ch20.doc

[Osborn] chapter 20

Learning Outcomes [Number and Title] Learning Outcome 1 Describe the infectious process and its effects on the body.Learning Outcome 2 Identify risk factors for infection.Learning Outcome 3 Describe the chain of infection.Learning Outcome 4 Describe measures to prevent and control infection.Learning Outcome 5 Identify common pathogens causing infection.Learning Outcome 6 Differentiate between active and passive immunity.Learning Outcome 7 Describe Healthy People 2010 guidelines for prevention of

infection.Learning Outcome 8 Identify the assessment and interventions required by a patient

with an infection.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for PracticeCopyright 2010 by Pearson Education, Inc.

1. The nurse is assessing a wound on the medial surface of a patient’s left foot. Which of the following assessment findings would indicate that the patient is exhibiting signs of inflammation? (Select all that apply.)

1. Imprint of the patient’s sock is visible above ankle2. Reports pain of 7/10 at site of wound3. Erythema is present around wound4. Skin from ankle to toes is cool to the touch5. Pedal pulse is weaker in the left foot

Correct Answers: Imprint of the patient’s sock is visible above ankle Reports pain of 7/10 at site of wound Erythema is present around wound

Rationale: Imprint of the patient’s sock is visible above ankle. The imprint of the patient’s sock at the ankle is likely due to edema in the foot. Reports pain of 7/10 at site of wound. Pain is caused by pressure on the local nerve endings. Erythema is present around wound. Erythema is caused by increased blood flow to the area. Skin from ankle to toes is cool to the touch. The skin would be warm, not cool, to touch. Pedal pulse is weaker in the left foot. A weak pedal pulse in the foot could indicate something other than an inflammatory response.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


2. A patient asks the nurse why the infected area on his arm is so red. Which of the following should the nurse respond to this patient?

1. The body has increased the blood supply to the area.2. Body fluids are leaking into the area.3. White blood cells are trying to kill the infection.4. The body is walling off the infected area to prevent it from spreading.

Correct Answer: The body has increased the blood supply to the area.

Rationale: During the vascular phase of the inflammatory process, vasodilation occurs to increase the blood supply to the area, causing redness and increased warmth of the area. Body fluids leaking into the area would lead to edema. White blood cells trying to kill the infection would lead to pus formation. The body’s walling off of the infected area is an activity seen in the cellular phase of the inflammatory process.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 1


3. A patient with an infection of the wrist and forearm is to wear a splint. The nurse realizes this device will help:

1. Support the limb because of the loss of function related to the pain and swelling.2. Reduce the redness.3. Stop exudate and pus formation.4. Decrease the white blood cell count.

Correct Answer: Support the limb because of the loss of function related to the pain and swelling.

Rationale: One of the five cardinal symptoms of local inflammation is the loss of function related to pain and swelling. The splint will help support the painful limb. The splint will not reduce the redness, stop exudate and pus formation, nor decrease the white blood cell count.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 1


4. The nurse is caring for a patient with an infection who is complaining about remaining in the hospital since he has so much work to do and is responsible for caring for his young children. Which of the following should the nurse do to help this patient?

1. Discuss ways the client can reduce the stress in his life.2. Review methods to maintain good skin hygiene.3. Suggest the client be more conscious about the cleanliness of his home

environment.4. Instruct on the need to increase carbohydrates in his diet.

Correct Answer: Discuss ways the client can reduce the stress in his life.

Rationale: Individuals may develop a weakened immune system from chronic stress, so the nurse should discuss ways to reduce the stress in this patient’s life. There is no evidence to suggest that the patient is not maintaining good skin hygiene or that his home environment is not clean. Rather than carbohydrates, it is protein, vitamins, and minerals that are needed for healthy immune system functioning.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Psychosocial IntegrityLO: 2


5. The nurse is caring for a patient who has had pneumonia twice in the last 6 months. Which of the following does this suggest to the nurse?

