ATI NUR 125 Exam 4

Correct Answer: Stress

Explanation: Stress incontinence occurs when there is an involuntary loss of urine due to physical pressure or stress on the bladder, such as during activities that increase intra-abdominal pressure. This can include actions like coughing, sneezing, laughing, or lifting heavy objects. The pressure from these activities forces urine out of the bladder, which is not fully controlled due to weakened pelvic floor muscles or sphincter problems.

Why the Other Choices Are Incorrect:

Overflow

Overflow incontinence occurs when the bladder cannot empty completely, resulting in leakage due to an overfilled bladder. It typically involves a continuous dribbling of urine rather than the occasional leakage associated with stress incontinence. This type is more common in individuals with bladder obstruction or nerve damage.

Reflex

Reflex incontinence involves the involuntary loss of urine without the sensation of needing to urinate. It typically occurs due to neurological impairments or injuries, such as spinal cord injuries, where the brain cannot control bladder function. The loss of urine happens automatically, not triggered by physical activities like sneezing or laughing.

Urge

Urge incontinence is characterized by a sudden and strong urge to urinate, followed by involuntary leakage. It often occurs with conditions such as overactive bladder, where the bladder muscles contract too frequently or intensely. The urge to urinate is usually felt urgently and precedes the leakage.

Functional

Functional incontinence occurs when physical or mental impairments prevent the person from reaching the bathroom in time. This type of incontinence is not due to issues with the bladder itself but rather due to physical disabilities (e.g., mobility issues) or cognitive impairments (e.g., dementia), making it difficult to respond to the need to urinate.

Summary:

Stress incontinence occurs when urine leaks due to physical stress or pressure on the bladder, such as coughing, sneezing, or laughing. Other types of incontinence, such as overflow, reflex, urge, and functional, involve different causes and mechanisms.

Correct Answer: Administer the vaccine as ordered.

Explanation:

Zostavax is a live attenuated vaccine designed to prevent shingles (herpes zoster) in adults aged 60 years and older. Shingles occurs due to the reactivation of the varicella-zoster virus, which remains dormant in nerve tissues after a person has had chickenpox. Since the patient has a history of chickenpox, they are at risk for shingles, making vaccination appropriate. The presence of prior infection does not contraindicate the vaccine but rather indicates a need for it. Zostavax helps boost the immune response and reduce the risk of shingles and its complications, such as postherpetic neuralgia.

Why the Other Choices Are Incorrect:

Counsel the patient that the vaccine may cause a severe reaction because of previous exposure. This is incorrect because prior infection with chickenpox does not lead to a severe reaction to the shingles vaccine. The purpose of Zostavax is to strengthen immunity in individuals who have already been exposed to the varicella-zoster virus. While mild side effects such as redness, swelling, or tenderness at the injection site may occur, severe reactions are rare

Hold the vaccine and notify the provider of the patient's history. This is incorrect because the patient’s history of chickenpox is not a contraindication for receiving the shingles vaccine. In fact, prior chickenpox infection confirms the need for vaccination, as it indicates the presence of the varicella-zoster virus in the body, which can later reactivate as shingles.

Request an order for a Varivax booster instead of the Zostavax. This is incorrect because Varivax is used for primary prevention of chickenpox, not shingles. Varivax is given to children and unvaccinated adults who have never had chickenpox. Since the patient has already had chickenpox, the appropriate vaccine for shingles prevention is Zostavax, not Varivax.

Summary:

The nurse should administer Zostavax as ordered because the vaccine is specifically designed to prevent shingles in adults who have already had chickenpox. Previous exposure to varicella-zoster virus does not increase the risk of severe reactions; rather, it makes the vaccine necessary. The provider does not need to be notified, and a Varivax booster is not appropriate for someone with a history of chickenpox.

Correct Answers:

Use a water-soluble lubricant to ease insertion

Perform a cleansing enema if the rectum is not clear

Insert the suppository into the rectum with the bullet-shaped end facing downward

Explanation:

 Use a water-soluble lubricant to ease insertion:

The nurse should use a water-soluble lubricant to help with the smooth and comfortable insertion of the rectal suppository. Lubricants reduce friction and prevent irritation to the rectal mucosa.

Perform a cleansing enema if the rectum is not clear:

A cleansing enema is needed if the rectum contains stool or debris, as this ensures that the medication is absorbed properly. A clean rectum helps the suppository to be more effective.

Insert the suppository into the rectum with the bullet-shaped end facing downward:

The bullet-shaped end should face downward to make the insertion easier and prevent the suppository from slipping out immediately after insertion.

Why the Other Choices Are Incorrect:

Ensure the suppository is stored at room temperature:

This is incorrect because rectal suppositories should be stored in the refrigerator to maintain their solid form and prevent them from becoming too soft or melting.

