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A nurse is caring for a client who is admitted to the hospital with suspected osteomyelitis. Which of the following laboratory tests should the nurse anticipate being ordered to aid in the diagnosis and monitoring of this condition?
- A. Erythrocyte sedimentation rate (ESR)
- B. Serum potassium levels
- C. Serum creatinine levels
- D. Prothrombin time (PT)
Correct Answer: A
Rationale: ESR is a marker of inflammation, commonly elevated in osteomyelitis, aiding in diagnosis and monitoring.
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The nurse is counseling a female client newly diagnosed with herpes simplex virus in the genitals. Which symptoms should the nurse educate the client to expect before an outbreak? Select all that apply.
- A. Lymphadenopathy
- B. Vaginal discharge
- C. Paresthesia
- D. Dysmenorrhea
- E. Malaise
Correct Answer: A,C,E
Rationale: Lymphadenopathy, paresthesia, and malaise are prodromal symptoms of genital herpes outbreaks, indicating viral reactivation.
The nurse is caring for a client with a central venous catheter (CVC). The nurse knows which of the following is a common symptom of Central Line-Associated Bloodstream Infections (CLABSI)?
- A. Diarrhea
- B. Fever and chills
- C. Productive cough
- D. Muscle spasms
Correct Answer: B
Rationale: Fever and chills are hallmark symptoms of CLABSI, indicating a systemic infection originating from the catheter site.
The nurse is caring for a client who was recently diagnosed with human immunodeficiency virus (HIV). Which of the following statements, if made by the client, would indicate a knowledge deficit? Select all that apply.
- A. I started researching ways to tell my family that I have AIDS.
- B. I recently stopped sharing household utensils and towels.
- C. I will need periodic blood tests to measure the amount of virus.
- D. I will not be able to continue my job as a phlebotomist.
- E. If I achieve undetectable viral load status, I won't be able to transmit the virus to others.
Correct Answer: A,B,E
Rationale: A: HIV does not equate to AIDS; this indicates a misunderstanding. B: HIV is not transmitted through household items. E: Undetectable viral load reduces but does not eliminate transmission risk.
The nurse is assessing a client for bacterial meningitis. Which of the following assessments should the nurse perform? Select all that apply.
- A. Oral temperature
- B. Patellar reflexes
- C. Weber and Rinne tests
- D. Glasgow Coma Scale
- E. Orthostatic blood pressure
Correct Answer: A,D
Rationale: Oral temperature assesses for fever, a key symptom of meningitis, and the Glasgow Coma Scale evaluates neurological status, critical for detecting meningitis-related changes.
The nurse is visiting the home of a client with Clostridium difficile. Which infection control measure should the nurse include?
- A. Ask the client to wear a surgical mask during the visit.
- B. Obtain vital signs with a disposable blood pressure cuff.
- C. Interview the client while maintaining 3 feet distance.
- D. Use sterile gloves when performing venipuncture.
Correct Answer: B
Rationale: Using a disposable blood pressure cuff prevents the spread of Clostridium difficile spores, which can persist on surfaces.