CH 71
The nurse is instructing the family on home care of a patient with shingles. The family member asks if their teenage children should stay in a different room. What is the best response by the nurse?
"Have they had chickenpox or the varicella vaccine?" Explanation: To answer the question correctly, the nurse needs to know if the children had chickenpox or the varicella vaccine. If the children had the vaccine or the disease, then they are considered immune and no precautions are needed. If the children have not been vaccinated for chickenpox nor had the disease, it would be best to maintain distance. Shingles is contagious. Even though the patient may be in pain, this should not guide the nurse's response.
Which statement made by a client with a chlamydial infection indicates understanding of the potential complications?
"I need to treat this infection so it doesn't spread into my pelvis because I want to have children some day." Explanation: Chlamydia is a common cause of pelvic inflammatory disease and infertility. It doesn't affect the kidneys or cause birth defects. It can cause conjunctivitis and respiratory infection in neonates exposed to infected cervicovaginal secretions during delivery. Use of a diaphragm isn't a risk factor.
A nurse is teaching personal hygiene care techniques to a client with genital herpes. Which statement by the client indicates the teaching has been effective?
"I will wear loose cotton underwear." Explanation: Wearing loose cotton underwear promotes drying and helps avoid irritation of the lesions. The use of lubricants is contraindicated because they can prolong healing time and increase the risk of secondary infection. Lesions shouldn't be rubbed or scratched because of the risk of tissue damage and additional infection. Cool, wet compresses can be used to soothe the itch. The use of moisturizer on lesions isn't recommended.
The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?
"Make sure your family has all their childhood immunizations." Explanation: To help prevent and control community-acquired infections, nurses should encourage childhood immunizations. Vaccines stimulate the body to produce antibodies against a specific disease organism. The immunization protects children as well as adults who may not have developed sufficient immunity. Following a proper diet and exercise regimen and going for regular checkups are important, but these measures do not help prevent or control community-acquired infections. Smoking cessation does not reduce the risk of such infections either.
A nurse is caring for a male client with gonorrhea who's receiving ceftriaxone (Rocephin) and doxycycline (Vibramycin). The client asks the nurse why he's receiving two antibiotics. How should the nurse respond?
"Many people infected with gonorrhea are infected with chlamydia as well." Explanation: Treatment for gonorrhea includes the antibiotic ceftriaxone. Because many people with gonorrhea have a coexisting chlamydial infection, doxycycline or azithromycin (Zithromax) is also ordered. There has been an increase in the number of resistant strains of gonorrhea, but that isn't the reason for this dual therapy. This combination of antibiotics doesn't reduce the risk of reinfection or provide a faster cure.
A client you are caring for has developed a bladder infection while in the hospital. The client has had a Foley catheter for two weeks. The client's family asks you how the client got this infection. What would be your best response?
"People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital." Explanation: Hospitalized clients are more susceptible to infections than well people because they are exposed to pathogens in the healthcare environment, may have incisions or invasive equipment (e.g., intravenous lines) that compromise skin integrity, or may be immunosuppressed from poor nutrition, their disease process, or its treatment. Although all answers are correct, the most complete answer is A
Which of the following nursing instructions is most important for the nurse to emphasize to the client with a new HSV-2 diagnosis?
"The flu shot is recommended for people over 6 months of age." Explanation: The influenza vaccine is recommended for all people over 6 months of age. The patient is in the recommended age range. Ascertaining if the patient has any chronic illnesses is important, but it does not change the recommendation by the Centers for Disease Control and Prevention. There is no recommendation that the immunization be given only if the patient works around children or the elderly.
A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?
An induration of 12mm Explanation: The size of the induration, not including the surrounding area of erythema, is measured in millimeters. The measurement determines whether the reaction is significant. For example, a tuberculin skin test is test is considered positive if the induration is 10 mm or greater in persons with no known risk factors for TB; smaller measurements are significant in certain risk groups, such as immunocompromised clients. The other answers are not indicative of positive results. (less)
The nurse observes a physician leave the room of a patient in isolation for Clostridium difficile (C. difficile). The physician uses the alcohol-based hand sanitizer hanging on the wall to wash her hands and leaves the door open. Which of the following actions should the nurse take?
Ask the physician to wash her hands with soap and water. Explanation: C. difficile is resistant to alcohol-based and other hand sanitizers; therefore physicians should be instructed to wash their hands with soap and water. The nurse could report the observation to the infection control department, but that does not address the immediate concern of the physician contaminating other patients. There is no need for the room door to be closed. The nurse must take action to ensure the safety of other patients.
You are working on a gerontology unit. A family member calls and tells you he wants to bring the family in to see one of the clients on the unit. The family member is concerned because several of the family members have colds. What instructions should you provide to someone with a respiratory infection?
Avoid visiting older adults. Explanation: The nurse should instruct anyone with respiratory infections to avoid visiting older adults until symptoms subside; older adults are more susceptible to infections because their defense mechanisms are less efficient. It is not essential for the client to avoid frozen or protein-rich foods or direct sunlight.
The nurse is caring for a client with genital herpes experiencing a reoccurrence. Which nursing diagnosis would be the priority?
