A clinic nurse is working with an older client. What action is most important for preventing infections in this client?

Instructing the client to wash minor wounds carefully

Assessing vaccination records for booster shot needs

Teaching hand hygiene to prevent the spread of microbes

Encouraging the client to eat a nutritious diet

Answer and Explanation

The Correct Answer is C

A.   Proper wound care is essential in preventing infections, particularly in older adults who may have thinner skin and slower healing processes. However, while this is important, it is just one aspect of a comprehensive infection prevention strategy and does not address broader systemic issues.
B.   Older adults are often at higher risk for infections due to waning immunity. Regular vaccinations, such as the flu vaccine, pneumococcal vaccine, and others, can significantly reduce the risk of serious infections. This action is critical but is part of a preventive framework rather than a standalone solution.
C.   Hand hygiene is one of the most effective measures to prevent the transmission of infections. Educating clients about proper handwashing techniques and when to wash their hands can significantly reduce the risk of infections, especially in older adults who may be more susceptible due to age-related immune changes.
D.   Nutrition plays a vital role in maintaining overall health and supporting the immune system. A well- balanced diet can help older adults fight infections more effectively. However, while important, diet alone may not be as immediately impactful in preventing infections as other measures like hand hygiene and vaccination.

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Correct Answer is ["A","C","D"]

Explanation

A. Trauma can cause an elevated WBC count as part of the body’s response to injury. The immune system reacts to tissue damage by increasing WBC production to facilitate healing and fight potential infections.
B. Hyperglycemia itself does not directly cause an elevated WBC count. However, it may be associated with conditions like diabetes, where infections are more common. Therefore, while hyperglycemia can occur concurrently with elevated WBC counts, it is not a direct cause of the increase.
C. Infection is one of the most common causes of an elevated WBC count. The body responds to infections (bacterial, viral, etc.) by increasing WBC production to help combat the invading pathogens.
D. Inflammation, whether due to autoimmune conditions, allergies, or other causes, can also lead to an increase in WBC count. The inflammatory process triggers the immune response, resulting in elevated levels of white blood cells.
E. While steroid injections can influence WBC counts, they often cause a redistribution of white blood cells rather than an increase in production. Corticosteroids can cause a decrease in certain types of white blood cells (like lymphocytes) but may increase neutrophils due to a release from the bone marrow.

A. Client report of intense feeling of heat in the fingers B. Pallor of the toes with cold exposure C. Feet that become reddened with ambulation D. Swelling of the joints of the fingers

Correct Answer is B

Explanation

A. This is not typical for Raynaud's phenomenon. Instead, Raynaud's is characterized by episodes of reduced blood flow to the extremities, often triggered by cold or stress, leading to sensations of coldness or numbness rather than warmth.
B. This finding aligns with Raynaud's phenomenon. During an episode, the blood vessels constrict in response to cold or stress, leading to pallor (whiteness) in the affected areas, such as the toes and fingers. This is a classic symptom of the condition.
C. While feet can become reddened due to increased blood flow after rewarming or after exposure to warmth, this is not a characteristic feature of Raynaud's phenomenon. In Raynaud's, the affected areas typically exhibit color changes from white (pallor) to blue (cyanosis) and then red (hyperemia) as blood flow returns, but redness upon ambulation is not specifically indicative of the phenomenon.
D. Swelling of the joints can occur in SLE due to arthritis or inflammation but is not a direct symptom of Raynaud's phenomenon. Raynaud's primarily affects blood flow and does not inherently cause joint swelling; however, a client with SLE may experience joint symptoms due to other underlying inflammatory processes.

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A clinic nurse is working with an older client. What action is most important for preventing infections in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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