Infection Answer Key

Conjunctivitis 1) The nurse is assessing a 20-year-old college student who is experiencing red, swollen eyes that are oozing a yellowish drainage. The client is complaining of photophobia. What is the most appropriate question for the nurse to ask the client? A) "Have you had extra caffeine this week?" B) "Did you get sand in your eye recently?" C) "Have you been exposed to HIV?" D) "Have any of your friends experienced these symptoms?" Answer: D Explanation: A) The client is exhibiting signs and symptoms of conjunctivitis. The nurse should explore ways in which the client may have been exposed. Most cases of conjunctivitis are spread by hand to eye contact. Exposure to HIV, sand in the eye, and caffeine are not known causes of conjunctivitis and would not be appropriate questions to ask this client to determine the cause of the symptoms. Page Ref: 566 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of conjunctivitis. 2) A client is being treated for trachoma after returning from a safari trip to Africa. Which potential complication should the nurse consider when planning this client's care? A) Scarring of the cornea B) Eye muscle weakness C) Damaged iris D) Retinal detachment Answer: A Explanation: A) Trachoma is a chronic form of conjunctivitis that causes the formation of granulation tissue that is abraded by the lashes, leading to scarring of the cornea and eventual blindness. Page Ref: 567 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 2. Identify risk factors and prevention methods associated with conjunctivitis. 3) The nurse is assessing clients in the eye clinic who have come to be seen for eye infections. For which client with conjunctivitis should the nurse be most concerned? A) The client from Iran B) The client from Brazil C) The client from New York City D) The client from Florida Answer: A Explanation: A) Trachoma, a chronic form of conjunctivitis, is endemic in poor, undeveloped countries, especially where there are water shortages, numerous flies, and crowded living conditions. It can eventually cause blindness, so the nurse would be most concerned about the client from Iran. None of the other clients lives in an area where the disease is endemic. 4) The nurse is planning care for a client with conjunctivitis. Which client statement supports the nursing diagnosis of Risk for Altered Vision? A) "I have had this infection for 3 days." B) "My mother is blind from retinopathy." C) "This is the fourth eye infection I have had in the last 6 months." D) "I think I caught the infection from my child." Answer: C Explanation: A) The concern for this client is the repeated infections that could be a chronic form of conjunctivitis that causes eventual blindness. Having the infection for 3 days is concerning but not as much as the potentially chronic form of the disease. Many adults catch "pink eye" from a child, but that is not usually the form that causes blindness. The client's mother has blindness from a source other than conjunctivitis. Page Ref: 568 Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Nursing Process: Evaluation Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with conjunctivitis. 5) The nurse is teaching a mother how to administer optical antibiotics to her child who has conjunctivitis. Which statement made by the mother indicates teaching has been effective? A) "I will drop the medication onto the eyeball." B) "I will wait 10 seconds between drops." C) "I will wash my hands before instilling the medication." D) "I will rub the eye with a cotton ball after I administer the medication." Answer: C Explanation: A) Teach the client to wash hands thoroughly before and after instilling eye medications. Handwashing is the single most important means of preventing transmission of infection. Medication is dropped into the lower conjunctival sac and should not be rubbed after instillation. The time between drops is 1-5 minutes, depending on the type of medication. The medication is not dropped on the eyeball but in the conjunctival sac of the lower lid. Page Ref: 569 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome: 6. Plan evidence-based care for an individual with conjunctivitis and the family in collaboration with other members of the healthcare team. 6) The nurse is teaching a mother to administer ophthalmic ointment to her infant with conjunctivitis. The nurse determines that learning goals have been met when the mother performs which action? A) Places the ointment on a swab and spreads it across closed eyelids. B) Instills the medication to the lacrimal duct. C) Uses sterile gauze to apply the ointment. D) Applies the ointment directly to the conjunctival sac. Answer: D Explanation: A) The ointment is applied to the conjunctival sac, not the lids or lacrimal duct, and is applied directly from the medication tube or vial. 7) The nurse is providing care for a pediatric client with bacterial conjunctivitis. Which interventions