Store the rectal suppository at room temperature:

This is incorrect because rectal suppositories should be stored in a cool environment, like the refrigerator, to prevent them from melting prematurely.

Summary:

To properly administer a rectal suppository, the nurse should use a water-soluble lubricant, perform a cleansing enema if needed, and insert the suppository with the bullet end facing downward. Additionally, rectal suppositories should be stored in the refrigerator, not at room temperature, to maintain their integrity.

Correct Answer:

Lima beans

Bran cereal

Raspberries

Explanation:

Lima beans: Lima beans are high in fiber, which can help to increase the bulk and water content of stools, making them easier to pass. Fiber is essential for promoting healthy bowel movements and preventing constipation. Including fiber-rich foods such as lima beans in the diet can support regularity and relieve constipation.

Bran cereal: Bran cereal is also high in fiber, particularly insoluble fiber, which adds bulk to the stool and helps it move through the intestines more easily. Consuming high-fiber cereals like bran is a recommended strategy for managing constipation. It is also important to increase fluid intake when increasing fiber to help prevent discomfort.

 Raspberries: Raspberries are an excellent source of dietary fiber. One cup of raspberries contains a significant amount of both soluble and insoluble fiber, both of which support digestive health and can help alleviate constipation. The fiber in raspberries helps to soften the stool and regulate bowel movements.

Why the Other Choices Are Incorrect:

Pudding: Pudding is low in fiber and can contribute to constipation. It is often made with ingredients like milk and sugar, which can have a binding effect on the stool. While pudding may be comforting for some, it does not support regular bowel movements and is not recommended for someone experiencing constipation.

White toast: White toast is made from refined flour, which is low in fiber. Refined grains lack the fiber found in whole grains, which is important for promoting healthy digestion. White bread and toast can contribute to constipation as they do not provide enough fiber to support bowel movement regularity.

Summary:

For a client with constipation, recommending fiber-rich foods is the best approach. Lima beans, bran cereal, and raspberries all contain high levels of fiber, which can help relieve constipation by increasing stool bulk and promoting regular bowel movements. Foods like pudding and white toast, which are low in fiber, should be avoided as they can contribute to constipation. Increasing dietary fiber and water intake are key strategies for managing constipation effectively.

Correct Answer: a toxoid

Explanation

The tetanus vaccine contains a toxoid, which is an inactivated form of the tetanus toxin. Rather than using the actual bacteria, the vaccine includes a modified version of the toxin that cannot cause disease but still stimulates the immune system to produce antibodies against tetanus. This helps the body recognize and fight off the real toxin if exposure occurs in the future.

Why the Other Choices Are Incorrect:

Inactivated bacteria – This is incorrect because the tetanus vaccine does not contain whole bacteria, inactivated or otherwise. Tetanus is caused by Clostridium tetani, which produces a neurotoxin, not by bacterial infection itself.

Inactivated viral antigen – This is incorrect because tetanus is caused by a bacterium, not a virus. Inactivated viral antigens are used in vaccines for viral diseases, such as the inactivated polio vaccine

Recombinant viral antigen – This is incorrect because recombinant viral antigens are used in some viral vaccines, such as the hepatitis B vaccine. The tetanus vaccine does not use recombinant technology or viral components

Summary

The tetanus vaccine is a toxoid vaccine, meaning it contains an inactivated form of the toxin produced by Clostridium tetani. This allows the immune system to build protection without causing disease. Unlike other vaccines, it does not contain whole bacteria or viral components.

Correct Answer: neomycin

Explanation:

Before administering the varicella vaccine, the nurse should assess the patient for a history of allergy to neomycin. Neomycin is an antibiotic that is used in the production of the varicella vaccine, and individuals who have a known allergy to neomycin may experience a hypersensitive reaction. Therefore, this allergy should be identified before administering the vaccine to ensure patient safety.

Why the Other Choices Are Incorrect:

Penicillin allergy is not a concern for the varicella vaccine. While penicillin is an important antibiotic, it is not involved in the formulation of the varicella vaccine. Therefore, penicillin allergy does not affect the administration of this vaccine.

Egg allergy is not a concern for the varicella vaccine. Unlike some vaccines, such as the flu vaccine, which are grown in eggs, the varicella vaccine is not produced using eggs. As a result, egg allergies do not pose a risk for those receiving the varicella vaccine.

Milk allergy is not relevant to the varicella vaccine. The varicella vaccine does not contain milk or milk derivatives, so an allergy to milk would not affect the administration of this vaccine

Summary:

The most important allergy to assess before administering the varicella vaccine is a history of allergy to neomycin, as it is used in the vaccine's production. Penicillin, egg, and milk allergies are not relevant to the safety of the varicella vaccine.

