Conjunctivitis and Influenza Answer Key

Otitis Media 1) The nurse walks into an examination room and sees a young child demonstrate a specific behavior. Which health problem should the nurse suspect the child is experiencing? A) Sore throat B) Hunger C) Otitis media D) Head cold Answer: C Explanation: A) Pulling at the ear is a characteristic sign of otitis media in a young child. Pulling at the ear does not indicate a sore throat, hunger, or a head cold. Page Ref: 578 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of otitis media. 2) A client with newly diagnosed otitis media tells the nurse that the left ear has been aching for weeks. Since this health problem has been untreated for so long, which additional problem is this client at risk for developing? A) External otitis B) Meningitis C) Pneumonia D) Influenza Answer: B Explanation: A) The bacterial infection from otitis media may also migrate internally, leading to the development of bacterial meningitis. Otitis media is not known to cause external otitis. Otitis media does not cause pneumonia or influenza. Page Ref: 576 Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Nursing Process: Assessment Learning Outcome: 2. Identify risk factors and prevention methods associated with otitis media. 3) A new mother is distraught because her infant has a fever of 102ºF and is diagnosed with otitis media. What should the nurse instruct the mother to help the child's fever and pain? A) Swaddle the baby in blankets. B) Feed the baby solid foods. C) Administer acetaminophen. D) Bathe the baby with cool water. Answer: C Explanation: A) Swaddling the baby with blankets is not going to reduce the fever or help the pain. The baby may not be of the age to take solid foods. Acetaminophen will help reduce the child's fever and reduce the pain. Bathing with cool water is not an appropriate intervention to reduce the fever of a baby. Page Ref: 582 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across life span for individuals with otitis media. 4) An adolescent with otitis media is experiencing extreme pain. Which should the nurse emphasize to address the diagnosis of Acute Pain for this client? A) Apply a cold compress to the affected ear. B) Report abrupt relief of pain immediately. C) Continue plans for air travel. D) Report increased pain when moving the outer ear. Answer: B Explanation: A) Abrupt relief of pain may mean that the tympanic membrane has perforated. Heat should be applied to dilate surrounding blood vessels and decrease swelling. The pain of otitis media is not aggravated by movement of the external ear. Drastic changes in barometric pressure can increase pain considerably, so clients are discouraged from traveling by air. Page Ref: 582 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with otitis media. 5) During a home visit, the nurse instructs a young mother to bottle-feed the baby in the upright position. Which health problem will this position help prevent from developing in this child? A) Choking B) Aspiration C) Sinus infection D) Otitis media Answer: D Explanation: A) Infants and small children who are bottle-fed in a supine position have a greater probability of developing otitis media because the eustachian tube opens when the child sucks, and the horizontal angle provides easy access to the middle ear. Children are not prone to sinus infection at that age. Choking results from holes in bottle nipples that are too big. Aspiration is caused by feeding too much too fast. Page Ref: 577 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 2. Identify risk factors and prevention methods associated with otitis media. 6) A client has completed the full course of antibiotics prescribed to treat otitis media. Which primary manifestation of the disorder will be relieved as evidence that treatment has been effective? A) Impaired hearing B) Dizziness C) Pain D) Nausea and vomiting Answer: C Explanation: A) Ear pain is the most common symptom of otitis media that motivates the client to seek health care. Secondary symptoms associated with the disease include dizziness, impaired hearing, and nausea and vomiting. Page Ref: 582 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome: 7. Evaluate expected outcomes for an individual with otitis media. 7) A 2-year-old child with otitis media is prescribed amoxicillin clavulanate 250 mg/5 mL three times daily by mouth for 10 days. What should the nurse teach the mother about this medication? A) "It is ok to stop the antibiotic if the child begins to have side effects." B) "Give the antibiotic for the full 10 days as prescribed." C) "It is important to measure the prescribed dose in a household teaspoon." D) "Be sure to administer a loading dose of the medication when you get home." Answer: B Explanation: A) Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon could contain less than 5ml, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. Page Ref: 579 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with otitis media. 8) The nurse is teaching the parents of an infant with acute otitis media. What would be most important for the nurse to teach the parents? A) Administer a decongestant for nasal congestion. B) Keep the baby in a flat position during sleep. C) Administer acetaminophen to relieve pain and decrease fever. D) Place the baby to sleep with a pacifier. Answer: C Explanation: A) Parents are taught to administer acetaminophen to relieve the discomfort and decrease fever associated with acute otitis media. Decongestants are not recommended for treatment of acute otitis media. A flat position could exacerbate the discomfort. Elevating the head slightly is recommended. Placing infants to sleep with a pacifier can increase the incidence of otitis media. Page Ref: 580 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 6. Plan evidence-based care for an individual with otitis media and the family in collaboration with other members of the healthcare team. Pneumonia 1) An 86-year-old client is admitted with pneumonia. What manifestations would the nurse expect to find when assessing this client? Select all that apply. A) Hemoptysis B) Increased appetite C) Change in level of consciousness D) Respiration of 24 E) Lethargy Answer: A, C, D, E Explanation: A) Frequently, caregivers or family members note that the client looks generally ill. The client is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20. Page Ref: 587 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1. Describe the pathophysiology, etiology, and clinical manifestations of pneumonia. 