1. A client has acute rhinitis. What is the most important intervention for the nurse to perform?

ANS: A

Bacterial infection often occurs with acute rhinitis. The nurse should assess for symptoms because treatment may be warranted. It is not essential to assess for allergies or the use of nasal spray, or to determine whether drug use is occurring. All of these interventions are focused on determining a cause for repeated acute rhinitis and are primarily the responsibility of the health care provider. The nurse should focus on client assessment and should determine whether a secondary infection is present.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

2. A client has pharyngitis. Which symptom helps the nurse determine whether the infection is bacterial versus viral?

ANS: D

Generally a rash can appear with bacterial pharyngitis, but not with viral. The other symptoms are characteristic of both.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 33-2, p. 643

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. It is suspected that a client has bacterial pharyngitis. What is the best intervention?

ANS: D

A common cause of bacterial pharyngitis is group A streptococcal virus, which can lead to serious complications. Both RATs and culture and sensitivity can diagnose this bacterium; however, with an RAT, the health care provider can obtain results in about 15 minutes, and definitive treatment can begin much sooner. A broad-spectrum antibiotic would not be administered before it was determined whether the infection was bacterial. A sputum specimen is needed for lung infection but not for throat infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Implementation)

4. The nurse is caring for a client with recurrent bacterial pharyngitis. Which is the nurse’s highest priority intervention?

ANS: D

Management of bacterial pharyngitis involves the use of antibiotics and the same supportive care provided for viral pharyngitis. Stress the importance of completing the entire antibiotic prescription, even when symptoms improve or subside. Failure to take all prescribed antibiotics is often the cause of recurrent infections. Although it is important for overall health that the client know his or her HIV status, it is not the highest priority intervention in the treatment plan. Allergens do not cause bacterial infections. Nasal cultures would not be a high priority unless the client had “failed” treatment with more than one antibiotic and was compliant with treatment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

5. A client who has had acute tonsillitis develops drooling and reports severe throat pain. What is the nurse’s priority intervention?

ANS: A

The nurse should first assess the throat for signs of peritonsillar abscess. If present, the nurse should call the health care provider immediately because aspiration of the abscess may be needed to maintain the airway.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

6. The nurse has determined that a client has an acute sore throat. What is the nurse’s best action?

ANS: A

A dry cough and difficulty swallowing may indicate that the client is developing laryngitis. The nurse should assess whether the client can speak or shows any changes in his or her voice. The other interventions are not appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction in Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

7. A client who is immune compromised develops muscle aches and fever. The client is admitted to the hospital for several days and is diagnosed with influenza. At discharge, the client asks when he can go back to work. What is the nurse’s best response?

ANS: C

Immune compromised clients are contagious for several weeks. The client should remain at home until he is not contagious.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 645

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)