1. Immunodeficiency2. Poor self-care habits3. Poor air quality in the home4. Poor nutritional status

Correct Answer: Immunodeficiency

Rationale: A failure in the immune system will lead to a tendency to develop unusual or recurrent severe infections. Immunodeficiency should be considered when an individual has frequent, severe, documented infections such as pneumonia. There is no evidence to suggest that the patient has poor self-care habits or has poor air quality in the home. There is not enough information to assume that the patient needs a pneumonia vaccination or that the patient has poor nutritional status.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Physiological IntegrityLO: 2


6. An older patient tells the nurse that he does not understand why she is getting infections now since she never had the problem before. Which of the following is the nurse’s best response to this patient?

1. The immune system gets weaker as we age.2. Have you changed your personal grooming habits?3. It always happens when people have chronic diseases.4. It’s because of a poor diet.

Correct Answer: The immune system gets weaker as we age.

Rationale: As people age, the immune system weakens as a result of decreasing thymus gland function. The nurse should not assume that the patient has changed her personal grooming habits. The nurse should also not assume that the patient has a chronic disease. A poor diet can contribute to a weakened immune system, but the nurse should not assume that the patient’s diet is poor.

Cognitive Level: ApplyingNursing Process: Implementation Client Need: Health Promotion and MaintenanceLO: 2


7. A 36-year-old patient asks why he developed an infection after being cut while working with wood. He claims to have experienced similar cuts, but this is the first one that became infected. The nurse’s best response would be:

1. “You were particularly susceptible to this type of infection-causing bacteria.”2. “The wood was probably contaminated with a virile bacteria.”3. “What makes you sure there was never an infection before?”4. “As we age, our bodies just don’t fight off infections as easily.”

Correct Answer: “You were particularly susceptible to this type of infection-causing bacteria.”

Rationale: Once the organism enters a host, the host must be susceptible to infection before an infection will occur. If the body has weakened defenses, infection can occur. There is no evidence to suggest that the wood was contaminated with a virile bacteria. The nurse should not confront the patient by questioning if the patient knew if he’s had an infection from wood before. The patient is in his 30s and would not have a reduced ability to fight infections, as seen more frequently in the elderly.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 3


8. A patient admitted with a gastrointestinal infection tells the nurse that she started to feel sick a few days after visiting with out-of-town family. Which of the following should the nurse ask this patient?

1. Were any family members sick or recovering from a similar illness?2. How often do you wash your hands?3. Did you eat your meals at home or in public places?4. Do you have a history of stomach ulcers?

Correct Answer: Were any family members sick or recovering from a similar illness?

Rationale: The nurse should ask if there were any other family members sick or recovering from a similar illness. Within the chain of infection, a causative agent or microorganism must exist in order for infection to occur. The organism must have a reservoir. Human reservoirs can be carriers or people who do not have the infection but carry the microorganism. People can be in a period of incubation, have a subclinical infection, be recovering from an infection, or be chronic carriers of the infection. Although important, hand washing and location of eating meals would not help find the source of the infection. Having a history of stomach ulcers may or may not help identify the cause of the infection.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 3


9. A patient who changes his own skin lesion dressings tells the nurse that he developed a new skin lesion on another body part. The nurse realizes this patient is most likely describing which of the following modes of transmission?

1. Indirect contact2. Direct contact3. Vehicle4. Vector-borne

Correct Answer: Indirect contact

Rationale: Indirect contact involves the susceptible person being exposed to the organism through a contaminated object such as a contaminated dressing. Direct contact occurs when there is actual person-to-person contact, as seen with a sexually transmitted disease. Vehicle transmission occurs when the organism’s life is maintained on something outside the reservoir until it is passed to the susceptible host. The vehicle is a nonliving object. Vector-borne transmission occurs when a disease-producing organism is carried by a living host and transfers the organism to a susceptible host.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 3


10. A patient tells the nurse that she doesn’t wash her hands very much because the skin on her hands is dry and cracked. Which of the following should the nurse instruct this patient?

