53, 54, 55 & 56.
23. What is B-cell proliferation dependent on? a. Presence of NK (natural killer) cells b. Complement system c. Antigen stimulation d. Lymphokines
C. Antigen stimulation. Antigen stimulation is the sole focus of B-cell proliferation.
9.A young gay patient being treated for his third sexually transmitted disease does not see why he should usecondo "they don't work." Which is the most appropriate response? a. "Condoms may not provide 100% protection, but when used correctly and consistently with every act of sexua they reduce your risk of getting infected with HIV or other sexually transmitted diseases." b. "You are correct. Condoms don't always work, so your best protection is to limit your number of partners." c. "Condoms do not provide 100% protection, so you should always discuss with your sexual partners their HIV they have any STD." d. "Condoms do not provide 100% protection, but when used with a spermicide you can be assured of complete p against HIV and other STDs."
A. "Condoms may not provide 100% protection, but when used correctly and consistently with every act of sexual activity they reduce your risk of getting infected with HIV or other sexually transmitted diseases."
5. Which of the following is a CDC criterion for the progression of HIV infection to AIDS? a. Increase in viral load b. Decreased ratio of CD8 to CD4 c. Increase in white blood cells d. Increased reactivity to skin tests
A. Increase in viral load. AIDS is the end stage of an HIV infection. The CDC has developed criteria for the diagnosis of AIDS, which are: inc even with pharmacologic interventions, increase in the ratio of CD8 to CD4, decline in theWBCs, and a decreased tests.
1. When assigned to a newly admitted patient with AIDS, the nurse says, "I'm pregnant. It is not safe for me ormy b assigned to his case." Which is the most appropriate response by the charge nurse? a. "This patient would not be a risk for your baby if you use standard precautions and avoid direct contact with b fluids." b. "You should ask for a transfer to another unit because contact with this patient would put you and your baby a AIDS." c. "Wear a mask, gown, and gloves every time you go into his room and use disposable trays, plates, and utensils meals." d. "We should recommend that this patient be transferred to an isolation unit."
A. "This patient would not be a risk for your baby if you use standard precautions and avoid direct contact with bodily fluids." HIV is transmitted from human to human through infected blood, semen, cervicovaginal secretions, and breastmil Standard Precautions by all staffmembers for all patients all the time simplifies this issue.
23. The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in _________ of the onset of symptoms to have maximum benefit. a. 3 hours b. 4 hours c. 6 hours d. 8 hours
A. 3 hours t-PA must be given within 3 hours of the onset of symptoms to be beneficial.
17. What is the term for transplantation of tissue between members of the same species? a. Allograft b. Autograft c. Isograft d. Homograft
A. Allograft The allograft is the transplantation of tissues between members of the same species, such as a graft for ful burns.
15.A male patient is concerned about telling others he has HIV infection. What should the nurse stress whendiscu a. Care providers and sexual partners should be told about his diagnosis. b. There is no reason to hide his disease. c. Secrecy is a poor idea because it will lower his self-esteem. d. His diagnosis will be obvious to most people with whom he will come into contact.
A. Care providers and sexual partners should be told about his diagnosis. Nurses have a responsibility to assess each patient's risk for HIV infection and counsel those at risk about HIVtes behaviors that put them at risk, and about how to reduce or eliminate those risks. The diagnosis needs to be carefu shared only with caregivers who need to know for the purpose of assessment and treatment.
25. The LPN/LVN has arrived at the patient's bedside with a unit of packed cells to be connected to an IV t When the RN arrives, what is the first thing the nurses must do? a. Check to ensure that the donor and recipient numbers match according to policy b. Request the patient to sign the card on the packed cells c. Immediately administer the packed cells d. Check the patient's ID bracelet and then administer the packed cells
A. Check to ensure that the donor and recipient numbers match accordingly to policy. Donor and recipient numbers are specific and must be thoroughly checked.
15. What should the nurse include to assess for in the plan of care for a patient undergoing plasmapheresis a. Hypotension b. Hypersensitivity c. Urticaria d. Flank pain
A. Hypotension. Hypotension occurs during plasmapheresis because of transient volume changes in the blood.
9. What is the substance released by the T cells that stimulates the lymphocytes to attack an inflammation? a. Lymphokine b. Epinephrine c. B cells d. Histamine
A. Lymphokine Lymphokines help attract macrophages to the site of the inflammation.
28. What should the nurse do because of the increasing strength of the dose in the injections for immunotherapy? a. Observe the patient for at least 20 minutes after administration b. Take the vital signs every 10 minutes for an hour c. Have the patient lie down quietly for an hour d. Place a warm compress on the area to speed its absorption
A. Observe the patient for at least 20 minutes after administration. The patient should be observed for 20 minutes after the increased dose of the allergen. If anaphylaxis is g will do so within that time frame.
