A nurse is reinforcing teaching with a client about breast self-examinations.Which of the following statements by the client indicates an understanding of the teaching?

Condition: Sepsis.

2 actions:

Administer a broad-spectrum antibiotic,

Perform a swab culture of the AVF site.

2 parameters:

White blood cell count,

Blood cultures.

Rationale for correct condition: Sepsis is indicated by the client's fever, elevated heart rate, and respiratory rate, combined with signs of infection at the AVF site. Chronic conditions like diabetes and renal disease increase sepsis risk. The symptoms and history align with systemic infection spreading from the AVF site. Sepsis requires immediate intervention to prevent severe complications. Elevated temperature and infection signs suggest systemic involvement.

Rationale for actions: Administering antibiotics is crucial to control the infection. Swab culture identifies the causative organism. Indwelling catheter is unnecessary here. Aspirin does not treat infection. Bed rest alone is insufficient. Monitoring WBC count tracks infection response. Blood cultures confirm sepsis diagnosis. Creatinine is less urgent for immediate management. Blood glucose is relevant but not immediate. AVF site circumference monitors local rather than systemic infection.

Rationale for parameters: WBC count indicates immune response. Blood cultures identify bacteria, confirming sepsis. Creatinine is routine but not urgent. Blood glucose tracks diabetes control, less immediate. AVF circumference monitors local inflammation. Cellulitis is localized, not systemic. AVF thrombosis lacks systemic signs like fever. Endocarditis requires specific cardiac symptoms.

Rationale for incorrect conditions: Cellulitis does not explain systemic symptoms. AVF thrombosis lacks systemic infection signs. Endocarditis has distinct cardiac symptoms absent here.

Choice A rationale

Adverse effects of antituberculosis medications do occur, but taking a single medication doesn't necessarily reduce their frequency or severity. Combination therapy aims to prevent resistance, not specifically to avoid side effects.

Choice B rationale

Multiple medications in TB treatment don't directly protect the liver from toxic effects. In fact, they may increase the risk of hepatotoxicity, but the benefit outweighs the risk due to reduced resistance.

Choice C rationale

The primary reason for using multiple antituberculosis medications is to prevent the development of drug resistance. TB bacteria can quickly become resistant when only one medication is used, leading to treatment failure.

Choice D rationale

TB treatment typically involves multiple drugs regardless of the severity of the disease to ensure effective eradication of the bacteria and prevent resistance.