You are turning your patient in bed and notice that a confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for due to all three of these factors: confusion, lethargy, and items in the bed?

Correct Answer: B

Rationale: This patient is at great risk for skin breakdown due to the presence of three specific risk factors: confusion, lethargy, and items in the bed. While confusion puts the patient at risk for falls, confusion and lethargy together may lead to a lack of mobility. However, skin breakdown is the primary concern in this scenario as it is associated with all three risk factors - confusion, lethargy, and the presence of items in the bed. Therefore, the correct answer is 'Skin breakdown'.

Correct Answer: A

Rationale: The chain, or cycle, of infection includes the germ (microorganism), agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host. This sequence describes how infections are passed from one person to another. Choice B is incorrect because it refers to types of immunity, not components of the chain of infection. Choice C is also incorrect as it lists terms unrelated to the chain of infection. Choice D is incorrect as it describes transmission types, not components of the chain of infection. Understanding the chain of infection is crucial in preventing the spread of infections by breaking one or more links in the chain, such as interrupting the mode of transmission through proper hand hygiene.

Correct Answer: A

Rationale: After pregnancy, women with MS are at higher risk for exacerbation of symptoms due to the postpartum period. There is no increased risk for congenital defects in infants born to mothers with MS. Symptoms of MS may actually improve during pregnancy, likely due to hormonal changes. MS does not significantly impact the onset of labor. Therefore, the correct response is that MS symptoms may worsen after pregnancy, making option A the accurate answer. Options B, C, and D are incorrect as they do not accurately reflect the risks associated with pregnancy in individuals with MS.

Correct Answer: A

Rationale: The correct answer is 'nosocomial.' A nosocomial infection is defined as one that is not present upon admission to a healthcare facility but instead occurs during the patient's stay. In this case, since Mary was diagnosed with a skin infection after being admitted to the nursing home, it is considered a nosocomial infection. Nosocomial infections are a significant concern in healthcare settings, and infection control measures are in place to prevent their spread. Choices B, C, and D are incorrect. 'Systemic' refers to a condition affecting the entire body, not specific to a healthcare setting. 'Resident flora' and 'resident aura' are not commonly used terms in healthcare and do not relate to infections acquired in healthcare facilities.

Correct Answer: B

Rationale: This patient is at great risk for skin breakdown due to the presence of three specific risk factors: confusion, lethargy, and items in the bed. While confusion puts the patient at risk for falls, confusion and lethargy together may lead to a lack of mobility. However, skin breakdown is the primary concern in this scenario as it is associated with all three risk factors - confusion, lethargy, and the presence of items in the bed. Therefore, the correct answer is 'Skin breakdown'.

Correct Answer: A

Rationale: The most critical information for the nurse to provide to a patient with a significant smoking history is options for smoking cessation. Smoking is the primary cause of lung cancer, making smoking cessation essential in reducing the risk of developing the disease. Annual sputum cytology testing is not a standard screening test for lung cancer; instead, CT scanning is being explored for this purpose. Erlotinib therapy is used in lung cancer treatment but not for preventing tumor risk in individuals without cancer. CT screening for lung cancer is still under investigation and is not primarily aimed at prevention but rather early detection in high-risk individuals.

Correct Answer: C

Rationale: The correct action for the nurse to include in care when the patient is seen for a routine annual physical exam, according to CDC guidelines, is to ask whether the patient has been screened for hepatitis C. CDC guidelines recommend screening patients born between 1945 and 1965 for hepatitis C due to the high prevalence of undiagnosed cases in this age group. Starting the hepatitis B immunization series is not necessary as the patient already had hepatitis A infection. Teaching the patient about hepatitis A immune globulin is not indicated in this scenario. Testing for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM) is not needed as the patient has already had hepatitis A.

Correct Answer: D

Rationale: Elderly patients are prone to dehydration because they have a lower and diminished sense of thirst. This reduced sensation of thirst makes them less likely to drink an adequate amount of fluids, leading to dehydration. While it is true that elderly individuals may also have changes such as decreased stomach mucus production and saliva production, these factors do not directly contribute to dehydration. Drinking more coffee and tea, as mentioned in choice A, is not a consistent behavior among all elderly individuals and is not a primary reason for their increased risk of dehydration.

Correct Answer: C

Rationale: To prevent falls, it is essential to keep the patient's call bell within reach so they can easily call for help when needed. This allows for timely assistance and can prevent falls. While low beds can reduce the severity of injuries in case of a fall, they do not prevent falls from happening. Having family members in the room at all times is not a realistic or practical solution. Side rails can actually increase the severity of falls as patients may attempt to climb over them, and using side rails as fall prevention is considered a restraint practice that can lead to entrapment and other risks.