340 week 11-13

Sarah Billings is a​ 16-year-old female client with SLE. Sarah was admitted to the hospital for prednisone therapy. She will be discharged home​ tomorrow, and you are beginning home care teaching with her and her family. Which is a priority educational need of the family that you will include in the teaching​ session? Hand washing and other infection prevention methods. Applying sunblock and wearing long sleeves to protect from sun exposure. Encouraging frequent rest periods between activities. Exercising in the shower to help ease morning stiffness in the joints.

Hand washing and other infection prevention methods.

The nurse is caring for a client with AIDS who has come to the clinic for an HIV viral load test. The client​ asks, "What is a viral load​ test?" Which response by the nurse is the most​ appropriate? "This test detects​ anemia, leukopenia, and thrombocytopenia." "This test is used to detect HIV antibodies." "This test is the most widely used screening test for HIV infection." "This test measures the amount of actively replicating HIV."

"This test measures the amount of actively replicating HIV."

Christopher Adams was found unresponsive in his crib at 8 weeks old. Brought to the pediatric emergency department​ (ED) by​ ambulance, he was pronounced dead on arrival. The healthcare provider has told this information to his parents. Which action should the nurse take to support the family at this​ time? Ask the parents if​ they'd like to spend a few moments with Christopher alone Call the hospital chaplain to come and pray with the family Assemble written literature about sudden infant death syndrome for the parents to take home Separate the parents from Christopher immediately so that they can comprehend what just happened

Ask the parents if​ they'd like to spend a few moments with Christopher alone

The nurse is providing care for a couple who experienced a fetal demise of their baby at 31 weeks​' gestation. Which action by the nurse is most appropriate when providing culturally competent care to this​ family? Referring the parents to the healthcare provider to determine their needs Discouraging the parents from holding their infant due to their noted religious affiliation Asking the parents what they would like to include in the bereavement package Contacting the hospital chaplain to talk with the parents

Asking the parents what they would like to include in the bereavement package

During the assessment of a client with a spinal cord injury that resulted from a motor vehicle crash​ (MVC), the nurse determines that the client has a poor cough with breathing. Based on this​ finding, which is the most appropriate action by the​ nurse? Place the patient in a prone position to promote the drainage of secretions. Use tracheal suctioning to remove secretions. Prepare the client for intubation and mechanical ventilation. Assess lung sounds and respirations every 1-2 hours.

Assess lung sounds and respirations every 1-2 hours.

Which item is included in a focused immune system​ assessment? ​(Select all that​ apply.) Assess the musculoskeletal system Inspect the mucous membranes Assess the genitourinary system Assess skin​ color, moisture, and temperature Observe for fatigue and weakness

Assess the musculoskeletal system Inspect the mucous membranes Assess skin​ color, moisture, and temperature Observe for fatigue and weakness

Which action helps prevent burnout when caring for dying​ clients? Not approaching work personally Talking about​ other, more positive topics with dying clients Assessing personal needs to grieve and process loss Expressing personal feelings about death to clients

Assessing personal needs to grieve and process loss

Which initial nursing assessments would be the highest priority in the client who has been involved in a motor vehicle crash ​(MVC)? ​(Select all that​ apply.) Assessing skin color Assessing the pupillary reflex Assessing pulses Assessing the gag reflex Assessing breath sounds

Assessing skin color Assessing the pupillary reflex Assessing pulses Assessing breath sounds

The nurse is determining which clients would benefit from interventions to prevent suicide. Based on age​ alone, which client is at the highest risk for​ suicide? A​ 54-year-old male client diagnosed with shin splints from playing tennis A​ 23-year-old college student who was fired from​ part-time employment A​ 62-year-old male client with an elevated PSA level A​ 46-year-old female client whose husband has asked for a divorce

A​ 23-year-old college student who was fired from​ part-time employment

A client presents to the emergency department experiencing a severe anaphylactic reaction. Which action by the nurse is the most appropriate for treating this​ reaction? Give oral diphenhydramine​ (Benadryl) Apply epinephrine directly to the site of entry Administer epinephrine intravenously Administer epinephrine subcutaneously

Administer epinephrine intravenously

Which nursing interventions address the highest priority of care for a client experiencing a severe hypersensitivity​ reaction? ​(Select all that​ apply.) Administer oxygen via nasal cannula at prescribed rate Assess respiratory status continuously Monitor urine output Administer subcutaneous epinephrine as prescribed Teach client when and how to use an anaphylactic kit

Administer oxygen via nasal cannula at prescribed rate Assess respiratory status continuously Administer subcutaneous epinephrine as prescribed

Which nursing diagnoses are applicable to clients affected by​ HIV/AIDS? ​(Select all that​ apply.) Alterations in skin integrity related to cutaneous infections Alteration in​ nutrition, less than body requirements Potential for fear related to prognosis Alteration in​ nutrition, more than body requirements Potential for enhanced wellness

Alterations in skin integrity related to cutaneous infections Alteration in​ nutrition, less than body requirements Potential for fear related to prognosis Potential for enhanced wellness

The nurse is providing care to a client who received sternal injuries as the result of an airbag deployment after a motor vehicle crash​ (MVC). The client is currently experiencing an abnormal heart rate. Which diagnostic test does the nurse anticipate for this​ client? An EEG An ECG A CT scan An MRI scan

An ECG

The nurse is caring for a client experiencing seizure activity after a motor vehicle crash​ (MVC). Which diagnostic test does the nurse anticipate will be ordered for this​ client? ECT A UA An ECG An EEG

An EEG

A client with a terminal illness has just died and the nurse is found in the medication room crying. What should the nurse manager​ do? Select all that apply. Ask if there is anyone that the nurse would like to talk to at this time Provide the nurse with a sedative and send home Permit the nurse time to grieve Document that the nurse is hypersensitive and needs additional training Remind the nurse that postmortem care needs to be completed

Ask if there is anyone that the nurse would like to talk to at this time Permit the nurse time to grieve

The nurse is triaging a group of clients who were involved in a​ multiple-car accident during​ rush-hour traffic. Several clients are being admitted to the emergency department. Which​ clients, based on cultural or religious​ beliefs, may refuse treatment from the health care​ staff? Select all that​ apply. Jews Christians Christian Scientists ​Jehovah's Witnesses Muslims

Christian Scientists ​Jehovah's Witnesses

Which independent nursing interventions are used to treat rheumatoid​ arthritis? ​(Select all that​ apply.) Educate about​ low-impact aerobics Arthrodesis to fuse cervical​ vertebrae, wrists, ankles Alternate periods of activity and rest Promote a​ well-balanced diet Avoid sun exposure

Educate about​ low-impact aerobics Alternate periods of activity and rest Promote a​ well-balanced diet

The nurse is reviewing the medical history of a​ 34-year-old client who is coming to the office for the first prenatal visit at 8 weeks. The nurse notes that this is the client​'s third pregnancy with 1 term birth at 39 weeks and a miscarriage at 8 weeks. Which conclusion does the nurse formulate after reviewing the medical history for this​ client? Has no impact on future pregnancies Decreased risk for a miscarriage Increased risk for a miscarriage Has an increased risk for infection

Has no impact on future pregnancies

The health care provider diagnosed Mrs. Megumi with rheumatoid arthritis. You have just completed health promotion teaching on RA. Which statement by Mrs. Megumi indicates a need for further​ teaching? I will have my husband open the jars at home. I will meet with the physical therapist to learn daily range of motion exercises and to learn low impact exercises. I should not get a flu shot. I will rest when my pain increases and I can use hot or cold for pain relief.

I should not get a flu shot.

You have provided teaching to Mrs. Megumi regarding methotrexate injection. Which statement by Mrs. Megumi indicates the need for further​ teaching? I will avoid crowds while taking this medication. I will purchase a wig to wear when my hair falls out in a few weeks. I will need to take this medication for several weeks before it will help me. I will report difficulty breathing or yellow skin.

I will purchase a wig to wear when my hair falls out in a few weeks.

You want to establish rapport with Mr. Vann to let him know you are available to talk about death. Which statements might help you begin a dialogue with Mr.​ Vann? Select all that apply. Are you going to change your mind about ​dying? I would like to know more about your thoughts on dying. Can you eat a little bit of ​food? Do you think you need hospice ​services? Would you like to talk about what​'s happening to ​you?

I would like to know more about your thoughts on dying. Would you like to talk about what​'s happening to ​you?

Mr. Glass is HIV positive and is being treated with highly active antiretroviral therapy​ (HAART) and protease inhibitors​ (PI) therapy. His laboratory results show increased triglycerides. Based on the laboratory​ results, what is Mr. Glass at risk for developing related to the HIV​ infection? Increased risk for elevated cholesterol and diabetes Increased risk for developing kidney disease and lung cancer Increased risk for developing skin cancer and pneumonia Increased risk for developing stomach cancer and lymphoma

Increased risk for elevated cholesterol and diabetes

Which nursing diagnosis is appropriate for an adolescent client newly diagnosed with​ SLE? ​(Select all that​ apply.) Increased risk of fluid volume imbalance Potential for infection Potential for disturbed body image Increased risk of skin breakdown Potential for impaired memory

Increased risk of fluid volume imbalance Potential for infection Potential for disturbed body image Increased risk of skin breakdown

A client with a disorder of the immune system is encouraged to exercise. What is the rationale for this​ activity? Improve stamina Decrease circulation of lymph fluid Promote weight loss Increase​ NK-cell function

Increase​ NK-cell function

You are caring for​ Susan, a​ 40-year-old client who is 38 weeks pregnant. Susan reported to the hospital with complaints of decreased fetal movement. After an​ ultrasound, it is determined that Susan has experienced a fetal demise. Which order is anticipated for​ Susan's continued​ care? Oxygen Beta hCG test Induction of labor Surgical consult

Induction of labor

The nurse is planning care for a client admitted with a hypersensitivity reaction. Which potential problem is the priority for the nurse to​ address? Impaired skin integrity Acute pain Altered nutrition Ineffective airway clearance

Ineffective airway clearance

Which clinical manifestation is not expected for a client diagnosed with​ SLE? Alopecia Red butterfly rash on the face Leg and eye edema Painful or swollen joints Joint deformity

Joint deformity

Which actions are appropriate for a dying client who is​ comatose? Select all that apply. Keep skin dry and clean Keep lights at a low level Turn and reposition every 2 hours Apply artificial tears Provide stimulation every hour

Keep skin dry and clean Keep lights at a low level Turn and reposition every 2 hours Apply artificial tears

The nurse is conducting a seminar regarding the recent increase in motor vehicle collisions​ (MVCs) within the community. Which statement made by the nurse during the seminar is most​ accurate? MVCs are the primary cause of death in children 0-10 years old. MVCs are the primary cause of death in individuals 11-27 years old. MVCs are the primary cause of death in individuals 69-89 years old. MVCs are the primary cause of death in individuals 28-48 years old.

MVCs are the primary cause of death in individuals 11-27 years old.

When planning care for a client admitted with a hypersensitivity​ reaction, the nurse addresses the potential problem of impaired tissue perfusion. Which intervention will assist in addressing this potential​ problem? Providing calm reassurance Elevating the head of the bed Monitoring urine output Assessing for pain

Monitoring urine output

Mr. Reginald Grimly comes to the mental health clinic and reports that he feels so down and lacks any energy. The nurse knows that this client has a history of bipolar disorder. The nurse would expect Mr. Grimly to be on what medication for his bipolar​ disorder? Selective serotonin reuptake inhibitors​ (SSRI) Antianxiety Mood stabilizers Antipsychotics

Mood stabilizers

Mr. Edward asks you about his new diagnosis of PJP. Which of the following statements are true regarding Pneumocystis jiroveci pneumonia​ (PJP)? Select all that apply. PJP is the most common opportunistic infection in AIDS clients. PJP is caused by a common environmental fungus. PJP occurs in clients with weakened immune systems PJP causes inflammation and fluid buildup in the lungs. PJP causes imminent death in all clients.