Correct Answer:

Avoid bubble baths

Void after sex

Explanation:

 Avoid bubble baths: Bubble baths can contain harsh chemicals that may irritate the urethra and the urinary tract. This irritation increases the likelihood of bacterial growth, which can lead to a UTI. For patients who are prone to UTIs, it's important to avoid any products that could further compromise the urinary tract's natural defenses. Using mild, unscented soaps instead of bubble baths is a safer option to reduce irritation.

Void after sex: After sexual intercourse, bacteria can be introduced into the urinary tract. Voiding soon after sex helps to flush out any bacteria that may have entered the urethra, thereby reducing the risk of a UTI. This practice is particularly beneficial for women, who have a shorter urethra, making it easier for bacteria to travel to the bladder.

Why the Other Choices Are Incorrect:

Douche regularly: Douching can disturb the natural balance of bacteria in the vaginal area, removing beneficial microorganisms and increasing the risk of infections such as UTIs. Regular douching can also lead to irritation and disrupt the vaginal pH, making the area more susceptible to harmful bacteria. Therefore, this is not recommended, particularly for patients prone to UTIs.

Drink 3-4 glasses of water per day: This amount of water is insufficient for maintaining adequate hydration. The general recommendation for hydration is about 8 glasses (64 ounces) of water per day, or more if necessary based on activity level and climate. Drinking enough water helps flush out bacteria from the urinary tract, which is crucial for preventing infections like UTIs.

Drink orange juice daily: While orange juice contains vitamin C, which can support the immune system, it can also irritate the bladder in some people, especially those who have a sensitive urinary tract. Citrus juices like orange juice can increase bladder discomfort and exacerbate symptoms of a UTI. It is better to recommend water or other non-acidic fluids for hydration.

Summary:

For a patient with a history of UTI and sepsis, it's essential to avoid practices that increase the risk of infection. Avoiding bubble baths and voiding after sexual intercourse are key preventive measures. Adequate hydration, but at a level higher than 3-4 glasses per day, is important for flushing bacteria from the urinary tract. Douching, inadequate fluid intake, and excessive consumption of acidic beverages like orange juice should be avoided to reduce the risk of future UTIs.

Correct Answer: Inactivated viral antigen

Explanation:

The hepatitis A vaccine is made from an inactivated (killed) hepatitis A virus. This means the virus has been rendered non-infectious while still retaining the ability to stimulate an immune response. The body recognizes the viral antigen and produces antibodies that provide immunity against future hepatitis A infections.

Why the Other Choices Are Incorrect:

Inactivated bacteria – This is incorrect because hepatitis A is caused by a virus, not bacteria. Inactivated bacterial vaccines (e.g., pertussis) are used for bacterial infections, not viral ones.

A toxoid – This is incorrect because a toxoid vaccine contains an inactivated toxin rather than the pathogen itself. Toxoid vaccines are used for diseases caused by bacterial toxins, such as tetanus and diphtheria, but not for viral infections like hepatitis A.

Recombinant viral antigen – This is incorrect because recombinant vaccines use genetically engineered viral proteins to stimulate immunity. An example is the hepatitis B vaccine, which uses a recombinant surface antigen. However, the hepatitis A vaccine is made from the inactivated virus rather than a recombinant antigen.

Summary:

The hepatitis A vaccine is an inactivated viral antigen vaccine, meaning it contains a killed hepatitis A virus that still stimulates an immune response. This helps the body develop immunity without causing an actual infection.

Correct Answer: Enzymes

Explanation:

Metabolism or biotransformation of drugs occurs primarily under the influence of enzymes, particularly liver enzymes, which detoxify, degrade, and prepare biologically active chemicals for elimination from the body. Enzymes, such as cytochrome P450, catalyze chemical reactions that modify drugs, often making them more water-soluble for easier excretion. This process helps prevent the accumulation of potentially harmful substances in the body.

Why the other choices are incorrect:

Hormones

Hormones regulate many body processes, including metabolism, but they do not directly catalyze the breakdown of drugs. Enzymes are responsible for the actual biochemical transformation of drugs.

Proteins

While enzymes are proteins, the term "proteins" is too broad and non-specific. Not all proteins are involved in drug metabolism. Only specific enzymes, a subset of proteins, participate in the breakdown and transformation of drugs.

Carbohydrates

Carbohydrates are essential for providing energy to the body but do not play a role in the biotransformation or metabolism of drugs. Enzymes, specifically, are the catalysts for the breakdown of medications

Summary:

Enzymes play a crucial role in drug metabolism by detoxifying and transforming biologically active chemicals so that they can be eliminated from the body. This process mainly occurs in the liver and is essential for preventing harmful accumulation of substances.