2) A nurse is caring for a 72-year-old male client admitted to the hospital with pneumonia. The client asks the nurse if there are things he can do to decrease the risk for developing pneumonia in the future. Which would be the most appropriate response by the nurse? Select all that apply. A) "You should drink a yogurt drink once a day that is supplemented with L. casei immunitas cultures." B) "You can start by not smoking." C) "You can get the pneumonia vaccination, which may help to decrease your risk in the future." D) "Avoiding alcohol will help." E) "There is nothing that you can do to decrease your risk of pneumonia in the future." Answer: B, C, D Explanation: A) Research indicates a high rate of pneumonia in clients with frequent exposure to cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex. Alcohol interferes with the actions of macrophages. Studies suggest that supplements containing micronutrients that approximate the recommended dietary allowances can assist in preventing infections. A balanced diet can also decrease the risk of respiratory infections. Pneumonia vaccines can also be considered to decrease the risk of development in the future. There is not an established body of scientific evidence that supports the claim that L. casei immunitas cultures can improve immune function. Telling the client he cannot decrease his risk in the future is incorrect. 3) The nurse is caring for a 72-year-old client who is hospitalized with a second episode of pneumonia in the past 18 months. The client has expressed frustration to the nurse and states, "I never got sick when I was younger. Why is this happening?" Which response by the nurse is most appropriate? A) "As you grow older, your immune system just quits working." B) "As you grow older, there is a decrease in the immune response, which puts you at greater risk for developing an infection." C) "As you grow older, there in an overall increase in the speed and strength of your immune response." D) "As you grow older, there is an increase in the number of B cells in the circulation, which hinders the immune response." Answer: B Explanation: A) As a person grows older, there is an overall decrease in the speed and strength of the immune response. The immune system does not quit working totally. There is a decrease in the number of B cells in circulation. Page Ref: 590 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with pneumonia. 4) The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a client with pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the nurse include in this client's plan of care? A) Perform chest percussion every 4 hours and prn. B) Administer the pneumococcal vaccine prior to discharge. C) Limit fluid intake to 1,000 mL per day. D) Provide the client with smoking cessation education. Answer: A Explanation: A) Chest percussion can help clear secretions. Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a client with pneumonia; however, they would be aligned with a different nursing diagnosis. Patients with pneumonia are encouraged to increase fluid intake. Page Ref: 596 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with pneumonia. 5) The nurse is providing discharge teaching to a client recovering from pneumonia. Which client statement indicates that additional teaching is needed? A) "I can't get the influenza vaccine due to my allergy to eggs." B) "I will get the influenza vaccine every year." C) "I will get the pneumococcal vaccine every fall." D) "I will get the pneumococcal vaccine as soon as I recover from this pneumonia." Answer: C Explanation: A) Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS. Page Ref: 597 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome: 7. Evaluate expected outcomes for an individual with pneumonia. 6) A client with pneumonia develops a fever. Which interventions should the nurse use to attain the goal of normal body temperature? Select all that apply. A) Increase the temperature of the room environment to prevent shivering. B) Administer antipyretic medications. C) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance. D) Use ice packs and a tepid bath every 2 hours. E) Promote frequent rest periods to increase energy reserve. Answer: B, E Explanation: A) Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance. Page Ref: 595 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 6. Plan evidence-based care for an individual with pneumonia and the family in collaboration with other members of the healthcare team. 7) The nurse is caring for a client who develops a fever and productive cough after having an appendectomy. Which orders should the nurse expect from the healthcare provider for this health problem? Select all that apply. A) Sputum cultures B) Antibiotics C) Chest physiotherapy D) Bronchial washing for culture E) Isolation precautions Answer: A, B, C Explanation: A) The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. Bronchial washings are not routine testing for this scenario. The client likely has an infectious disease and is not contagious. Isolation precautions are usually not ordered for noncontagious infections. Page Ref: 595 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with pneumonia. Sepsis 1) A client is admitted to the Intensive Care Unit with a systemic infection. What manifestations will the nurse most likely assess in this client? Select all that apply. A) Tachycardia B) Pain C) Edema D) Anorexia E) Fever Answer: A, D, E Explanation: A) Fever, tachycardia, and anorexia are the most common symptoms of a systemic infection. Edema and pain are symptoms of a local infection. 