PJP is the most common opportunistic infection in AIDS clients. PJP is caused by a common environmental fungus. PJP occurs in clients with weakened immune systems PJP causes inflammation and fluid buildup in the lungs.

The nurse is conducting a routine assessment for a​ school-age client. Which finding would support the diagnosis of seasonal​ allergies? Pale nasal mucosa Decrease in body temperature Weight appropriate for age Pallor of the skin

Pale nasal mucosa

The nurse is providing care to a client who experienced a perinatal loss 4 weeks ago. The client is tearful and still grieving the loss of her child. Which nonpharmacologic therapy can the nurse recommend to this​ client? Group therapy Hormone therapy Massage therapy Antidepressant therapy

Group therapy

A nurse is caring for​ 32-year-old client,​ Clara, and her​ husband, following the loss of her​ 35-week fetus. Clara is​ crying, and says​ "I should not have gone out in the boat while I was pregnant. That is why my baby​ died." Which emotion is Clara​ sharing? Anger Guilt Denial Betrayal

Guilt

The home care nurse is concerned that a​ 75-year-old widowed male client is at risk for suicide. Which data caused the nurse to come to this conclusion when conducting the home​ assessment? Wears oxygen at home Multiple scatter rugs throughout the home Malfunctioning smoke detectors Handguns located in the bedroom and living room

Handguns located in the bedroom and living room

The nursing is providing discharge instructions for a client with AIDS. Which instructions should the nurse​ emphasize? Select all that​ apply. Signs and symptoms of opportunistic infections and cancers Medications and side effects Infection prevention and transmission Necessity of spiritual counseling Importance of regular​ follow-up examinations and monitoring of immune status

Signs and symptoms of opportunistic infections and cancers Medications and side effects Infection prevention and transmission Importance of regular​ follow-up examinations and monitoring of immune status

The nurse has been caring for Joseph​ Manuel, a​ 2-year old-child born with congenital​ defects, over a period of several months. During the night​ shift, Joseph died and the nurse learns about his death upon coming to work the next day. What should the nurse do to handle personal grief about​ Joseph's death? Analyze actions to see if more nursing care could have been provided Accept that clients die and move on Focus on the care that assigned clients need for the shift Talk with​ co-workers who also had a relationship with the deceased client

Talk with​ co-workers who also had a relationship with the deceased client

The nurse is planning care for a client who recently made an unsuccessful suicide attempt. Which interventions would the nurse include in this client​'s plan of ​care? Select all that apply. Talking openly about suicidal thoughts Discussing ways to successfully commit suicide Taking threats of suicide seriously Searching the client​'s room Implementing suicide precautions

Talking openly about suicidal thoughts Taking threats of suicide seriously Searching the client​'s room Implementing suicide precautions

The nurse manager of an oncology unit is planning a program to assist staff with needs after the death of a client. What should the manager include in this​ staff-training program? Select all that apply. Keeping personal feelings about death and dying within Talking to each other about the loss of a client Importance of using grief counseling as a resource Information to process the loss of a client Doubling efforts to prevent another client death

Talking to each other about the loss of a client Importance of using grief counseling as a resource Information to process the loss of a client

Which activity should the nurse recommend to the client on an inpatient unit when the client has thoughts of​ suicide? Keeping track of feelings in a journal Playing a checkers with other clients Talking with the nurse Reading a book

Talking with the nurse

The nurse is providing discharge instructions to a client who is recovering from low back pain that resulted from a motor vehicle crash​ (MVC). Which instruction is the priority for this​ client? Perform daily exercise as instructed as a lifelong routine Avoid occupations that require physical use of the body Sit in a chair with the hips higher than the knees Sleep on the abdomen or on the back with legs extended flat on the bed

Perform daily exercise as instructed as a lifelong routine

The nurse is planning a care conference for a client who suffered massive injuries as the result of a motor vehicle crash​ (MVC). Which members of the health care team will the nurse invite to the care conference for this ​client? Select all that​ apply. ​Nurse-midwife Emergency medical technician​ (EMT) Physician Physical therapist Surgeon

Physician Physical therapist Surgeon

A client with terminal cancer is experiencing dyspnea. Which actions should the nurse use to help this​ client? Select all that apply. Provide oxygen as prescribed Elevate both legs Provide small frequent meals Place pillows behind head Raise the head of the bed

Provide oxygen as prescribed Place pillows behind head Raise the head of the bed

Which interventions are appropriate for treating imbalanced nutrition in clients with​ HIV? ​(Select all that​ apply.) Encouraging the client to eat only when hungry Providing or assisting with oral hygiene Identifying causes of altered nutrition Providing supplementary vitamins and enteral feedings Providing a low calorie diet

Providing or assisting with oral hygiene Identifying causes of altered nutrition Providing supplementary vitamins and enteral feedings

The nurse is caring for a client with AIDS and has identified the problem of imbalanced nutrition. The client is currently underweight. Which interventions are appropriate for this​ client? Select all that​ apply. Providing supplementary vitamins Serving large portions Identifying the cause of altered nutrition Providing foods high in protein and calories Assisting with oral hygiene

Providing supplementary vitamins Identifying the cause of altered nutrition Providing foods high in protein and calories Assisting with oral hygiene

Which characteristics are risk factors for the development of rheumatoid​ arthritis? ​(Select all that​ apply.) Male sex Psychological stressors Genetic predisposition Diet Family history

Psychological stressors Genetic predisposition Family history

Based on your​ assessment, which diagnostic tests would you anticipate the health care provider to order for Mrs.​ Megumi? Select all that apply. Rheumatoid factor​ (RF) MRI Synovial fluid aspirated from​ non-inflamed joints Complete blood count​ (CBC) Sedimentation rate

Rheumatoid factor​ (RF) Complete blood count​ (CBC) Sedimentation rate

Which assessment finding requires priority monitoring for a client admitted with a hypersensitivity​ reaction? Forgetfulness Constipation Skin rash Elevated blood pressure

Skin rash

The​ nurse, working in an internal medicine​ practice, prepares to see a client diagnosed with rheumatoid arthritis on the last visit. The client is complaining of pain and discomfort in the hands and knees. Which treatments can be used to reduce the pain and discomfort that the client is​ experiencing? Select all that​ apply. Taking corticosteroids Increasing sun exposure Taking NSAIDs Eating a balanced diet Exercising

Taking corticosteroids Taking NSAIDs Eating a balanced diet Exercising

Which injury prevention strategies would be applicable to teach a family in order to prevent a motor vehicle crash​ (MVC) injury for a newborn or infant​ client? ​(Select all that​ apply.) Use a car seat every time the infant is in the car. Dress the infant in clothes that allow the straps to go between the legs. Choose an​ infant-only or convertible car seat. Place the infant in a​ rear-facing car seat at least until age 1. Place blankets under the baby and under the seat belt.

Use a car seat every time the infant is in the car. Dress the infant in clothes that allow the straps to go between the legs. Choose an​ infant-only or convertible car seat. Place the infant in a​ rear-facing car seat at least until age 1.

What is a modifiable risk factor in the development of immune​ disorders? Gender Age Weight Race

Weight

Which statement is false regarding SLE medications and their associated side​ effects? Corticosteroid therapy can cause cushingoid symptoms. When the client is on aspirin​ therapy, renal toxicity is a side effect for which the client should be monitored. There is an increased risk of​ infection, malignancy, and bone marrow depression when the client is treated with azathioprine. With aspirin​ therapy, thrombosis prevention is a positive side effect.

When the client is on aspirin​ therapy, renal toxicity is a side effect for which the client should be monitored.

Which fact regarding allergic reactions in children is important for the nurse to​ consider? Food allergies are rare in children. They are at higher risk for respiratory distress. Children quickly outgrow peanut allergies. Breastfeeding is a risk factor in the development of food allergies.

They are at higher risk for respiratory distress.

Why are nonsteroidal​ anti-inflammatory agents​ (NSAIDs) used to treat rheumatoid​ arthritis? To reduce inflammation To reduce joint destruction To slow the development and progression of bone erosion To alter the course of the disease

To reduce inflammation

Mrs. Megumi reports she is often stiff in the morning. What are effective ways that you can educate her to decrease her morning​ stiffness? Select all that apply. Use assistive devices to decrease stress on the joints while performing ADLs. Perform range of motion​ (ROM) exercises while taking a hot shower or bath each morning. Do all of the household chores each night before going to bed. Take NSAIDs with a glass of milk and​ crackers, 30 minutes before getting out of bed each morning. Perform ROM exercises several times during the night to prevent morning stiffness.

Use assistive devices to decrease stress on the joints while performing ADLs. Perform range of motion​ (ROM) exercises while taking a hot shower or bath each morning. Take NSAIDs with a glass of milk and​ crackers, 30 minutes before getting out of bed each morning.

Which laboratory test is not used in the diagnosis of​ SLE? ​Anti-DNA antibody testing Triglyceride levels Urinalysis Complete blood count Erythrocyte sedimentation rate

Triglyceride levels

Kayla​ Ruiz, age​ 28, has signs of severe anaphylaxis including asthma and urticaria. She was brought to the emergency department from the factory job where she just started working today. She has no history of asthma or drug​ use, nor is she taking any prescription medications. Based on this​ data, which diagnosis does the nurse anticipate for this​ client? Type 4 delayed hypersensitivity Allergic reaction Type 1​ IgE-mediated hypersensitivity Type 2 cytotoxic hypersensitivity

Type 1​ IgE-mediated hypersensitivity

Robert Johnson is a​ 65-year-old client who is scheduled for an orthopedic procedure this afternoon. The nurse administers an intravenous medication as ordered. Ten minutes after the start of the​ infusion, Mr. Johnson complains of itching and you notice that his lips and tongue are swollen. Which type of reaction will the nurse document in the​ client's medical​ record? Type I Type II Type IV Type III

Type I

A client is having a hypersensitivity response that was triggered when an allergen interacted with IgE. Which type of hypersensitivity response does the nurse​ anticipate? Type IV response Type I response Type III response Type II response

Type I response

The nurse is caring for a client receiving a blood transfusion. Which type of hypersensitivity reaction can occur as a result of this​ transfusion? Type IV Type II Type I Type III

Type II

The nurse is educating a student nurse about hypersensitivity​ reactions. Which hypersensitivity reaction releases enzymes that increase tissue​ damage? Type III Type I Type IV Type II

Type III

A client is admitted to the emergency department with​ red, itchy patches on both legs that appeared 24 after camping. The nurse expects that the client is experiencing which type of hypersensitivity​response? Type III Type IV Type II Type I

Type IV

The nurse is providing care for a client who may be experiencing a fetal demise. Which order does the nurse anticipate for this​ client? Pregnancy test CT scan Emergency cesarean section Ultrasound

Ultrasound

A nurse is reviewing the report from a client who just received her​ 20-week ultrasound. The ultrasound report noted a​ two-vessel cord and recommended​ follow-up ultrasounds to follow the fetal growth every 4 weeks until delivery. Based on these​ results, which condition is this client at risk for that may increase the risk of fetal demise and perinatal​ loss? Trauma Placental abruption Congenital malformation Umbilical cord abnormality

Umbilical cord abnormality

Which physical clinical manifestations may occur for the client who experiences a fetal​ demise? ​(Select all that​ apply.) Vaginal spotting Severe back pain Change in fetal movement Chest pain Dysuria

Vaginal spotting Severe back pain Change in fetal movement

The nurse assesses and monitors a pediatric client in the office after the administration of scheduled immunizations. Which reaction indicates the need for priority​ intervention? Localized erythema Urticaria Fussiness Pain at injection site

Urticaria

The nurse identifies a client with risk factors for suicide. Which question would be appropriate for the nurse to ask when assessing the client​'s thoughts about​ suicide? ​"Do you have weapons in your​ home?" ​"Have you made funeral​ plans?" ​"Have you been giving away your​ possessions?" ​"Do you ever think of harming yourself when you​'re feeling​ down?"