27. Which symptom would be classified as a mild transfusion reaction? a. Orthopnea b. Tachycardia c. Hypotension d. Wheezing
A. Orthopnea Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough.
11.The nurse should instruct the patient who is diagnosed with AIDS to report signs of Kaposi sarcoma, which include: a. Reddish-purple skin lesions b. Open, bleeding skin lesions c. Blood-tinged sputum d. Watery diarrhea
A. Reddish-purple skin lesions. Kaposi sarcoma is a rare cancer of the skin and mucous membranes characterized by blue, red, or purple raised le in Mediterranean men. Kaposi sarcoma: firm, flat, raised or nodular, hyperpigmentated, multicentric lesions on the skin and mucous membranes.
3. The patient, age 21, has been treated for chlamydia and has a history of recurrent herpes. What should thenurse c patient about? a. Sexual history, risk reduction measures, and testing for HIV b. Getting an appointment at a family planning clinic c. Testing for HIV and what the test results mean d. Abstinence and a monogamous relationship
A. Sexual history, risk reduction measures, and testing for HIV. Chlamydia is considered a sexually transmitted disease (STD). As such it requires further testing and a sexualhisto sexual partners.
10.A 21-year-old male who has been an IV heroin user has been experiencing fever, weight loss, and diarrhea and diagnosed as having AIDS. At this time, he has a low-grade fever, severe diarrhea, and a produc-tive cough. He is ad Pneumocystis jiroveci. What should the nurse do when caring for the patient? a. Use a gown, mask, and gloves when assisting the patient with his bath b. Wear a gown when assisting the patient to use the bedpan c. Use a gown, mask, and gloves to administer oral medications d. Use a mask when taking the patient's temperature
A. Use a gown, mask and gloves when assisting the patient with his bath. The use of Standard Precautions and body substance isolation has been shown not only to reduce the risk pathogens, but also to reduce the risk of transmission of other disease between the patient and the health care worker.
22.What is the major negative effect of cell-mediated immunity? a. Depression of bone marrow b. Rejection of transplanted tissue c. Activation of the T cells d. Stimulation of the B cells
B. Rejection of transplanted tissue. Cell-mediated immunity has the negative effect of rejection of transplanted tissue. Activation of T cells an cells are the positive basis of the cell-mediated immunity.
2. The anxious male patient is fearful that he has been exposed to a person with an HIV infection. He states he does not want to go to a laboratory for the ELISA tests because he does not want to be identified. What wouldbe th helpful response? a. "There really is not an option, you will need to get the Western blot test first." b. "There is an FDA-approved home test called OraQuick." c. "The rapid test Reveal can identify all the HIV strains." d. "You can be tested anonymously for ELISA. If you are seronegative, your concerns are over."
B. "There is an FDA-approved home test called OraQuick." The OraQuick is a home OTC test approved by the FDA. One seronegative on the ELISA is not evidence becausese not have taken place. The Western blot test follows if the ELISA is positive.
23. After what period of time would the home health nurse make a mental health appointment for a patient with an HIV infection after assessing a diminished ability to attend to daily functioning? a. 1 week b. 2 weeks c. 3 weeks d. 1 month
B. 2 weeks. Patients with HIV infection have a great deal of anxiety and guilt, which may interfere with the daily function relationships and making decisions. When this apathy is assessed for a period of 2 weeks, the nurse should refer mental health consult.
24. What timeframe must blood be transfused within once it has been removed from refrigeration? a. 2 hours b. 4 hours c. 6 hours d. 3 hours
B. 4 hours. Blood must be administered within 4 hours after removal from refrigeration, and blood components with removal.
