Tuberculosis Answer Key

Infection 1) The nurse is concerned that a client with bowel and bladder dysfunction is at risk for developing an infection. Which actions should the nurse take to help reduce this client's risk for developing an infection? Select all that apply. A) Turn and reposition the client every 2 hours. B) Monitor intake and output. C) Provide hygienic care after episodes of incontinence. D) Use standard precautions when handling linen after episodes of incontinence. E) Cover wounds with antibiotic ointment and sterile gauze. Answer: B, C, D Explanation: A) Turning and repositioning is an intervention to maintain tissue integrity. Monitoring for dehydration will help reduce the risk of developing an infection because of bowel and bladder dysfunction. Providing hygienic care after episodes of bowel or bladder incontinence will ensure that the skin remains intact, reducing the risk of infection. Using proper biohazard precautions after episodes of incontinence will reduce the risk of transmitting an infection. Covering wounds with antibiotic ointment and sterile gauze is an intervention to maintain tissue integrity. Page Ref: 526 Cognitive Level: Applying Client Need: Safe and Effective Care Environment Nursing Process: Implementation Learning Outcome: 2. Examine the relationship between infection and other concepts/systems. 2) A nurse is planning an in-service on preventing infection for the hospital staff nurses on a medicalsurgical unit. Which nursing intervention is most effective in reducing the risk of infections? A) Raising the temperature in the client's room B) Assessing vital signs once daily C) Wearing a mask for client care D) Performing hand hygiene Answer: D Explanation: A) Hand hygiene is always the first and best way to stop the spread of microorganisms, which cause infections. Raising the temperature in a client's room would contribute to the growth of microorganisms. Assessing vital signs is important but should be done more frequently than once daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation. Page Ref: 531 Cognitive Level: Applying Client Need: Safe and Effective Care Environment Nursing Process: Planning Learning Outcome: 1. Summarize the physiology of the immune system related to infection prevention. 3) The nurse is assessing an 80-year-old client who is recovering following a cholecystectomy. Which factor would increase this client's susceptibility to infection? Select all that apply. A) Intact mucous membranes B) Surgical incision C) Dry skin D) Active bowel sounds Answer: B, C, D Explanation: A) Certain factors will increase a client's susceptibility to microorganism growth and infection. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact. Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the body against infection. Page Ref: 526 Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Nursing Process: Assessment Learning Outcome: 3. Identify commonly occurring alterations in the immune system that increase the risk for or occurrence of infection and their related 4) The nurse is caring for a client who is being discharged following an appendectomy. Which instruction is the most important for the nurse to teach this client regarding wound healing? A) "Thoroughly irrigate the wound with hydrogen peroxide once a day." B) "Apply a lubricating lotion to the edges of the wound twice a day." C) "Add more fruits and vegetables to your diet." D) "Notify the physician if you notice swelling, warmth, or tenderness at the wound site." Answer: D Explanation: A) A client being discharged with an open surgical wound has to be instructed on the detection of infection, as the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing. Applying lubricating lotion to the edges of a wound would impede the healing process. Page Ref: 551 Cognitive Level: Applying Client Need: Safe and Effective Care Environment Nursing Process: Implementation Learning Outcome: 4. Differentiate common assessment procedures used to examine for the presence of infection client across the life span. 5) The nurse is caring for a client who is experiencing a systemic infection after a total knee replacement. Which diagnostic tests will be used to validate the presence of this infection? Select all that apply. A) Serum electrolyte levels B) Urinalysis C) White blood cell differential D) White blood cell count E) Wound culture Answer: B, C, D, E Explanation: A) Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess for the presence of bacteria or blood in the urine. An elevated WBC and 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms. Page Ref: 555-557 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's infection status. 6) The nurse is teaching a class on infection control. Which nursing measure is most appropriate in breaking a link in the chain of infection? Select all that apply. A) Place contaminated linens in a paper bag. B) Use personal protective equipment (PPE). C) Cover one's cough by placing the mouth in the elbow. D) Wear sterile gloves for client care. Answer: B, C Explanation: A) Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. PPE, according to OSHA standards, has to be used whenever the situation dictates. Covering one's mouth when coughing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. Gloves have to be worn but are to be changed between client, and hands are to be washed. Page Ref: 544-549 Cognitive Level: Applying Client Need: Safe and Effective Care Environment Nursing Process: Implementation Learning Outcome: 6. Explain management of immune health and prevention of infection. 