The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following? Bacteria Virus Lymphoma Leukemia

Bacteria

A practitioner is preparing to do a lumbar puncture on a client with suspected meningitis. Which area on the spine does the practitioner choose to obtain a cerebrospinal fluid (CSF) sample? Between L3 and L4 Between T12 and L1 Between C7 and C8 Between T1 and T2

Between L3 and L4

Which diagnosis puts a client at risk for developing an immunologic form of interstitial lung disease? Rheumatoid arthritis Cancer Asbestosis Septicemia

Rheumatoid arthritis

What is the most common gram-negative bladder infection found in hospitalized clients? Catheter-induced infection Neurogenic bladder Stone formation Urinary incontinence

Catheter-induced infection

Your client is being prepared for surgery. His health care provider has indicated that he will order antibiotics as prophylaxis. Which of the following medications would you anticipate being ordered? Penicillin G Amoxicillin Cephalosporin Vibramycin

Cephalosporin

A client is admitted to the hospital in Addisonian crisis 1 month after a diagnosis of Addison disease. The nurse knows which clinical manifestation would support this diagnosis? Hyperactive deep tendon reflexes and slow, shallow breathing Cerebral spinal fluid leakage and impaired swallowing Irregular heart rate and decreased temperature Change in level of consciousness and profound hypotension

Change in level of consciousness and profound hypotension

The nurse is monitoring a client who has undergone cystoscopy because the client's history indicates urinary infection. Which of the following would the nurse need to report to the physician? Chills and fever Dysuria and discolored or malodorous urine Hematoma and frank bleeding Flank pain and rapid pulse

Chills and fever

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? Stress ulcer Disseminated intravascular coagulation (DIC) Septicemia Stevens-Johnson syndrome from the administration of antibiotics

DIC

A client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. He's fatigued from lack of sleep; urinates frequently, even during the night; and has lost weight recently. Tests reveal the following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl (6.9 mmol/L), and potassium level 3.8 mEq/L (3.8 mmol/L). Which nursing diagnosis is most appropriate for this client? Deficient fluid volume related to inability to conserve water Imbalanced nutrition: Less than body requirements related to hypermetabolic state Deficient fluid volume related to osmotic diuresis induced by hypernatremia Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency

Deficient fluid volume related to inability to conserve water

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first? Institute droplet precautions. Obtain the child's vital signs. Ask the parent about medication allergies. Inquire about the health of siblings at home.

Institute droplet precautions.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in which organ? Brain Lungs Liver Kidneys

Lungs

The pathogenesis of multi-organ dysfunction syndrome (MODS) is not clearly understood at this time. Supportive management is currently the focus of treatment in this disorder. What is not a major risk factor in MODS? Advanced age Alcohol abuse Respiratory dysfunction Infarcted bowel

Respiratory dysfunction

An acutely ill client is developing multiple organ dysfunction syndrome (MODS). The nurse knows that which statements regarding multiple organ dysfunction syndrome are accurate? Select all that apply. Organs affected include kidneys, lungs, liver, brain, and heart. MODS rarely occurs with septic shock. Homeostasis is disrupted. Risk factors for development of MODS include severe trauma, hepatic dysfunction, and prolonged hypotension. Treatment is primarily supportive of the affected organs.

Organs affected include kidneys, lungs, liver, brain, and heart. Homeostasis is disrupted. Risk factors for development of MODS include severe trauma, hepatic dysfunction, and prolonged hypotension. Treatment is primarily supportive of the affected organs.

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? Shock Pancreatic necrosis MODS Tetany

Pancreatic necrosis

The nurse caring for a client diagnosed with a ruptured appendix will assess for which high-risk complication? Peritonitis Vomiting Diarrhea Gastritis

Peritonitis

A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza? Septicemia Pneumonia Meningitis Pulmonary edema

Pneumonia

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention? Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months Promoting communication with the client and family along with addressing end-of-life issues Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

Promoting communication with the client and family along with addressing end-of-life issues

A client in the intensive care unit died shortly after developing multiple organ dysfunction syndrome (MODS). Which health problem most likely preceded the client's MODS? Heart failure Disseminated intravascular coagulation Acute renal failure Sepsis

Sepsis

A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? Treatment with antimicrobial prophylaxis as soon as possible Admission to the nearest hospital for observation No treatment unless the roommate begins to show symptoms Bedrest at home for 72 hours

Treatment with antimicrobial prophylaxis as soon as possible

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? Place a cooling blanket beneath the client Provide oxygen or anticonvulsants, whichever is available Turn the client to the side during a seizure and do not restrain movements Suction the client's mouth and pharynx

Turn the client to the side during a seizure and do not restrain movements

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which primary conditions? Select all that apply. abruptio placenta severe preeclampsia septicemia isoimmunization ectopic pregnancy

abruptio placenta severe preeclampsia septicemia

The physician prescribed imipenem-cilastatin (Primaxin), the nurse should be aware that the use of this medication would be contraindicated or used with caution in which clients? Select all that apply. child 7 years of age with a fractured femur and septicemia. client 27 years of age with a seizure disorder and an abdominal infection. client 54 years of age with liver failure and endocarditis. client 59 years of age with a dysrhythmia and serious infection of the leg. client 67 years of age with renal failure and an infection near the heart.

client 27 years of age with a seizure disorder and an abdominal infection. client 54 years of age with liver failure and endocarditis. client 67 years of age with renal failure and an infection near the heart.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in the brain. lungs. liver. kidneys.

lungs.

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6°F (37°C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16 breaths/minute, and heart rate (HR) 78 bpm, but these signs are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)? temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24 breaths/min temperature 100.7° F (38.2° C), BP 118/68 mm Hg, HR 84 bpm, RR 20/ breathsmin temperature 99.5° F (37.5° C), BP 126/80 mm Hg, HR 58 bpm, RR 16 breaths/min temperature 97.5° F (36.4° C), BP 98/64 mm Hg, HR 98 bpm, RR 18/ breathsmin

temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24 breaths/min

Which condition is a complication of infection in which pathogens gain access to the blood? Septicemia Bacteremia Septic shock Chronic infection

Septicemia