28.A patient is in which stage of Alzheimer disease when she demonstrates "sundowning"? a. Early stage b. Second stage c. Third stage d. Final stage
B. Second stage "Sundowning" is seen in the AD patient in the second stage of the disease.
24. The HIV-infected patient who has just seroconverted says he just cannot take all those confusing, expensiveanti medications. He says he still feels fine, anyway. What should the nurse keep in mind when counseling this patient? a. Resumption of the ART later in the disease is just as effective b. Adherence to the ART protocol is essential to the success of the treatment c. Cessation of the ART may prevent the emergence of a resistant strain of HIV d. Once ART is initiated it cannot be restarted in the same patient
B. Adherence to the ART protocol is essential to the success of the treatment. Compliance and adherence to the ART protocol is essential to its success. Cessation of the medication may stimul of a resistant strain of HIV virus. ART can be restarted, but the optimum time to startis soon after seroconversion.
10. Immediately after the nurse administers an intradermal injection of a suspected antigen during alle patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most ap-pro a. Elevate the arm above the shoulder b. Administer subcutaneous epinephrine c. Apply a warm compress to area d. Apply a local anti-inflammatory cream to the site
B. Administer subcutaneous epinephrine. Injection of subcutaneous epinephrine should be given at the first sign of allergy.
20. What should the nurse emphasize when counseling an anxious HIV-positive mother about the care of herHIV infant? a. The baby will develop AIDS and refer her to a local AIDS support group. The baby will remain HIV-positive fo life. b. Although infants of HIV-infected mothers may test positive for HIV antibodies, not all infants are infected wit c. She has not yet developed AIDS, and that it is possible the baby will not develop AIDS for many years. d. If the infant is started on zidovudine (AZT) within the first month after delivery, AIDS can be prevented.
B. Although infants of HIV-infected mothers may teat positive for HIV antibodies, not all infants are infected with it. The decline in pediatric AIDS incidence is associated with the increased compliance with universal counseling an pregnant women and the use of zidovudine by HIV-infected pregnant women and their newborninfants. Infants bo mothers will have positive HIV antibody results as long as 15 to 18 monthsafter birth. This is caused by maternal cross the placenta during gestation and remain in the in-fant's circulatory system.
24. An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and "little" strok with right hemiplegia. To afford him the best visual field, the nurse should approach him: a. from the right side. b. from the left side. c. from the center. d. from either side
B. From the left side. Another perceptual problem is hemianopia, which is characterized by defective vision or blindness in half of the the patient has hemianopia, which is common, the patient should be approached from thenonparalyzed side.
7. What would the nurse recommend for a 94-year-old home health patient with deteriorated cell-mediate a. Avoiding the influenza vaccine b. Getting pneumonia c. Having skin tests for all antigens d. Taking large doses of beta-carotene
B. Getting pneumonia
6. What should the nurse look for when reviewing a patient's chart to determine whether she has progressedfrom H AIDS? a. CD4+ count below 500, chronic fatigue, night sweats b. HIV-positive test result, CD4+ count below 200, history of opportunistic disease c. Weight loss, persistent generalized lymphadenopathy, chronic diarrhea d. Fever, chills, CD4+ count below 200
B. HIV-positive test results, CD4+ count below 200, history of opportunistic disease. Patients who have progressed from HIV disease to AIDS will have the condition in which the CD4+ cell countdrop cells/mm3 and have a history of opportunistic diseases.
19.A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury. What does the nurse know about this condition? a. It is an ominous indicator of permanent paralysis. b. It is possibly a temporary condition and will clear. c. It degenerates into a spastic paralysis. d. It will progress up the cord to cause seizures.
B. It is possibly a temporary condition and will clear. A period of flaccid paralysis following a cord injury is called areflexia, or spinal shock, and may be temporary.
30. What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis? a. Arrange for humidified oxygen per mask b. Place the child in respiratory isolation c. Inquire about drug allergy d. Hold NPO until orders arrive
B. Place the child in respiratory isolation. Persons with bacterial meningitis are placed in respiratory isolation until the pathogen can no longer be cultured.
13. The patient who had an asthma-like reaction to a desensitization shot was medicated with a subcutane epinephrine. What effect should the nurse assure the anxious patient this will have? a. Cause vasodilation b. Produce bronchodilation c. Cause productive coughing d. Reduction of pulse rate
B. Produce bronchodilation. The drug epinephrine is given in the case of anaphylaxis because it is a quick-acting drug that produces b and vasoconstriction, which relieves respiratory distress. The drug can be ordered to be repeated every 2 patient may experience an increase in heart rate.
