A client has been diagnosed with shingles. What interventions should the nurse implement to provide appropriate care? Select all that apply.
Monitor vital signs, pain level, neurological status, and eye function.
Administer medications as prescribed and monitor for adverse effects.
Encourage the client to scratch the affected area for temporary relief.
Isolate the patient until all lesions are crusted over if direct contact with vesicles is possible.
Provide comfort measures such as cool compresses, loose clothing, distraction techniques, and relaxation methods.
Correct Answer : A,B,D,E
Choice A rationale:
The nurse should monitor vital signs, pain level, neurological status, and eye function for a client with shingles to assess for any complications or worsening of the condition. Vital signs may indicate signs of infection, pain level may help assess the effectiveness of pain management, neurological status can indicate any neurological complications, and eye function is important as shingles affecting the ophthalmic nerve can lead to eye complications.
Choice B rationale:
Administering medications as prescribed is crucial to manage the symptoms and complications of shingles. Antiviral medications can help reduce the severity and duration of the outbreak, while pain medications may be necessary to alleviate discomfort. The nurse should also monitor for adverse effects to ensure the client's safety during treatment.
Choice D rationale:
Isolating the patient until all lesions are crusted over is necessary to prevent the spread of the varicella-zoster virus, which causes shingles. Direct contact with vesicles can lead to transmission of the virus to susceptible individuals, particularly those who have not had chickenpox or received the varicella vaccine.
Choice E rationale:
Providing comfort measures is essential in managing the symptoms of shingles. Cool compresses can help relieve pain and inflammation, loose clothing can prevent irritation of the affected area, distraction techniques can divert the client's attention from discomfort, and relaxation methods can help reduce stress and promote healing.
Choice C rationale:
Encouraging the client to scratch the affected area is not appropriate care for shingles. Scratching can lead to skin damage, increase the risk of infection, and potentially worsen the condition. It is essential to advise against scratching and promote gentle care of the affected area instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should advise the patient with chickenpox to avoid contact with pregnant women, immunocompromised individuals, newborns, and people who have not had chickenpox or been vaccinated. Chickenpox is highly contagious and can be severe or even life-threatening for vulnerable populations. This precaution helps protect those who are at a higher risk of complications from the infection.
Choice B rationale:
Sharing personal items such as towels and utensils should be avoided during chickenpox. Chickenpox spreads through respiratory droplets and direct contact with fluid from the blisters. Sharing personal items can increase the risk of transmission to others.
Choice C rationale:
It is not appropriate for the nurse to recommend scratching the chickenpox lesions. Scratching can lead to secondary bacterial infections and scarring. The patient should be encouraged to use methods like calamine lotion or antihistamines to relieve itching.
Choice D rationale:
The patient should not return to work or school until all lesions are crusted over and they are no longer contagious. Typically, this occurs about 6-7 days after the rash first appears. Returning too early can increase the risk of spreading the virus to others.
Correct Answer is C
Explanation
Choice A rationale:
"I should take my medications regularly and complete the full course of therapy" is a correct statement. TB treatment involves multiple drugs taken for an extended period, typically 6 to 9 months, to ensure complete eradication of the bacteria and prevent drug resistance.
Choice B rationale:
"I will report any adverse effects of the medications, such as skin rash or eye inflammation" is a correct statement. TB medications can have side effects, and it's crucial for the patient to report any adverse reactions to their healthcare provider for appropriate management.
Choice C rationale:
"I can stop taking the medications once I start feeling better" is an incorrect statement. TB treatment requires completing the full course of therapy, even if the patient's symptoms improve. Stopping treatment prematurely can lead to treatment failure and the development of drug-resistant TB.
Choice D rationale:
"I understand that the treatment may require surgery if there is extensive lung damage" is a correct statement. In some cases of TB, particularly if there is significant lung damage or complications, surgical intervention may be necessary.
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