NUR 310 Week 2 Infection/Tissue Integrity

Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor?

Pseudomonas The purulent exudates of greenish-blue pus with a fruity odor signifies the colonization of Pseudomonas. Proteus colonization causes pus with a fishy odor. The colonization of Bacteroides causes brownish pus with a fecal odor. Staphylococcus colonization results in purulent exudate of creamy yellow pus. *creamy yellow pus (colonization with Staphylococcus) *greenish blue pus causing staining of dressing and accompanied by a "fruity" odor (colonization with pseudomonas) *beige pus with a "fishy" odor (colonization with proteus) *brownish pus with a "fecal" odor (colonization with aerobic coliform and bacteroides -usually occurs after intestinal surgery)

What is the mechanism of action for wet-to-damp saline-moistened gauze for wound debridement?

Removing the necrotic tissue mechanically Wet-to-damp saline-moistened gauze mechanically removes the necrotic tissue. The dilution of viscous exudates is promoted through the continuous wet-gauze technique. Topical enzyme preparations cause a breakdown of the denatured protein of eschar. Moisture-retentive dressings promote the spontaneous separation of necrotic tissue through autolysis.

While obtaining the health history of a 15-month-old toddler, the child of a migrant worker, a nurse learns that the infant recently had a fever, runny nose, cough, and white spots in the mouth lasting 3 days. A rash started on the face and spread to the whole body. What communicable disease does the nurse suspect the infant suffered from?

Rubella Rubeola** Pertussis Varicella White spots in the mouth (Koplik spots) and the rash, combined with increased mucus secretions (coryza), are indicative of measles (rubeola). Rubella (German measles) does not cause Koplik spots. Pertussis (whooping cough) has a distinctive cough, but there are no Koplik spots or rash. Varicella (chickenpox) features skin lesions rather than a rash and lesions in the mouth.

Which urinalysis finding indicates a urinary tract infection?

Presence of crystals Presence of bilirubin Presence of ketones Presence of leukoesterase** Leukoesterases are released by white blood cells as a response to an infection or inflammation. Therefore, the presence of this chemical in urine indicates a urinary tract infection. The presence of crystals in the urine indicates that the specimen had been allowed to stand. Presence of bilirubin in the urine indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting. The presence of ketones indicates diabetic ketoacidosis.

Trimethoprim/sulfamethoxazole is prescribed for a child with a urinary tract infection. Which statement by the parent about the drug indicates that the nurse's instructions about administration have been understood?

"Mealtime is a good time to give the medication." "I'll make sure to give each pill with 6 to 8 oz (180 to 240 mL) of fluid."** "It must be taken with orange juice to ensure acidity of urine." "The drug has to be taken every 4 hours to maintain a blood level." This is a sulfa drug; water must be encouraged to prevent urine crystallization in the kidneys. This drug does not have to be given with meals; it is administered every 12 hours. Orange juice causes an alkaline urine; water is the best fluid to be administered with this drug. This drug maintains the blood level for 8 to 12 hours; it is an intermediate-acting drug.

Which statements regarding acne are correct?

Acne is a hormonal disease. Acne may be caused by stress.** Family history could be a reason for it***. Propionibacterium acnes causes acne.*** Acne is commonly found on the face, chest, lower back, and neck. Stress and family history may cause acne formation. The causative organism is Propionibacterium acnes. Acne is not a hormonal disease; rather, it is a skin disease due to hormonal imbalance. Acne is commonly found on the face, chest, upper back, and neck where there are a higher number of sebaceous glands.

How would the nurse describe the exudate characteristic of a serosanguineous wound?

Blood-tinged amber fluid Blood-tinged amber fluid is characteristic of serosanguineous wound exudate. Greenish-blue pus, creamy yellow pus, and beige pus with a fishy odor are characteristics of purulent wound exudate.

What is the most common cause of ophthalmia neonatorum in infants born to adolescent mothers?

Chlamydia

A client who is recovering from deep partial-thickness burns develops chills, fever, flank pain, and malaise. The primary healthcare provider makes a tentative diagnosis of urinary tract infection. Which diagnostic tests should the nurse expect the primary healthcare provider to prescribe to confirm this diagnosis?

Cystoscopy and bilirubin level Specific gravity and pH of the urine Urinalysis and urine culture and sensitivity*** Creatinine clearance and albumin/globulin (A/G) ratio The client's manifestations may indicate a urinary tract infection; a culture of the urine will identify the microorganism, and sensitivity will identify the most appropriate antibiotic. A cystoscopy is too invasive as a screening procedure; altered bilirubin results indicate liver or biliary problems, not urinary signs and symptoms. Creatinine clearance reflects renal function; A/G ratio reflects liver function. Although an increased urine specific gravity may indicate red blood cells (RBCs), white blood cells (WBCs), or casts in the urine, which are associated with urinary tract infection, it will not identify the causative organism.

