Strategy: Think Maslow.

(1) appropriate, but not a priority

(2) appropriate, but not a priority
(3) unnecessary during chemotherapy
(4) correctchemotherapy can lead to immunosuppression, which predisposes client
to infection; handwashing is one of most effective means of decreasing infection
transmission
117. The nurse is caring for clients on the medical/surgical unit. The nurse
identifies that which of the following clients would be MOST at risk for
developing herpes zoster?
1.
2.
3.
4.

A 19-year-old with a broken tibia in Bucks traction.

A 50-year-old with a diabetic foot ulcer.
A 62-year-old heart transplant with suspected rejection.
An 84-year-old with chronic obstructive pulmonary disease.

Strategy: Think about each answer choice.

(1) has an acute trauma, is not immunocompromised
(2) has a bacterial infection, is not immunocompromised
(3) correctimmunocompromised due to immune suppression therapy, clients with
compromised immune system at risk for reactivation of the varicella zoster virus
(4) has chronic disease, is not immunocompromised
118. The nurse is caring for a young adult admitted to the hospital with a
severe head injury. The nurse should position the patient
1.
2.
3.
4.

with his neck in a midline position and the head of the bed elevated 30.
side-lying with his head extended and the bed flat.
in high Fowlers position with his head maintained in a neutral position.
in semi-Fowlers position with his head turned to the side.

Strategy: All answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) correctdecreases intracranial pressure
(2) decreases venous blood return
(3) too elevated, would increase intracranial pressure
(4) head should be maintained in neutral position
119. A woman at the health clinic asks the nurse if she should get a flu shot.
Which of the following factors, if learned by the nurse in the history, would
NOT be a reason for this woman to receive the flu vaccine?
1.
2.
3.
4.

The
The
The
The

client
client
client
client

is 69 years old.
had bronchitis twice last year.
volunteers at a preschool.
lives with two large dogs.

Strategy: Think about each answer choice.

(1) recommended for people over 65
(2) recommended for people with chronic respiratory or cardiovascular disease
(3) recommended for people who come in contact with young children
(4) correctnot at risk for getting the flu from a dog