Nokea
A client informs the nurse, 'I think I am getting sick.' The chief symptoms of the client are low-grade fever, headache, and having no energy. What stage of the infection does the nurse recognize the client is experiencing?
- A. Incubation period
- B. Prodromal stage
- C. Acute stage
- D. Convalescent stage
Correct Answer: B
Rationale: In the prodromal stage, the initial symptoms appear; they may be vague and nonspecific. Possible symptoms include mild fever, headache, and loss of usual energy. The incubation period does not exhibit any recognizable symptoms. The acute stage is when the symptoms become severe and specific to the affect tissue or organ. The convalescent stage is when symptoms subside as the host overcomes the infectious agent.
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A family member wants to donate blood for a client who needs a blood transfusion. What information from the family member would make them ineligible for donation?
- A. The family member was serving in the military in England in 1993 for 2 years.
- B. The family member had a surgical procedure 4 years previously for an inguinal hernia.
- C. The family member received a blood transfusion 10 years previously at a hospital in Canada.
- D. The family member takes an antihypertensive medication for control of blood pressure.
Correct Answer: A
Rationale: The American Red Cross bans blood collection from anyone who has lived in the United Kingdom for a total of 6 months or longer between 1980 and 1996, lived in various countries in Europe including while serving in the military since 1980, received a blood transfusion in the United Kingdom, or lived 5 or more years in various European countries from 1980 to the present. There is a higher risk among these potential donors for BSE or 'mad cow disease.' The other answers are not exclusion criteria for donating blood.
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?
- A. The client has a multidrug-resistant strain of bacteria.
- B. The client has been misdiagnosed and has another type of microorganism present.
- C. Staphylococcus aureus cannot be treated by antibiotics.
- D. Staphylococcus aureus is a fungus and must be treated with an antifungal agent, not an antibiotic.
Correct Answer: A
Rationale: 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.
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 is diagnosed with a viral illness and requests an antibiotic to 'cure' the 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?
- A. I will speak with the physician again. You will only get better while taking an antibiotic.'
- B. Prescribing antibiotics for a viral infection may result in drug-resistant bacteria.'
- C. You need to think positively, and you will get better soon.'
- D. Taking antibiotics when you don't need them will make you sick.'
Correct Answer: B
Rationale: 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. Informing the client that taking unnecessary antibiotics will cause illness is not detailed enough to be an informative response.
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.