7. As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In thenudocumentation, which would best describe the patient's inability to assess spatial position of his body? a. Agnosia b. Proprioception c. Apraxia d. Sensation
B. Proprioception. Patients may experience a loss of proprioception with a stroke. This may include apraxia and agnosia (a total or partial ability to recognize familiar objects or people)
2. An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticar wheezing after having eaten a peanut butter sandwich. What should be the nurse's first intervention? a. Apply cool compresses to urticaria b. Provide oxygen per non-rebreathing mask c. Cover patient with a warm blanket d. Prepare for venipuncture for the delivery of IV medication
B. Provide oxygen per non-rebreathing mask. Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the pa to be intubated. Covering the patient with a warm blanket is not wrong, but not an initial intervention.
19. For most people who are HIV-positive, marker antibodies are usually present 10 to 12 weeks after exposure.W development of these antibodies called? a. Immunocompetence b. Seroconversion c. Opportunistic infection d. Immunodeficiency
B. Seroconversion. Seroconversion is the development of antibodies from HIV, which takes place approximately 5 days to 3 months a generally within 1 to 3 weeks. Although the conversion has taken place, the patient isnot yet immunodeficient.
21. The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait,which ca patient to: a. stagger and need support of a walker. b. shuffle with arms flexed. c. fall over to one wide when walking. d. take small steps balanced on the toes.
B. Shuffle with arms flexed. The propulsive gait causes the patient to shuffle with his arms flexed and with a loss of postural reflexes.
7.A male patient is advised to receive HIV antibody testing because of his multiple sexual partners and injectable should the nurse inform the patient to ensure understanding? a. The blood is tested with the highly sensitive test called the Western blot. b. The blood is tested with an ELISA; if positive, it is tested again with an ELISA, followed by a Western blot if the ELISA is positive. c. A series of HIV tests is performed to confirm if the patient has AIDS. d. If the HIV tests are seronegative, the patient can be assured that he is not infected.
B. The blood is teated with an ELISA; if positive, it is tested again with an ELISA, followed by a western blot if the ELISA is positive.
18. In which patient should the nurse be most concerned about immunodeficiency disorder? a. The patient taking desensitization injections (immunotherapy) b. The patient on long-term radiation therapy for cancer. c. The overweight patient d. The patient recently diagnosed with lupus erythematosus.
B. The patient on long-term radiation therapy. Radiation destroys lymphocytes and depletes the stem cells. Prolonged radiation depresses the bone mar
14. Why should interventions such as promotion of nutrition, exercise, and stress reduction be undertaken bythe n patients who have HIV infection? a. They will promote a feeling of well-being in the patient. b. They will improve immune function. c. They will prevent transmission of the virus to others. d. They will increase the patient's strength and ability to care for himself or herself.
B. They will improve immune function. HIV disease progression may be delayed by promoting a healthy immune system. Useful interventions for HIV include the following: nutritional changes that maintain lean body mass, regular exercise, and stress reduction.
19. What is the purpose of plasmapheresis in the treatment of rheumatoid arthritis? a. To add corticosteroids to relieve pain b. To remove pathologic substances present in the plasma c. To remove waste products such as urea and albumin d. To add antinuclear antibodies
B. To remove pathological substances present in the plasma. Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease.
4.A patient has just been diagnosed as HIV-positive. He asks the nurse, "Does this mean I have AIDS?" Which re-sp informative? a. "Most people get AIDS within 3 to 12 weeks after they are infected with HIV." b. "Don't worry. You may never get AIDS if you eat properly, exercise, and get plenty of rest." c. "It varies with every individual, but the average time is 8 to 10 years from the time a person is infected, and som longer." d. "You can expect to develop signs and symptoms of AIDS within 6 months."
C. "It varies with every individual, but the average time is 8 to 10 years from the time a person is infected, and some longer."
8.A 28-year-old married attorney with one child is in the first trimester of her second pregnancy. The patientstates risk for HIV, so she would not need to be counseled about testing for HIV. Which is themost appropriate response? a. "She's a professional woman in a monogamous relationship. She obviously is not at risk." b. "Women are not at great risk. The greatest risk is with gay men." c. "The fastest-growing segment of the population with AIDS is women and children. d. "We need to review her chart to determine if her first child was infected."