​"Do you ever think of harming yourself when you​'re feeling​ down?"

A young female client diagnosed with systemic lupus erythematosus​ (SLE) asks what caused her disease. Which response by the nurse is the most​ appropriate? ​"I can give you a booklet that describes the most current thinking about​ SLE." ​"The cause can be different in different​ people." ​"Researchers don't know the​ cause." ​"You will have to ask your health care provider that​ question."

​"I can give you a booklet that describes the most current thinking about​ SLE."

The nurse is performing an assessment on a client who complains of joint pain and stiffness. The client was admitted to the unit with a diagnosis of rheumatoid arthritis. Which reported signs and symptoms from the client interview would not be consistent with the clinical manifestations of rheumatoid​ arthritis? ​"I have trouble with walking because of the​ pain, and when I am finally done with my morning chores and sit​ down; my knees get so stiff I can hardly get up after I​ rested." ​"Whenever my disease gets​ worse, my joints get​ red, hot and​ swollen." ​"I am just tired all the​ time, and feel very​ weak." ​"I am in so much pain in the​ morning! It is very hard for me to get out of bed and start my day. I can hardly move my​ legs; my knees feel like they are​ frozen."

​"I have trouble with walking because of the​ pain, and when I am finally done with my morning chores and sit​ down; my knees get so stiff I can hardly get up after I​ rested."

Mrs.​ Smith, age 62​ years, enjoys gardening and spending time with her​ 6-year-old granddaughter, Callie. Callie experienced her first bee sting last week while at the​ pool, and it resulted in a trip to the emergency department. Mrs. Smith tells the nurse of her upcoming visit with Callie and their gardening plans. Which statement made by Mrs. Smith alerts the nurse to the need for further​ education? ​"If Callie gets stung by a​ bee, I will remove the stinger and apply ice to reduce her​ pain." ​"I will be attentive to​ Callie's breathing pattern if she is stung by a bee and use the epinephrine pen as​ directed." ​"I will get a detailed description of the severity and treatment of​ Callie's first bee sting from her​ mother." ​"I will be sure that Callie wears her​ Medic-Alert bracelet."

​"If Callie gets stung by a​ bee, I will remove the stinger and apply ice to reduce her​ pain."

You are providing nursing care for Ms.​ James, who was diagnosed with HIV last year. Ms. James tells you that she has become isolated and depressed because she fears she will never have another sexual relationship. Which response is most​ appropriate? ​"It is possible to be happy while having only nonsexual​ relationships." ​"It is important that you avoid meeting new people because that can lead to unsafe​ sex." ​"It is important that you accept that you may never have another sexual relationship​ again." ​"It is important to continue to meet people and develop social relationships while practicing safer​ sex."

​"It is important to continue to meet people and develop social relationships while practicing safer​ sex."

Mrs. Lavelle was recently diagnosed with systemic lupus erythematosus​ (SLE) and is experiencing extreme fatigue and a fever. She is anxious about her condition and asks you whether she should expect her condition to get progressively worse. Which is the best response to Mrs.​ Lavelle's question? ​"It is likely that you will experience periods of remission and​ exacerbation." ​"It is likely that your condition will be​ cured." ​"It is likely that your condition will get progressively​ worse." ​"It is likely that your condition will go into permanent​ remission."

​"It is likely that you will experience periods of remission and​ exacerbation."

The nurse is caring for a client recently diagnosed with rheumatoid arthritis​ (RA). The client​ states, "I always take care of​ myself, how could this happen to​ me?" Which response by the nurse is most appropriate regarding the​ client's risk for developing​ RA? ​"RA occurs when there is a family history of the​ disease." ​"RA occurs when there is a family history of coronary artery​ disease." ​"RA occurs for clients with a history of using herbal​ remedies." ​"RA occurs for clients who are​ underweight."

​"RA occurs when there is a family history of the​ disease."

A nurse is participating in a community health fair. Which statement made by a participant indicates the teaching about rheumatoid arthritis was​ understood? ​"Rheumatoid arthritis causes joint inflammation related to a history of joint​ trauma." ​"Rheumatoid arthritis is an autoimmune disorder and has associated genetic​ factors." ​"Rheumatoid arthritis is the most common arthritis in the United States and may affect only one​ joint." ​"Rheumatoid arthritis results in increased uric acid due to impaired purine​ metabolism."

​"Rheumatoid arthritis is an autoimmune disorder and has associated genetic​ factors."

Becky confides she is not only worried about contracting HIV from her​ father, but she had sexual relations with a stranger she met about 3 weeks ago. After your​ education, she is thinking about getting tested for HIV. Which statement indicates Becky understands​ sero conversion? I will not know for sure if I have seroconverted for 6​ months, so I should wait to test until then. I should get an HIV test right away to determine if I have seroconverted. I will​ seroconvert, because my father is HIV positive. ​"The HIV antibodies are detectable anywhere from 6 weeks to 6 months after the initial infection.

​"The HIV antibodies are detectable anywhere from 6 weeks to 6 months after the initial infection.

A client with SLE would like to know the options for contraceptives to prevent pregnancy. Which response by the nurse is the most appropriate for this​ client? ​"The estrogen in oral contraceptives has been known to trigger an acute exacerbation of​ SLE." ​"Condoms are not recommended because of latex allergies associated with​ SLE." ​"Women with SLE have trouble conceiving so you​ don't have to worry about​ contraception." ​"The only form of contraception appropriate for you is​ abstinence."

​"The estrogen in oral contraceptives has been known to trigger an acute exacerbation of​ SLE."

A father comes to the emergency department after receiving a phone call informing him that his daughter was involved in a motor vehicle crash​ (MVC). When he approaches the triage​ desk, he asks​ frantically, "How is my​ daughter?" Which response by the nurse is most appropriate in this​ situation? ​"Your daughter is young and has youth on her​ side; I'm sure​ she'll be​ fine." ​"Everything will be​ okay; please take a seat and​ I'll check on her for​ you." ​"Your wife called and I told her​ everything, so you can check with​ her." ​"She's being examined now.​ She's awake and talking.​ We'll take you to see her​ soon."

​"She's being examined now.​ She's awake and talking.​ We'll take you to see her​ soon."

Jessica​ Stevens, a​ 72-year-old client with terminal lung​ cancer, is hospitalized with pneumonia. Jessica is not expected to survive and is asked about decisions for her care. Jessica asks the nurse what this means. How should the nurse respond to​ Jessica's question? ​"The family must decide to what extent you want the healthcare team to intervene in your​ death." ​"The healthcare provider will decide if it is in your best interest to remain alive on a ventilator or if you should be allowed to​ die." ​"Do you want your family notified when you are ready to​ die?" ​"The healthcare team will honor your directive about how you want to​ die."

​"The healthcare team will honor your directive about how you want to​ die."

A client lives in a group home and visits the community mental health center regularly. During one visit with the​ nurse, the client​ states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to​ ask? "Why are the voices starting ​again?" "How long have you heard the ​voices?" "Are you going to hurt ​yourself?" "When do you hear the ​voices?"

"Are you going to hurt ​yourself?"

Mrs. Joanne Stevens is a​ 63-year-old client who is in the hospital after undergoing heart​ transplantation, and she is receiving cyclosporine medication. The nurse is educating the client. Which teaching point should not be included in the​ session? ​"Exercise is​ important, so you should walk inside the​ mall." ​"It is important for you to consume a​ well-balanced diet." ​"There are groups that you can attend for emotional​ support." ​"Adequate sleep and rest are important to your​ recovery."

"Exercise is​ important, so you should walk inside the​ mall."

Which question should the nurse ask to best determine the seriousness of a client​'s suicidal​ ideation? "Does your family know you​'re ​here?" "How are you planning to harm ​yourself?" "Have you made a living ​will?" "How long have you been thinking about harming ​yourself?"

"How are you planning to harm ​yourself?"

The nurse is discussing the immunosuppressive treatment with a client diagnosed with SLE. The nurse knows that the client understands the treatment side effects when the client makes which​ statement? ​"I can take aspirin for a joint​ pain, since nothing is wrong with my​ kidneys." ​"I will take my medications first thing in the morning on an empty​ stomach, to help the medication to be​ absorbed." ​"I will call the medical office and report if I am experiencing​ chills." ​"I don't have to use contraception since I am more than 40 years​ old."

"I will call the medical office and report if I am experiencing​ chills."

Which comment by the client indicates an understanding of the nurse​'s teaching regarding sertraline​ (Zoloft)? "Dry mouth is a permanent side effect." "I can take my medicine with St. John​'s wort." "This medicine can exacerbate suicidal thinking." "This medication will cause me to gain weight."

"This medicine can exacerbate suicidal thinking."

The nurse is caring for a​ 42-year-old client and her husband who experienced a intrauterine fetal demise at 21 weeks​' gestation. They are holding the​ baby, wrapped in a baby​ blanket, and the husband states that they would like to have the baby blessed. What response indicates that the nurse requires further education in perinatal​ loss? "Our chaplain will not bless a baby unless it could have survived outside of the womb when born." "We have holy water in our perinatal loss bereavement​ kit, would that be something you would want to be used in the ​blessing?" "Let me get the operator to call hospital chaplain for this request." "If it is okay with​ you, I would like to take some photos of the blessing for the memory book of your ​child?"

"Our chaplain will not bless a baby unless it could have survived outside of the womb when born."

A client with acute​ mania, who has previously threatened​ suicide, has been admitted to the inpatient unit voluntarily. The nurse approaches the client with medication to be taken orally as prescribed by the primary healthcare provider. The client​ states, "I don​'t need that stuff." Which is the best response by the​ nurse? "You are not allowed to refuse medications." "The medication will help stabilize your mood." "I will get you some written information about the medication." "I will give you a shot if you don​'t take this medication by mouth."

"The medication will help stabilize your mood."

The nurse is caring for a client who was recently tested for HIV at the client​'s request. The client asks the​ nurse, "Will this test really tell me if I have​ HIV?" Which response by the nurse is the most​ appropriate? "You should be using condoms when you have sex." "With the​ state-of-the art testing we now​ have, antibodies confirming HIV infection can be detected within 5 days of​ infection." "The presence of antibodies indicative of HIV infection can be detected in blood 6 weeks to 6 months after the initial​ infection." "Why do you think you need an HIV ​test?"

"The presence of antibodies indicative of HIV infection can be detected in blood 6 weeks to 6 months after the initial​ infection."

The nurse is caring for a pregnant client in the obstetrics clinic. The client has a history of rheumatoid arthritis. Which statement by the client would require a follow up by the​ nurse? ​"I might carry my baby longer than the normal 40 weeks for the​ pregnancy." ​"I need to schedule extra rest periods throughout the​ day." ​"Now that I am in my second​ trimester, I actually feel​ good, and my joints are not hurting​ either." ​"When my joints hurt I can take an​ aspirin."

"When my joints hurt I can take an​ aspirin."