2) The nurse is preparing an educational session on sepsis. What should the nurse include as a major risk factor for the development of this health problem? A) Pneumococcal bacteria B) Leukocytosis on the complete blood count C) Undiagnosed urinary tract infection D) Elevated temperature Answer: C Explanation: A) Sepsis is an entire-body inflammatory process. Sepsis is most often the result of gram-positive infections from Staphylococcus and Streptococcus bacteria but may also follow gramnegative bacterial infections such as Pseudomonas, Escherichia coli, and Klebsiella. A portal of entry for sepsis is the urinary system. Leukocytosis occurs with sepsis if the client is able to mount an immune response. An elevated temperature is a manifestation of sepsis. 3) A 1-month-old infant is admitted to the hospital with a temperature of 102°F. Why is this client going to be evaluated for the presence of sepsis? A) Absence of sweat glands B) Immature immune system C) Inadequate red blood cells D) Poor lung elasticity Answer: B Explanation: A) A child less than 3 months of age with a temperature higher than 100.4°F should be evaluated for sepsis because the child is at increased risk secondary to an immature immune system. The child is not evaluated for sepsis because of the absence of sweat glands, inadequate red blood cells, or poor lung elasticity. 4) The nurse identifies the diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a client with septicemia. Which intervention will address this client's health problem? A) Monitor heart rate every hour. B) Assess temperature every 4 hours. C) Monitor pupil reactions every 8 hours. D) Monitor for cyanosis. Answer: D Explanation: A) Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a client with septicemia, but a change in skin color will alert the nurse immediately of decreased tissue perfusion. 5) An elderly client who resides in a long-term care facility is admitted to the hospital with sepsis. The family is tearful and does not understand how their family member got so sick from a bed sore. What should the nurse teach the family to help in the care of the client? A) Alert the staff when the IV runs dry. B) Help the nurse with dressing changes. C) Assist the client to the bathroom so there is not a fall. D) Assist the client with meals to obtain optimal nourishment. Answer: D Explanation: A) Poor nutritional status and a slow-functioning immune system contribute to the risk for sepsis in the older client. The family can help by assisting and encouraging the client to take in the proper nourishment needed. The family is not responsible for IV or dressing changes. Assisting the client to the bathroom should be done by the staff who are responsible for client safety. 6) An elderly client with sepsis has been admitted to the nursing unit. The nurse is planning care and determines that one goal for this client is to maintain normal mental status. Which outcome evaluation implies that the goal has been met? A) The client is agitated. B) The client has a Glasgow coma score of 4. C) The client responds to questions appropriately. D) The client's pupils are fixed and dilated. Answer: C Explanation: A) A client who responds to questions appropriately is alert and oriented. Restlessness or agitation in a client with sepsis can be a sign that the client's condition is deteriorating. The client with a Glasgow coma score of 4 is comatose. When pupils are fixed and do not respond to light, death is imminent. 7) The healthcare provider has prescribed a client to have peak and trough blood levels drawn to evaluate the therapeutic effect of an IV antibiotic. When should the nurse schedule the blood samples to be drawn? Select all that apply. A) Prior to the discontinuing the antibiotic B) A few minutes before the next scheduled dose of medication C) During the infusion of the antibiotic D) 30 minutes after the IV administration E) 1-2 hours after the oral administration of the medication Answer: B, D Explanation: A) Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range–that is, the minimum and maximum blood levels at which the drug is effective–is known for a given drug. By measuring blood levels at the predicted peak (1-2 hours after oral administration, 1 hour after intramuscular administration, and 30 minutes after IV administration) and trough, usually a few minutes before the next scheduled dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects. 8) An 80-year-old client is recovering in the ICU from septicemia. Which intervention will help prevent further infection for this client? A) Foley drainage on the bed at the client's feet B) Oral and skin care C) Turn, cough, and deep breathe q shift. D) Sterile wound care Answer: B Explanation: A) Good oral and skin care will prevent breakdown and prevent entry by bacteria. In order to prevent skin breakdown and promote respiratory function, the client is turned at least every 2 hours. The Foley drainage bag is always kept below the level of the client's bladder to prevent reflux. There is no evidence that this client has a wound. 9) A nurse working in the ICU is receiving a client diagnosed with early septic shock from the Emergency Department. The nurse will recognize which symptoms associated with this condition? Select all that apply. A) Normal blood pressure B) Rapid and deep respirations C) Shallow respirations D) Warm and flushed skin E) Lethargic mental status F) Decreased urine output Answer: A, B, D Explanation: A) Septic shock has an early phase and a late phase. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. The other manifestations occur in the late phase of shock. 10) List the pathophysiology concepts related to the onset of sepsis in sequential order. 1. Macrophage-producing cytokines are released. 2. Endotoxin released by microorganisms sets off an out-of-control inflammatory process. 3. Neutrophils arrive and multiply, occluding capillaries. 4. Vasodilation with increased capillary permeability and fluid leak. Answer: 2, 1, 4, 3 Explanation: The pathophysiology of sepsis occurs as follows: Endotoxin released by microorganisms sets off an out-of-control inflammatory process; macrophage-producing cytokines are released; vasodilation with increased capillary permeability and fluid leak; neutrophils arrive and multiply, occluding capillaries.