Which influenza vaccine is administered by way of the intranasal route?

Flumist

Which condition is an example of a bacterial infection?

Impetigo Impetigo is the bacterial infection of skin caused by group A β-hemolytic streptococci or Staphylococcus aureus. Candidiasis is the fungal infection caused by Candida albicans. Plantar warts and verucca vulgaris are viral infections caused by the human papilloma virus.

A nurse is caring for an infant born with a myelomeningocele who is scheduled for surgery. What is the priority preoperative goal for this infant?

Keeping the infant sedated Keeping the infant infection free** Ensuring maintenance of leg movement Ensuring development of a strong sucking reflex Prevention of infection is the priority both before and after the repair of the sac. Sedatives are not indicated; analgesics are administered as needed. Leg movement may be a postoperative goal, although it may be unrealistic because these infants' lower bodies are usually paralyzed. The sucking reflex is not associated with myelomeningocele.

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?

Necrotizing Fasciitis Necrotizing fasciitis destroys subcutaneous tissue and fascia and predisposes the client to infection and sepsis. Although fluid volume and physical mobility are important, they are not the primary concern at this time. Necrotizing fasciitis is a problem of the integumentary, not the urinary, system.

Which vaccine is used to prevent a human papilloma virus infection?

1) Varivax 2) RotaTeq 3) Gardasil** 4) Hepatitis A vaccine Gardasil is a quadrivalent vaccine used to prevent genital cancers and warts caused by human papilloma virus. Varivax is associated with protection from the varicella virus; this vaccine is sometimes given in combination with the MMR vaccine. The RotaTeq vaccine is used to vaccinate against a rotavirus infection. The hepatitis A vaccine is used to protect against the hepatitis A virus.

A client is receiving antibiotics and antifungal medications for the treatment of a recurring vaginal infection. What should the nurse encourage the client to do to compensate for the effect of these medications?

1) Eat yogurt with active cultures daily.** 2) Avoid spicy foods. 3) Drink more fruit juices. 4) Take a multivitamin every day. Yogurt contains Lactobacillus acidophilus, which replaces the intestinal flora destroyed by antibiotics. Spicy foods, fruit juices, and multivitamins are not relevant to antibiotics or intestinal flora.

Which clinical manifestation is associated with cellulitis?

1) Lymphadenopathy** 2) Occasional papules 3) Vesicles that evolve into pustules 4) Isolated erythematous pustules Cellulitis is accompanied by lymphadenopathy. Occasional papules are present in folliculitis. Herpes simplex viral infections evolve the vesicles into pustules. Isolated erythematous pustules occur in folliculitis bacterial infections.

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care at home. What should the nurse instruct the client to do?

1) Skip the oral hypoglycemic pill, drink plenty of fluids, and stay in bed. 2) Avoid food, drink clear liquids, take a daily temperature, and stay in bed. 3) Eat as much as possible, increase fluid intake, and call the office again the next day. 4) Take the oral hypoglycemic pill, drink warm fluids, and check blood sugar before meals and at bedtime.** Physiological stress increases gluconeogenesis, requiring continued pharmacological therapy despite an inability to eat; fluids prevent dehydration and monitoring blood sugar levels permits early intervention if necessary. Skipping the oral hypoglycemic can precipitate hyperglycemia; serum glucose levels must be monitored. Food intake should be attempted to prevent acidosis; oral hypoglycemics should be taken and serum glucose levels should be monitored. Telling the client to eat as much as possible, increase fluid intake, and call the office again the next day are incomplete instructions; oral hypoglycemics should be taken and serum glucose levels should be monitored. Eating as much as possible can precipitate hyperglycemia.

A client has symptoms associated with salmonellosis. Which data are most relevant for the nurse to obtain from the client's history?

1)Any rectal cancer in the family 2)All foods eaten in the past 24 hours** 3)Any recent extreme emotional stress 4)An upper respiratory infection in the past 10 days The salmonella organism thrives in warm, moist environments; all foods eaten within the last 24 hours are the most relevant data. Washing, cooking, and refrigerating food limit the growth of or eliminate the organism. Salmonellosis is unrelated to cancer. The salmonella organism, not stress, causes salmonellosis. The salmonella organism is ingested; it is not an airborne or blood-borne infection.

Which complication may be caused by sepsis in burns?

1)Diarrhea 2)Constipation 3)Paralytic ileus** 4)Curling's ulcer Paralytic ileus, or hypoactive bowel, is a complication caused by sepsis in clients with burns. Diarrhea can be caused by the use of enteral feedings or antibiotics. Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions. It is caused by a generalized stress response to decreased blood flow to the gastrointestinal tract in clients with burns.

