General health promotion measures a nurse can teach a group of clients in order to prevent infections include (Select all that apply)
a. controlling portals of exit of infectious organisms.
b. eliminating personal behaviors that might lead to infection.
c. examining cultural behaviors that might promote infection.
d. maintaining good nutritional status.
e. preventing displacement of normal flora.
B, C, D, E
Some people are more susceptible to infections than others. Factors that influence host suscepti-bility include personal behaviors (drug use, sexual practices), cultural behaviors (eating raw fish for example), nutrition, and the preservation of indigenous normal flora specific for certain tis-sues. Knowledge of portals of exit is important for preventing transmission of disease, but since they involve excretions and secretions, they cannot be totally controlled.
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During an examination, the nurse asks the patient to perform the Valsalva maneuver and notices that the patient has a moist, red, doughnut-shaped protrusion from the anus. The nurse knows that this finding is consistent with a:
a. Rectal polyp. b. Hemorrhoid. c. Rectal fissure. d. Rectal prolapse.
A nurse is cleansing the skin around the pin site of a client. Which of the following signs confirms the need to obtain a wound culture?
A) Numbness at the site B) Cool temperature at the site C) Swelling distal to the site D) Purulent drainage from the site
A score of 12 on the MMSE would indicate:
a. situational depression b. cognitive impairment, probably dementia c. delirium d. a normal result
Which of the following nursing measures is appropriate in breaking a link in the chain of infection?
A) Use personal protective equipment (PPE) sparingly. B) Wear gloves at all times. C) Cover one's mouth and nose when sneezing. D) Place contaminated linens in a paper bag.