HESI case study: Dave Mason Questions
With Verified Answers
You lquestion lDave lregarding lhis limmunization lstatus. lYour linitial lconcern lis ldetermining lhis
lpotential lsusceptibility lto l__________ linfection.
- lstaphylococcus
- ltetanus
- lhepatitis
- lstreptococcus l- lAnswer l- l- ltetanus
Because lof lthe lnature lof lDave's lwounds land ltheir lgross lcontamination lwith ldirt land ldebris, lhe lis
lespecially lsusceptible lto ltetanus linfection. lWounds lcontaminated lwith ldirt lmay lharbor lthe
lmicroorganism, lClostridium ltetani. lC. ltetani lthrives lin lan lanerobic lenvironment lwhich lis lreadily
lprovided lby ldeep lpuncture lwounds. lA lneurotoxin lproduced lby lC. ltetani lcan laffect lnerves land
lmuscles lnear lthe lwound, land lalso lcirculate lto lother lparts lof lthe lbody, lcausing lgeneralized lmuscle
lspasms. lImmunization lagainst ltetanus lis lavailable. lAfter lprimary lvaccination lagainst ltetanus,
lboosters lare lindicated levery l10 lyears. lFor lminor, luncontaminated lwounds, lthis lprovides ladequate
lprotection lagainst ltetanus. lFor lmore lserious lwounds, la lbooster lis lrecommended lif lone lwas lnot
lreceived lwithin lthe lpreceding l5 lyears. lDave lcannot l recall lwhen lhe llast lreceived la ltetanus l'shot.'
Your ltime lwith lDave lhas lbeen lbrief, lbut lyou lare lable lto lset lpriorities lfor lhis lcare. lWhich lof lthe
lfollowing lis lpertinent land lmost limportant lfor lDave's lcare lat lthis ltime?
- lImpaired lPhysical lMobility lrelated lto linjured lleft lthigh
- lFear lrelated lto lpotentially-serious linjury lto lleft lthigh
- lRisk lfor lInfection lrelated lto lloss lof lprotective lskin lbarrier lat linjured lleft lthigh
- lIneffective lPeripheral lTissue lPerfusion lrelated lto lleft lthigh linflammation l- lAnswer l- l- lRisk lfor
lInfection lrelated lto lloss lof lprotective lskin lbarrier lat linjured lleft lthigh
, Risk lfor lInfection lis lrelevant land lDave's lmost limportant lproblem. lHis lskin, la lmajor ldefense lagainst
linvasion lof lpathogens, lis lcompromised. lHe lis lat lrisk lfor lwound linfection, land lmay lbe lat lrisk lfor
ltetanus linfection.
In lcaring lfor lDave, lyour lprimary lnursing lgoal lis lto:
- lprevent linfection lof lDave's lwound
- lprevent lthe ltransmission lof lmicrobes lfrom lDave's lwound lto lother lpersons
- lalleviate lDave's lfears labout lhis lwound
- lcleanse land ldress lDave's lwound lutilizing lprinciples lof lasepsis l- lAnswer l- l- lprevent linfection lof
lDave's lwound
Risk lfor lInfection lis lDave's lmost limportant lproblem. lYour lprimary lgoal lis lto lprevent lDave's lwound
lfrom lbecoming linfected.
You luse lStandard lPrecautions lwhile lworking lwith lDave. lStandard lPrecautions lare lused lwith lDave
lbecause:
- lit lis llikely lthat lhis lwound lis lcontaminated
- lit lis llikely lthat lhis lwound lis lcolonized lwith la lhighly-transmissible lpathogen
- lhe lis lat lrisk lfor linfection
- lStandard lPrecautions lare lindicated lwith lall lpatients l- lAnswer l- l- lStandard lPrecautions lare lindicated
lwith lall lpatients
Standard lPrecautions lare lstrategies ldesigned lto lprevent ltransmission lof linfection. lThey lapply lto lthe
lcare lof lall lpatients, lregardless lof ldiagnosis lor linfection lstatus.
You lprepare lto lcare lfor lDave's lwound, lby lcarrying lout lthe lmost limportant lactivity lfor lpreventing
lthe ltransmission lof lmicroorganisms, lwhich lis:
- lhandwashing
- lwearing lclean, lnon-sterile lgloves
With Verified Answers
You lquestion lDave lregarding lhis limmunization lstatus. lYour linitial lconcern lis ldetermining lhis
lpotential lsusceptibility lto l__________ linfection.