should the nurse use as part of the collaborative management of the client? Select all that apply. A) Dark sunglasses B) Cold eye compresses C) Contact the client's school nurse. D) Careful hand hygiene E) Antiviral therapy Answer: A, C, D Explanation: A) Dark glasses will help to reduce the photophobia that many clients with conjunctivitis experience. It is often appropriate for the nurse to contact the client's school nurse to discuss increased prevention and student education. A warm compress, not cold, should be used in the management of conjunctivitis. Warm compresses relieve discomfort and reduce swelling by increasing circulation to the eye. Careful hand hygiene is a standard method for managing the client with conjunctivitis. Antibiotics, not antiviral medications, are prescribed with conjunctivitis. 8) The nurse is providing discharge instructions for a client who has acute conjunctivitis from Staphylococcus. Which should the nurse include when teaching this client? Select all that apply. A) "It is ok to rub your eyes with a clean, soft cloth for itching." B) "Do not share towels, make-up, or contact lenses with anyone else, as this can spread the infection." C) "You can soak your eyelids with warm saline to soften crusts and exudates that may form." D) "Wash your hands before cleansing the eye and administering eye drops." E) "You may go back to sharing towels when the infection is gone." Answer: B, C, D Explanation: A) Sharing supplies, such as towels, make-up, or contact lenses, is never a good idea, due to potential for cross-contamination from person to person. But during an actual infection, instructions should include discouragement of using the same equipment after the infection is cleared. Towels need to be washed in hot water. Make-up and contact lenses should be discarded and not reused. Therefore, this action should be included in instructions. Prevention of crosscontamination by handwashing (hand hygiene) will minimize the risk of bringing in other organisms to an already infected eye. This action should be encouraged at all times, but especially when there already is an infection present. Soaking the lids with sterile saline will soften the crusts from exudates that accompany the Staphylococcus infection and should be included in the instructions. The action of rubbing one's eyes can traumatize the eyes further and should not be encouraged. Rubbing also brings the risk of cross-contamination from other sources, including the other eye if only one eye is involved. This action is inappropriate and should not be included in care. 9) A nurse is caring for a client diagnosed with trachoma. When providing client education regarding this condition, the nurse will include which statements? Select all that apply. A) "This condition is caused by Chlamydia trachomatis." B) "It is common in the United States." C) "It is the primary cause of preventable blindness worldwide." D) "Early symptoms include inflammation of the cornea." E) "The causative organism is usually Staphylococcus aureus." Answer: A, C Explanation: A) Early manifestations of trachoma include redness, eyelid edema, tearing, and photophobia. Small conjunctival follicles develop on the upper lids. The inflammation also causes superficial corneal vascularization and infiltration with granulation tissue. Scarring of the conjunctival lining of the lid causes entropion (inversion of the eyelid). The lashes then abrade the cornea, eventually causing ulceration and scarring. The opacity of the scarred cornea results in loss of vision. This condition is caused by Chlamydia trachomatis, and is endemic in poor, undeveloped countries, especially where there are water shortages, numerous flies, and crowded living conditions. Trachoma is rarely seen in the United States except in Native Americans who live in the Southwest. 10) A nurse is caring for a pediatric client with acute conjunctivitis. (See image.) The client presents with purulent discharge and crusting of the eye. The nurse suspects that the cause of the condition is: A) Viral. B) Allergic. C) Bacterial. D) Fungal. Answer: C Explanation: A) The major difference between bacterial and viral conjunctivitis is that bacterial conjunctivitis has a purulent discharge that may result in crusting, whereas the discharge from viral conjunctivitis is serous (watery). Allergic conjunctivitis produces watery to thick drainage and is characterized by itching. Fungal is incorrect. Page Ref: 566 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of conjunctivitis. Influenza 1) The nurse is assessing a client with acute malaise and muscle aches. Which questions should the nurse ask to determine whether the client is experiencing influenza? Select all that apply. A) "Have you had a flu shot this year?" B) "Is your cough productive?" C) "Have you been exposed to anyone with the flu?" D) "Are you having any trouble urinating?" E) "Do you have dizziness?" Answer: A, B, C Explanation: A) Based on the presenting symptoms, the nurse would ask whether the client has had a flu shot or been exposed to the flu. Usually, the cough of an influenza client is nonproductive. A productive cough may indicate a different diagnosis. Insufficient voiding and dizziness are not routine manifestations of influenza. 