1. Use a hand lotion with high fat or oil content to protect the skin.2. Wash hands with cold water instead.3. Wash hands with hot water instead.4. Wash hands without soap.

Correct Answer: Use a hand lotion with high fat or oil content to protect the skin.

Rationale: Hand washing can lead to dermatitis from the frequent contact with water and soap. The cracked, dry skin can lead to the avoidance of hand washing. The nurse should instruct the patient to use a moisturizer that contains fats and oils to increase skin hydration and provide a protective skin barrier. Tepid water, and not cold or hot water, should be used to help prevent hand dermatitis. Washing hands without soap is not recommended.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Safe, Effective Care EnvironmentLO: 4


11. The nurse is planning to irrigate an infected wound. Which of the following should the nurse do to reduce exposure to pathogens?

1. Wear a mask or eye/face shield.2. Wear a sterile gown.3. Place the patient in a side-lying position.4. Have the patient hold the wound irrigant.

Correct Answer: Wear a mask or eye/face shield.

Rationale: Masks and face shields or eye shields should be worn by health care personnel when performing procedures that are likely to cause splashing of blood or body fluids. A sterile gown is not indicated for this procedure. There is not enough information to determine if the patient should be placed in a side-lying position. It is not appropriate to have the patient hold the wound irrigant.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Safe, Effective Care EnvironmentLO: 4


12. The nurse is changing a patient’s bed linens. Which of the following should be done with the soiled linens?

1. Carry the linens away from the nurse’s body and place them in a linen hamper.

2. Place the soiled linens on the floor so all soiled laundry from the room may be easily collected.

3. Place the soiled linens on a chair and remove them when leaving the room.4. Shake the linens, put them in a soiled pillowcase, and place it on the floor.

Correct Answer: Carry the linens away from the nurse’s body and place them in a linen hamper.

Rationale: Linens should be changed so that there is little contact between the dirty linens and the nurse’s uniform, carried away from the nurse’s body, and placed in an appropriate hamper. Placing dirty linens on the floor or laying them on a chair could lead to further contamination of the environment. Dirty linens should not be shaken nor put in a soiled pillow case and then placed on the floor.

Cognitive Level: Applying Nursing Process: ImplementationClient Need: Safe, Effective Care EnvironmentLO: 4


13. The admitting department alerts the nurse in a medical–surgical unit that a patient with active tuberculosis (TB) is being admitted to the unit. Which type of precautions should be the priority based upon the patient’s diagnosis?

1. Airborne2. Standard 3. Droplet 4. Contact

Correct answer: Airborne

Rationale: While all precautions are important, airborne precautions are designed to protect against infectious agents that are transmitted through particles that remain suspended in the air and can become inhaled or deposited on a host, as seen with tuberculosis. Standard precautions are designed to reduce the risk of transmission of pathogens from blood and body fluids containing blood. Droplet precautions protect against the risk of transmission of infection through the air from droplets that travel short distances, generated through talking, coughing, or sneezing. Contact precautions reduce the risk of organism transmission through direct or indirect contact such as by shaking hands or touching an inanimate object in the patient’s environment.

Cognitive Level: ApplyingNursing Process: PlanningClient Needs: Safe, Effective Care EnvironmentLO: 5


14. A patient who has been on antibiotic therapy for several months has been diagnosed with Clostridium difficile. Which of the following should be done to help this patient?

1. Discontinue the antibiotics.2. Change the antibiotic to penicillin.3. Change the antibiotic to erythromycin.4. Instruct the patient to avoid raw fruits and vegetables.

Correct Answer: Discontinue the antibiotics.

Rationale: Clostridium difficile is an anaerobic bacterium that occurs as an overgrowth in the gastrointestinal tract of patients during or after antibiotic therapy. Treatment includes discontinuing the current antibiotic and beginning Vancomycin or Metronidazole. Penicillin or erythromycin are not indicated in the treatment of Clostridium difficile. Raw fruits and vegetables are implicated as a source for a pseudomonas infection.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Physiological IntegrityLO: 5


15. A patient has been diagnosed with an infection caused by an organism that was in an inappropriately cooked meat product. The nurse realizes this patient’s infection is most likely caused by a:

1. Parasite.2. Virus.3. Fungus.4. Bacteria.

Correct Answer: Parasite.

