Patient Data
The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.
Temperature 98.8° F (37.1° C)
Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic
Serum blood glucose 185 mg/dL (10.2 mmol/L)
White blood cell count 11.2 x 103/µL (11.2 x 109/L)
Capillary refill greater than 3 seconds bilateral lower extremities
Bilateral lower extremities skin warm, dry, and pink
Correct Answer : A,D,F
Rationale:
A. Temperature 98.8° F (37.1° C): A normal body temperature indicates resolution of the infection and a positive response to antibiotic therapy for cellulitis. Fever reduction is a key indicator of therapeutic effectiveness.
B. Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic: While pain is low, the description of neuropathic pain unrelated to cellulitis does not reflect improvement in the infection itself, so it is not a primary indicator of therapeutic response.
C. Serum blood glucose 185 mg/dL (10.2 mmol/L): Although improved from the initial hyperglycemia, this level is still above the normal range. It does not directly indicate resolution of cellulitis or therapeutic effectiveness of antibiotic therapy.
D. White blood cell count 11.2 x 103/µL (11.2 x 10⁹/L): The decrease toward normal limits from an elevated WBC demonstrates a positive hematologic response to treatment and reduced systemic inflammation caused by the infection.
E. Capillary refill greater than 3 seconds bilateral lower extremities: Prolonged capillary refill indicates peripheral perfusion deficits. Persistent abnormal refill is not a sign of therapeutic response and may reflect ongoing vascular compromise.
F. Bilateral lower extremities skin warm, dry, and pink: Improvement in skin color, warmth, and absence of edema or erythema reflects resolution of cellulitis and effective local tissue recovery, consistent with therapeutic response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Polydipsia and polyuria: These symptoms are more commonly associated with uncontrolled diabetes mellitus rather than hypertension. They are not direct complications of elevated blood pressure.
B. Elevated blood urea nitrogen: Hypertension can damage renal blood vessels, leading to impaired kidney function and elevated BUN levels. This is a significant complication that indicates progressive end-organ damage.
C. Dry and irritated skin: This is a nonspecific symptom that may result from dermatologic conditions, dehydration, or environmental factors. It is not typically associated with hypertension complications.
D. New onset of bradycardia: Bradycardia is not a usual complication of hypertension itself, though it may occur as a side effect of certain antihypertensive medications such as beta-blockers. It is not a primary complication to anticipate.
Correct Answer is B
Explanation
A. Urge the client to have regular STI screening every two years: Screening every two years is insufficient for individuals with recurrent STIs. More frequent testing is recommended to prevent reinfection and detect new infections early.
B. Answer questions directly and correct any misinformation: Providing accurate, evidence-based information helps the client understand STI transmission, prevention, and treatment. Direct responses foster trust, support informed decision-making, and address misconceptions effectively.
C. Clarify that all STIs are transmitted through sexual intercourse: Not all STIs are transmitted solely through intercourse; some, like herpes or HPV, can be transmitted via skin-to-skin contact. This statement could be misleading and does not fully educate the client.
D. Provide counseling that most contraceptives protect against infection: Most contraceptives, such as oral contraceptives or IUDs, do not protect against STIs. Only barrier methods, like condoms, reduce the risk of STI transmission.
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