The brain waves of a client on life support are absent. In response to the family​'s question about the client being​ dead, for how long should the nurse explain that the brain waves must be absent before death can be ​declared? 24 hours or longer One week or longer 1 hour or longer 12 hours or longer

24 hours or longer

You know that understanding the underlying dynamics of suicide will help you assess and plan for care for Mrs. Ivansky. Although depression can lead to​ suicide, suicide is primarily described as which type of​ event? A dyadic event between two people involving​ guilt, rejection, or abandonment A multiple relationship involving​ guilt, resentment, and pity A multiple relationship event involving​ anger, submission, and fear A triadic event between three people involving depression and anxiety

A dyadic event between two people involving​ guilt, rejection, or abandonment

A client is admitted with an open fracture of the tibia that resulted from a motor vehicle crash​ (MVC). Which item is the priority to ask during the nursing​ assessment? A history of tetanus immunizations Any previous injuries to the leg The use of any antibiotics within the last 3 months Whether the wound was exposed to dirt or gravel

A history of tetanus immunizations

To determine the causes of a hypersensitivity​ reaction, a skin prick test may be used. Which statements best describe this skin test procedure and​ results? ​(Select all that​ apply.) The allergen is diluted only if a severe systemic reaction is anticipated. A positive response may include​ pruritus, erythema, and development of a wheal. The client must avoid contact with the allergen for 48 hours after the skin test. A positive response can be determined within 15 to 20 minutes. The diluted allergen extract is intradermally injected in the forearm area.

A positive response may include​ pruritus, erythema, and development of a wheal. A positive response can be determined within 15 to 20 minutes.

The nurse is caring for a terminally ill client. Which assessment findings indicate to the nurse that the client has passed​ away? Select all that apply. Anorexia Dyspnea Absence of reflexes Absence of respiration No movement

Absence of reflexes Absence of respiration No movement

You suggest having a family meeting with all of Mr. Vann​'s relatives present. You encourage his family members to participate his physical care to the extent that they feel comfortable and are able to do so. You talk about the stages of grief and bereavement.​ Because you know you have shared a lot of information at one​ time, you give them booklets from the hospice agency about how to make Mr. Vann comfortable and deal with his death. You let them know to contact you if they have questions. After some more​ discussion, everyone there recognizes the fact that Mr. Vann is oriented and able to make decisions for​ himself, so no one criticizes his decision to stop eating. The family has reached which stage of​grief? Depression Acceptance Bargaining Denial

Acceptance

Which nursing intervention is appropriate for a client having difficulty breathing following a motor vehicle crash​(MVC)? Assessing neurological status Administering oxygen per order Prescribing narcotic analgesics Facilitating passive​ range-of-motion exercises

Administering oxygen per order

The community health nurse plans education sessions at local community centers to promote safer sex and prevention of sexually transmitted infections. Which group of adolescents would benefit the most from this education due to an increased risk of contracting​ HIV? Latin American boys who identify as heterosexual African American adolescents Girls affected by gender dysphoria Caucasians aged​ 16-20

African American adolescents

What makes an individual more prone to develop a disorder of the immune​ system? ​(Select all that​ apply.) African American race Male sex Psychological stressors Genetic predisposition Physical stressors

African American race Psychological stressors Genetic predisposition Physical stressors

While assessing a pediatric​ client, the nurse notes a high eosinophil count in the laboratory results. Which diagnosis does the nurse anticipate based on this laboratory​ result? Rubella Lyme disease Allergies Salmonella

Allergies

In performing a physical assessment on a client who is experiencing a hypersensitivity​ reaction, which findings would the nurse​ anticipate? ​(Select all that​ apply.) Altered respiratory rate Eyes with tearing and redness Skin lesions or rashes ​Cold, moist skin Adventitious breath sounds

Altered respiratory rate Eyes with tearing and redness Skin lesions or rashes Adventitious breath sounds

The nurse assesses a client who was involved in a motor vehicle crash​ (MVC). The nurse documents tachypnea and dyspnea. Which nursing diagnosis will the nurse use to plan appropriate interventions for this​ client? Altered gastrointestinal status Altered respiratory status Altered neurological status Altered circulatory status

Altered respiratory status

The nurse is preparing a stillborn infant for the parents​' viewing. Prior to this​ viewing, what should the nurse discuss with the​ parents? Appearance of the newborn Need to videotape the visit Time limitations for visit The need for taping the hands together

Appearance of the newborn

The nurse is working in a primary care office. A client diagnosed with rheumatoid arthritis has returned for a​ follow-up visit. The client states that his pain is controlled on NSAIDs. The nurse would supply what education related to the disease process and supportive​ care? Select all that​ apply. Application of heat or cold to relieve pain Take NSAIDs at regular intervals with food or milk Be aware of the adverse effects of prescribed medications Exercise in the shower because​ warm, moist heat promotes mobility Avoid exercise

Application of heat or cold to relieve pain Take NSAIDs at regular intervals with food or milk Be aware of the adverse effects of prescribed medications Exercise in the shower because​ warm, moist heat promotes mobility

The nurse on the inpatient orthopedic unit is preparing the client for surgery. The client was admitted for right knee joint replacement surgery. The nurse wants to use the right teaching handouts for this type of surgery. Which surgical teaching handout is the nurse going to​ use? Arthroscopy Arthroplasty Arthrodesis Synovectomy

Arthroplasty

The nurse creates an explanation of laboratory testing for a​ non-English-speaking client with SLE. What does the nurse ask the interpreter to translate for this client in regard to the types of blood materials evaluated by the laboratory​ tests? Select all that​ apply. Platelets Antibodies T cells Proteins Lymphocytes

Antibodies Proteins

You meet Mr. Vann​'s ​daughter, Clara, at the door of her home. She invites you​ in, and you notice that she has dark circles under her eyes. She begins by telling you that she and her father are very close. She has not eaten or slept well since her father​'s announcement. What kind of loss is Clara​ experiencing? Actual loss Perceived loss Compensated loss Anticipatory loss

Anticipatory loss

A client is brought to the hospital by police and admitted involuntarily. The client is diagnosed with schizophrenia. Which medication would the nurse expect the healthcare provider to prescribe for this​ client? Mood stabilizers Antidepressants Antipsychotics Anxiolytics

Antipsychotics

Mr. Edwards was diagnosed with HIV over 12 years ago. He tells you that he faithfully takes his highly active antiretroviral therapy​ (HAART). He asks you how can he possibly have AIDS now. What is your best​ response? Antiretroviral medications can delay the onset of​ AIDS, but the medications are not a cure for AIDS. Antiretroviral medications and vaccinations can cure AIDS. You will only get AIDS if you stop taking the highly active antiretroviral therapy ​(HAART). The antiretroviral therapy doesn​'t ​matter; once you are HIV​ positive, it is just a matter of time before you develop full blown AIDS.

Antiretroviral medications can delay the onset of​ AIDS, but the medications are not a cure for AIDS.

The nurse is admitting a​ client, Justin​ Walker, who received potentially​ life-threatening injuries secondary to a motor vehicle collision earlier this evening. Upon moving the client into a trauma examination​ room, which assessment is the priority for Mr.​ Walker? Assessment for neurological injuries Assessment for abdominal injuries Assessment for orthopedic injuries Assessment for a patent airway

Assessment for a patent airway

When planning care for a client admitted with a hypersensitivity​ reaction, the nurse addresses the potential problem of airway clearance. Which interventions will assist in addressing this potential​ problem? Select all that​ apply. Auscultating lung sounds Placing the client in a supine position Administering oxygen Assessing level of consciousness Administering epinephrine

Auscultating lung sounds Administering oxygen Assessing level of consciousness Administering epinephrine

Anthony Edwards is a​ 48-year-old man recently diagnosed with Acquired Immunodeficiency Syndrome​ (AIDS). He was initially diagnosed 12 years ago as HIV positive. Immediately upon​ diagnosis, Mr. Edwards began a highly active anti retroviral therapy​ (HAART). His CD4 count has remained above​ 500/mm3 for the past 12 years. He resides with his​ partner, Michael, who is also HIV positive and receives HAART. They have been together almost 11 years. Mr. Edwards has a​ daughter, but she has not visited her father since he recently revealed his HIV positive status to her. Since being diagnosed with​ HIV, Mr. Edwards has been able to work from​ home, instructing an online history course for the local community college. Mr. Edwards and his partner are sexually active and use appropriate condoms. Mr. Edwards is​ diabetic, but has otherwise remained healthy. He has never abused intravenous drugs and has never received a blood transfusion. Mr. Edwards is being admitted to the hospital with AIDS. He​ states, "I know I have​ HIV, but I am certain I do not have AIDS. I just have pneumonia right now." Which findings indicate Mr. Edwards has​ AIDS? Select all that apply. Fecal impaction CD4 count less than​ 200/mm3 Opportunistic Infection HIV seropositive per ELISA test Platelet aggregation disorder

CD4 count less than​ 200/mm3 Opportunistic Infection HIV seropositive per ELISA test

The nurse is participating in a yearly required​ ride-along with the paramedics who service the hospital emergency department​ (ED). During the​ ride-along, the nurse is treating a​ 45-year-old male​ client, Clyde​ Waters, who has been injured in a motor vehicle crash. Mr. Waters sustained a suspected head injury and the nurse phones the ED to provide a report prior to his arriving at the ED for further treatment. Which diagnostic test does the nurse anticipate will be ordered based on the current assessment​ findings? Ice and heat therapy CT and MRI scans Basic metabolic panel Complete blood count​ (CBC)

CT and MRI scans

Mr. Edward​'s CD4 cell count is currently low​ (109/mm3) leading to his current development of AIDS related pneumonia. Which opportunistic infections are common manifestations of​ AIDS? Select all that apply. Cryptorchidism Candida albicans​ (oral thrush) ​(PJP) Mycobacterium avium complex​ (MAC) Tuberculosis​ (TB)

Candida albicans​ (oral thrush) ​(PJP) Mycobacterium avium complex​ (MAC) Tuberculosis​ (TB)

Ms. Knopp is a​ 31-year-old woman with a history of HIV. She presents to the healthcare provider for a regularly scheduled appointment. You notice that her latest laboratory report shows that her CD4​ T-cell count is less than​ 200/mm3. What would you assess for during Ms.​ Knopp's examination? Rheumatoid arthritis Dysmenorrhea Candidiasis Psoriasis

Candidiasis

Mrs. Megumi tearfully​ states, I dont think I can continue arranging flowers at the flower shop. My customers always ask me whats wrong with my hands. Just look at them. I dont even want my husband to look at them. You are developing a nursing care plan for Mrs. Megumi. Which nursing diagnosis is a priority at this​ time? Client is in acute pain. Client exhibits a disturbed body image. Client has impaired communication. Client is exhibiting activity intolerance.

Client exhibits a disturbed body image.

The nurse is evaluating outcomes of care provided to a client dying from a terminal illness. Which observations indicate that care has been​ effective? Select all that apply. Client crying and stating that no one will even mourn for him once he dies Client talking about leaving pain and sadness behind upon death Client​'s family sitting and talking with the client Client resting comfortably in bed Client requests pain medication every 4 hours

Client talking about leaving pain and sadness behind upon death Client​'s family sitting and talking with the client Client resting comfortably in bed Client requests pain medication every 4 hours

You return to visit Mrs. Ivansky two weeks later and find that she is​ smiling, talkative, and in her kitchen baking cookies for a visit this week from one of her sons. During a phone conversation with the​ daughter, you provide her with which additional information about her​ mother's care? Clients who have talked about suicide and then been treated with antidepressants no longer need suicide precautions or someone to stay with them for observation of their behavior and moods. Clients who have talked about suicide and then been treated with antidepressants are still at risk for suicide once they start to feel better because they now have the energy to complete a plan. Clients who have talked about suicide and then been treated with antidepressants are more likely to never have a suicide crisis again and the daughter can focus on her​ mother's medical conditions. Clients who have talked about suicide and then been treated with antidepressants only need a short course of treatment.