A child recovering from a severe asthma attack is given oral prednisone 15 mg twice daily. What is the priority nursing intervention?

1)Having the child rest as much as possible 2)Checking the child's eosinophil count daily 3)Preventing exposure of the child to infection** 4)Offering nothing by mouth to the child except oral medications Prednisone reduces the child's resistance to certain infectious processes and, as an antiinflammatory drug, masks infection. The child will self-limit activity depending on respiratory status. The eosinophil count is often consistently increased in children with asthma. The child will need adequate hydration to help loosen and expel mucus.

The clinic nurse is planning care for a client found to have chlamydia. Which treatment should the nurse plan to implement?

Administration of 1 g of azithromycin orally in a single dose The treatment of choice for chlamydial infection is 1 g of azithromycin orally in a single dose. The one-dose course is preferred because of its ease of completion. Acyclovir may be prescribed in a 7-day course for a genital herpes outbreak. Administering 250 mg of ceftriaxone intramuscularly in a single dose is the drug therapy recommended for gonorrhea. Benzathine penicillin G given intramuscularly as a single 2.4 million unit dose is the treatment for primary, secondary, and early latent syphilis.

What is the nurse's priority concern when caring for an infant born with exstrophy of the bladder?

Development of infection The constant seepage of urine from the exposed ureteral orifices makes the area susceptible to infection; infection must be prevented or controlled because it may ultimately lead to renal failure. Urine retention will not occur because of the constant seepage of urine. Although skin excoriation is a major concern, it is secondary to the development of a life-threatening infection. Although dehydration is a major concern, risk for infection is the priority for the infant at this time.

Which is the preferred drug of choice for the treatment of syphilis in a pregnant adolescent?

Penicillin G*** Doxycycline Tetracycline Erythromycin 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.

A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include?

Purpose of bronchodilators Importance of meticulous oral hygiene** Technique used in pursed-lip breathing Methods used to maintain a dust-free environment Microorganisms in the mouth are transferred easily to the tracheobronchial tree and are a source of potential infection; meticulous oral hygiene is essential to reduce the risk of respiratory infection. Bronchodilators will not prevent infection; they dilate the bronchi. Pursed-lip breathing will not prevent infection; it promotes gas exchange in the alveoli and facilitates more effective exhalation. It is impossible to maintain a dust-free environment.

The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." Which information should the nurse consider about rabies when planning care for this client?

Rabies is an acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system. Rabies is a viral infection that enters the body through a break in the skin and is characterized by convulsions and choking. Rabies is not caused by a bacteria; its outstanding symptoms are convulsions and choking. Rabies is not associated with a bacterial septicemia; it is caused by a virus. The virus specifically attacks nervous tissue and is carried in the saliva of infected animals.

A 6-year-old child comes to the school nurse reporting a sore throat, and the nurse verifies that the child has a fever and a red, inflamed throat. When a parent of the child arrives at school to take the child home, the nurse urges the parent to seek treatment. If the sore throat is not treated, what illness is of most concern to the nurse?

Rheumatic fever The child's symptoms are suggestive of hemolytic Streptococcus infection. Rheumatic fever is an inflammatory disease involving the joints, heart, central nervous system, and subcutaneous tissue that can occur if the infection is not treated. It is thought to be an autoimmune process that causes connective tissue damage. Tetanus is not caused by a streptococcal infection. The disorder described is not influenza or scarlet fever.

Which fungal infection does the client refer to as jock itch?

Tinea pedis Tinea cruris** Tinea corporis Tinea unguium Tinea cruris is a fungal infection commonly referred to as jock itch. It clinically manifests with well-defined scaly plaque in the groin area. Tinea pedis is a fungal infection commonly referred to as athlete's foot. It is clinically manifested as interdigital scaling and maceration, scaly plantar surfaces, erythema, and blistering. Tinea corporis is a fungal infection commonly referred to as ringworm. It is clinically manifested as an erythematous annular, ringlike, scaly lesion with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.

Which are barrier methods of contraception?

condoms, Lea's shield (cap), diaphragm 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.

Which condition is characterized by infection of a client's bone or bone marrow?

osteomyelitis Osteomyelitis is infection of bone or bone marrow. Osteomalacia is a condition characterized by softening of bones due to calcium or vitamin D deficiency. Herniated disc is caused by structural damage of the intervertebral discs in which the nucleus pulposus seeps through a torn or stretched annulus. Spinal stenosis is narrowing of the spinal canal.

A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. What could be the possible condition in the client?

tinea pedis