7) The nurse is teaching a child care class for mothers of young children. What should the nurse teach as being the most common mode of transmission of infectious disease? A) Children who are playing board games B) Children who are sitting together eating meals C) Children who are playing with the same toy D) Children who don't wash their hands after using the bathroom Answer: D Explanation: A) The fecal-oral and respiratory routes are the most common sources of transmission in children. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. Playing with board games will not transmit infectious disease. Eating together will not transmit infectious disease. Poor hand hygiene is a common source of transmission. Page Ref: 527 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and caring interventions across the life span for individuals with infection. 8) A pediatric client is receiving antibiotics for the treatment of Staphylococcus aureus. Which nursing interventions are priorities when caring for this client? Select all that apply. A) Encourage adequate fluid intake. B) Monitor for allergic reaction. C) Assess renal and liver function. D) Obtain a baseline electrocardiogram. E) Monitor vital signs. Answer: A, B, C, E Explanation: A) Nursing interventions to support antibiotic therapy include encouraging an adequate fluid intake, monitoring for manifestations of an allergic reaction, assessing renal and hepatic function, and assessing vital signs. A baseline electrocardiogram is appropriate for antimalarial medication. Page Ref: 541 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 8. Compare and contrast common independent and collaborative interventions for clients with infection. Cellulitis 1) A nurse is assessing a client who has recently returned from a camping trip. The client is being seen for edema in the right foot. When assessing the foot, the nurse notes a sore on the foot and suspects cellulitis. Which further data will the nurse assess to support the suspicion? A) BUN and creatinine B) Breath sounds C) Blood cultures D) Redness, pain, and drainage at the site Answer: D Explanation: A) Classic signs of cellulitis are swelling, pain, redness, and possibly drainage at the site. BUN, creatinine, and blood cultures are ordered by the physician and are not nursing assessments. Breath sounds are not indicated at present, as the infection is in the foot. Blood cultures are ordered by the physician and are not nursing assessments. 2) The nurse is teaching a group of adolescents at a local high school about skin infections. Which students are at risk for developing cellulitis? Select all that apply. A) The female student who plucks her eyebrows B) The student with diabetes C) The student practicing hand hygiene D) The student who squeezes pimples E) The student who engages in contact sports Answer: A, B, D Explanation: A) The student who plucks hair risks an infected hair follicle, which can lead to cellulitis, as can squeezing pimples. The student with diabetes is at risk for foot lesions, which can lead to cellulitis if left untreated. Hand hygiene does not pose a risk for cellulitis. Contact sports do not pose a risk for cellulitis. 3) An adolescent is diagnosed with cellulitis from picking the scabs on healing facial pimples. The mother scolds the child for eating too many oily foods that cause the acne. What should the nurse teach the family? A) Antibiotics are the best way to prevent cellulitis. B) Oily foods do not cause pimples or cellulitis. C) Consumption of oily foods poses an increased risk for cellulitis. D) Popping the pimples spreads the germs over the face. Answer: B Explanation: A) Foods do not cause acne and, therefore, cellulitis. Antibiotics are the best way to treat, not prevent, cellulitis. Popping pimples drives the infection deeper into the skin and may cause more serious infections. Page Ref: 560-564 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 cellulitis. 4) The nursing is caring for a client who is hospitalized for cellulitis of the foot. Which nursing diagnoses should the nurse use to plan this client's care? Select all that apply. A) Social Isolation related to skin infection B) Altered Skin Integrity related to skin infection C) Acute Pain related to skin infection D) Disturbed Sleep Pattern related to skin infection E) Powerlessness related to inability to control the infection Answer: B, C Explanation: A) Clients with cellulitis have Altered Skin Integrity and will also have Acute Pain at the site. Controlling pain is a priority. Disturbed Sleep Pattern, Social Isolation, and Powerlessness are not supported by the information given. 