Clients who have talked about suicide and then been treated with antidepressants are still at risk for suicide once they start to feel better because they now have the energy to complete a plan.

The nurse is planning care for an Asian American adolescent male client who has attempted suicide twice. Which information will the nurse use to understand the client​'s risk for future suicide​ attempts? Select all that apply. Client​'s education level Number of siblings in the family Client​'s age Client​'s race and culture Amount and frequency of alcohol ingestion

Client​'s age Client​'s race and culture Amount and frequency of alcohol ingestion

Hearing of Mr.Edwards​' ​ hospitalization, his daughter Becky comes to visit him. Before she goes into his​ room, she tells you she is concerned about contracting HIV from her father or his​ partner, Michael. She asks you about her risk factors for contracting HIV. Which behaviors do you tell her are risks for contracting​ HIV? Select all that apply. Hugging her father or coming in close contact with her father. Coming into direct contact with her father​'s blood. Sharing insulin needles with her father. Using the same bathroom facilities as her father. Eating a meal her father has prepared.

Coming into direct contact with her father​'s blood. Sharing insulin needles with her father.

Mrs. Avery is a​ 26-year-old woman who has been experiencing​ fatigue; joint​ pain; difficulty swallowing because of ulcers in the​ mouth; and a red rash over her face and upper trunk. She has been diagnosed with SLE. Which treatment would you expect to be ordered for Mrs.​ Avery? Surgical drainage of affected joints Antibiotic therapy Corticosteroid therapy Physical therapy to improve mobility

Corticosteroid therapy

The nurse is providing care to a client with a disorder of the immune system that causes inflammation. Which pharmacologic therapy does the nurse anticipate for this​ client? Intravenous immunoglobulins Influenza vaccine Corticosteroid therapy Prophylactic antibiotics

Corticosteroid therapy

The nurse is caring for a client with SLE who reports pain and discomfort. Which treatment option does the nurse anticipate for this​ client? Select all that​ apply. Corticosteroids Increased sun exposure Exercise NSAIDs Good nutrition

Corticosteroids Exercise NSAIDs Good nutrition

The nurse is assessing a client who is undergoing diagnostic testing to determine whether the immune system is functioning properly. Which item will be included in the health history portion of the nursing ​assessment? Palpating the joints Observing for stiffness during movement Inspecting the skin for bruising Determining the date of the last tuberculin skin test

Determining the date of the last tuberculin skin test

The nurse is caring for a client with asthma who is recovering from an acute exacerbation. Which complementary and alternative therapy does the nurse educate this client to begin after​ hospitalization? Daily vitamin C Weekly​ gene-transfer therapy Daily use of a maintenance inhaler Weekly use of a rescue inhaler

Daily vitamin C

A nurse is caring for a client who is deficient in T cells. Which result of this T cell deficiency does the nurse​ anticipate? Select all that​ apply. Decrease in monocytes Decrease in granulocytes Decrease in leukocytes Hypersensitivity reaction Impaired cellular immunity

Decrease in leukocytes Impaired cellular immunity

Which are clinical manifestations of imminent​ death? Select all that apply. Decrease in volume of Korotkoff sounds Edema and increased respiratory secretions Increased heart rate ​Cheyne-Stokes breathing Mottling

Decrease in volume of Korotkoff sounds ​Cheyne-Stokes breathing Mottling

A client reports he has not been feeling well and is concerned that he has been exposed to HIV. Which client symptoms and assessment findings would support a diagnosis of primary HIV​ infection? Select all that​ apply. Decreased WBCs on complete blood count Malaise and​ flu-like symptoms High serum potassium level Elevated ESR​ (erythrocyte sedimentation​ rate) Headache and visual disturbances

Decreased WBCs on complete blood count Elevated ESR​ (erythrocyte sedimentation​ rate) Malaise and​ flu-like symptoms

What are the goals of the pharmacologic management of the client with​ HIV? ​(Select all that​ apply.) Decreasing symptoms Stimulating hematopoietic response Curing the infection Prolonging life for the affected individual Treating opportunistic infections and cancers

Decreasing symptoms Stimulating hematopoietic response Prolonging life for the affected individual Treating opportunistic infections and cancers

Which are manifestations of respiratory failure in the dying​ client? Select all that apply. Difficulty breathing Anxiety Wheezing Breathlessness Diaphoresis

Difficulty breathing Anxiety Wheezing Breathlessness

You schedule a time to come back tomorrow to talk with Mrs.​ Ivansky's daughter. As you prepare a teaching​plan, you know that you will want to include which​ approaches? Select all that apply. Do not promise secrecy because it might endanger Mrs.​ Ivansky's life. Suggest an inpatient placement until she is not talking of suicide. Help the daughter to involve other​ people, even​ neighbors, to keep her mother safe. Take Mrs. Ivansky and her issues seriously and help the daughter to take them seriously. Offer reassurance to the daughter and the other family members.

Do not promise secrecy because it might endanger Mrs.​ Ivansky's life. Help the daughter to involve other​ people, even​ neighbors, to keep her mother safe. Take Mrs. Ivansky and her issues seriously and help the daughter to take them seriously. Offer reassurance to the daughter and the other family members.

In which situation will a healthcare worker be at risk for HIV​ infection? ​(Select all that​ apply.) Urine contact with damaged skin Direct puncture in a vein with a contaminated needle Inhalation of airborne droplets Prolonged blood contact on damaged skin Deep injury with visible blood from a contaminated needle

Direct puncture in a vein with a contaminated needle Prolonged blood contact on damaged skin Deep injury with visible blood from a contaminated needle

The nurse is caring for a client who experienced a miscarriage at 17 weeks gestation. Which type of grief will the nurse assess this client for during the​ 2-week follow-up​ visit? Anticipatory Bittersweet Dysfunctional Disenfranchised

Disenfranchised

Which maternal complications may result from intrauterine fetal demise ​(Select all that​ apply.) Disseminated intravascular coagulation Glycosuria Infection Uterine rupture Sepsis

Disseminated intravascular coagulation Infection Sepsis

A client suffered a traumatic​ above-the-elbow amputation of his left arm as the result of a motor vehicle crash​ (MVC). The client is​ withdrawn, does not look at the injured left​ arm, and asks to be left alone. Which nursing diagnosis is the priority for this ​client? Disturbed body image Altered physical activity Impaired respiratory status Potential for flexion contracture

Disturbed body image

The nurse is caring for a client dying of a terminal illness that was diagnosed 3 months ago. Which psychosocial behaviors should the nurse expect the client to exhibit at this​ time? Select all that apply. Fear Anxiety Edema Anticipatory grief Indifference

Fear Anxiety Anticipatory grief

Which lab test will be positive for HIV antibodies if blood or oral mucosal transudate of an infected person reacts with the surface antigen of killed HIV​ virus? Western blot Estrone ​Ora-Quick Rapid​ HIV-1 ELISA​ (enzyme-linked immunosorbent​ assay)

ELISA​ (enzyme-linked immunosorbent​ assay)

The nurse is caring for a client who reports trouble breathing and severe itching after receiving a flu vaccination. Which medication does the nurse prepare for this​ client? Ibuprofen Triple antibiotic ointment Acetaminophen Epinephrine

Epinephrine

Your​ client, Alexandra​ Kowalski, is a​ 16-year-old cross-country runner diagnosed with juvenile idiopathic arthritis. Which diagnostic test does the nurse anticipate will be ordered for​ Alexandra? Urine cultures Electrolyte panel Erythrocyte sedimentation rate Coagulation tests

Erythrocyte sedimentation rate

Rino Megumi is a​ 42-year-old florist. She is seeking evaluation and treatment for complaints of​ red, swollen wrists and hands. She reports intermittent symptoms starting approximately 6 weeks ago. You note her hands are​ swan-necked. She states she is not able to arrange flowers for her customers without experiencing pain in her hands.Mrs. Megumis vital signs are T 97.9​°​F, P 88​ bpm, R​ 18/min, and BP​ 147/72 mmHg. She​ states, Im acting just like my mother. I have pain and stiffness all​ over, especially when I get up in the morning. My wrists hurt when you press on them. I just cant move my joints like I used to. Just look at how weird my fingers look. I have bumps on my​ toes, too. And I have been feeling very tired lately. Her hand grips are weak bilaterally. Which of the following significant lab findings would you expect in a client diagnosed with rheumatoid​ arthritis? Erythrocyte sedimentation rate 90​ mm/hr Antinuclear antibodies Titer​ 1:20 WBC 7500 mm3 Rheumatoid factor​ 1:20

Erythrocyte sedimentation rate 90​ mm/hr

What diagnostic tests are used for rheumatoid​ arthritis? ​(Select all that​ apply.) Renal function test Erythrocyte sedimentation rate​ (ESR) Kidney biopsy Antinuclear antibody​ (ANA) test ​C-reactive protein​ (CRP)

Erythrocyte sedimentation rate​ (ESR) ​C-reactive protein​ (CRP)

The nurse is preparing to discuss issues of sexuality with a client with AIDS. Which discussion point would be the most beneficial to the client​ initially? Establishing a trusting relationship and nonjudgmental attitude Arranging for a spiritual advisor to visit the client Advising the client that sexual relations are not recommended Providing the client with names of support groups for persons with AIDS

Establishing a trusting relationship and nonjudgmental attitude

What were the three main causes of fatalities in motor vehicle crashes​ (MVCs) in​ 2011? ​(Select all that​ apply.) Age Failure to use seatbelts Speeding Animals in the roadway ​Alcohol-impaired driving

Failure to use seatbelts Speeding ​Alcohol-impaired driving

Maryann Dodge is a​ 45-year-old female who is being assessed because her husband is concerned that she is suicidal and depressed. Which assessment information is important for the nurse to obtain from Mrs.​ Dodge? Family history of seasonal allergies History of learning difficulties History of seizures Family history of mood disorders

Family history of mood disorders

The nurse is providing education to a client with HIV who wishes to pursue complementary therapies to decrease the side effects of antiretroviral therapies. Which complementary therapy is not recommended for this​ client? Vitamin supplements Aroma therapy Meditation therapy Garlic supplements

Garlic supplements

The nurse is reviewing literature to present to a group of students on the risk of acquiring HIV. Which​ at-risk populations will the nurse include in the​ presentation? Select all that​ apply. Gay men Bisexual individuals IV drug users Clients with neuropathy The male prison population

Gay men Bisexual individuals IV drug users The male prison population

A client dying from a terminal illness who has been receiving pain medication is now comatose. Which actions should the nurse take to ensure this client​'s ​comfort? Select all that apply. Suggest tube feedings for nutritional support Gently splint joints when repositioning the client Use incontinence pads Provide artificial tears Cover with several blankets to maintain warmth

Gently splint joints when repositioning the client Use incontinence pads Provide artificial tears

A client with a history of a joint pain and autoimmune disease presents to the clinic. Which questions will the nurse include in the nursing assessment of this​ client? Select all that​ apply. Have you had any recent​ infections? Have you had any fever or generalized​ weakness? Do you have any​ rashes? Do you have any numbness or tingling in your​ extremities? What kind of medications are you taking​ currently?

Have you had any recent​ infections? Have you had any fever or generalized​ weakness? Do you have any​ rashes? What kind of medications are you taking​ currently?

