Nokea
A client comes to the clinic and informs of having a 'painful area under my armpit.' The nurse observes a 2-cm raised area that is erythremic and has a white substance inside of it. What does the nurse suspect the client may be experiencing?
- A. A lesion
- B. An abscess
- C. A fluid-filled vesicle
- D. A cancerous tumor
Correct Answer: B
Rationale: To prevent the spread of pathogens to adjacent tissues, a fibrin barrier forms around the injured area. Inside the barrier, a thick, white exudate (pus) accumulates. This collection of pus is called an abscess, which may break through the skin and drain or continue to enlarge internally. A lesion would not be filled with pus, nor would a cancerous tumor. A fluid-filled vesicle is associated with a viral type illness.
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The nurse is teaching a health class in the local public health center. What instructions should the nurse provide as the single most important measure to prevent the spread of infection?
- A. Minimal social contact
- B. Regular immunizations
- C. Thorough handwashing
- D. Sufficient food intake
Correct Answer: C
Rationale: 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.
A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?
- A. An induration of 12 mm
- B. An uneven erythemic area
- C. An induration of less than 1 mm
- D. An induration of 4 mm
Correct Answer: A
Rationale: 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 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.
The nurse is giving an educational talk to a local parent-teacher association. A parent asks how to help the family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?
- A. Encourage your family to adopt a healthy diet and exercise regimen.
- B. Encourage your family to stop smoking.
- C. Make sure your family has all their childhood immunizations.
- D. Make sure your family has regular check-ups.
Correct Answer: C
Rationale: 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 check-ups 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.
The nurse is working on a gerontology unit. A family member calls and tells the nurse they want 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 the nurse provide to someone with a respiratory infection?
- A. Avoid intake of frozen foods.
- B. Avoid visiting older adults.
- C. Avoid direct sunlight.
- D. Avoid meats and other protein-rich foods.
Correct Answer: B
Rationale: 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.
A client informs the nurse of having been using a douche to cleanse the vagina on a daily basis and is now experiencing itching and burning in the vaginal area. What should the nurse explain to the client that occurs when the vaginal pH is changed?
- A. It causes destruction of the normal flora of the vagina and allows the development of vaginal infections.
- B. The bottle must be contaminated with bacteria, and when the pH is changed, it allows the bacteria to enter the vaginal area.
- C. It will cause an allergic reaction in the vaginal area.
- D. When the vaginal pH is changed, it allows cancer cells to spread from the vagina to the cervix.
Correct Answer: A
Rationale: The acid environment is unfavorable for the multiplication of pathogenic bacteria and fungi. A change in vaginal pH or destruction of the normal flora, however, can promote the development of a vaginal infection. Bacteria do not cause the vaginal pH to change; the pH change allows bacteria to grow. Change in vaginal pH does not cause an allergic reaction and does not allow the development of cancer cells.