Impaired Skin Integrity Explanation: The priority nursing diagnosis focuses on the Impaired Skin Integrity. Interventions would include nursing instruction on the care of the skin to prevent further infection to self and others. The nurse would also focus on the management of the disease. Because this is a reoccurrence, Knowledge Deficit is not a priority. Psychosocial nursing diagnoses are not a priority at this time unless other data suggests.
Which of the following describes host interaction with an organism?
Infection Explanation: Infection indicates a host interaction with an organism. The term colonization is used to describe microorganisms present without host interference or interaction. Infectious disease is the state in which the infected host displays a decline in wellness due to the infection. Reservoir is the term used for any person, plant, animal, substance, or location that provides nourishment for microorganisms and enables further dispersal of the organisms
The nurse is completing the admission assessment on a patient with renal failure. The patient states, "I was diagnosed with impetigo yesterday." Which of the following is the appropriate nursing intervention?
Initiate contact isolation protocol. Explanation: Impetigo is a bacterial infection transmitted via contact. Therefore, the nurse should initiate contact isolation protocol. The patient would not be taking an antiviral medication for impetigo, would not need a negative pressure room, and would not wear a mask when outside the room.
A patient presents with vulvar itching and diffuse green vaginal discharge. Upon evaluation, she is prescribed metronidazole (Flagyl). What is the paramount nursing intervention in discharge planning?
Instruct the patient not to drink alcohol with this treatment. Explanation: While counseling to abstain from sex for 1 week is appropriate, the most important intervention is counseling to avoid alcohol during Flagyl treatment. Alcohol consumption while taking Flagyl creates a severe gastrointestinal reaction of nausea, vomiting, and flushing. Flagyl does not have to be taken with milk, and further STI testing is indeed recommended with the diagnosis of an STI
Which of the following terms describes the time interval after primary infection when a microorganism lives within the host without producing clinical evidence?
Latency Explanation: Latency is the time interval after primary infection when a microorganism lives within the host without producing clinical evidence. Virulence is the degree of pathogenicity of an organism. The incubation period is the time between contact and onset of sign and symptoms. Susceptibility is not possessing immunity to a particular pathogen.
Which of the following interventions should a nurse perform after administering injections of penicillin to a patient with an infection?
Make the patient wait at least 30 minutes before leaving Explanation: After administering injections of penicillin, the nurse should make the patient wait at least 30 minutes before allowing him or her to leave the health care facility. This is because reactions are frequent and can be severe enough to be fatal. It is not essential for the patient to avoid fluid or food intake or lie down for four hours after receiving penicillin
Which intervention should a nurse perform after administering an injection of penicillin to a patient with an infection?
Make the patient wait at least 30 minutes before leaving the health care facility. Explanation: After administering injections of penicillin, the nurse should make the patient wait at least 30 minutes before allowing him or her to leave the health care facility. This is because reactions are frequent and can be severe enough to be fatal. The muscle in which the injection is given does not need to be massaged. There is no indication for the patient to deep breathe or to lie flat for 6 hours following the injection.
The nurse is completing a community education via a pamphlet on sexually transmitted diseases. Which key point would the nurse place in bold letters?
Many people are asymptomatic and show no symptoms contributing to the spread of the disease. Explanation: The nurse is most correct to place information regarding prevention of sexually transmitted diseases in bold letters. The information that many people are asymptomatic and show no symptoms is an important point to stress. Common age-groups are an interesting fact. Repercussions of the disease are also important to highlight; however, prevention is most important
Which of the following is the most effective treatment for trichomoniasis?
Metronidazole (Flagyl) Explanation: The most effective treatment for trichomoniasis is metronidazole and tinidazole. Penicillin G benzathine is used for syphilis. Doxycycline and azithromycin are used in the treatment of Chlamydia.
The six elements necessary for infection include a causative organism, a reservoir of available organisms, a portal or mode of exit from the reservoir, a mode of transmission from reservoir to host, a susceptible host, in addition to which of the following?
Mode of entry to host Explanation: The six elements necessary for infection are a causative organism, a reservoir of available organisms, a portal or mode of exit from the reservoir, a mode of transmission from reservoir to host, a susceptible host, and a mode of entry to host. A mode of entry to the host, not a mode of exit from the host, is necessary for infection.
The nurse is required to manage and minimize sepsis in a patient with severe infection. Which of the following would be an appropriate nursing intervention?
Monitor the patient's vital signs. Explanation: When caring for a patient susceptible to developing sepsis, the nurse should monitor vital signs every 4 hours or as ordered medically, because changes may be the earliest indication of sepsis. The nurse should also encourage fluid and food intake in the patient, as sufficient intake helps restore biologic defense mechanisms. The patient may be weak and, therefore, need not be encouraged to perform mild activity. (l
Your client was admitted to your unit for observation regarding possible sepsis. As her nurse, you monitor her carefully and are to report any suspicious findings, which could indicate the development of systemic infection. What would be your primary nursing tasks in this effort?
Monitor your client's vital signs. Explanation: Clients who are septic will exhibit two or more of the following: temperature greater than 100.4°F (38°C) or less than 96.8°F (36°C), heart rate greater than 90 beats/minute, respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mm Hg, and WBC count greater than 12,000 cells/mm3 or 10% immature (band) forms.
The nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and has developed oral thrush. What type of infection is the nurse aware that has developed due to the immunocompromised state of the client?
