A nurse is assessing a 45-year-old patient who was admitted … | 마이메르시 MyMerci
마이메르시 — 문제와 상세 해설까지 전부 무료 무료로 시작하기
Adult Health
문제

A nurse is assessing a 45-year-old patient who was admitted with suspected influenza. Which assessment finding would be most indicative of influenza rather than a common cold?

해설
Influenza is characterized by sudden onset of high fever with severe body aches and fatigue, distinguishing it from the gradual, milder symptoms of a common cold. Other options describe cold-like features.
같은 주제 다음 문제A nurse is assessing a 45-year-old patient who was admitted with suspected influenza. Whic…

심화 해설

Clinical Judgment This question evaluates the core clinical judgment needed to differentiate between the common cold and influenza. A cold typically presents with gradual onset of upper respiratory symptoms (nasal congestion, runny nose, sore throat) and mild systemic symptoms. In contrast, influenza is characterized by sudden onset, high fever (usually >101°F/38.3°C), and severe myalgia and fatigue. Option 4 includes all three of these key elements, making it the critical cue that best indicates influenza. Memory Tip: The mnemonic to distinguish influenza from a cold is "Sudden, Severe, Systemic." If symptoms are sudden, severe, and systemic, suspect influenza. KR vs US: In Korea, the term 'dog gam' (flu) is sometimes used interchangeably for influenza and the common cold, but in US clinical settings, they are clearly distinguished. In particular, when influenza is suspected, prompt administration of antivirals (e.g., Oseltamivir) and isolation precautions (airborne + droplet isolation) are emphasized.

임상 시나리오

Clinical Pearl: Rapid Triage for Influenza-Like Illness

Use the “Sudden + Systemic” rule to differentiate influenza from other upper respiratory infections. Influenza typically presents with an abrupt onset of high fever (>100.4°F/38°C), severe myalgia, and profound fatigue. A gradual onset with predominantly nasal symptoms strongly suggests a common cold.

Key Assessment Markers
  • Onset: Sudden (influenza) vs. Gradual (cold)
  • Fever: High, often 102°F-104°F (influenza) vs. Low-grade or absent (cold)
  • Systemic Signs: Severe body aches, headache, extreme exhaustion (influenza) vs. Malaise (cold)
  • Respiratory Signs: Dry cough common early in influenza; productive cough with discolored sputum may signal secondary bacterial infection requiring further evaluation.
Nursing Actions
  1. Place patient on Droplet Precautions immediately upon suspicion of influenza.
  2. Collect nasopharyngeal swab for rapid influenza diagnostic test (RIDT) or viral culture as ordered.
  3. Initiate empiric antiviral therapy (e.g., oseltamivir) within 48 hours of symptom onset for high-risk patients, without waiting for test results.
  4. Monitor for signs of respiratory distress or sepsis, especially in immunocompromised, very young, or elderly patients.

NCLEX Alert: A question stem describing a patient with a “sudden” high fever and “severe” body aches during flu season is a strong cue for influenza. Do not confuse this with the insidious onset of a cold or the localized purulent sputum of bacterial pneumonia.

핵심 개념

Merci NCLEX-RN Question Bank 3,445 문제 · 로그인 없이 바로 볼 수 있어요

마이메르시로 국가고시 완벽 대비

기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요.

무료로 시작하기
App Store Google Play

학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.