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 C
Explanation
Choice A rationale:
Chemoprophylaxis involves using medications to prevent TB infection or its progression in individuals at high risk of exposure. While it is an important strategy, it is not specifically related to administering the BCG vaccine.
Choice B rationale:
Screening for TB involves identifying individuals who are at risk of infection or have active disease through various tests such as tuberculin skin tests and chest X-rays. Although screening is a crucial aspect of TB control, it is not the strategy involving BCG vaccine administration.
Choice C rationale:
Vaccination with the BCG vaccine is an individual-level strategy aimed at providing protection against TB, particularly in infants or children at high risk of TB exposure or infection. The BCG vaccine does not provide complete protection against TB but has been shown to reduce the risk of severe forms of the disease, such as TB meningitis and miliary TB, in children.
Choice D rationale:
Surveillance involves monitoring the incidence and prevalence of TB at the population level. It does not directly involve administering the BCG vaccine to individuals at risk.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
Surgery for extensive lung damage may be considered in very rare cases of complications from TB, but it is not an adjunctive measure commonly required for TB treatment. The primary treatment for TB involves antibiotic therapy and adjunctive measures to manage complications.
Choice B rationale:
Corticosteroids may be required as adjunctive therapy for pericarditis, a complication of TB that affects the lining around the heart. Corticosteroids help reduce inflammation and improve the patient's condition.
Choice C rationale:
Nutritional support is often necessary for patients with TB, as the disease can lead to malnutrition and weight loss. Adequate nutrition is crucial for supporting the immune system and facilitating recovery.
Choice D rationale:
Fluid therapy may be required for patients with TB who experience dehydration due to fever, night sweats, and reduced oral intake. Proper hydration helps maintain organ function and aids in the elimination of waste products.
Choice E rationale:
Pain management is essential for patients with TB, especially for those experiencing chest pain, which can be a symptom of the disease or a complication. Adequate pain control improves the patient's comfort and compliance with treatment.
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