1.1 Infection EAQ
What disease is more commonly seen in preschoolers? Sinusitis Lung cancer Hypertension Angina pectoris
Sinusitis Rationale Toddlers and preschoolers are very prone to developing upper respiratory tract infections such as sinusitis. Lung cancer is seen commonly in young or middle-aged adults due to a smoking habit. Hypertension is commonly seen in middle-aged adults due to an unhealthy diet, lack of exercise, and stress. Angina also tends to affect young and middle-aged adults.
Which viral infection will cause the nurse to observe for warts? Pox virus Rhabdovirus Epstein-Barr virus Papillomavirus
Papillomavirus Rationale Warts are caused by papillomavirus. Pox viruses cause smallpox. Rhabdovirus causes rabies. Epstein-Barr causes mononucleosis and Burkitt's lymphoma.
Which stage of HIV would a client with a CD4+ T-cell count of 325 cells/mm 3 be classified? Stage 1 Stage 2 Stage 3 Stage 4
Stage 2 Rationale 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.
Which bacteria causes toxic shock syndrome in female clients? Treponema pallidum Streptococcus faecalis Staphylococcus aureus Neisseria gonorrhoeae
Staphylococcus aureus Rationale Staphylococcus aureus causes toxic shock syndrome. Treponema pallidum causes syphilis. Streptococcus faecalis causes genitourinary tract infections and infection of surgical wounds. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease.
Which drug treats hay fever by preventing leukotriene synthesis? Zileuton Cromolyn sodium Chlorpheniramine Diphenhydramine
Zileuton Rationale Zileuton[1][2] is a leukotriene antagonist drug; this substance prevents the synthesis of leukotrienes and helps in managing and preventing hay fever. Cromolyn sodium stabilizes mast cells and prevents the opening of mast cell membranes in response to allergens binding to immunoglobulin E. Chlorpheniramine and diphenhydramine are antihistamines and prevent the binding of histamine to receptor cells and decrease allergic manifestations.
A client is undergoing highly active antiretroviral therapy (HAART). From what viral disease could the client possibly be suffering? Hepatitis Herpes simplex virus (HSV) Human papillomavirus (HPV) Human immunodeficiency virus (HIV)
Human immunodeficiency virus (HIV) Rationale Highly active antiretroviral therapy (HAART) is a combination of antiretroviral drugs used to treat human immunodeficiency virus (HIV). Because hepatitis, herpes simplex virus (HSV), and human papillomavirus (HPV) are not retroviral, HAART is ineffective for these disorders.
An infant with cardiopulmonary disease who displays signs and symptoms of bronchiolitis and pneumonia was admitted to the hospital. What condition is the infant likely to have? Poliomyelitis Pneumococcal infection Meningococcal infection Respiratory syncytial virus infection
Respiratory syncytial virus infection Rationale Respiratory syncytial virus infections are the most common cause for hospitalization of infants younger than 1 year of age; this disease especially affects premature infants and infants with cardiopulmonary disease. Poliomyelitis is caused by the poliovirus. Streptococcus pneumonia infections cause meningitis, sepsis, pneumonia, and otitis media. Neisseria meningitidis causes meningitis.
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client? Use standard precautions. Employ airborne precautions. Plan interventions to limit direct contact. Discourage long visits from family members.
Use standard precautions. Rationale The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states that standard precautions should be used for all clients; these precautions include wearing of gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact and discouraging long visits from family members will unnecessarily isolate the client.
The nurse determines that a young female client who is being treated for a sexually transmitted infection (STI) understands instructions regarding future sexual contacts. Which client statement confirms the nurse's conclusion? "If I have sex, nothing I do will really prevent me from getting another STI." "If I get another STI, I can take any antibiotic, because I'm not allergic to any of them." "I won't have unprotected sex again, and I'll tell my partners to be tested for STIs." "I have to ask my partners if they have an STI, and if they say no I'll know that I can have sex."
