A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

Distinguish the difference between herpes varicella and herpes zoster.

Explain that the risk of developing shingles decreases with age.

Affirm that a person with shingles has a history of chickenpox infection.

Ask the client to describe the type of shingles that her brother has.

Instruct client to report the development of fatigue and low-grade fever.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Distinguishing the difference between herpes varicella and herpes zoster is important for client education. Herpes varicella (chickenpox) and herpes zoster (shingles) are caused by the same virus, the varicella-zoster virus (VZV). After a person recovers from chickenpox, the virus remains dormant in the nerve tissues and can reactivate years later as shingles. Educating the client about the relationship between these two conditions helps in understanding the risk and nature of shingles.

Choice B reason: Explaining that the risk of developing shingles decreases with age is incorrect. In fact, the risk of developing shingles increases with age, especially in individuals over 50. The immune system's ability to keep the varicella-zoster virus dormant decreases with age, leading to a higher likelihood of reactivation as shingles. Therefore, this choice is not appropriate for client education.

Choice C reason: Affirming that a person with shingles has a history of chickenpox infection is accurate. Shingles occurs when the dormant varicella-zoster virus reactivates in someone who has previously had chickenpox. This information helps the client understand the connection between past chickenpox infection and the potential for developing shingles.

Choice D reason: Asking the client to describe the type of shingles that her brother has is not relevant to the client's own risk or education about shingles. The focus should be on providing accurate information about shingles and its relation to chickenpox, not on the details of another person's condition.

Choice E reason: Instructing the client to report the development of fatigue and low-grade fever is important because these can be early symptoms of shingles. Early identification and treatment of shingles can help manage symptoms and reduce complications. Educating the client on what to watch for and when to seek medical attention is crucial for effective management.

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Correct Answer is C

Explanation

Choice A reason: Administering PRN pain medication can help manage the client's discomfort, but it does not address the underlying cause of the pain. It is essential to assess and identify the source of the pain before administering pain relief. Providing pain medication without a thorough assessment may mask symptoms of a serious underlying issue.

Choice B reason: Observing the leg for swelling is important, as swelling can indicate complications such as compartment syndrome or infection. However, it is not the first action the nurse should take. While swelling is a significant sign, assessing blood flow to the extremity is more critical and should be prioritized.

Choice C reason: Assessing peripheral pulses is the correct first intervention. The presence of foot pain in a client with an external fixation device for a fractured femur could indicate compromised blood flow to the lower extremity. Assessing the peripheral pulses will help determine if there is adequate circulation. If pulses are weak or absent, it may suggest a serious vascular issue that requires immediate intervention to prevent further complications such as tissue ischemia or necrosis.

Choice D reason: Auscultating blood pressure is a routine assessment but does not directly address the immediate concern of left foot pain in this scenario. Blood pressure assessment is important for overall health monitoring but is not the priority when dealing with a possible vascular complication in the affected limb. Ensuring adequate blood flow to the extremity takes precedence.

A. Biliary duct obstruction. B. Surgical site infection. C. Hepatorenal failure. D. Acute pancreatitis.

Correct Answer is D

Explanation

Choice A reason: Biliary duct obstruction can cause symptoms similar to those described, such as abdominal pain and vomiting. However, the key indicators of acute pancreatitis are the elevated serum amylase and lipase levels, which are significantly higher than normal. These enzymes are typically elevated in cases of pancreatitis, making this the more accurate diagnosis.

Choice B reason: Surgical site infection could cause fever and pain, but it would not typically result in elevated serum amylase and lipase levels. These enzymes are specific to pancreatic inflammation and damage, which is characteristic of acute pancreatitis. Therefore, surgical site infection is less likely given the lab results.

Choice C reason: Hepatorenal failure involves liver and kidney dysfunction, which can present with various symptoms, including abdominal pain and vomiting. However, it does not typically cause a significant increase in serum amylase and lipase levels. These elevated levels are more indicative of pancreatic inflammation, pointing towards acute pancreatitis.

Choice D reason: Acute pancreatitis is characterized by upper abdominal pain radiating to the back, vomiting, fever, and significantly elevated serum amylase and lipase levels. These symptoms and lab results align with the diagnosis of acute pancreatitis, making it the correct choice.

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A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

A client receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI) has which nursing problem?

A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?

The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

The nurse has conducted a cancer prevention community education program. In evaluating the participants' understanding of the carcinogens, which statement indicates an accurate understanding?

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect?

A nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?