Opportunistic Explanation: An opportunistic or superinfection occurs among immunocompromised hosts. Examples would be yeast infections in the mouth, bladder infections, gastroenteritis, and Pneumocystis carinii. An acute infection has a sudden onset with serious and sometimes life-threatening manifestations. A chronic infection is an extended infection that resists treatment. A secondary infection is a complication of some other disease process that occurred first.
Which of the following is the medication of choice for early syphilis?
Penicillin G benzathine Explanation: A single dose of penicillin G benzathine intramuscular injection is the medication of choice for early syphilis or early latent syphilis of less than 1 year's duration. Patients who are allergic to penicillin are usually treated with doxycycline or tetracycline. Rocephin is not the medication of choice for syphilis.
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?
Pneumonia Explanation: Pneumonia is the most common complication of influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye's syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren't associated with influenza.
A nurse implements aseptic technique as a means to break the chain of infection at which element?
Portal of entry Explanation: The use of aseptic technique interrupts the chain of infection at the portal of entry. Employee health, environmental sanitation, and disinfection and sterilization interfere with the reservoir element. Hand hygiene, control of secretions, and excretions and proper trash and waste disposal interfere with the portal of exit. Isolation, proper food handling, airflow control, standard precautions, sterilization, and hand hygiene interfere with the means of transmission.
The nurse is working in the labor and delivery suite when a client with active herpes simplex virus type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care will the nurse prepare for?
Prepare for a cesarean section. Explanation: The nurse is most accurate to prepare for a cesarean section because the mother has an active lesion and does not want to transmit the virus to the newborn. Antibiotic therapy, at this time, does not prevent the transmission of the infection. A full assessment is always completed on the newborn and is not an adjustment in the plan of care. Antibacterial ointment is not placed on the mother's lesions.
A client is diagnosed with a viral illness and requests an antibiotic to "cure" his illness. When the request is refused by the physician, the client states to the nurse, "I will never get better."What is the best response by the nurse?
Prescribing antibiotics for a viral infection may result in drug-resistant bacteria." Explanation: Causes of antibiotic resistance, a consequence of bacterial mutations that interfere with the mechanism of antibiotic action, are related to inappropriate prescription of antibiotics for viral (rather than bacterial) infection. Because viral infections are often self-limiting, with symptoms control, the client will get better. Indicating that the client is not thinking positively is a nontherapeutic comment. Option D is not an informative response.
A patient complains of nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucous membranes to be pale and dry. The patient has sunken eyes with the following vital signs: pulse 122 and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which of the following is the priority nursing intervention?
Request an order from the physician for IV rehydration therapy. Explanation: The patient is demonstrating hemodynamic instability that could lead to shock, therefore IV rehydration therapy is indicated for this patient. Once the patient becomes hemodynamically stable, then oral rehydration therapy may begin. Although it is appropriate for the nurse to take vital signs frequently, the patient needs fluid replacement and that need should be addressed first. Stool specimens can be obtain once the patient is hemodynamically stable.
Pelvic infection is most commonly caused by which of the following?
Sexual transmission Explanation: Pelvic infection is most commonly caused by sexual transmission but can also occur with invasive procedures such as endometrial biopsy, surgical abortion, hysteroscopy, or insertion of an intrauterine device.
Which organism is responsible for impetigo?
Staphylococcus aureus Explanation: Staphylococcus aureus is the responsible organisms for impetigo. Histoplasma capsulatum is responsible for histoplasmosis. Bacillus anthracis is responsible for anthrax. Clostridium difficile is responsible for some diarrheal diseases.
Painless chancre or ulcerated lesions are associated with which systemic disease?
Syphilis Explanation: Syphilis is manifested by a painless chancre or ulcerated lesion. Psoriasis is exhibited by plaques with scales. Kaposi's sarcoma are cutaneous lesions blue-red or dark brown in color. Urticaria is wheals or hives due to infection or allergic reactions
Which statement reflects what is known about the Ebola and Marburg viruses?
The diagnosis should be considered in a patient who has a febrile, hemorrhagic illness after traveling to Asia or Africa. Explanation: The diagnosis should be considered in a patient who has a febrile, hemorrhagic illness after traveling to Asia or Africa, or who has handled animals or animal carcasses from those parts of the world. Antibiotic therapy, such as penicillin, would not be effective for the treatment of viruses. Treatment must be largely supportive maintenance of the circulatory and respiratory systems. The infected patient likely would need ventilator and dialysis support through the acute phases of illness. The viruses are usually spread by exposure to blood or other body fluid, insect bite, and mucous membrane exposure. Symptoms include fever, rash, and encephalitis which progress rapidly to profound hemorrhage, organ destruction, and shock.
A family member of a client in a long-term care facility asks the nurse why he cannot insert a catheter so the client will not develop skin breakdown from being wet. What should the explanation include when the nurse responds to the family member?
The invasive nature of the catheter provides a portal for infection. Explanation: Catheters provide a portal for infection because they are invasive. Although catheters are not used as frequently in older adults for the control of urinary incontinence, there are some bed-confined clients who use them. Family requests for catheters may be considered, but physicians make the decision if it will benefit the patient. Catheters are not flushed daily with anything
When a hospitalized patient is in contact precautions, which of the following responses is necessary?
