A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?
Arrange for the patient to receive gamma globulin.
Assess frequently for herpes zoster.
Be aware of the patient's immunity to chickenpox.
Encourage the patient to have a pneumonia vaccine.
The Correct Answer is C
A. Arrange for the patient to receive gamma globulin.
Gamma globulin is a blood product that contains antibodies and is sometimes used for post-exposure prophylaxis in certain situations, such as for individuals who are immunocompromised or pregnant and have been exposed to varicella (chickenpox) or measles. However, for a frail, older adult who had chickenpox as a child and has been exposed to varicella again, arranging for gamma globulin may not be necessary if the patient is already immune to chickenpox.
B. Assess frequently for herpes zoster.
Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. While exposure to varicella can increase the risk of developing shingles in individuals who are susceptible, frequent assessment for herpes zoster is not necessary in this case if the patient is known to have had chickenpox in the past.
C. Be aware of the patient's immunity to chickenpox.
This option is the correct choice. Since the patient had chickenpox as a child, they likely have immunity to chickenpox. Being aware of this immunity helps the nurse understand that the patient may not develop chickenpox again even after exposure to varicella.
D. Encourage the patient to have a pneumonia vaccine.
Encouraging the patient to have a pneumonia vaccine is unrelated to the immediate concern of exposure to varicella. While pneumonia vaccines are important for older adults, especially those who are frail, the priority in this scenario is to determine the patient's immunity to chickenpox due to prior infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Superficial infections are caused by fungus.
While fungal infections can indeed cause superficial skin infections like tinea (ringworm) or candidiasis, they are not the common factor for the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions primarily involve bacterial infections of the hair follicles, typically caused by Staphylococcus aureus bacteria.
B. Parasites get underneath the skin.
Parasitic infections can cause various skin conditions, but they are not the common factor for folliculitis, furuncles, and carbuncles. These conditions are specifically related to bacterial infections of the hair follicles rather than parasitic infestations.
C. Hair follicles are infected or inflamed.
This is the correct choice and the common factor for folliculitis, furuncles, and carbuncles. All three conditions involve the infection or inflammation of hair follicles, primarily due to Staphylococcus aureus bacteria. Folliculitis is the inflammation of one or more hair follicles, furuncles are deeper infections involving the hair follicle and surrounding tissue, and carbuncles are clusters of interconnected furuncles with deeper tissue involvement.
D. There is an allergic response to an allergen.
An allergic response to an allergen does not play a role in the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions are primarily infectious in nature, involving bacterial colonization and subsequent inflammation of the hair follicles rather than an allergic response.
Correct Answer is B
Explanation
A.Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.
B.High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).
C.Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.
D.A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.
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