Which are nonpharmacological pain management interventions for a dying​ client? Select all that apply. Heat therapy Mouth care Reposition every 2 hours Massage Meditation

Heat therapy Mouth care Massage Meditation

The nurse is providing care to a client who was severely injured as the result of a motor vehicle crash​ (MVC). The client was the driver and the spouse died as the result of the accident. The client is exhibiting symptoms of grief. Which nursing action is most appropriate for this​ client? Ask the health care provider for an inpatient psychiatric referral. Let the client know that anger directed toward the staff is not a positive way to deal with the MVC. Help the client understand that working through feelings about what occurred is an ongoing process. Tell the client that his family and friends will be his support system in this situation.

Help the client understand that working through feelings about what occurred is an ongoing process.

The nurse educator is teaching a group of nursing students about nonspecific immune responses. Which item will the educator not include in​ presentation? Body fluids Skin Mucus Helper T cells

Helper T cells

The nurse is caring for a client with SLE. Which diagnostic test does the nurse anticipate for this​ client? Cognitive tasks testing Radiologic tests Urinalysis Hematological studies

Hematological studies

The nurse would like to teach a group of adolescents about improving safety while driving. Based on the most recent​ statistics, which primary cause of motor vehicle crashes​ (MVCs) will the nurse focus on during the teaching​ session? Weather Aggressive driving Health conditions Human error

Human error

The nurse is providing care to a client who sustained a whiplash injury as result of a motor vehicle crash​ (MVC). Which pharmacologic treatment is most appropriate for this ​client? Lidocaine Tocolytics Sedatives Hydrocodone

Hydrocodone

Which assessment information is important for the nurse to obtain in a potentially suicidal ​client? Select all that apply. History of suicide attempts Family history of neurological disorder History of depression History of suicidal ideation Family history of mood disorders

History of suicide attempts History of depression History of suicidal ideation Family history of mood disorders

A client is noted to have a type I IgE hypersensitivity reaction with a systemic response. Which clinical manifestations would the nurse​ anticipate? ​(Select all that​ apply.) Hives Wheezing Stridor Hypotension Allergic rhinitis

Hives Wheezing Stridor Hypotension

Which pharmacologic therapy may be indicated for a client diagnosed with postpartum depression following a perinatal​ loss? IV fluids Hormone therapy Blood transfusion Antibiotics

Hormone therapy

In which care areas are nurses more likely to experience frequent client​ deaths? Select all that apply. Orthopedic surgery Hospice Oncology Emergency department Intensive care unit

Hospice Oncology Emergency department Intensive care unit

Which question should not be included in the health history portion of the nursing assessment for a client with a disorder of the immune​ system? Are you taking any​ antibiotics? How far can you walk without​ stopping? When did you receive your pneumococcal pneumonia​ vaccine? Do you have any food​ allergies?

How far can you walk without​ stopping?

Which treatment for disorders of the immune system is a complementary and alternative​ therapy? ​Gene-transfer therapy Intravenous immunoglobulins Hematopoietic​ stem-cell transplantation Immune stimulation with vitamin A

Immune stimulation with vitamin A

A client is starting treatment for a hypersensitivity reaction. Which pharmacological therapy does the nurse anticipate will be initiated to develop IgG antibodies to the​ allergen? Antihistamines Corticosteroids Immunotherapy Nonsteroidal​ anti-inflammatory medications

Immunotherapy

The nurse is caring for a hospitalized client with a decreased CD4​ T-cell count. What is this client​'s priority​ need? Planning diet and nutrition Implementing careful infection control measures Teaching regarding safer sex Referring to social work for counseling

Implementing careful infection control measures

Paul Vann is a​ 99-year-old Cherokee​ Indian, a former steel​ welder, who lives with his daughter Clara and her family in a downtown area. He has been in good health for his entire life. His wife died thirty years ago. He takes no medication except for some herbal remedies. Mr. Vann follows traditional Cherokee religious practices. He always told his family that only his oldest​ friend, a Cherokee medicine​ man, could help him with health matters. Last​ week, Mr. Vann unexpectedly announced that he saw an owl outside his bedroom window. Clara became concerned about this because in the Cherokee tradition the appearance of the owl means that her father is going to die very soon.​ Clara decides to contact the local hospice​ agency, where you work as an intake nurse. Clara tells​ you, "I don​'t know if you are the right place to​ call, but I would like to have you visit us." You let Clara know that you can come over later that day. She sounds relieved. As you drive to Mr. Vann​'s ​home, you reflect on your​ five-year career in home health nursing. You like the sense of being needed and the opportunity for professional development. What else have you found characteristic of home health​ nursing? In the home​ setting, the nurse totally focuses on the needs of the client. Nurses caring for​ home-bound clients in an urban setting have the same challenges as those in rural areas. In the​ home, the nurse gets firsthand knowledge of family dynamics. Cultural beliefs and practices are more visible in the home setting. Power and control issues in delivering care in a home are different than those in a hospital.

In the​ home, the nurse gets firsthand knowledge of family dynamics. Cultural beliefs and practices are more visible in the home setting. Power and control issues in delivering care in a home are different than those in a hospital.

Besides methotrexate and​ indomethacin, what other medications might the health care provider consider when developing Mrs. Megumis treatment​ plan? Select all that apply. Propanolol​ (Inderal) Infliximab​ (Remicade) Celecoxib​ (Celebrex) Acetaminophen​ (Tylenol) Aspirin

Infliximab​ (Remicade) Celecoxib​ (Celebrex) Aspirin

The nurse is caring for a client with AIDS who has been receiving protease inhibitors​ (PIs). Which side effects will the nurse inquire about during the health history for this​ client? Select all that​ apply. Kaposi sarcoma Insulin resistance Hypothyroidism Diabetes mellitus Elevated cholesterol and triglycerides

Insulin resistance Diabetes mellitus Elevated cholesterol and triglycerides

The nurse is reviewing the medical record of a client diagnosed with​ severe, persistent asthma exacerbated by seasonal allergies. Which medication would the nurse expect to see on the​ client's medication​ list? Epinephrine pen Leukotriene modifiers Antihistamines Calcium channel blocker

Leukotriene modifiers

The nurse is caring for Ms.​ Ruiz, a client recently diagnosed with rheumatoid arthritis. Ms. Ruiz is being seen by the primary care provider for a​ follow-up visit after a recent hospitalization. The nurse prepares to assess Ms. Ruiz. Which clinical manifestation found during the assessment process supports this​ client's diagnosis? Weight gain over the last several months Increased energy ​Low-grade fever Morning stiffness that lasts for thirty minutes

Low-grade fever

A client is admitted to the emergency department with a head injury following a motor vehicle crash​ (MVC). Which nursing action is priority for this​ client? Monitoring for lower back pain Establishing IV access Determining the presence of a fractured jaw Maintaining cervical spine precautions

Maintaining cervical spine precautions

The nurse receives a call from a healthcare provider to admit a client with systemic lupus erythematosus​ (SLE). In​ SLE, autoantibodies form immunocomplexes. Which is the consequence of the tissue damage for this​ client? Select all that​ apply. Malaise Joint pain Maculopapular rash Cough Fever

Malaise Joint pain Maculopapular rash Fever

Mr. Edward​'s daughter Becky tells you she doesn​'t know anyone with HIV except her father and Michael. Which populations are at risk for contracting​ HIV? Select all that apply. Men who have sex with men​ (MSM) Heterosexuals with multiple partners People who reside in an area of mosquito infestation with known HIV positive population Intravenous drug users Hemophiliacs receiving multiple blood transfusions

Men who have sex with men​ (MSM) Heterosexuals with multiple partners Intravenous drug users Hemophiliacs receiving multiple blood transfusions

The nurse is discussing the​ body's first and second lines of defense against infections with a client. Which item will the nurse include as a first line of​ defense? Teeth T lymphocytes Mucosa White blood cells

Mucosa

A client diagnosed with SLE reports painful swollen joints during an appointment at a medical clinic. Which medication does the nurse anticipate will be ordered for this​ client? Immunosuppressive agent Morphine sulfate NSAIDs Topical corticosteroid

NSAIDs

What types of pharmacologic therapies may be useful after a motor vehicle crash ​(MVC)? ​(Select all that​ apply.) Narcotics Sedatives ​Anti-inflammatory agents Lidocaine Antiemetics

Narcotics Sedatives ​Anti-inflammatory agents Lidocaine

Sarah​ Smith, a community health registered​ nurse, is conducting a community educational session on preventive actions that can decrease the number of motor vehicle crashes​ (MVCs) and the related mortality and morbidity. Based on recent research on the​ subject, which ethnic group will the nurse focus on to provide the greatest benefit in the community in which she​ works? Hispanics Whites Native Americans African Americans

Native Americans

A client diagnosed with rheumatoid arthritis​ (RA) is being seen in an outpatient clinic. Which diagnostic test results would indicate presence of​ RA? Select all that​ apply. Negative antinuclear antibodies Decreased bone density Negative rheumatoid factor​ (RF) Positive​ anti-citrulline antibodies Increased erythrocyte sedimentation rate​ (ESR)

Negative rheumatoid factor​ (RF) Positive​ anti-citrulline antibodies Increased erythrocyte sedimentation rate​ (ESR)

During change of​ shift, a unlicensed assistive personnel​ (UAP) finds a client who committed suicide by using a belt on the upper doorjamb in the hospital room. The nursing staff was in report and responded to the cries for​ help, but was not able to save the client. What should the hospital administrator do to assist the nursing​ staff? Select all that apply. ​Nothing, because the nursing staff was not at fault for the client​'s death Notify social services for immediate grief counseling Analyze the client​'s medical record for signs of pending suicide that were missed Suggest all staff return to work Encourage the staff to talk to each other about the experience and offer support

Notify social services for immediate grief counseling Encourage the staff to talk to each other about the experience and offer support

A recently admitted terminally ill client has not requested pain medication for several hours. Which action should the nurse​ take? Assume that the client does not want to take pain medication Administer pain medication as prescribed Observe for physical clues and assess the client for pain Wait until the client asks for pain medication

Observe for physical clues and assess the client for pain

What is the clinical term for abnormal tissue that leads to joint damage and immobilization in the pathophysiology of rheumatoid​ arthritis? Synovial membrane Pleurodesis Uveitis Pannus

Pannus

Helen Ivansky is an​ 82-year-old woman who emigrated from Russia with her husband when she was 35. She is a Russian Orthodox Catholic with 4​ children, all of whom are grown. Her husband passed away 5 years​ ago, and she now lives alone in an apartment. Mrs. Ivansky has a history of kidney failure. She receives home dialysis three times a week and weekly visits from a home health nurse. Her kidney failure is​ progressing; she has had four hospitalizations in the past 6 months for acute exacerbations. Her only daughter lives approximately 45 minutes away. She visits every weekend to do her mothers shopping and calls every evening. Mrs. Ivanskys 3 sons live in other areas of the country and come to visit when they can. Mrs. Ivansky wears a Lifeline necklace on which she can push a button to receive emergency assistance if she is sick or has an accident. You are the home health nurse visiting Mrs. Ivansky this week. You note that her weight is up 5 lbs from 2 days​ago, her blood pressure is​ 164/90 mmHg, and she has​ 2+ pitting edema of the ankles. Mrs. Ivanskys lungs are​clear, but she becomes mildly short of breath when she gets up and walks to the bedroom. When she​ returns, you ask how she is doing​ emotionally, and Mrs. Ivansky admits that she is very depressed and the days just seem to drag on forever. She cries when she talks about her sons and grandchildren and wishes they were closer. She praises her daughter for caring for​ her, but worries that she is taking her away from her family. Mrs. Ivansky states that she may not let someone know the next time she has an acute episode of kidney failure or if her heart starts to fail. She says she is a burden to everyone and wishes it were not against her religious beliefs to commit suicide. Aware that Mrs. Ivansky is Russian​ Orthodox, you begin to explore her feelings about dying and suicide. As you continue to talk with Mrs.​ Ivansky, you learn that she suffered from depression after the birth of each of her children. She spent some time with a therapist but was never treated with antidepressants because they were not yet available when her children were born. She tells you that she considered suicide before when she felt she had become a burden on her​ husband, particularly after the birth of their​ daughter, the youngest child. What information regarding suicide will lead you to continue to encourage Mrs. Ivansky to discuss her feelings and her health​ history? Select all that apply. People of all​ social, religious, economic​ backgrounds, and ages commit suicide. People who talk about suicide will not actually commit suicide. All suicidal talk and behavior must be taken​ seriously, and not considered a bid for attention. Talking about the intent helps you assess the lethality of any suicide plan. The majority of completed suicides are committed by people who are not psychotic.