C. "The fastest-growing segment of the population with AIDS is women and children. Increases in AIDS cases in women and heterosexuals and a slowing of cases in the men who have sex with men(MS direct reflection of early educational efforts directed at the MSM population, who were believed to be the only pop Women need to be assessed for different manifestations of HIV in- fection. It is the current recommendation for vo for all pregnant women.
25. What medication times should the nurse use in writing out a schedule for taking antiretroviral medication three times a day? a. 8 AM - 2 PM - 8 PM b. 8AM - 4PM - 12 AM c. 8AM - 5PM - 1 AM d. Be given with meals
C. 8am-5pm-1am Antivirals should be given around the clock to keep the therapeutic level of the ART at a constant level.
16. The HIV patient asks the nurse about what to expect in terms of disease progression. The nurse tells this pa-tien disease can vary greatly among individuals, the usual pattern of progression includes: a. viremia, clinical latency, opportunistic diseases, and death. b. asymptomatic phase, clinical latency, ARC, and AIDS. c. acute retroviral syndrome, early infection, early symptomatic disease, and AIDS. d. transitional viral syndrome, inactive disease, early symptomatic infection, and opportunistic diseases
C. Acute retroviral syndrome, early infection, early symptomatic disease, and AIDS. The progression from HIV to AIDS includes initial exposure, primary HIV infection, asymptomatic HIV infection, disease, and AIDS.
5. The nurse takes into consideration that when the antigen and antibody react, the complement system is a. toughens the cell wall. b. generates more T cells. c. attracts phagocytes. d. makes the antigen resistant.
C. Attracts phagocytes. The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody proteins destroy the cell membrane and attract phagocytes.
6. How does normal aging change the immune system? a. Depresses bone marrow b. T cells become hyperactive c. B cells show deficiencies in activity d. Increase in the size of the thymus
C. B cells show deficiencies in activity. Normal aging causes deficiencies in both B and T cell activation, but the bone marrow is essentially unco thymus decreases in size.
21. Because the older adult has decreased production of saliva and gastric secretions, they are at risk for: a. mouth ulcers. b. fissures in corners of the mouth. c. gastrointestinal infections. d. bloating.
C. Gastrointestinal infections. Deficient saliva and gastric secretions make the older adult prone to gastrointestinal infections.
16.A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, what should receive? a. Larger doses each week b. Higher concentrations each week c. Increased amounts and concentrations in 6-week cycles. d. The same amount and concentration each visit.
C. Increased amounts and concentrations in 6-week cycles. Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produce Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period.
22. The depressed patient with AIDS says, "I don't understand why I am going to be getting doses of testos-terone. W will that do me now?" What should the nurse keep in mind about testosterone when responding? a. It can lower viral load b. It can lighten depression c. It can increase lean body mass d. It can increase appetite
C. It can increase lean body mass. Testosterone can increase body mass and lean weight.
18. What do the activated monocytes and macrophages produce in the presence of an inflammatory process? a. Reduction of red cells b. Increase in WBCs c. Neopterin d. Increase in T-helper cells increase natural killer (NK) cells
C. Neopterin Neopterin is produced in the presence of an inflammatory reaction and is increased in HIV disease.
21. Why are snacks high in potassium, such as bananas and apricot nectar, recommended? a. Electrolytes are lost through diaphoresis. b. Sodium is lost through frequent diarrhea. c. Potassium will support weight gain. d. Potassium helps fight infection.
C. Potassium will help support weight gain. HIV disease progression may be delayed by promoting a healthy immune system. Nutritional changes that mainta increase weight, and ensure appropriate levels of vitamins and micronutrients are helpful.
31. What is the purpose of a "drug holiday" in the treatment of Parkinson disease? a. Change all drugs b. Allow the natural dopamine levels to rise c. Restart drugs at a lower dosage with favorable results d. Reduce the extrapyramidal symptoms
C. Restart drugs at a lower dosage with favorable results. A "drug holiday" is a period of time when all drugs are withdrawn from the person with Parkinson disease. Thedru restarted at a lower dose with favorable results.
33. Following a myelogram the nurse should include in the postprocedure care assessment for: a. elevation of blood pressure. b. urine retention. c. sensation in lower extremities. d. slurred speech.
C. Sensation in lower extremities. Postmyelogram care includes the assessment to ensure there is no leakage of CSF, sensation and strength ofthe low headache. To avoid a headache, the patient should be flat for a few hours.
34. Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately? a. The infection needs to be treated with IV antibiotics to prevent paralysis b. The brain may swell quickly causing seizures c. The disease can rapidly progress into respiratory failure d. IV hydration is needed to prevent possible fatal hypotension
C. The disease can rapidly progress into respiratory failure. Hospitalization is necessary for GBS patients because the disease progresses very quickly and respiratory
1. Which of the following is an example of immunocompetence? a. A child that is immune to measles because of an inoculation b. A person who has seasonal allergies every fall c. When the symptoms of a common cold disappear in 1 day d. A neonate having a natural immunity from maternal antibodies
C. When the symptoms of a common cold disappear in 1 day. Immunocompetence is demonstrated by the immune system responding appropriately to a foreign stimu body's integrity is maintained as with cold symptoms that resolve with residual illness.
8.A patient who works in a plant nursery and has suffered an allergic reaction to a bee sting is stabilized a discharge from the clinic. During discussion of prevention and management of further allergic re-actions identifies a need for additional teaching based on which comment? a. "I need to think about a change in my occupation." b. "I will learn to administer epinephrine so that I will be prepared if I am stung again." c. "I should wear a Medic-Alert bracelet indicating my allergy to insect stings." d. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."
D. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."
3. What is the etiology of autoimmune diseases based on? a. Reaction to a "superantigen" b. Immune system producing no antibodies at all c. T cells destroying B cells d. B and T cells producing autoantibodies
D. B and T cells producing autoantibodies. Autoimmune disorders are failures of the tolerance to "self." B and T cells produce autoantibodies that ca pathophysiologic tissue damage. Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish "self" protein from "foreign" protein.
22. What does the nurse know about the stroke patient who has expressive aphasia? a. Has difficulty comprehending spoken and written communication b. Cannot make any vocal sounds c. Has total loss and comprehension of language d. Can understand the spoken word, but cannot speak
D. Can understand the spoken word, but cannot speak. The patient with expressive aphasia has difficulty articulating words, but can understand the written and spoken.
12. The nurse recommends to the busy mother of three that the antihistamine fexofenadine (Allegra) wou beneficial than diphenhydramine (Benadryl) because Allegra: a. is inexpensive. b. contains a stimulant for an energy boost. c. does not dry out the mucous membranes. d. does not induce drowsiness.
D. Does not induce drowsiness. Allegra does not induce drowsiness as does Benadryl.
12.A patient states that he feels terrific, but a blood test shows that he is HIV-positive. It is important for thenurse him that HIV may remain dormant for several years. What is true of the patient duringthis time? a. He is not dangerous to anyone. b. He experiences minor symptoms only. c. He experiences decreased immunity. d. He is contagious.
D. He is contagious. A prolonged period in which HIV is not readily detectable in the blood follows within a few weeks or months ofth This titer, or viral load, falls dramatically as the immune system responds and controls theHIV infection, and it m years. During this period, there are few clinical symptoms of HIV infec-tion, although an individual is still capable to others.
20. The nurse explains that when the patient received tetanus antitoxin with the antibodies in it, the patient has ______ type of immunity. a. Active natural b. Passive natural c. Active artificial d. Passive artificial
D. Passive artificial When a person receives an inoculation of antibodies from another source, as with tetanus antitoxin, it is c passive artificial immunity.
29. Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person withmyasthe a. Improves speech b. Improves visual disturbances c. Reduces pain d. Promotes nerve impulse transmission
D. Promotes nerve impulse transmission. Prostigmine and Mestinon improve the nerve impulses and alleviate the symptoms.
20.A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a the neck and "goose flesh." What should be the primary nursing intervention based onthese assessments? a. Place patient in flat position and check temperature b. Administer oxygen and check oxygen saturation c. Place on side and check for leg swelling d. Sit upright and check blood pressure
D. Sit upright and check blood pressure. These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. As- sessments for impaction or a urine infection can help to evaluate this condition.
26. The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm 35 minutes. He is complaining of chills, itching, and shortness of breath. What should be the nurse's initia a. Cover with a warm blanket b. Take the patient's temperature c. Elevate the head of the bed d. Stop the transfusion and continue with saline
D. Stop the transfusion and continue with saline. Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, and cou intervention should be to stop the transfusion and continue with saline. Elevation of the head, takingvital covering with a warm blanket are not wrong, but are not of primary importance at this time.