"I won't have unprotected sex again, and I'll tell my partners to be tested for STIs." Rationale The most effective strategies for preventing sexually transmitted infections in one's self and sex partners are the use of condoms and having sex partners tested to determine their status and get treatment if necessary. There are protective measures that can be used to help prevent the transmission of STIs. The emphasis should be on prevention, not treatment; some STIs have no cure. Asking partners whether they have an STI does not always elicit a truthful answer; protection is necessary to help prevent the transmission of STIs.
A teenage mother is diagnosed with syphilis. What would be the drug of choice for this client if she wishes to continue breast-feeding? Doxycycline Tetracycline Azithromycin Benzathine penicillin
Benzathine penicillin Rationale Benzathine penicillin is safe to use for syphilis in lactating women. Doxycycline and tetracycline are used in the treatment of syphilis in nonpregnant women. Azithromycin is not the drug of choice for the treatment of syphilis.
Which are barrier methods of contraception? Select all that apply. Condom Lea's shield Diaphragm Spermicidal foam Coitus interruptus
Condom, Lea's shield, Diaphragm Rationale A condom is considered a barrier method of contraception because it prevents the entrance of sperm into the vagina. Lea's shield is a reusable vaginal contraceptive made of silicone. A diaphragm is a cervical covering used to prevent sperm from reaching the egg. Spermicidal foams are a chemical methods of contraception. Coitus interruptus is a withdrawal contraceptive method.
A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? No special precautions are required. Cover the infected site with a dressing. Drape the client with a covering labeled biohazardous. Place a surgical mask on the client.
Cover the infected site with a dressing. Rationale Covering the infected site with a dressing will contain secretions and set up a barrier, thus decreasing the risk for transmission to others. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Draping the client with a sheet marked biohazardous does not protect the client's privacy. A wound infected with MRSA can be transmitted to others via contact, not the airborne route; thus a mask is unnecessary.
Which diseases may occur due to rickettsial infections? Select all that apply. Leprosy Lyme disease Epidemic typhus West Nile fever Rocky Mountain spotted fever
Epidemic typhus, Rocky Mountain spotted fever Rationale Typhoid fever and Rocky Mountain spotted fever are caused by rickettsial infections. Spirochetes and Mycobacterium leprae cause leprosy. Borrelia burgdorferi cause Lyme disease. The West Nile virus causes West Nile fever.
An adolescent reports scrotal pain, redness, dysuria, and fever. Which condition does this adolescent have? Varicocele Epididymitis Testicular torsion Testicular cancer
Epididymitis Rationale Epididymitis is a condition associated with scrotal pain, dysuria, redness, and fever. Varicocele can be palpated as a worm-like mass situated above the testicles. Manifestations of testicular torsion include nausea, vomiting, and abdominal pain. The presence of a heavy, hard mass that is palpable accompanied by back pain and shortness of breath is associated with testicular cancer.
The bacteria Clostridium botulinum causes which condition in a client? Upper respiratory tract infection Toxic shock syndrome Urinary tract infection Food poisoning with progressive muscle paralysis
Food poisoning with progressive muscle paralysis Rationale Clostridium botulinum bacteria causes food poisoning with progressive muscle paralysis. Toxic shock syndrome is caused by the bacteria Staphylococcus aureus. Many viruses and bacteria can cause upper respiratory tract infection but Clostridium is not one of them. Klebsiella-Enterobacter organisms most likely cause urinary tract infections.
Which sexually transmitted disease is treated with antiviral drugs? Syphilis Gonorrhea Genital herpes Chlamydial infection
Genital herpes Rationale Genital herpes is a sexually transmitted disease caused by herpes simplex virus. Therefore antiviral drugs are used to treat this condition. Bacteria cause syphilis, gonorrhea, and chlamydial infections.