People of all​ social, religious, economic​ backgrounds, and ages commit suicide. All suicidal talk and behavior must be taken​ seriously, and not considered a bid for attention. Talking about the intent helps you assess the lethality of any suicide plan. The majority of completed suicides are committed by people who are not psychotic.

The nurse is conducting a seminar on perinatal loss for healthcare providers on​ maternal-newborn unit. Which risk factor is appropriate for the nurse to include in the educational​ session? Placental abruption Caucasian race Pregnancy age of less than 20 Retroverted uterus

Placental abruption

You are caring for Mrs.​ Johnson, a​ 25-year-old client who just delivered a stillborn infant. While reviewing her medical record and documenting your​ nurse's notes, you review that the client arrived to the hospital with a large amount of vaginal bleeding. Which risk factor in the​ client's history may have caused the event to​ occur? Age of 25 Placental abruption Previous use of oral contraceptives Postterm pregnancy

Placental abruption

The client was admitted to an inpatient unit for uncontrolled pain caused by rheumatoid arthritis​ (RA). Which ongoing problems will the client have in relation to the​ RA? Select all that​ apply. Poor​ self-esteem Ineffective role performance Chronic pain Weight gain Fatigue

Poor​ self-esteem Ineffective role performance Chronic pain Fatigue

You found that Mr. Vann​'s pulse rose from 60 to 80 beats per minute and his systolic blood pressure dropped from 110 to 90 mmHg as he went from lying down to sitting up in his chair again. What condition did you​ confirm, and what is its​ cause? Hypertension caused by anxiety. Hypoxia caused by hyperventilation. Hyperemia caused by depression. Postural hypotension caused by dehydration.

Postural hypotension caused by dehydration.

A client and her husband are preparing for the delivery of their son. The client was diagnosed with an intrauterine fetal demise earlier in the day and was admitted for induction of labor and delivery. Which interventions would be appropriate for this​ couple? Select all that​ apply. Secure a private room near the nursery so the couple will not be so sad with other babies around. Provide access to support systems within the hospital to help them manage their grief. Immediately start the interventions for the induction of labor. Ask the mother what sort of music and lighting she wants. Encourage the couple to ask questions.

Provide access to support systems within the hospital to help them manage their grief. Ask the mother what sort of music and lighting she wants. Encourage the couple to ask questions.

The nurse is providing care for a client with SLE who is hospitalized during an exacerbation. The client is receiving cytotoxic and antineoplastic medications. Which is the priority goal for this​ client? Providing psychological support Assisting with pain management Preventing infections Maximizing mobility

Preventing infections

A client is newly admitted with a suspected autoimmune deficiency in which the number of leukocytes is decreased. Which type of interventions should the nurse focus on when planning the​ client's care? Select all that​ apply. Fluid support Prevention of infection Allow for rest periods Nutritional support Blood pressure support

Prevention of infection Allow for rest periods Nutritional support

A clinic nurse is assessing a client with a history of rheumatoid arthritis. The nurse would anticipate which assessment​ finding? Intermittent joint​ pain, mostly in the great toe Joint stiffness in the​ spine, hips, and knees Multiple joints and organs​ affected, and may have high fever and rheumatoid rash Progressive joint stiffness and deformation

Progressive joint stiffness and deformation

Which independent intervention is focused on the immune​ system? ​(Select all that​ apply.) Proper rest Proper nutrition Limiting activity Stress reduction Adequate exercise

Proper rest Proper nutrition Stress reduction Adequate exercise

A client is undergoing a skin test to assist with diagnosis of a hypersensitivity reaction. Which action should the nurse take when the healthcare provider orders a prick​ test? Puncturing the skin through the diluted allergenic extract Injecting the allergen extract intradermally Placing a patch with the allergen on the skin Instructing a client to swallow a pill with the allergen

Puncturing the skin through the diluted allergenic extract

What lab tests are frequently used to determine food​ allergies? ​(Select all that​ apply.) Type and screen WBC count and differential Complement assay Radioallergosorbent test​ (RAST) Immune complex assay

Radioallergosorbent test​ (RAST) Immune complex assay

What lab tests are frequently used to determine food​ allergies? ​(Select all that​ apply.) Type and screen WBC count and differential Radioallergosorbent test​ (RAST) Immune complex assay Complement assay

Radioallergosorbent test​ (RAST) Immune complex assay

In a community​ setting, the nurse is providing care to a client who was recently diagnosed with SLE. Which is the goal of care for this​ client? Select all that​ apply. Reduce inflammation Prevent infections Maintain skin integrity Reduce pain Prevent joint deformity

Reduce inflammation Prevent infections Maintain skin integrity Reduce pain

The nurse is volunteering in one of the local free autoimmune disease clinics. The next client was recently diagnosed with rheumatoid arthritis. What are the goals of care for clients with rheumatoid​ arthritis? Select all that​ apply. Reduce pain Reduce inflammation Cure the disease Preserve function Prevent deformity

Reduce pain Reduce inflammation Preserve function Prevent deformity

The nurse is concerned that a client is threatening to commit suicide. Which behavior did the nurse observe in this​ client? Talking about ways to commit suicide Watching horror movies Refusing to talk with friends and family Reading books about what happens after death

Refusing to talk with friends and family

Which is a function of the immune​ system? ​(Select all that​ apply.) Opportunistic infection Removal and destruction of cellular debris Hypersensitivity reaction Recognition and defense against infections Identification and destructions of malignant cells

Removal and destruction of cellular debris Recognition and defense against infections Identification and destructions of malignant cells

The nurse is providing care to a client who attempted suicide prior to being admitted to the mental health care unit. Which intervention is a priority for this​ client? Administering​ antidepressants, per order Removing the disposable razor from the bedside Updating the family Reviewing admission paperwork

Removing the disposable razor from the bedside

After receiving the order for the antidepressant medication and completing your suicide risk​ assessment, you evaluate Mrs. Ivansky to be at low risk for suicide based on her statement that she would not seek any more treatment if her condition changed. Keeping her in a safe environment will involve which​ interventions? Select all that apply. Review the safety of Mrs. Ivanskys immediate​ environment, including the home dialysis equipment. Ask the daughter if someone in the family can come and stay with Mrs. Ivansky for a few days. Create a contract with Mrs. Ivansky to not engage in any behavior that would directly harm her. Consult with the health care provider about placing Mrs. Ivansky in a psychiatric treatment center. Arrange with your home health agency for Mrs. Ivansky to receive daily visits for the next 10 days.

Review the safety of Mrs. Ivanskys immediate​ environment, including the home dialysis equipment. Ask the daughter if someone in the family can come and stay with Mrs. Ivansky for a few days. Create a contract with Mrs. Ivansky to not engage in any behavior that would directly harm her. Arrange with your home health agency for Mrs. Ivansky to receive daily visits for the next 10 days.

Myra​ Sterling, a​ 56-year-old client is suspected of having an autoimmune disorder. Which diagnostic test would the nurse question as inappropriate for this​ client? Serotonin levels Complete blood count Immunoglobulin levels Polymerase chain reaction

Serotonin levels

During an​ assessment, the nurse learns that a​ 53-year-old female client engages in multiple chronic​ self-destructive behaviors. Which data did the nurse assess in this client to come to that​ conclusion? Select all that apply. Smokes three packs of cigarettes a day Smokes marijuana with husband and friends every evening after dinner Drinks a​ six-pack of beer each day Takes 400 mg of ibuprofen twice a day Takes diazepam​ (Valium) 10 mg four times a day for leg cramps

Smokes three packs of cigarettes a day Smokes marijuana with husband and friends every evening after dinner Drinks a​ six-pack of beer each day Takes diazepam​ (Valium) 10 mg four times a day for leg cramps

Which nonpharmacologic therapies may be appropriate following a motor vehicle crash ​(MVC)? ​(Select all that​ apply). Spiritual counseling Case management Psychological counseling Analgesic therapy Hormone therapy

Spiritual counseling Case management Psychological counseling

Which term reflects the loss of a fetus during the first 20 weeks of​ gestation? Fetal demise Therapeutic abortion Stillbirth Spontaneous abortion

Spontaneous abortion

A client that is 28 weeks pregnant calls the office with some concerns. The OB nurse takes the call and asks what symptoms she is having. What symptoms would indicate that the client requires an examination by the healthcare​ professional? Select all that​ apply. Spotting Cramping Severe back pain Headache No fetal movement

Spotting Cramping Severe back pain No fetal movement

At the end of your​ visit, you are documenting your care for Mrs. Ivansky. It is important to include which information in your documentation regarding her immediate​ status? All team reviews of Mrs. Ivanskys care regarding her thoughts of suicide Decisions to move Mrs. Ivansky from a less restrictive environment Signs and symptoms of impending congestive heart failure Statements from Mrs. Ivansky that indicate thoughts of suicide or​ self-harm

Statements from Mrs. Ivansky that indicate thoughts of suicide or​ self-harm

The nurse manager of an oncology unit observes a staff nurse say to a dying​ client, "You cannot die now. I don​'t handle death well." What should the manager do at this​ time? Explain to the client that the nurse was just kidding Document the observation for later discussion during the annual performance appraisal Suggest the nurse talk with a grief counselor to learn how to handle the care of clients facing death Remind the nurse that clients cannot control the time of death

Suggest the nurse talk with a grief counselor to learn how to handle the care of clients facing death

Which assessment is a priority for a client who suffers a perinatal loss who is diagnosed with postpartum​ depression? Suicidal thoughts Change in appetite Fatigue Anxiety

Suicidal thoughts

You are assessing Doreen​ Hampshire, a​ 25-year-old woman who has mood​ swings, has regularly been calling in sick to​ work, and has withdrawn from her friends. Which best describes this phase of a suicidal​ client? Suicide attempt Suicide Suicide threat Suicidal ideation

Suicide threat

After you wash your​ hands, Clara takes you to her father​'s bedroom. Mr. Vann is sitting up in an easy chair. He is alert and cooperative. He has refused all food for several​ days, but he does sip water occasionally. Which activity is your first​ priority? Take Mr. Vann​'s vital signs. Offer Mr. Vann some water. Assess Mr. Vann​'s fall risk. Ask Mr. Vann why​ he's not eating.

Take Mr. Vann​'s vital signs.

The nurse is caring for an older client in an assisted living facility. The client is sick with an upper respiratory infection for the third time in 5 months. The​ client's daughter asks why her mom is getting sick so often. The nurse will base the response on which​ rationale? Insulin susceptibility is increased. T cells are less responsive to the antigens and B cells slow down with the production of antibodies. T cells are more responsive to the antigens and​ B-cell production increases. Hypersensitivity response is increased.

T cells are less responsive to the antigens and B cells slow down with the production of antibodies.