The patient should be placed in a private room when possible. Explanation: When possible, the patient requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased environmental contamination. Masks are not needed, doors do not need to be closed, and a room with negative air pressure is not required.
You are teaching a health class in the local public health center. What instructions should you provide as the single most important measure to prevent the spread of infection?
Thorough handwashing Explanation: Hand hygiene remains the single most important measure to prevent the spread of infection. It reduces the number of transient and resident microorganisms. Sufficient food intake helps restore biologic defense mechanisms but does not prevent spread of infections. Although minimal social contact and regular immunizations may help prevent the spread of infection, especially community-acquired infections, these are not practical measures.
Nursing students are reviewing information about infectious diseases and events associated with infection. Students demonstrate understanding of the information when they identify the incubation period as which of the following?
Time between exposure and onset of symptoms Explanation: The incubation period is time between contact or exposure and the development of the first signs and symptoms. The presence of microorganisms without the host interacting with them is called colonization. The state in which the host displays a decrease in wellness characterizes an infectious disease. The process of the host shedding the microorganisms to another reflects the mode of ex
Nursing students are reviewing the various infectious diseases that require transmission-based precautions. The students demonstrate understanding of the information when they identify which infectious disease as requiring airborne precautions?
Tuberculosis Explanation: Airborne precautions are used for clients with tuberculosis. Contact precautions would be appropriate for clients wtih scabies or impetigo. Droplet precautions are appropriate for clients with rubella
A nurse would perform handwashing instead of using an alcohol-based product for which situation?
When hands are visibly soiled from client care Explanation: Handwashing would be done when the hands become visibly dirty or contaminated wtih biologic material from client care. Otherwise, an alcohol-based product could be used, for example, before putting on gloves for inserting a urinary catheter, after taking a client's temperature or blood pressure, or during client care when moving from a contaminated body site to clean body site.
The nurse is scheduled to administer tetanus, diphtheria, and pertussis (Tdap) vaccine to a patient at the clinic. The patient states, "I had a reaction the last time I got an immunization." What action should the nurse take first?
Withhold the immunization. Explanation: The nurse should withhold the immunization until a further investigation of the type of reaction and immunization received is completed. Patients who have had serious reactions or encephalopathy after receiving the pertussis vaccine should not receive the vaccine again. The patient may suffer a severe reaction if the Tdap is administered without investigation. Documentation of the reaction cannot happen until the nurse receives further information
The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when
the vesicles and pustules have crusted. Explanation: When the lesions have crusted, the patient is no longer contagious to others. The child remains contagious when the rash is present. The child remains contagious if the fever occurs as the rash is progressing. The child remains contagious when the rash is changing into vesicles and pustules.
A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
thirst or irritability. Explanation: Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs.
You are caring for a client with breast cancer who has been receiving chemotherapy. The client was admitted with an infected lesion on her left leg. The physician has ordered Neupogen. What will Neupogen do for this client?
• Boost the immune system • Increase white blood cell production Explanation: Bone marrow transplantation or administration of drugs that boost white blood cell production, such as filgrastim (Neupogen), may help immunosuppressed clients. Neupogen does not increase the platelet count or boost red blood cell production.
A client comes to the emergency department reporting severe diarrhea. The client is pale with dry mucous membranes and poor skin turgor. The nurse would suspect Eschericha coli (E. coli) as the potential cause when the client states which of the following?
"Yesterday for lunch, I ate a hamburger that was on the rare side." Explanation: Escherichia coli infection is often associated with the ingestion of undercooked ground beef, which should be cooked until the meat is no longer pink and the juices run clear. Salmonella is associated with undercooked eggs and chicken. Campylobactor also is commonly associated with improperly cooked or stored chicken. Drinking contaminated water from a mountain spring is associated with Giardia lamblia infection.
A client with syphilis is to receive penicillin G benazathine 1.2 million units IM as a single dose. The pharmacy supplies the medication, which is labeled as 2.4 million units/4 mL. How many milliliters would the nurse administer? Enter the number ONLY.
2 Explanation: The dosage ordered is one-half the amount of the drug supplied. Therefore, the nurse would give 2 mL. To calculate the amount, set up a proportion: 2.4/4 = 1.2/x; cross multiply and solve for x, which is 2. (less
Max Thornton, a 24-year-old chef, is being seen by a physician at the urology group where you practice nursing. He has developed a painless ulcer on his penis and is rather concerned about his health. The urologist will be communicating his diagnosis of syphilis and prescribing treatment. What would you expect the physician prescribe as treatment?
IV penicillin G—single dose Explanation: A single dose of parenterally administered penicillin G (Pfizerpen, Wycillin) is used to treat primary and secondary syphilis
The nurse is instructing a client with herpes simplex virus type 2 (HSV-2) about self-care and precautions. Select the answer which would not be a part of this instruction.
A condom does not need to be used during sexual activity if the disease is dormant. Explanation: A condom does need to be used during sexual activity even if the disease is dormant. Keep lesions dry using alcohol, peroxide, witch hazel, and warm air from a hair dryer. Inform all potential sexual partners of the HSV infection even if it is in an inactive state. Wear loose clothing that promotes air circulation about the genitals.
The nurse is caring for a client with an abscess on his back. The nurse observes purulent drainage coming from the abscess. What type of specimen does the nurse anticipate the physician will order to determine the type of bacteria present in the exudate?
