A nurse is caring for a client whose throat culture is positive for group A streptococcus 24 hours after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority?

Reinforce teaching about gargling with warm saline several times daily.

Ask the client to identify friends and family who have been in close contact.

Instruct the client to take antipyretics as directed for elevated temperature.

Notify the client to return to the clinic for initiation of antibiotic therapy.

Answer and Explanation

The Correct Answer is D

Choice A reason:
While gargling with warm saline can provide symptomatic relief for a sore throat, it does not address the underlying bacterial infection. Therefore, it is not the priority action once a diagnosis of group A streptococcus has been confirmed.

Choice B reason:
Identifying close contacts is important for public health tracking and potentially preventing the spread of the infection. However, the immediate priority for the client is the initiation of treatment to address the infection.

Choice C reason:
Taking antipyretics can help manage fever and provide comfort to the client. While managing symptoms is important, it is secondary to initiating antibiotic therapy, which addresses the cause of the symptoms.

Choice D reason:
The priority action is to notify the client to return to the clinic for initiation of antibiotic therapy. Group A streptococcus is a bacterial infection that requires antibiotics for treatment. Prompt initiation of antibiotics is crucial to prevent complications and promote recovery.

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Correct Answer is C

Explanation

Choice A reason: Hypotension
Hypotension, or low blood pressure, can be a consequence of dehydration, which is a common complication of DI due to the excessive loss of water. However, hypotension is not a direct neurological effect of DI. It is more of a circulatory system response to the changes in fluid volume within the body.

Choice B reason: Poor skin turgor
Poor skin turgor is an indicator of dehydration, which can occur in DI due to the large volume of urine excreted. Skin turgor refers to the skin's ability to change shape and return to normal (elasticity), and it becomes less elastic when the body is dehydrated. While this is an important sign to monitor, it is not a neurological effect.

Choice C reason: Ataxia
Ataxia, which is a lack of muscle coordination affecting speech, eye movements, the ability to swallow, walking, picking up objects, and other voluntary movements, can be a neurological effect of DI if severe dehydration and electrolyte imbalance affect the brain. Symptoms such as confusion and muscle cramps can also be associated with ataxia, making it a relevant neurological effect to monitor in a client with DI.

Choice D reason: Dilute urine
Dilute urine is a primary symptom of DI, not a neurological effect. It is the result of the kidneys' inability to concentrate urine due to a deficiency in the anti-diuretic hormone (ADH) or the kidneys' response to ADH. Monitoring urine concentration is crucial in managing DI, but it does not represent a neurological effect.

A. Activities that could result in bleeding B. All visitors from entering the client's room C. Oral fluid intake to between meals only D. Fresh flowers and potted plants in the room

Correct Answer is D

Explanation

Choice A reason:
Activities that could result in bleeding should be minimized for a client with neutropenia due to the increased risk of infection from open wounds. However, this is not the primary restriction related to neutropenia itself but rather a general precaution for patients with low platelet counts or other clotting issues.

Choice B reason:
Restricting all visitors from entering the client's room is not necessary unless the visitors are sick or have been exposed to infectious diseases. Neutropenic patients are at increased risk for infection, so visitors should be screened for illness, but complete isolation is not required.

Choice C reason:
Modifying oral fluid intake to between meals only is not a standard restriction for neutropenic patients. Adequate hydration is essential, and there are no specific neutropenia-related reasons to restrict fluids to between meals.

Choice D reason:
Fresh flowers and potted plants should be avoided in the room of a neutropenic patient. They can harbor fungi and other microorganisms that could cause infection in an immunocompromised individual. Neutropenic precautions typically include avoiding standing water and plants that may contain harmful bacteria or fungi.

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A nurse is caring for a client whose throat culture is positive for group A streptococcus 24 hours after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority?

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