5) The nurse is preparing discharge instructions for an older client with cellulitis of the leg. What should the nurse teach the client and family regarding ways to prevent this health problem from occurring in the future? A) "Keep the client off her leg as much as possible." B) "Bring the client to the doctor if there is a fall." C) "Maintain a healthy diet." D) "Do not allow the client to walk without assistance." Answer: C Explanation: A) The elderly are susceptible to cellulitis, as their immune system and skin are compromised as they age. The best preventive measure to maintain skin integrity and a healthier immune system is good nutrition. Exercise is a good way to promote health, including walking. There is no data to support that the client needs assistance to ambulate. Cellulitis can occur on any part of the body, so preventing the client from using body parts, such as the legs, is not reasonable and does not prevent cellulitis. The nurse would instruct the family regarding signs and symptoms of developing cellulitis after a fall. It is not always necessary to bring the client to the doctor for a fall if no injuries were sustained. 6) The nurse is teaching a client with cellulitis about ways to avoid future infections. Which client statements indicate that teaching has been effective? Select all that apply. A) "I should use antibiotic soap to cleanse the wounds." B) "I should eat a lot of rice to increase my intake of vitamin C." C) "I will contact the doctor if I have a temperature of 99.5°F or higher." D) "I will not swim in lakes." E) "I can stop taking the antibiotics when the swelling subsides." Answer: A, D Explanation: A) It is recommended that the client wash affected areas with an antibacterial soap. The water in lakes can be contaminated and can cause an infection. Vitamin C-rich foods include citrus fruits and strawberries, but not rice. The healthcare provider should be contacted for a body temperature of 101°F or higher. Antibiotics are taken for the full course ordered. 7) A client receiving intravenous antibiotics for 3 days as treatment for cellulitis is being prepared for discharge. Which discharge order should the nurse anticipate for this client? A) Low-sodium diet prescribed B) Home healthcare aide for the client C) Oral antibiotics to be continued at home D) Orders for evaluation by physical therapy Answer: C Explanation: A) Antibiotics should be taken for 10 days. A low-sodium diet is not indicated for cellulitis. The client may or may not need a home health aide. There is no evidence to suggest the client needs home physical therapy. 8) The nurse is providing discharge instructions to a client recovering from cellulitis. Which client statement indicates that this teaching has been effective? A) "I will monitor for signs of infection such as fever, chills, malaise, and redness or tenderness at the site." B) "If the lesion looks healed, I will stop taking the antibiotics so that I will not develop resistance to antibiotics." C) "If pustules develop, I will squeeze the lesion to remove the pus." D) "Drainage from the site is an expected finding, and I should not be concerned." Answer: A Explanation: A) The client will need to be taught to monitor for the signs and symptoms of infection. Infection may be manifested by fever, chills, erythema, tenderness, and drainage at the site, especially if it is cloudy or serous. Changes in the color, amount, and odor from drainage are cause for concern and should be monitored. The physician must be notified if these symptoms occur. Pustules are never to be squeezed open, as there is risk of greater infection. Stopping antibiotics before the doses are complete causes resistance. 9) A home health nurse manager is instructing a new staff regarding evidence-based practices of wound management. Which will the manager's teaching include? Select all that apply. A) "Wounds should be kept dry and should not be covered until a scab forms." B) "Allowing a wound to remain dry or applying a dry wound covering may slow the healing process." C) "Wound covering helps maintain a dry environment, decreasing the chance of infection such as cellulitis." D) "Proper wound moisture management can reduce pain and improve the cosmetic outcome." E) "Three methods for proper wound management include cleansing techniques, proper wound covering, and ointment application." Answer: B, D, E Explanation: A) Individuals with open wounds are more susceptible to contracting a skin infection such as cellulitis. Many believe wounds should be kept dry and should not be covered until a scab forms. However, this slows wound healing and leaves the wound exposed to potential pathogens if the scab comes off. Wound covering helps to maintain a moist environment, decreasing the chance of infection such as cellulitis. The three methods of proper moist wound management include cleansing techniques, proper wound covering, and ointment application. Proper wound moisture management also reduces pains and improves the cosmetic outcome. 10) A nurse is caring for a client diagnosed with Erysipelas whose lower extremities are bright red and raised with well-defined borders. (See image.) The causative organism of this condition is likely: A) Group B streptococcus. B) Group A streptococcus. C) Staphylococcus aureus. D) Candida albicans. Answer: B Explanation: A) Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders. B) Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders. C) Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders. D) Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders. Page Ref: 560 Cognitive Level: Understanding Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of cellulitis.