The nurse is caring for a client diagnosed with a systemic staphylococci infection from the client’s own flora. The nurse correctly notes that this is an example of a(n):

Exogenous Infection.

Endogenous Infection.

Community Acquired Infection.

Nosocomial Infection.

Answer and Explanation

The Correct Answer is B

Choice A rationale
An exogenous infection occurs when a pathogen enters a patient’s body from their environment. For example, a healthcare worker can spread the infection due to poor adherence to infection control practices. This is not the case here as the infection is from the client’s own flora.
Choice B rationale
An endogenous infection is caused by the body’s normal flora. These microorganisms may act as opportunistic pathogens when the host is susceptible. In this case, the client’s systemic staphylococci infection originated from their own flora, making it an endogenous infection.
Choice C rationale
A community-acquired infection is one that was present or incubating prior to the patient being admitted to the hospital. Since the infection in this case originated from the client’s own flora and not from the community, this choice is incorrect.
Choice D rationale
A nosocomial infection, also known as a hospital-acquired infection, is an infection that is acquired in a hospital or other healthcare facility. Since the client’s infection originated from their own flora and not from the hospital environment, this choice is incorrect.

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Correct Answer is A

Explanation

Choice A rationale
The client reports mild pain in the upper left arm at 2/10 on a scale of 0 to 10. This indicates that the interventions were effective in managing the pain associated with the infection and cellulitis.
Choice B rationale
The client’s early morning finger stick blood glucose (FSBG) was 97 mg/dL (5.4 mmol/L). This is within the normal range, indicating that the interventions were effective in maintaining the client’s blood glucose levels within the normal range.
Choice C rationale
The client’s left upper arm is slightly reddened when compared with the right upper arm. This could be a sign of inflammation or infection, suggesting that the interventions were ineffective in completely resolving the infection and cellulitis.
Choice D rationale
The client reports that her back is more achy since she came to the hospital. This could be due to a variety of factors, including the hospital bed or a lack of physical activity. It is unrelated to the expected outcomes of the interventions for the infection and cellulitis.

A. Insist family members provide most of the client’s personal care. B. Maintain a personal space of at least 2 feet when assessing the client. C. Ask permission before touching a client during the physical assessment. D. Consider the client’s ethnicity as the most important factor in planning care.

Correct Answer is C

Explanation

Choice A rationale
Insisting that family members provide most of the client’s personal care may not be culturally appropriate. It may place undue burden on the family and may not respect the client’s autonomy or preferences.
Choice B rationale
Maintaining a personal space of at least 2 feet when assessing the client may not be culturally appropriate. Different cultures have different norms and expectations about personal space, and this distance may be seen as too distant or impersonal in some cultures.
Choice C rationale
Asking permission before touching a client during the physical assessment is a culturally appropriate nursing intervention. It shows respect for the client’s personal space and autonomy, and acknowledges cultural differences in norms about touch.
Choice D rationale
Considering the client’s ethnicity as the most important factor in planning care is not a culturally appropriate nursing intervention. While a client’s ethnicity can influence their health beliefs and behaviors, it is only one aspect of their identity and should not be the sole basis for planning care. Hildegard Peplau Hildegard Peplau Explore

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The nurse is caring for a client diagnosed with a systemic staphylococci infection from the client’s own flora. The nurse correctly notes that this is an example of a(n):

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is caring for a newly admitted client. Which intervention is the best example of a culturally appropriate nursing intervention?

Correct Answer is C

Explanation

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