The nursing student is preparing an educational handout for the parents of a client with juvenile idiopathic arthritis​ (JIA). Based on the​ etiology, risk​ factors, and clinical manifestations of the​ disease, which topic will be addressed in the​ handout? Teaching about the​ symptoms: JIA can affect multiple joints and organs and clients might experience acromegaly. Teaching about the importance of monitoring growth rates in children. Teaching about the permanent and progressive nature of the disorder. Teaching about the frequency of the​ disease: JIA is more frequent in boys than girls.

Teaching about the importance of monitoring growth rates in children.

Which item is true regarding the pathophysiology and etiology of​ SLE? ​(Select all that​ apply.) The inflammatory response leads to anaphylactic shock. The immune complex deposits trigger an inflammatory response. SLE is a result of deposition of​ antigen-antibody complexes in connective tissues. The etiology is known. Manifestations can be mild to​ fatal, with remissions and exacerbations.

The immune complex deposits trigger an inflammatory response. SLE is a result of deposition of​ antigen-antibody complexes in connective tissues. Manifestations can be mild to​ fatal, with remissions and exacerbations.

Prior to calling the health care​ provider, you decide to complete a formalized suicide risk assessment. Part of your assessment will include the identification of lethality to determine what​ factor? The potential lethality of Mrs. Ivanskys suicide plan The likelihood that Mrs. Ivansky will attempt suicide The authenticity of Mrs. Ivanskys cry for help to prevent suicide The cause of Mrs. Ivanskys distress or depression

The likelihood that Mrs. Ivansky will attempt suicide

A nurse educator is conducting a review session with nursing students taking a​ maternal-newborn course. The educator asks the class to discuss the risk factors associated with fetal demise and perinatal loss. Which responses by the students indicate appropriate understanding of this​ topic? Select all that​ apply. Thyroid disease Diabetes Infection Anemia Rh negative

Thyroid disease Diabetes Infection

Which maternal disease processes detected by blood tests can contribute to a perinatal​ loss? ​(Select all that​ apply.) Cystic fibrosis Thyroid disease Diabetes Infectious disease Rh incompatibility

Thyroid disease Diabetes Infectious disease Rh incompatibility

The nurse is conducting a presentation at a local school during a​ parent-teacher association​ (PTA) meeting regarding childhood safety. The nurse is asked a question about enhancing car safety. Which topics are appropriate for the nurse to share with the ​group? Select all that​ apply. Using either the lap or shoulder belt as long as the seat feels and is secure Securing the car seat in the front or back seat as long as it is belted to the seat Placing children over the age of 1 in a​ rear-facing seat Using a​ forward-facing belt-positioning booster seat for children over 40 lb. in the back seat For children 4​' 9" and​ taller, making sure that the lap belt fits low and tight across the​ lap/upper thigh area and that the shoulder belt is snug across the chest and shoulder

Using a​ forward-facing belt-positioning booster seat for children over 40 lb. in the back seat For children 4​' 9" and​ taller, making sure that the lap belt fits low and tight across the​ lap/upper thigh area and that the shoulder belt is snug across the chest and shoulder

Millie Baron is a​ 63-year-old woman who has attempted suicide and is having a thorough assessment. Which client goal would be inappropriate for this​ client's plan of​ care? Verbalizes feelings of spiritual misguidance Begins to feel she wants to live Discusses feelings of power Expresses positive feelings of self

Verbalizes feelings of spiritual misguidance

From her​ history, you know that Mrs. Ivansky is Russian Orthodox Catholic. What spiritual assessment data should you​ obtain? Select all that apply. Whether or not her religious faith and beliefs bring her strength and comfort Information about what religious practices are important to her How her parents influenced her choice of religion and faith If there are religious artifacts around the​ home, particularly in rooms where she spends the majority of her time Information about relationships and practices that she holds sacred and if they provide her comfort

Whether or not her religious faith and beliefs bring her strength and comfort Information about what religious practices are important to her If there are religious artifacts around the​ home, particularly in rooms where she spends the majority of her time Information about relationships and practices that she holds sacred and if they provide her comfort

Which motor vehicle crash​ (MVC) injury is caused by torsion or jostling of a body​ part? Whiplash Head trauma Punctured lungs Dashboard knee

Whiplash

Mrs. Megumi reports that she has tried to use warm packs during acute attacks of​ inflammation, but she states they seem to make my hands hurt worse. Which statement from the nurse indicates an understanding of pain management for a client with​ RA? You can use cold packs instead of heat to decrease the inflammation. Be sure to take an extra dose of your medication when you need it to decrease the pain and swelling. Only heat should be used to reduce swelling and acute inflammation. You need to increase your activity during times of acute inflammation and pain.

You can use cold packs instead of heat to decrease the inflammation.

Jonah​ Smith, a​ 2-month-old client, is being seen in a pediatric office for a​ well-child visit. The​ client's mother says that she has read that her baby is protected against infections because of the protection that the mother had from diseases. She knows these antibodies cross the​ placenta, and therefore she questions the need for immunizations. In addition the client is breastfeeding. Which response by the nurse is the most​ appropriate? ​"Breast-feeding will protect your baby against all​ infections." ​"In order to protect your baby against any​ infections, it is necessary that your infant receive all the immunizations as​ scheduled." ​"The immunity that your baby received from you is going to disappear over​ time; this is why your baby needs to be protected by other​ methods." ​"Breast-feeding must be continued until 10 months in order to convey the best possible​ immunity."

​"The immunity that your baby received from you is going to disappear over​ time; this is why your baby needs to be protected by other​ methods."

You educate Mr. Edwards about his AIDS diagnosis and his current opportunistic infections. He asks you about a​ violet-colored lesion that has appeared on his leg. Which statements are true regarding the lesion Mr. Edwards​described? Select all that apply. ​"The lesions are often a presenting symptom in AIDS and can be found on the​ skin, gastrointestinal​ tract, lungs, and lymphatic system. ​"The lesions are called Kaposi​ sarcomas, the most common cancer associated with AIDS. ​"The cancerous lesions are caused by the human herpes virus. ​"The lesions are caused by a​ virus, and will always be painless. ​"Your immune system is unable to fight off bacteria that cause the lesions in AIDS patients.

​"The lesions are often a presenting symptom in AIDS and can be found on the​ skin, gastrointestinal​ tract, lungs, and lymphatic system. ​"The lesions are called Kaposi​ sarcomas, the most common cancer associated with AIDS. ​"The cancerous lesions are caused by the human herpes virus.

Mr. Rappaport has been diagnosed with rheumatoid arthritis. He tells you that he is having trouble doing the prescribed physical therapy exercises because of stiffness. What intervention could you suggest to Mr. Rappaport to help him follow the prescribed physical therapy​ program? ​"Stop exercising for a few​ weeks." ​"Try doing your exercises in the​ shower." ​"Try exercising for several hours each day at the​ gym." ​"Wear light-weight clothing when you​ exercise."

​"Try doing your exercises in the​ shower."

The nurse is caring for a client considering pregnancy. The client has a family history of primary immune deficiencies and wants to know the risk for her child. Which statement by the nurse is most​ appropriate? ​"A weight-loss program will significantly decrease your​ infant's risk of getting one of these​ diseases." ​"You may want to seek genetic counseling to determine the specific​ risk." ​"Tell me more about your concerns regarding​ pregnancy." ​"You should consider​ long-term contraceptive use because of the risk of a severe immunodeficiency in your​ offspring."

​"You may want to seek genetic counseling to determine the specific​ risk."

A client with AIDS asks the nurse why he seems to get bronchitis so often. Which response by the nurse is the most​ appropriate? ​"Your infection-fighting cells are diminished because of​ AIDS." "Are you still smoking ​cigarettes?" "Bronchitis is caused by a bacterial​ infection, and AIDS is from a​ virus, so I don​'t think there is a​ connection." "Taking extra vitamin C usually helps ward off​ infections."

​"Your infection-fighting cells are diminished because of​ AIDS."

The nurse is planning interventions for a client with an autoimmune disease. Which modifiable risk factors can affect the development of immune diseases and require specific​ education? Select all that​ apply. ​Alcohol, drug, and cigarette use Gender Early introduction of solid foods Chronic stress Race

​Alcohol, drug, and cigarette use Early introduction of solid foods Chronic stress

Which initial assessments are essential to make in a client sustaining injuries as the result of a motor vehicle crash ​(MVC)? ​(Select all that​ apply.) Genitourinary assessment ​Circulation/bleeding assessment Neurological assessment Orthopedic assessment Airway assessment

​Circulation/bleeding assessment Neurological assessment Orthopedic assessment Airway assessment

The parents of an adolescent client dying from complications related to cystic fibrosis ask the nurse what signs to expect when their child is about to die. What should the nurse explain as signs of cardiovascular​ failure? Select all that apply. ​Cheyne-Stokes respirations ​Clammy, cold skin Tachycardia Reduced blood pressure Mottling of the skin

​Clammy, cold skin Reduced blood pressure Mottling of the skin

You scheduled a return visit to Mr. Vann​'s home in two weeks. Just before that​ date, however, you receive a call from Clara. "Dad died in his sleep." she says "We have just held his final services" You ask Clara if she would like for you to make a​ follow-up visit to her home. "Not ​now," she​ says, "I feel so​ tired, and I just need to be alone with my thoughts for a while." Which stage of bereavement is Clara​ experiencing? Renewal Awareness of loss ​Conservation/withdrawal Healing

​Conservation/withdrawal

You discuss HIV testing with Mr.​ Edwards' daughter. Which of the following tests is the most widely used initial screening test for HIV​ antibodies, even though it does not detect the HIV​ virus? HIV viral load tests Absolute CD4 lymphocyte count Western Blot ​Enzyme-linked immunosorbent assay​ (ELISA)

​Enzyme-linked immunosorbent assay​ (ELISA)

The nurse is providing care to a client who is diagnosed with posttraumatic stress disorder​ (PTSD). Which factors could interfere with the nurse establishing trust during a therapeutic encounter with this​ client? Select all that apply. ​Irritability, aggressiveness Depersonalization Nightmares Ineffective coping Hypervigilance

​Irritability, aggressiveness Depersonalization Hypervigilance

Luis​ Garcia, 8 years of​ age, comes to the clinic every 2 weeks for allergy injections for his peanut allergy.​ "I hate these shots and I hate coming​ here," says Luis.​ "I don't even know how these stupid shots work. Maybe they​ don't work," he continues. After calming​ him, the nurse begins to explain in simple terms how the shots keep him safer if he comes in contact with peanuts. Which rationale will the nurse use when responding to​ Luis? The injection reduces the amount of histamine that is released when Luis comes in contact with peanuts. Luis is benefitting from the​ anti-inflammatory effects of immunotherapy. The injection delays​ Luis's hypersensitive response to peanuts until treatment can be initiated. ​Luis's body is developing IgG​ antibodies, which will respond if he comes in contact with peanuts.

​Luis's body is developing IgG​ antibodies, which will respond if he comes in contact with peanuts.

Mrs. Ivansky tells you that her daughter has been giving her St.​ John's Wort, an herbal remedy for depression. As you teach Mrs. Ivansky about the new prescription for duloxetine​ (Cymbalta), a serotonin and norepinephrine reuptake inhibitor​ (SNRI), you ensure that she understands that if she continues to take the St.​ John's Wort and the​ duloxetine, she may experience which serious medication​ interaction? Myocardial depression ​Sedative-hypnotic intoxication Hypertensive crisis Serotonin syndrome

​Sedative-hypnotic intoxication

Where are most cases of HIV​ occurring? Asia Eastern Europe Latin America ​Sub-Saharan Africa

​Sub-Saharan Africa