A culture Explanation: A culture identifies bacteria in a specimen taken from a person with symptoms of an infection. The source of the specimen may be body fluids or wastes, such as blood, sputum, urine, or feces, or the purulent exudate, collection of pus, from an open wound. A test for ova and parasites is a stool specimen that is examined for evidence of any forms in the infecting microorganism's life cycle. A WBC count may determine that infection is present in the body but does not isolate the bacteria. A sensitivity test is done to determine which antibiotic inhibits the growth of a nonviral microorganism and will be most effective in treating the infection.
A client has been admitted with primary syphilis. Which signs or symptoms should the nurse expect to see with this diagnosis?
A painless genital ulcer that appeared about 3 weeks after unprotected sex Explanation: A painless genital ulcer is a symptom of primary syphilis. Macules on the palms and soles after fever are indicative of secondary syphilis, as is patchy hair loss. Wartlike papules are indicative of genital warts
A nurse is developing a plan of care for a female client experiencing her first outbreak of genital herpes. Which nursing diagnosis would the nurse most likely identify as the priority?
Acute pain related to the development of the genital lesions Explanation: Although deficient knowledge, ineffective coping, and hyperthermia are possible nursing diagnoses, the priority would be acute pain because the initial infection is usually very painful and lasts about 1 week
Which of the following medications are used to suppress viral load of the HSV-2 infection?
Acyclovir (Zovirax) Explanation: The antiviral agents acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir) are recommended to suppress the viral load and decreases recurrence and shedding. Flagyl and Cleocin are not used for this action
You are caring for a client with an impaired immune system. You are concerned about the client acquiring a nosocomial infection. What intervention would help nurses control nosocomial infections?
Apply principles of medical and surgical asepsis. Explanation: Nosocomial infections are acquired when receiving care in a healthcare facility. To help prevent and control nosocomial infections, nurses should apply principles of medical and surgical asepsis whenever they care for clients. Childhood immunizations control community-acquired infections. Maintaining a proper diet and exercise regimen and use of antibiotics do not help control nosocomial infections. (less)
The nurse is providing discharge instructions to a female client following inpatient therapy for a gonorrhea infection. The client is being discharged on doxycycline (Vibramycin) for 7 days. Which nursing instruction is essential for a therapeutic outcome?
Complete all prescribed medication. Explanation: The prescribed discharge medication is an antibiotic; thus, the therapeutic outcome would be to have no further infection. The nurse is most correct to instruct to complete all doses or the infection could return. Vibramycin does not have a cardiac side effect; thus, the client does not need to obtain a pulse prior to administration. It is correct to instruct the client to use an alternate form of birth control and take on an empty stomach (if tolerated); however, that instruction does not determine the therapeutic outcome
SARS is caused by which of following?
Coronavirus Explanation: SARS is caused by the coronavirus.
A client with suspected primary syphilis is to undergo diagnostic testing. Which of the following would the nurse expect to be done to confirm this diagnosis?
Direct identification in a specimen from the chancre lesion Explanation: The conclusive diagnosis of syphilis can be made by direct identification of the spirochete obtained from the chancre lesions of primary syphilis. Serologic tests such as VDRl, RPR-CT, and FTA-ABS are used in the diagnosis of secondary and tertiary syphilis.
Symptoms of pelvic infection usually begin with which of the following?
Dyspareunia Explanation: Symptoms of pelvic infection usually begin with vaginal discharge, dyspareunia (painful sexual intercourse), lower abdominal pelvic pain, and tenderness that occur after menses. Other symptoms include fever, general malaise, anorexia, nausea, headache, and possibly vomiting.
Patients who have had pelvic inflammatory disease (PID) are prone to which of the following complications?
Ectopic pregnancy Explanation: All patients who have had PID need to be informed of the signs and symptoms of ectopic pregnancy because they are prone to this complication. Other complications include bacteriemia with septic shock and thrombophlebitis with possible embolization. Patients who have PID are not prone to inguinal lymphadenopathy.
A nurse is preparing a presentation for a local community group in a small rural area about hantavirus pulmonary syndrome. Which of the following would the nurse suggest as a major prevention strategy?
Eliminating rodent food sources in areas near humans Explanation: Prevention of hantavirus pulmonary syndrome focuses on reducing human contact with rodents and their droppings. One prevention strategy is to eliminate rodent food sources in areas close to humans and using traps in areas where humans work and rodents may enter. Vaccination would be appropriate to prevent pertussis. Avoidance of whirlpool spas eliminates a risk factor for Legionnaire's disease. Wearing insect repellent could help to prevent West Nile Virus, which is transmitted from infected mosquitoes
A client visits the clinic with the complaint of a circular rash on the upper right arm. The rash is diagnosed as tinea corporis. What type of infection does the nurse anticipate the client will be treated for?
Fungus Explanation: One type of fungal infection is superficial (dermatophytoses), which affect the skin, hair, and nails; examples include tinea corporis, or ringworm, and tinea pedis, also known as athlete's foot. Rickettsiae, protozoans, and mycoplasma have different characteristics and transmission than fungus.
The nurse is presenting a community lecture about STIs. She emphasizes that some STIs are easily cured with early and adequate treatment. Which of the following is not among these easily treated diseases?