Rationale: Parasites are pathogens that infect and cause disease in other animals. Protozoa are considered parasites and are small single-celled animals that can be transmitted to the host by direct contact, mainly through ingested food or water or through another type of vector. Organisms within inappropriately cooked meat products are not associated with viruses, fungi, or bacteria.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 5


16. The nurse is reviewing information about the most common types of pathogens used in a biological warfare attack. Which of the following organisms would present like the flu?

1. Anthrax2. Smallpox3. Neisseria meningitides4. Enterobacteriaceae

Correct Answer: Anthrax

Rationale: Anthrax symptoms are flulike and include fever, nonproductive cough, headache, and malaise. Smallpox symptoms include high fever, headache, malaise, and a vesicular pustular rash on the face and extremities. Neisseria meningitides and Enterobacteriaceae are not considered as likely pathogens to be used in biological warfare.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Safe, Effective Care EnvironmentLO: 6


17. The nurse is planning to provide vaccinations to a school-aged child. Which of the following should the nurse most likely review prior to administering these vaccinations?

1. The current year’s immunization schedule for children2. The current immunization schedule for adolescents3. The current immunization schedule for adults4. The list of viruses included in the pneumonia vaccination solution

Correct Answer: The current year’s immunization schedule for children

Rationale: The immunization schedule for children is revised annually and published each year in January by the Centers for Disease Control and Prevention. The schedule for adolescents and adults is revised less frequently, except for the influenza vaccine recommendations that are published annually. The client is school-aged, not adult. It is not necessary for the nurse to review the list of viruses included in the pneumonia vaccination solution.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 6


18. A patient tells the nurse that he does not want to get any immunizations. In which of the following ways should the nurse respond to this patient?

1. It is a method to reduce the onset of some infections.2. I don’t like to get injections either.3. Some of the vaccinations don’t really work.4. You will wish you had gotten the immunization if you get an infection.

Correct Answer: It is a method to reduce the onset of some infections.

Rationale: The nurse should explain the purpose of immunizations. Immunizations are one way to prevent the onset of infections. The nurse should not discuss personal sentiments about injections or the effectiveness of vaccinations. The nurse should not pressure the patient with the onset of an infection if a vaccination is not administered.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 6


19. A patient is scheduled to receive a vaccination but is experiencing a mild upper respiratory infection. Which of the following should the nurse do?

1. Administer the vaccination.2. Schedule the patient to return in 1 month for the vaccination.3. Tell the patient that the vaccination is no longer needed.4. Administer half of the vaccination and schedule the patient to return in 1 week

for the remainder of the dose.

Correct Answer: Administer the vaccination.

Rationale: This patient is demonstrating a condition that might compromise the ability of the vaccine to produce immunity. However, an individual with a mild, acute illness such as diarrhea or upper respiratory tract infection can be safety vaccinated. The nurse should not delay the vaccination, nor should the nurse tell the patient that the vaccination is no longer needed. It is not appropriate to administer half of the vaccination and schedule the patient to return in a week for the remainder of the dose.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 7


20. The mother of a newborn asks the nurse why she should consent to immunizing her baby with the hepatitis B vaccine. The nurse’s best response is:

1. “This vaccination will produce antibodies to help prevent your baby from ever getting hepatitis B”

2. “Your baby will be healthier and won’t even remember getting the hepatitis B shot.”

3. “Hepatitis B is very easily spread, even among very young children.” 4. “The hepatitis B vaccination is safe and covered by your insurance.”

Correct Answer: “This vaccination will produce antibodies to help prevent your baby from ever getting hepatitis B.”

