Nokea
You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis:
- A. Diabetes
- B. Liver failure
- C. Long-term care resident
- D. Inmate
- E. IV drug user
- F. HIV
- G. U.S. resident
Correct Answer: C,D,E,F
Rationale: Remember from our lecture we discussed the risk factors for developing TB and to remember them I said remember the mnemonic "TB Risk". It stands for tight living quarters (LTC resident, prison, homeless shelter etc.), below or at the poverty line (homeless), refugee (especially in high risk countries), immune system issue such as HIV, substance abusers (IV drugs or alcohol), Kids less than the age of 5....all these are risk factors.
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The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?
- A. A red area is a positive reading that means the client has tuberculosis.
- B. The skin test is the only procedure needed to diagnose tuberculosis.
- C. A positive reading means exposure to the tuberculosis bacilli.
- D. Do not get another skin test for one (1) year if the skin test is positive.
Correct Answer: C
Rationale: A positive TB skin test (C) indicates exposure to TB bacilli, not active disease, requiring further testing (e.g., chest X-ray). Redness alone (A) is not diagnostic; induration is measured. The skin test (B) is not definitive for diagnosis. Annual testing (D) may be needed in high-risk groups.
Which agents should the nurse suspect as being the cause of the victims' symptoms? Select all that apply.
- A. Anthrax
- B. Sarin gas
- C. Smallpox
- D. Radiation
- E. Cyanide
- F. Ebola virus
Correct Answer: B, E
Rationale: Sarin gas and cyanide are chemical agents that can cause rapid onset of dyspnea, weakness, and nausea, consistent with the symptoms described.
If the client complains of GI side effects associated with rifampin (Rifadin), which nursing action is best?
- A. Administering the drug at night
- B. Giving the drug with food or at mealtimes
- C. Encouraging the client to drink plenty of water
- D. Providing the client with an antacid
Correct Answer: B
Rationale: Giving rifampin with food can reduce gastrointestinal side effects, such as nausea, without compromising its efficacy.
Which information should the nurse teach the client diagnosed with acute sinusitis?
- A. Instruct the client to complete all the ordered antibiotics.
- B. Teach the client how to irrigate the nasal passages.
- C. Have the client demonstrate how to blow the nose.
- D. Give the client samples of a narcotic analgesic for the headache.
Correct Answer: A
Rationale: Completing antibiotics (A) ensures treatment of bacterial sinusitis, preventing resistance. Irrigation (B) is supportive, nose-blowing (C) is routine, and narcotics (D) are excessive for sinus headaches.
The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first?
- A. Check the tubing for any kinks.
- B. Suction the airway for secretions.
- C. Assess the lip line of the ET tube.
- D. Sedate the client with a muscle relaxant.
Correct Answer: A
Rationale: High airway pressure may result from kinks (A), a common cause requiring immediate check. Suctioning (B), lip line (C), and sedation (D) follow if needed.