Genital herpes Explanation: Chlamydia, gonorrhea, and syphilis are easily cured with early and adequate treatment. Genital herpes is not.
After teaching a group of students about sexually transmitted infections (STIs), the instructor determines that additional teaching is necessary when the students identify which STI as curable with treatment?
Genital herpes Explanation: Besides AIDS, the five most common STIs are chlamydia, gonorrhea, syphilis, genital herpes, and genital warts. Of these, chlamydia, gonorrhea, and syphilis are easily cured with early and adequate treatment. Genital herpes recurs.
Which infection control equipment is necessary for the client diagnosed with Clostridium difficile diarrhea?
Gloves Explanation: The client diagnosed with Clostridium difficile diarrhea requires contact isolation. Contact isolation precautions require the use of glove and a gown if soiling is likely. A mask, face shield, and N-95 respirator aren't necessary to maintain contact isolation.
A client is hospitalized with a Clostridium difficile infection. Which of the following would the nurse include when providing care to this client?
Gloves and gowns for all client contact Explanation: Care of a client with C. difficile infection requires contact precautions with the use of gowns and gloves for all client contact. These spores are resistant to alcohol; therefore, the nurse needs to use soap and water to wash the hands. Bleach-based solutions and cleaning products are preferred for clean-ups
A physician tells a client to return 1 week after treatment to have a repeat culture done to verify the cure. This order would be appropriate for a woman with which condition?
Gonorrhea Explanation: Gonococcal infections can be completely eliminated by drug therapy. This cure is documented by a negative culture 4 to 7 days after therapy is finished. Genital warts aren't curable and are identified by appearance, not culture. Genital herpes isn't curable and is identified by the appearance of the lesions or cytologic studies. The diagnosis of syphilis is done using dark-field microscopy or serologic tests.
The infection control nurse collects data that indicates an increase in the number of clients in the hospital with multidrug-resistant infections. What priority education should healthcare providers receive?
Hand hygiene Explanation: Infections with multidrug-resistant microorganisms are very difficult to destroy with current pharmacologic agents, increasing the need to be vigilant about performing hand hygiene measures. It is unnecessary to use contact precautions, administer antibiotics prophylactically, or empty trash cans immediately for the preventions of multidrug-resistant infections. (less)
A nurse is assessing a woman with vaginal discharge. The nurse suspects bacterial vaginosis when the client states which of the following?
I noticed a strange fishy odor during my period." Explanation: Bacterial vaginosis is characterized by a fishlike odor that is particularly noticeable after sexual intercourse or during menstruation. Most clients do not experience local discomfort or pain; more than one half of clients do not notice any symptoms. Intense itching is often associated with candidiasis or trichomoniasis. A cottage-cheese like discharge is associated with candidiasis. A thin, yellow discharge is most commonly noted with trichomoniasis.
The nurse is observing a nursing assistant leave the room of patient diagnosed with Clostridium difficile (C. difficile) without washing hands. Which of the following is the highest priority action the nurse should follow?
Have the nursing assistant wash hands with soap and water. Explanation: Although all actions listed are appropriate, the priority nursing action is to ensure that nursing assistants wash their hands with soap and water. Allowing nursing assistants to continue with their job without washing their hands will lead to the nursing assistant infecting other patients with whom they come in contact. The potential for health care-associated acquisition is increased because the spore is relatively resistant to disinfectants and can be spread on the hands of health care providers.
Which type of sexually transmitted disease is the nurse most accurate to highlight in the client's history as it remains dormant in the body and can reoccur at any time?
Herpes infection Explanation: The nurse is most accurate to highlight the herpes infection as the virus can remain dormant in the ganglia of the nerves. Symptoms are usually more severe with the initial outbreak. Subsequent episodes are usually shorter and less intense. The other infections are important to note in the history.
A group of students are reviewing class material on sexually transmitted infections in preparation for a test. The students demonstrate understanding of the material when they identify which of the following as the cause of condylomata?
Human papilloma virus Explanation: Genital warts or condylomata are caused by the human papilloma virus (HPV). Herpes virus causes genital herpes. Treponema pallidum is the cause of syphilis. Haemophilus ducreyi bacillus is the cause of chancroid
Which of the following is the most common sexually transmitted infection (STI) among young, sexually active people?
Human papillomavirus (HPV) Explanation: HPV infection is the most common STI among young, sexually active people. Millions of Americans are infected with HPV, many unaware that they carry the virus.
A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
Foul-smelling discharge from the penis Explanation: Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.
A client is in the acute care facility for the administration of intravenous (IV) antibiotics to treat bacterial pneumonia. The client begins to have severe diarrhea 3 days after the IV antibiotics with abdominal cramping and pain. What does the nurse suspect the client has developed due to the antibiotic use?
Pseudomembranous colitis Explanation: When a client is taking an antibiotic, a superinfection can result from overgrowth of microorganisms not affected by the drug. This can lead to a serious inflammation of the colon called pseudomembranous colitis accompanied by potentially life-threatening diarrhea. Report fever, abdominal cramps, and severe diarrhea immediately. The other distractors are incorrect and not related to the use of the antibiotics
A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?
Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. Explanation: Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis.
After discussing the vaccine available for human papillomavirus with the mother of a 12-year-old female client, the mother agrees to have her daughter immunized. It is July when the nurse administers the first dose. The nurse would instruct the mother to bring the girl in for her second dose at which time?
