The practical nurse (PN) is caring for a client admitted with a diagnosis of herpes zoster. The client has draining lesions and reports that the affected area is painful. Which action should the PN take first?
Administer a prescribed analgesic.
Measure the client's temperature.
Initiate contact isolation precautions.
Apply cool, wet compresses to the lesions.
The Correct Answer is C
Choice A reason: Administering a prescribed analgesic is important for managing the client's pain and improving their comfort. However, before addressing the client's pain, it is crucial to ensure that appropriate infection control measures are in place. Herpes zoster (shingles) is a contagious condition, especially when there are draining lesions. The first priority is to prevent the spread of the infection to other clients and healthcare workers.
Choice B reason: Measuring the client's temperature is important for monitoring for signs of systemic infection, such as fever. While this is a necessary assessment, it is not the most immediate priority. Ensuring that appropriate isolation precautions are in place takes precedence to prevent the transmission of the infection.
Choice C reason: Initiating contact isolation precautions is the most critical action to take first. Herpes zoster can be spread through direct contact with the fluid from the lesions. Implementing contact isolation precautions, such as wearing gloves and gowns, and placing the client in a private room, helps to contain the infection and protect others. This is the first step in managing the client's condition and ensuring a safe environment for all.
Choice D reason: Applying cool, wet compresses to the lesions can help soothe the affected area and provide some relief from the pain and discomfort associated with herpes zoster. However, this is not the immediate priority. The first action should be to implement isolation precautions to prevent the spread of the infection. Once isolation measures are in place, the nurse can then focus on providing symptomatic relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Driving a car is an activity that should be limited until after the first postoperative visit. Postoperative clients might experience discomfort, dizziness, or medication side effects that can impair their ability to drive safely. The stress and physical demands of driving can also affect the healing process, so it's important to avoid this activity until the healthcare provider gives clearance.
Choice B reason: Eating high-fiber foods is generally encouraged postoperatively to prevent constipation and ensure smooth bowel movements. There is no reason to limit high-fiber foods after a transurethral prostatectomy unless otherwise specified by the healthcare provider.
Choice C reason: Kegel exercises can help strengthen the pelvic floor muscles and are often recommended after prostate surgery to improve bladder control. However, it is important to follow the healthcare provider's guidance on when to start these exercises and how frequently they should be done.
Choice D reason: Walking around the house is a light activity that can aid in recovery by promoting circulation and preventing blood clots. It is usually recommended to start light activity soon after surgery, unless contraindicated by the healthcare provider.
Correct Answer is B
Explanation
Choice A reason: Aldosterone is a hormone produced by the adrenal cortex that helps regulate sodium and potassium levels in the body. While aldosterone levels can indicate adrenal function, they are not as commonly used as cortisol levels in diagnosing adrenal cortex failure. Aldosterone regulation is also influenced by the renin-angiotensin-aldosterone system, making it a less direct indicator of overall adrenal cortex function compared to cortisol.
Choice B reason: Cortisol is a glucocorticoid hormone produced by the adrenal cortex and plays a vital role in regulating metabolism, immune response, and stress. Measuring cortisol levels is a primary method for assessing adrenal cortex function. Low cortisol levels can indicate adrenal insufficiency or failure, such as in conditions like Addison's disease. Evaluating cortisol levels provides a direct assessment of the adrenal gland’s ability to produce essential hormones necessary for the body's normal functioning.
Choice C reason: Thyroxine (T4) is a hormone produced by the thyroid gland, not the adrenal cortex. It plays a crucial role in regulating metabolism, growth, and development. While thyroxine levels are important for thyroid function assessment, they do not directly reflect the functioning of the adrenal gland. Therefore, thyroxine levels are not relevant in diagnosing adrenal cortex failure.
Choice D reason: Insulin is a hormone produced by the pancreas and is essential for regulating blood glucose levels. It is not related to the adrenal cortex. Monitoring insulin levels is important for diagnosing and managing diabetes mellitus but does not provide information about the functioning of the adrenal gland. Insulin levels are not used to assess adrenal cortex function.
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