Which type of continuing care should a client expect if discharged home with an infusion device to continue treatment for a leg wound? Home care Rehabilitation Skilled nursing care Outpatient therapy
Home care Rationale Clients who are discharged with an infusion device to continue drug therapy at home should expect home care services to teach appropriate administration of drug therapy in the client's home. The client is being discharged to the home and not to rehabilitation or to a skilled nursing facility. Outpatient therapy is not identified as a method for continuing antibiotic therapy with an infusion device.
A 16-year-old client has a steady boyfriend with whom she is having sexual relations. She asks the nurse how she can protect herself from contracting human immunodeficiency virus (HIV). Which guidance is most appropriate for the nurse to provide? Ask her partner to withdraw before ejaculating. Make certain their relationship is monogamous. Insist that her partner use a condom when having sex. Seek counseling about various contraceptive methods.
Insist that her partner use a condom when having sex. Rationale A condom covers the penis and contains the semen when it is ejaculated; semen contains a high percentage of HIV in infected individuals. Preejaculatory fluid carries HIV in an infected individual, so withdrawing before ejaculation is not effective. Although a monogamous relationship is less risky than having multiple sexual partners, if one partner is HIV positive, the other person is at risk for acquiring HIV. The client is not asking about various contraceptive methods. Most contraceptives do not provide protection from HIV.
A school nurse is teaching a group of parents about the early signs of rubeola (measles). What sign related to rubeola should alert the parents to seek medical help? Macular rashes Scaly skin patches Bald patches on the scalp Generalized vesicular skin lesions
Macular rashes Rationale Rubeola (measles) starts with a discrete maculopapular rash on the face and spreads downward, eventually becoming confluent. Scaly skin occurs with eczema or dermatitis. Bald patches occur with tinea capitis (ringworm). Vesicular skin lesions occur with varicella (chickenpox).
Which nursing intervention prevents footdrop in a client with osteomyelitis? Elevating the foot with the use of pillows Consistently flexing the affected extremity Encouraging the client to change positions Neutral positioning of the foot with the use of a splint
Neutral positioning of the foot with the use of a splint Rationale A client with osteomyelitis is at an increased risk for footdrop, which results in an abnormal gait. Neutral positioning of the foot with the use of a splint can reduce the risk of footdrop in the client with osteomyelitis. Elevating the client's foot on pillows can reduce the risk of edema. Asking the client with osteomyelitis to flex the affected extremity can result in flexion contracture. Encouraging the client with osteomyelitis to change positions helps prevent complications associated with immobility and promotes comfort; carefully handle the involved limb and avoid excessive manipulation which may lead to a pathologic fracture.
Which is the preferred drug of choice for the treatment of syphilis in a pregnant adolescent? Penicillin G Doxycycline Tetracycline Erythromycin
Penicillin G Rationale According to the Center for Disease Control and Prevention, penicillin G is the preferred drug of choice for any stage of syphilis in pregnant women. Both doxycycline and tetracycline are contraindicated during pregnancy. Erythromycin may not be able to cure a fetal infection.
After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis? Nodules on the pinna Redness of the eardrum Lesions in the external canal Excessive soft cerumen in the external canal
Redness of the eardrum Rationale Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination. Nodules on the pinna may be an indication of rheumatoid arthritis, chronic gout, or basal or squamous cell carcinoma. Lesions in the external canal may cause a decrease in hearing acuity but not the manifestation of otitis media. Excessive soft cerumen in the external canal impacts the hearing acuity but not the manifestation of otitis media.
Which diseased condition associated with the client's heart is an example of an autoimmune disease? Uveitis Rheumatic fever Myasthenia gravis Graves' disease
Rheumatic fever Rationale Rheumatic fever is a heart disorder that is an example of an autoimmune disease. Uveitis is an eye disorder that is an example of an autoimmune disease. Myasthenia gravis is a muscle disorder that is an example of an autoimmune disease. Graves' disease is an endocrine disorder that is an example of an autoimmune disease.
Which virus can cause encephalitis in adults and children? Rubella virus Parvovirus Rotaviruses West Nile virus
West Nile virus Rationale The West Nile virus causes encephalitis. German measles is caused by rubella. Gastroenteritis is caused by parvovirus. Rotavirus also causes gastroenteritis.