- lstaphylococcus
- ltetanus
- lhepatitis
- lstreptococcus l- lAnswer l- l- ltetanus
Because lof lthe lnature lof lDave's lwounds land ltheir lgross lcontamination lwith ldirt land ldebris, lhe lis
lespecially lsusceptible lto ltetanus linfection. lWounds lcontaminated lwith ldirt lmay lharbor lthe
lmicroorganism, lClostridium ltetani. lC. ltetani lthrives lin lan lanerobic lenvironment lwhich lis lreadily
lprovided lby ldeep lpuncture lwounds. lA lneurotoxin lproduced lby lC. ltetani lcan laffect lnerves land
lmuscles lnear lthe lwound, land lalso lcirculate lto lother lparts lof lthe lbody, lcausing lgeneralized lmuscle
lspasms. lImmunization lagainst ltetanus lis lavailable. lAfter lprimary lvaccination lagainst ltetanus,
lboosters lare lindicated levery l10 lyears. lFor lminor, luncontaminated lwounds, lthis lprovides ladequate
lprotection lagainst ltetanus. lFor lmore lserious lwounds, la lbooster lis lrecommended lif lone lwas lnot
lreceived lwithin lthe lpreceding l5 lyears. lDave lcannot l recall lwhen lhe llast lreceived la ltetanus l'shot.'
Your ltime lwith lDave lhas lbeen lbrief, lbut lyou lare lable lto lset lpriorities lfor lhis lcare. lWhich lof lthe
lfollowing lis lpertinent land lmost limportant lfor lDave's lcare lat lthis ltime?
- lImpaired lPhysical lMobility lrelated lto linjured lleft lthigh
- lFear lrelated lto lpotentially-serious linjury lto lleft lthigh
- lRisk lfor lInfection lrelated lto lloss lof lprotective lskin lbarrier lat linjured lleft lthigh
- lIneffective lPeripheral lTissue lPerfusion lrelated lto lleft lthigh linflammation l- lAnswer l- l- lRisk lfor
lInfection lrelated lto lloss lof lprotective lskin lbarrier lat linjured lleft lthigh
, Risk lfor lInfection lis lrelevant land lDave's lmost limportant lproblem. lHis lskin, la lmajor ldefense lagainst
linvasion lof lpathogens, lis lcompromised. lHe lis lat lrisk lfor lwound linfection, land lmay lbe lat lrisk lfor
ltetanus linfection.
In lcaring lfor lDave, lyour lprimary lnursing lgoal lis lto:
- lprevent linfection lof lDave's lwound
- lprevent lthe ltransmission lof lmicrobes lfrom lDave's lwound lto lother lpersons
- lalleviate lDave's lfears labout lhis lwound
- lcleanse land ldress lDave's lwound lutilizing lprinciples lof lasepsis l- lAnswer l- l- lprevent linfection lof
lDave's lwound
Risk lfor lInfection lis lDave's lmost limportant lproblem. lYour lprimary lgoal lis lto lprevent lDave's lwound
lfrom lbecoming linfected.
You luse lStandard lPrecautions lwhile lworking lwith lDave. lStandard lPrecautions lare lused lwith lDave
lbecause:
- lit lis llikely lthat lhis lwound lis lcontaminated
- lit lis llikely lthat lhis lwound lis lcolonized lwith la lhighly-transmissible lpathogen
- lhe lis lat lrisk lfor linfection
- lStandard lPrecautions lare lindicated lwith lall lpatients l- lAnswer l- l- lStandard lPrecautions lare lindicated
lwith lall lpatients
Standard lPrecautions lare lstrategies ldesigned lto lprevent ltransmission lof linfection. lThey lapply lto lthe
lcare lof lall lpatients, lregardless lof ldiagnosis lor linfection lstatus.
You lprepare lto lcare lfor lDave's lwound, lby lcarrying lout lthe lmost limportant lactivity lfor lpreventing
lthe ltransmission lof lmicroorganisms, lwhich lis:
- lhandwashing
- lwearing lclean, lnon-sterile lgloves
