A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?
Vesicles on the skin
Respiratory failure
Sloughing of skin
Flu-like symptoms
The Correct Answer is B
Choice a) is incorrect because vesicles on the skin are a sign of cutaneous anthrax, not inhalation anthrax. Cutaneous anthrax is caused by direct contact with anthrax spores through a break in the skin. It causes a painless, black, necrotic lesion on the affected area.
Choice b) is correct because respiratory failure is a sign of inhalation anthrax, which is the most deadly form of anthrax. Inhalation anthrax is caused by breathing in anthrax spores that enter the lungs and spread to the bloodstream. It causes severe breathing problems, chest pain, shock, and death.
Choice c) is incorrect because sloughing of skin is a sign of necrotizing fasciitis, not inhalation anthrax. Necrotizing fasciitis is a rare bacterial infection that destroys the soft tissue under the skin. It causes severe pain, swelling, redness, blisters, and gangrene.
Choice d) is incorrect because flu-like symptoms are not specific to inhalation anthrax. Flu-like symptoms can be caused by many other conditions, such as influenza, common cold, or COVID-19. Flu-like symptoms include fever, cough, sore throat, headache, and muscle aches.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Check the tubing connections for leaks is not an action that the nurse should take. Leaks in the tubing connections can cause continuous or intermitent bubbling in the water seal chamber, not in the suction control chamber. The water seal chamber is the part of the closed chest drainage system that prevents air from entering the pleural space and allows air to escape from the chest tube. The nurse should check the tubing connections for leaks if there is bubbling in the water seal chamber and tighten them if necessary.
Choice B: Check the suction control outlet on the wall is not an action that the nurse should take. The suction control outlet on the wall is the source of negative pressure that helps drain fluid and air from the pleural space and maintain a patent chest tube. The suction control chamber is the part of the closed chest drainage system that regulates the amount of negative pressure applied to the chest tube. The nurse should check the suction control outlet on the wall if there is no bubbling in the suction control chamber and adjust it as prescribed.
Choice C: Continue to monitor the client's respiratory status is an action that the nurse should take. Slow, steady bubbling in the suction control chamber is an expected finding that indicates that the suction is working properly and that there are no leaks in the system. The nurse should continue to monitor the client's respiratory status and assess for signs of respiratory distress, such as dyspnea, tachypnea, cyanosis, or decreased oxygen saturation.
Choice D: Clamping the chest tube is not an action that the nurse should take. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition characterized by a buildup of air in the pleural space that compresses the lung and shifts the mediastinum. The nurse should only clamp the chest tube temporarily and briefly for specific purposes, such as changing or troubleshooting the drainage system, or as prescribed by the provider.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because the client's best motor response is 5, which means he can localize pain, not follow commands.
Choice B Reason: This is incorrect because the client's eye opening response is 3, which means he opens his eyes to pain, not to speech.
Choice C Reason: This is correct because the client's GCS score is 13, which indicates a severe impairment of consciousness. The GCS is a tool used to assess the level of consciousness of a person who has a head injury. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness. A GCS score of 8 or less indicates coma. The client's GCS score is 3 + 5 + 5 = 13, which is above the coma threshold, but still indicates a severe impairment of consciousness. The other choices are not consistent with the client's GCS score.
Choice D Reason: This is incorrect because the client's best verbal response is 5, which means he can orient himself to person, place, and time, not that he is unable to make vocal sounds.
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