Which is a leukotriene modifier used to manage and prevent allergic rhinitis? Zileuton Ephedrine Scopolamine Cromolyn sodium
Zileuton Rationale Zileuton is a leukotriene modifier used to manage and prevent allergic rhinitis. Ephedrine is an ingredient in decongestants used to treat allergic rhinitis. Scopolamine is an anticholinergic used to reduce secretions. Cromolyn sodium is a mast cell stabilizing drug used to prevent mast cell membranes from opening when an allergen binds to IgE.
A client diagnosed with osteomyelitis is being discharged. Which statement indicates a need for further teaching? "I will take the antibiotic at the same time every day." "I will take the antibiotic regularly until my symptoms subside." "I will take the antibiotic with food if I develop gastric distress when on the antibiotic." "I will notify my healthcare provider and stop taking the medication if I develop a rash or shortness of breath."
"I will take the antibiotic regularly until my symptoms subside." Rationale The antibiotic should be taken as prescribed for the full length of treatment. The client should not discontinue the medication when symptoms subside. The statements "I will take the antibiotic at the same time every day," "I will take the antibiotic with food if I develop gastric distress when on the antibiotic," and "I will notify my healthcare provider and stop taking the medication if I develop a rash or shortness of breath" demonstrate understanding of the discharge instructions.
Fill in the blank An older client who is living in a nursing home is admitted to the hospital to be treated with intravenous antibiotics for sepsis. After the client becomes agitated and attempts to pull out the IV, the healthcare provider prescribes a stat dose of haloperidol 0.5 mg intramuscularly (IM). The haloperidol is available in a vial that contains 2 mg/mL. How much solution will the nurse administer? Record your answer using two decimal places. Include a leading zero if applicable.
0.25 mL Rationale The prescribed dose is 0.5 mg. The available concentration is 2 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse should administer.
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? Applying cold compresses to the affected area Ensuring the client keeps the skin clean and dry Monitoring for neurological and cardiac symptoms Advising the client to launder all clothes with bleach
Applying cold compresses to the affected area Rationale 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 scabiei infection; the nurse should make sure that the client's clothes are bleached to prevent the transmission of the infection.
A child with a diagnosis of tuberculosis is admitted to the pediatric unit. Which location should the nurse select as the best placement for the child? Private room Isolation room Four-bed room Semiprivate room
Isolation room Rationale An isolation room is a private room fitted with special air handling and ventilation to prevent the transmission of airborne droplet nuclei 5 micrometers or smaller. It has monitored negative pressure to prevent air from moving from the room into the corridor of the facility. Room air is exchanged 6 to 12 times an hour to the outdoors or through a monitored high-efficiency filtration system. Mycobacterium tuberculosis remains suspended in the air for prolonged periods and is transmitted in air currents. A private room does not have the technical equipment to manage airborne droplet nuclei of 5 micrometers or smaller. Other children and people on the unit will be exposed to the infected individual's pathogens that travel through air currents. A four-bed room or semiprivate room will expose the children and other people on the unit to the infected individual's pathogens.
A client has a tuberculin purified protein derivative test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. What does the nurse conclude about the client based on this response? The client has contracted clinical tuberculosis. The client has passive immunity to tuberculosis. The client has been exposed to the tubercle bacillus. The client has developed a resistance to the tubercle bacillus.
The client has been exposed to the tubercle bacillus. Rationale Induration measuring 10 mm or more in diameter is interpreted as significant; it does not indicate that active tuberculosis is present. About 90% of individuals who have significant induration do not develop the disease. Exposure to the tubercle bacillus indicates exposure; infection can be past or present. Passive immunity occurs when the body plays no part in the preparation of the antibodies; a positive tuberculin purified protein derivative indicates the presence of antibodies, not how they were formed. Developing a resistance to the tubercle bacillus reaction indicates exposure, not resistance.