September Explanation: The vaccine for human papillomavirus is given in three intramuscular doses, with the initial dose followed by a second dose in 2 months, and a third dose in 6 months after the first dose. For this girl, the second dose would be given 2 months after July, which would be September.
A client with a Staphylococcus aureus infection present in a sacral pressure ulcer has received treatment with three courses of antibiotics without eliminating the infection. What does the nurse understand has occurred with the client?
The client has a multidrug-resistant strain of bacteria. Explanation: Some bacteria, such as Staphylococcus aureus, Streptococcus pneumoniae, and Escherichia coli, are developing multidrug resistance, the ability to remain unaffected by antimicrobial drugs such as antibiotics. There are no facts to indicate the client has been misdiagnosed. Staphylococcus aureus is treated with antibiotics and is a bacterium, not a fungus
You work on a long-term care unit. In the last two weeks more than half the clients on your unit have been diagnosed with gastroenteritis. What is the most likely reason?
The infection is being transmitted by healthcare personnel. Explanation: Healthcare personnel are in frequent and direct contact with many clients who harbor various microorganisms; the risk for transmitting pathogenic microorganisms between clients is high.
After demonstrating to a group of nursing students the proper technique for handwashing using soap and water, the nursing instructor determines that the teaching has been successful when the students demonstrate which of the following?
Vigorously scrubbing between the fingers Explanation: Effective handwashing requires at least 15 seconds of vigorous scrubbing with special attention to the area around nail beds and between fingers, where there is high bacterial load. Hands should be thoroughly rinsed after washing and then dried. Artificial fingernails should not be worn
A patient is placed in isolation for suspected tuberculosis. Which of the following actions should the nurse take when entering the patient's room?
Wear an N-95 respirator. Explanation: Tuberculosis is acquired via airborne transmission. With airborne precautions, the room door must remain shut to ensure the effectiveness of the negative pressure room. All personnel entering the room should wear an N-95 respirator or similarly approved respirator. A simple face mask with an eye shield is not an effective barrier to stop transmission. There is no need to minimize verbal interactions with a patient with tuberculosis.
How often should women diagnosed with human papillomavirus (HPV) have Pap smears?
Yearly Explanation: Women with HPV should have annual Pap smears because of the potential of HPV to cause dysplasia.
A nurse is caring for a male client with gonorrhea. The client asks how he can reduce his risk of contracting another sexually transmitted disease (STD). The nurse should instruct the client to:
wear a condom every time he has intercourse. Explanation: Wearing a condom during intercourse considerably reduces the risk of contracting STDs. Asking all potential sexual partners if they have an STD; considering intercourse safe if his partner has no visible discharge, lesions, or rashes; and expecting to limit the number of sexual partners won't reduce the risk of contracting an STD to the extent wearing a condom will. A monogamous relationship also reduces the risk of contracting STDs.
Which of the following are risk factors for the development of a sexually transmitted disease (STD)? Select all that apply.
• Multiple partners • Unprotected sex • Prostitution Explanation: Risk factor for STD include having multiple partners, having unprotected sex, participating in prostitution, starting sex at an early age, and being under 26 years of age.
Which of the following can be used for rehydration therapy for diarrheal disorders?
Oral rehydration solution (ORS) Explanation: ORS may be used for rehydration therapy for diarrheal disorders. Foods that are high in simple sugars, such as undiluted apple juice or gelatin, should be avoided. Sports drinks do not replace fluid losses correctly and should not be used.
During flu season, you are teaching clients at your clinic about the chain of infection. Which of the following are considered "links" in this chain? Select all that apply.
• Infectious agent • Portal of entry • Susceptible host Explanation: The six components involved in the transmission of microorganisms are described as the chain of infection. All components in the chain of infection must be present to transmit an infectious disease from one human or animal to a susceptible host: an infectious agent, an appropriate reservoir, exit route, means of transmission, portal of entry, and susceptible host
A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply.
• Temperature of 102°F • Heart rate of 120 beats/minute • Respiratory rate of 24 breaths/minute Explanation: Two or more of the following characterize sepsis: temperature greater than 100.4°F (38°C), heart rate greater than 90 beats/minute, respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mm Hg, WBC count greater than 12,000 cells/mm3, or 10% immature (band) forms. Blood pressure is not an indicator of sepsis, and a PaCO2 of 42 mm Hg is not an indicator. (less)
You are a school nurse teaching a health class about the chain of infection in the transmission of sexually transmitted diseases (STDs). A student asks you which part of the chain of infection can be missing when transmission occurs. What would be your best answer?
"All parts of the chain of infection have to be present for the disease to be passed to another human." Explanation: All components in the chain of infection must be present for an infectious disease to be transmitted from one human or animal to a susceptible host. This makes options A, B, and C .
The nurse is caring for a patient diagnose with severe acute respiratory syndrome (SARS). A family member asks what causes SARS. Which of the following responses by the nurse is accurate?
"Coronavirus" Explanation: SARS is caused by the coronavirus. All other answers are incorrect.
A 36-year-old patient is in the clinic for an annual physical. The patient asks the nurse "should I get a flu shot." Which of the following is the best response by the nurse?