11. Which person is most at risk for a hypersensitivity reaction? a. 26-year-old receiving his second desensitization injection b. 35-year-old starting back on birth control tablets c. The 52-year-old started on a new series of Pyridium for cystitis d. The 84-year-old receiving penicillin for an annually recurring respiratory infection
D. The 84-year-old receiving penicillin for an annually recurring respiratory infection. The 84-year-old with the deteriorated immune system is a prime candidate for a delayed hypersensitivity.
14. Health care facilities have reduced the incidence of serious latex reactions by: a. Having local and injectable corticosteroids on hand for employees b. Desensitizing staffwho are allergic c. Supplying extra handwashing stations in the halls d. Using only powder-free gloves.
D. Using only powder free gloves. Powder inside gloves can become aerosolized and cause inhalant reactions.
8. What is the process when the lens of the eye changes its curvature to focus on the retina? a. Accommodation b. Constriction c. Convergence d. Refraction
a. Accommodation The ability of the lens to alter its curvature as it focuses on the retina is accommodation.
14. What does diabetes retinopathy result from? a. Capillaries in retina hemorrhage b. Long-term overdosing of insulin c. Retinal detachment d. Aging
a. Capillaries in retina hemorrhage. Retinopathy is caused when the capillaries in the retina have aneurysms or hemorrhage.
10.What are surgical navigational systems? a. Computerized devices that guide the surgeon b. A set of detailed anatomic maps pinpointing specific areas of the brain c. A written set of progressive processes for the resection of small brain tumors d. The use of radioactive materials to pinpoint small tumors of the brain
a. Computerized devices that guided the surgeon. Surgical navigational systems are computerized devices that guide the surgeon and make possible the resection were once thought to be inoperable.
4. What does a tympanoplasty correct? a. Conductive hearing loss b. Sensorineural hearing loss c. Congenital hearing loss d. Functional hearing loss
a. Conductive hearing loss. Tympanoplasty can correct a conductive hearing loss.
15. When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition? a. Detached retina b. Macular degeneration c. Early sign of cataract d. Diabetic retinopathy
a. Detached retina. The standard complaint of a detached retina is the report of seeing flashing lights and having a curtain being drawn over the eyes.
22. What should the nurse include in the plan of care following a tympanoplasty? a. Elevating head of bed with operative side facing upward b. Enforcing bed rest for 72 hours c. Frequent turning, coughing, and deep breathing d. Continuous irrigation of the ear canal with antibiotic solutions
a. Elevating head of bed with operative side facing upward. Postoperative management for patients who have had a tympanoplasty consists of bed rest until the next morning. The head of the bed is elevated 40 degrees, and the operative side faces upward.
29. Why is otitis media found more frequently in children 6 to 36 months? a. Eustachian tubes in children are shorter and straighter. b. Infection descends via the eustachian tube to the throat. c. Children's eustachian tubes are more vertical and longer. d. Otitis media is seen equally in both children and adults.
a. Eustachian tubes in children are shorter and straighter. Children's shorter and straighter eustachian tubes provide easier access of the organisms from the nasopharynx to travel to the middle ear.
14. The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia causes of dementia are reversible and preventable. What is one example? a. Hypotension b. Alzheimer disease c. Diabetes d. Parkinson disease
a. Hypotension. Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic malnutrition can all be corrected to abolish the dementia.
32. What is the first sign of Bell's palsy? a. Inability to wrinkle forehead and pucker lips on affected side b. Sudden pain in nostril on affected side c. Excessive salivation on the affected side d. Excessive mucus running from nostril on affected side
a. Inability to wrinkle forehead and pucker lips on affected side. Unilateral weakness of the facial muscles usually occurs, resulting in a flaccidity of the affected side of the facewit wrinkle the forehead, close the eyelid, pucker the lips, smile, frown, whistle, or retract the mouth on that side. The asymmetric.
4.A patient is admitted with a secondary immunodeficiency from chemotherapy. The nursing plan of care include provisions for: a. infection control. b. supporting self-care. c. nutritional education. d. maintaining high fluid intake.
a. Infection control. Immune deficient persons are at risk for infection and need to be protected aggressively for contagion.
28. Which is a sign of acute angle closure glaucoma (AACG)? a. Large fixed pupil b. Nystagmus c. Bluish color in sclera d. Drooping eyelid
a. Large fixed pupil. Signs of AACG would be eye pain, large fixed pupil with reddened sclera, decreased vision, nausea, and vomiting.