Rationale: Stating that the vaccination will produce antibodies to help prevent the baby from getting hepatitis B provides the mother with a concise explanation of the benefit of the vaccination to her infant. According to the Healthy People 2010 objectives related to the prevention of infection, hepatitis B is a disease that can be prevented through universal vaccination. The other choices do not provide sufficient or correct information to support the mother’s decision-making process.

Cognitive Level: EvaluatingNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 7


21. A patient with tuberculosis tells the nurse that she does not want to continue taking the prescribed medication. Which action by the nurse is most appropriate?

1. Encourage the patient to complete the therapy to eliminate the disease from her body.

2. Document that the patient refuses to take the medication.3. Ask the patient to return home and consider changing her lifestyle to eliminate

contact with other people.4. Have a tuberculosis skin test to check and see if the patient transmitted the

disease to the nurse.

Correct Answer: Encourage the patient to complete the therapy to eliminate the disease from her body.

Rationale: According to the Healthy People 2010 guidelines for infectious diseases and emerging antimicrobial resistance, the nurse should encourage the patient to complete the therapy to eliminate the disease from her body. Documentation is important; however, it is not the correct intervention in this situation. Asking the patient to return home and change her lifestyle is not an appropriate response. Assuming the patient transmitted tuberculosis to the nurse might be extreme at this time.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 7


22. A patient is seen in the clinic for peptic ulcer disease. The nurse realizes this patient’s treatment will include:

Ways to prevent hospitalization. A plan to be admitted to the hospital for diagnostic testing. The need for a pneumococcal vaccination. Vaccination against hepatitis A.

Correct Answer: Ways to prevent hospitalization.

Rationale: According to Healthy People 2010, one strategy to reduce infectious diseases and emerging antimicrobial resistance is to reduce hospitalizations caused by peptic ulcer disease in the United States. Planning to admit this patient into the hospital would not support the Healthy People 2010 strategy. There is no evidence to suggest this patient needs either a pneumococcal or hepatitis A vaccination.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 7


23. The nurse is caring for four patients in a medical–surgical unit. Which patient should the nurse see first?

A patent admitted with infectious gastroenteritis who has had severe diarrhea for the last 24 hours

A patent admitted with pneumonia who is has small amounts of yellow productive sputum

A patent admitted with fever of unknown origin whose temperature is currently 99.0˚F

A patent admitted with an infected wound on the left foot whose WBC is 8,500 mm3

Correct Answer: A patient admitted with infectious gastroenteritis who has had severe diarrhea for the last 24 hours

Rationale: The nurse’s priority is the patient with infectious gastroenteritis who has had severe diarrhea for the last 24 hours; this patient is at risk for dehydration and could experience a fluid-volume deficit. Small amounts of yellow productive sputum are expected in a patient with pneumonia. A patient admitted with a fever whose temperature is currently 99˚F is not in acute distress. The patient with the infected leg wound currently has a white blood cell count within normal limits.

Cognitive Level: ApplyingNursing Process: PlanningClient Needs: Physiological IntegrityLO: 8


24. The nurse is reviewing the following laboratory results and determines that which of the following requires immediate intervention?

WBC 14,600 mm3

Monocyte count 6:% Wound culture showing no growth Sedimentation rate female patient 9 mm/hr

Correct Answer: WBC 14, 600 mm3

Rationale: A WBC of 14, 600 mm3 is well above the normal WBC range (4,000–10,000 mm3), and the client’s health care provider should be notified immediately. All of the other lab results are within acceptable ranges.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Physiologic IntegrityLO: 8


25. A patient is prescribed an intravenous antibiotic for an infection. The nurse realizes this intervention is appropriate to treat which of the following patient problems?

Fever Pain Fatigue Fluid-volume status

Correct Answer: Fever

Rationale: One intervention appropriate for a patient with an infection demonstrating a fever is the administration of antibiotics to treat the organism responsible for the infection. The administration of an antibiotic is not an intervention associated with the patient problems of pain, fatigue, or fluid-volume deficit.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Physiological IntegrityLO: 8


ch20.doc

Documents

Transcript of ch20.doc