The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.)
"Have you traveled outside of the United States?"
"Will you demonstrate how to wash your hands?"
"Can you explain the risk for infection in your home?"
"What are the signs and symptoms of infection?"
"Are you able to walk to the mailbox?"
"Who runs errands for you?"
Correct Answer : A,B,C,D
A. Asking about travel outside the United States helps identify potential exposure to infections that are more prevalent in certain areas.
B. Assessing handwashing techniques is crucial, as proper hand hygiene is a fundamental way to prevent infections.
C. Understanding the patient's perception of infection risk in their home environment can highlight potential areas for intervention.
D. Knowing the signs and symptoms of infection allows the nurse to evaluate the patient’s awareness and ability to recognize early signs of infection.
E. While mobility can affect overall health, it is not directly related to assessing the risk of infection.
F. Knowing who runs errands may provide context for the patient's support system, but it does not directly assess infection risk.
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Correct Answer is D
Explanation
A. The superior vena cava is responsible for returning deoxygenated blood from the upper body to the heart and is not directly involved in myocardial ischemia.
B. The carotid artery supplies blood to the brain and is not the primary focus in the context of myocardial infarction.
C. The pulmonary artery carries deoxygenated blood from the heart to the lungs and is not involved in coronary circulation.
D. The coronary arteries supply blood to the heart muscle itself. Ischemia during a myocardial infarction occurs when these arteries are blocked or narrowed, leading to a lack of blood flow and oxygen to the heart tissue.
Correct Answer is B
Explanation
A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.