A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.
Distinguish the difference between herpes varicella and herpes zoster.
Explain that the risk of developing shingles decreases with age.
Affirm that a person with shingles has a history of chickenpox infection.
Ask the client to describe the type of shingles that her brother has.
Instruct client to report the development of fatigue and low-grade fever.
Correct Answer : A,C,E
Choice A reason: Distinguishing the difference between herpes varicella and herpes zoster is important for client education. Herpes varicella (chickenpox) and herpes zoster (shingles) are caused by the same virus, the varicella-zoster virus (VZV). After a person recovers from chickenpox, the virus remains dormant in the nerve tissues and can reactivate years later as shingles. Educating the client about the relationship between these two conditions helps in understanding the risk and nature of shingles.
Choice B reason: Explaining that the risk of developing shingles decreases with age is incorrect. In fact, the risk of developing shingles increases with age, especially in individuals over 50. The immune system's ability to keep the varicella-zoster virus dormant decreases with age, leading to a higher likelihood of reactivation as shingles. Therefore, this choice is not appropriate for client education.
Choice C reason: Affirming that a person with shingles has a history of chickenpox infection is accurate. Shingles occurs when the dormant varicella-zoster virus reactivates in someone who has previously had chickenpox. This information helps the client understand the connection between past chickenpox infection and the potential for developing shingles.
Choice D reason: Asking the client to describe the type of shingles that her brother has is not relevant to the client's own risk or education about shingles. The focus should be on providing accurate information about shingles and its relation to chickenpox, not on the details of another person's condition.
Choice E reason: Instructing the client to report the development of fatigue and low-grade fever is important because these can be early symptoms of shingles. Early identification and treatment of shingles can help manage symptoms and reduce complications. Educating the client on what to watch for and when to seek medical attention is crucial for effective management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A complete blood count (CBC) is the most relevant laboratory value to review for a client with iron deficiency anemia who reports increased fatigue. The CBC will provide important information about the levels of red blood cells, hemoglobin, and hematocrit, which are directly affected by iron deficiency. Monitoring these values will help determine if the client’s anemia is worsening or if the iron supplements are not effectively improving the blood count.
Choice B reason: The platelet count is part of a CBC but is not directly related to the symptoms of fatigue in iron deficiency anemia. While platelet levels are important for assessing clotting function, they do not provide the necessary information about red blood cell levels or hemoglobin concentration that are central to diagnosing and managing anemia.
Choice C reason: Serum electrolytes are important to monitor for overall health and hydration status, but they are not specifically related to the client’s anemia or the symptom of fatigue. Electrolyte imbalances typically do not cause fatigue related to anemia, so this is not the primary laboratory value to review in this context.
Choice D reason: Liver enzymes are important for assessing liver function and potential liver damage, but they are not directly related to iron deficiency anemia or the symptom of fatigue. While it is important to monitor liver health, especially if the client is on medications that affect the liver, the complete blood count is more relevant to the symptoms described.
Correct Answer is D
Explanation
Choice A reason: Hypotension and venous pooling in the extremities are typically signs of neurogenic shock, which occurs immediately after a spinal cord injury. However, autonomic dysreflexia is characterized by severe hypertension, not hypotension. The symptoms in this scenario do not fit the presentation of autonomic dysreflexia.
Choice B reason: Reports of chest pain and shortness of breath are not the primary symptoms of autonomic dysreflexia. While autonomic dysreflexia can cause a variety of symptoms due to uncontrolled sympathetic nervous system activity, the hallmark symptoms are severe hypertension and headache, along with other specific signs like diaphoresis.
Choice C reason: Pain and a burning sensation upon urination and hematuria indicate a urinary tract infection or another urological issue, not autonomic dysreflexia. While a full bladder is a common trigger for autonomic dysreflexia, the symptoms described in this choice do not accurately reflect the condition.
Choice D reason: Profuse diaphoresis and a severe, pounding headache are classic symptoms of autonomic dysreflexia. This condition results from an overactive autonomic nervous system response to stimuli below the level of the injury, such as a full bladder. The resulting vasoconstriction leads to severe hypertension and symptoms like headache and sweating above the level of injury.
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