Author Question: A nurse is assessing an older patient and notes a cluster of fluid-filled vesicles on the right ... (Read 87 times)

karlynnae · **on:** Jul 11, 2018

A nurse is assessing an older patient and notes a cluster of fluid-filled vesicles on the right tho-racic area. The nurse suspects HZ. The patient asks the nurse, I really don't understand how I got shingles.

I don't even know anyone who has this infection. The nurse includes which of the following in formulating a response to the patient?
a. HZ is caused by a reactivation of dormant varicella zoster virus within the sensory neuron of the dorsal root ganglion
b. HZ is caused by the same virus as chick-enpox and requires exposure to an indi-vidual with active chickenpox
c. HZ is caused by the same virus as chick-enpox and requires direct contact with an individual with HZ
d. HZ is caused by the varicella zoster virus and occurs only in individuals who were never previously exposed to the virus

Question 2

A nurse assesses a nursing home resident's pressure ulcer to be a healing stage III. The primary reason reverse staging is never used is because:

a. even though all tissue layers are replaced as a wound heals, the healed skin is not as strong as it originally was.
b. not all tissue layers are replaced as a wound heals, and the healed skin is not as strong as it originally was.
c. reimbursement in nursing homes does not allow for reverse staging to be utilized.
d. the collagen layer is not replaced during wound healing.

kalskdjl1212 · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

ANS: A
HZ is a viral infection caused by a reactivation of the latent varicella zoster virus (the same virus that causes chickenpox) within the sensory neurons of the dorsal root ganglion, decades after the initial varicella zoster infection is established. HZ is infectious until the lesions are completely crusted over. Individuals do not have to have direct contact with someone who has either chick-enpox or HZ in order to have a reactivation; other factors such as illness and stress can cause the reactivation. Individuals who have HZ infection were previously exposed to the varicella zoster virus.

Answer to Question 2

ANS: B
Not all tissue layers are replaced as a wound heals. The wound fills with granulation tissue com-posed of endothelial cells, fibroblasts, collagen, and extracellular matrix. Muscle, subcutaneous fat, and dermis are not replaced. The healed skin is not as strong as it originally was. Reimburse-ment in long-term care is not the primary reason for not using reverse staging.