(Select all that apply): A nurse is caring for a client with shingles. Which interventions should the nurse include in the client's care? Select all that apply.
Monitor vital signs, pain level, and neurological status.
Isolate the patient until all lesions are crusted over.
Educate the patient and family about the disease process.
Encourage oral hygiene and a soft diet if oral lesions are present.
Correct Answer : A,C,D,E
Choice A rationale:
Monitoring vital signs, pain level, and neurological status is important to assess the client's overall condition and response to treatment.
Choice B rationale:
Isolating the patient until all lesions are crusted over is not necessary for shingles, as it is not as highly contagious as chickenpox.
Choice C rationale:
Educating the patient and family about the disease process is essential to help them understand the condition, its course, and the necessary measures for management and prevention of complications.
Choice D rationale:
Encouraging oral hygiene and a soft diet is important, especially if the patient has oral lesions, to promote comfort and prevent secondary infections.
Choice E rationale:
Administering medications as prescribed, such as antiviral medications, can help reduce the severity and duration of the shingles outbreak.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administering the Td vaccine only if the wound is severe is not the correct response. Tetanus prophylaxis is recommended based on wound type and vaccination history, not just the severity of the wound.
Choice B rationale:
This is the correct response. Tetanus prophylaxis involves giving Tetanus Immunoglobulin (TIG) for immediate protection against tetanus toxin, along with the Tetanus and Diphtheria (Td) vaccine to promote long-term immunity. The decision to administer TIG and Td vaccine depends on the patient's wound type and their vaccination history.
Choice C rationale:
Tetanus prophylaxis is necessary even if the client received the DTP vaccine in childhood. The immunity from childhood vaccines may wane over time, and tetanus prophylaxis is recommended after potential exposure to the tetanus-causing bacteria.
Choice D rationale:
Giving the Td vaccine every 5 years is not the correct approach. The recommended schedule for Td booster doses is every 10 years, not every 5 years.
Correct Answer is C
Explanation
Choice A rationale:
Varivax is not administered as a single dose during adulthood. The vaccine is given as two doses, usually separated by 4 to 8 weeks, to ensure adequate protection.
Choice B rationale:
Varivax can reduce the risk of developing shingles, especially in individuals who had chickenpox and received the vaccine. While it may not completely prevent shingles, it can lessen its severity.
Choice C rationale:
This is the correct response. Varivax is a live attenuated vaccine, which means it contains weakened forms of the varicella-zoster virus that causes chickenpox. It stimulates the immune system to produce a protective response without causing the disease.
Choice D rationale:
Varivax is not recommended only for healthcare workers. It is recommended for certain groups, including children, adolescents, and adults who have not had chickenpox or received the vaccine. Healthcare workers might be among the targeted groups due to their increased risk of exposure, but it is not limited to them.
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