2) The nurse is preparing an educational session on the importance of high-risk populations receiving an annual influenza vaccination. Which clients are considered high-risk for developing complications from the flu? Select all that apply. A) A 25-year-old pregnant woman at 20 weeks' gestation B) A 65-year-old woman C) A 3-year-old with cystic fibrosis D) A 35-year-old man with a severe allergy to eggs E) A 20-year-old healthcare worker Answer: A, B, C, E Explanation: A) Pregnant women, particularly during the second and third trimesters, are at increased risk of complications. People at increased risk of influenza or its complications include infants, young children, and anyone age 50 or older. Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary diseases, are more susceptible as well. The annual flu vaccination is recommended for all healthcare workers. A 35-year-old man with a severe allergy to eggs should not get a flu shot, because the vaccine contains eggs and it is not recommended. 3) The school nurse is planning a teaching session with the parents of students to reduce the spread of the flu virus throughout the school. What should the nurse include when teaching the parents of a diverse population about infection-control techniques? Select all that apply. A) "Cover your cough" education B) Appropriate hand hygiene C) Safe food preparation and storage D) Sanitizing high-touch items to kill pathogens E) Withholding immunizations for children with compromised immune systems Answer: A, B, D Explanation: A) Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as "cover your cough" education all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children, and this is not an infection-control strategy. To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. 4) A client with the flu is experiencing tachypnea. What intervention should the nurse use to address the diagnosis of Ineffective Breathing Pattern related to the flu? Select all that apply. A) Maintain adequate hydration. B) Teach the client coughing, deep breathing, and hydration. C) Prepare the client for the possibility of a tracheostomy tube. D) Keep the head of the bed elevated. Answer: A, B, D Explanation: A) Keeping the head of the bed elevated improves lung excursion and reduces the work of breathing. Coughing, deep breathing, and, hydration are essential for achieving airway clearance. Insertion of a tracheostomy and oxygen are not primary treatments for ineffective airway clearance. 5) The nurse makes a home visit to a client recovering from complications related to influenza. Which client statements indicate that desired outcomes have been met? Select all that apply. A) "I'm eating healthy foods now." B) "I went back to work." C) "I haven't had chills since I left the hospital." D) "I slept the whole night without coughing." E) "I was able to take a walk today." Answer: C, D Explanation: A) The client who is sleeping at night and is no longer experiencing chills from fever has recovered and is getting appropriate sleep time. Outcomes for those with the flu do not usually include walking, going to work, or eating a healthy diet. These would be included in a wellness plan of care. 6) The nurse is reviewing diagnostic and laboratory studies performed for an older client with influenza. Which result should the nurse recognize as being consistent with influenza? A) Decreased white blood cell count B) Increased BUN C) Decreased sodium level D) Fluid-filled lungs on chest x-ray Answer: A Explanation: A) The white blood cell count of a client with influenza will typically be decreased. Laboratory tests for BUN and sodium levels are not usually associated with influenza. Unless the client with influenza develops complications, the chest x-ray is clear. 7) The nurse is planning care for a client diagnosed with influenza. Which interventions should the nurse include when planning this client's care? Select all that apply. A) Placing droplet and contact precaution signs on the client room door B) Placing the client in a negative air flow room C) Placing a ventilator in the room D) Notifying other departments of the diagnosis E) Using appropriate PPE Answer: A, E Explanation: A) To prevent the spread of influenza, the client is placed in a private room with signs for droplet and contact precautions. It is appropriate for the healthcare workers to use appropriate PPE for these transmission-based precautions. Placing signs on the door is the way to notify other departments of precautions. Negative air flow rooms are for diseases such as chicken pox, measles, and SARS. There is no indication that this client will need a ventilator.