"The flu shot is recommended for people over 6 months of age." Explanation: The influenza vaccine is recommended for all people over 6 months of age. The patient is in the recommended age range. Ascertaining if the patient has any chronic illnesses is important, but it does not change the recommendation by the Centers for Disease Control and Prevention. There is no recommendation that the immunization be given only if the patient works around children or the elderly
Which of the following nursing interventions would a nurse be expected to do when caring for a client with syphilis? Choose all that apply.
All options are correct. Explanation: When caring for a client with syphilis, the nurse collects health information and a sexual history, inquires about the client's allergy history in anticipation of antibiotic treatment, and informs the client that notification of the sexual partner by the department of public health is important for his or her evaluation and treatment.
A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?
An isolation room three doors from the nurses' station Explanation: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.
Katrina Sterrett, a 26-year-old preschool teacher, is being seen by a physician who is part of the internist group where you practice nursing. She is undergoing her annual physical and is having many lab tests done as a condition of her employment and upcoming wedding. She is returning for her results and is devastated to learn that she has the sexually transmitted infection, gonorrhea. What would contribute to her ignorance of her condition?
Being asymptomatic Explanation: Many women who have gonorrhea are asymptomatic, a factor that contributes to the spread of the disease. Knowing the signs and symptoms of STIs will not help with an asymptomatic disease. Being sexually inactive currently will not prevent having been infected with a disease in the past. All options are not correct.
A nurse is caring for a client in the clinic. Which sign or symptom may indicate that the client has gonorrhea?
Burning on urination Explanation: Burning on urination may be a symptom of gonorrhea or urinary tract infection. A dry, hacking cough is a sign of a respiratory infection, not gonorrhea. A diffuse rash may indicate secondary stage syphilis. A painless chancre is the hallmark of primary syphilis. It appears wherever the organisms enter the body, such as on the genitalia, anus, or lips.
The nurse is caring for a group of clients at a public health clinic. Which sexually transmitted disease would the nurse focus the client education on curative goals?
Chlamydia Explanation: Chlamydia is the most common and fast spreading bacteria. Because it is a bacteria, with proper treatment, chlamydia is able to be cured. Sexually transmitted diseases that are viruses, such as HIV, HPV, and herpes, can lay dormant in the body thus being difficult to treat
A nurse would anticipate instituting contact precautions for a client with which of the following?
Clostridium difficile infection Explanation: Contact precautions would be appropriate for a client with an infection due to Clostridium difficile. Airborne precautions are appropriate for clients with measles or varicella. Droplet precautions are appropriate for clients with mumps. (l
Which of the following is a term used to describe microorganisms present without host interference or interaction?
Colonization Explanation: Colonization is used to describe microorganisms present without host interference or interaction. Infection indicates a hot interaction with an organism. Reservoir is any person, plant, animal, substance or location that provides living conditions for microorganisms and that enables further dispersal of the organism. Normal flora is persistent nonpathogenic organisms colonizing a host.
Which of the following terms refers to a state of microorganisms being present within a host without causing host interference or interaction?
Colonization Explanation: Understanding the principle of colonization facilitates interpretation of microbiologic reports. A susceptible host is a host that does not possess immunity to a particular pathogen. An immune host is a host that is not susceptible to a particular pathogen. Infection refers to host interaction with an organism. (less)
When assessing a client with suspected pertussis, which of the following would the nurse most likely find?
Paroxysmal cough Explanation: A client with pertussis usually presents with a sudden paroxysmal cough that is accompanied by a characteristic whoop. A high fever, chest pain, and diarrhea are associated findings of Legionnaire's disease.
Which stage of syphilis occurs when the infected person has no signs or symptoms of syphilis?
Primary Explanation: Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. Secondary syphilis occurs when the hematogenous spread of organisms from the original chancre leads to generalized infection. A period of latency occurs when the infected person has no signs or symptoms of syphilis. Tertiary syphilis presents as a slowly progressive inflammatory disease with the potential to affect multiple organs
Nursing students are reviewing information about sexually transmitted infections (STIs). They demonstrate a need for additional review when they identify which of the following as an example?
Shigella Explanation: Shigella is a gram-negative organism that invades the lumen of the intestine and causes disease and severe, watery diarrhea. Syphilis, human papillomavirus, and chlamydia are examples of STIs
A nursing assistant is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" The nurse reminds the nursing assistant to wash her hands and to ensure that the client is placed:
on contact isolation. Explanation: C. difficile can be transmitted from person to person by hands or waste containers such as a bedpan. A nurse who is in direct contact with the client should practice contact isolation, which includes wearing gloves and a gown. Protective isolation is used to protect a client who is immunocompromised, which isn't evident in this case. Neutropenic precautions are for clients with an absolute neutrophil count of 1,000/?l or less; this isn't evident in this case. A negative-pressure room is used when the organism is spread by the airborne route, which C. difficile diarrhea is not.
A nurse is teaching a client with genital herpes. Education for this client should include an explanation of:
the importance of informing his partners of the disease. Explanation: Clients with genital herpes should inform their partners of the disease to help prevent transmission. Petroleum products should be avoided because they can cause the virus to spread. The notion that genital herpes is only transmittable when visible lesions are present is false. Anyone not in a long-term, monogamous relationship, regardless of current health status, should follow safer-sex practices
