A client receiving parenteral nutrition by central venous access reports feeling unwell. The nurse assesses the client and suspects that the central line has become infected. Which of the following findings indicate that the client has developed a systemic infection? Select all that apply.
Edema
Purulent drainage at intravenous insertion site
Redness at insertion site
Nausea
Leukocytosis
Fever
Correct Answer : B,E,F
Choice A Reason: Edema is not a specific finding of a systemic infection, but rather a possible sign of fluid overload or impaired venous return. It can occur due to excessive infusion rate, heart failure, or obstruction of blood flow in or around the central line.
Choice B Reason: This is a correct choice. Purulent drainage at intravenous insertion site is a finding of a local infection that can spread systemically. It indicates bacterial invasion and inflammation of the skin and subcutaneous tissue around the catheter.
Choice C Reason: Redness at insertion site is a finding of a local infection that can spread systemically. It indicates increased blood flow and inflammation of the skin and subcutaneous tissue around the catheter.
Choice D Reason: Nausea is not a specific finding of a systemic infection, but rather a possible side effect of parenteral nutrition or a symptom of another condition. It can occur due to electrolyte imbalance, hyperglycemia, or gastrointestinal disorders.
Choice E Reason: This is a correct choice. Leukocytosis is a finding of a systemic infection that indicates increased production and release of white blood cells in response to infection. It can be detected by a blood test.
Choice F Reason: This is a correct choice. Fever is a finding of a systemic infection that indicates increased body temperature due to activation of the immune system and release of pyrogens. It can be measured by a thermometer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because drawing with crayons may be too childish or frustrating for a client with moderate Alzheimer's. Crayons may also pose a choking hazard or cause messes. The nurse should provide activities that are suitable for the client's cognitive and functional level, as well as their interests and preferences.
Choice B Reason: This is incorrect because dangling ribbons or a mobile may be too stimulating or confusing for a client with moderate Alzheimer's. These items may also trigger agitation or wandering behaviors. The nurse should provide activities that are calming and familiar for the client.
Choice C Reason: This is correct because listening to music, watching TV, or videos can be enjoyable and beneficial for a client with moderate Alzheimer's. Music can evoke memories, emotions, and positive responses. TV or videos can provide entertainment, education, and socialization. The nurse should choose music, TV shows, or videos that are appropriate and meaningful for the client.
Choice D Reason: This is incorrect because board games may be too complex or challenging for a client with moderate Alzheimer's. Board games may require memory, concentration, logic, or strategy skills that the client may have lost. The nurse should provide activities that are simple and easy for the client to follow.
Correct Answer is A
Explanation
Choice A Reason: This is the correct choice because driving a motorcycle is a high-risk activity that can expose the client to head trauma, especially if they do not wear a helmet. Traumatic brain injury (TBI) is a condition where the brain is damaged by an external force, such as a collision, fall, or assault.
Choice B Reason: This is incorrect because having high blood pressure is not a direct risk factor for traumatic brain injury. High blood pressure can increase the risk of stroke, which is a condition where the brain is damaged by an internal cause, such as a blood clot or hemorrhage.
Choice C Reason: This is incorrect because smoking and having a family history of brain cancer are not risk factors for traumatic brain injury. Smoking and genetic factors can increase the risk of developing brain tumors, which are abnormal growths of cells in the brain.
Choice D Reason: This is incorrect because golfing and driving a golf cart are low-risk activities that do not pose a significant threat to the client's head. Golfing and driving a golf cart may cause minor injuries, such as sprains, strains, or bruises, but not traumatic brain injury.
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