3. The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually gained consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow, what is s the most appropriate position for the patient? a. Neck placed in a neutral position b. Head raised slightly with hips flexed c. Supine in gravity neutral position d. Turn on right side with head elevated
a. Neck placed in a neutral position. Place the neck in a neutral position (not flexed or extended) to promote venous drainage.
8.A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing prevention should be planned with respect to this diagnostic test? a. Obtain an allergy history before the test. b. Ambulate the patient when returned to the room after the test. c. Use heated blanket to keep patient warm after procedure. d. Keep NPO for 6 to 8 hours after the test.
a. Obtain an allergy history before the test. Before the dye is injected, patients must be asked whether they have any allergies, specifically whether they have anaphylactic or hypotensive episodes from other dyes.
7. What is a common mistake that hinders communication when communicating with the hearing impaired? a. Overaccentuating words b. Facing the patient when speaking c. Speaking in conversational tones d. Speaking into the ear with the hearing aid
a. Overaccentuating words Do not overaccentuate words. Speak in a normal tone; do not shout or raise the pitch of voice.
18. What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid? a. Reinsert the ear mold. b. Change the battery. c. Recharge the hearing aid. d. Wash the ear mold with warm water.
a. Reinsert the ear mold. The whistling hearing aid is usually caused by a poor fit of the ear mold. Reinsertion of the ear mold usually stops the whistling.
17. While teaching community groups about AIDS, what should the nurse indicate as the most commonmethod of transmission of the HIV virus? a. Sexual contact with an HIV-infected partner b. Perinatal transmission c.Exposure to contaminated blood Nonsexual d. exposure to saliva and tears
a. Sexual contact with an HIV-infected partner
5. The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate? a. Sjögren syndrome b. Early cataracts c. Macular degeneration d. Retinal detachment
a. Sjögren syndrome The Sjögren syndrome of "dry eye" frequently appears after eye surgery. There is insufficient production of tears. Excessive use of antihistamines, antidepressants, and decongestants may cause this syndrome to appear.
30. Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp? a. The lamp can cause cataracts. b. The lamp can cause presbycusis. c. The lamp can cause keratitis. d. The lamp can cause ectropion.
a. The lamp can cause cataracts. The proteins in the lens of the eye are vulnerable to UV light and can develop cataracts.
18. The nurse is caring for a home health patient who had a spinal cord injury at C5 three years ago. The nurse based on the knowledge that the patient will be able to: a. feed self with setup and adaptive equipment. b. transfer self to wheelchair. c. stand erect with full leg braces. d. sit with good balance.
a. feed self with setup and adaptive equipment. A cord injury at C5 allows for ability to drive an electric wheelchair with mobile hand supports and feed self with equipment.
1. The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 ft what the normal eye can see at _____ ft. a. 10 b. 20 c. 30 d. 40
b. 20 The Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the patient can see at 20 ft what the person with normal vision can see at 40 ft.
12. How would a nurse record the behavior when a patient with Alzheimer disease attempts to eat using a napkin for a fork? a. Apraxia b. Agnosia c. Aphasia d. Dysphagia
b. Agnosia. Agnosia is a total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as brain damage.
9. When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact? a. American Red Cross b. American Foundation for the Blind for a list of agencies c. Local hospital social worker d. The public health department
b. American Foundation for the Blind for a list of agencies. The American Foundation for the Blind has lists of agencies to assist and educate the visually impaired patient.
24. A patient who had an enucleation of I the right eye has been admitted PACU. What should the nurse include in the plan of care? a. Turn, cough, and deep breathe every 3 hours. b. Apply a pressure dressing over the right eye socket. c. Document dressing assessment every 2 hours. d. Turn on the affected side.
b. Apply a pressure dressing over the right eye socket. A pressure dressing will be applied to the right eye socket and the dressing should be checked every hour for the first 24 hours.
12. Which complaint made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts? a. Pain in the eyes b. Difficulty driving at night c. Loss of peripheral vision d. Dry eyes
b. Difficulty driving at night. Blurring of vision and difficulty driving at night is often the first subjective symptom reported by a patient who has cataracts.
16. The nurse will assess for _________ when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain. a. mumps b. external otitis c. otitis media d. labyrinthitis
b. External otitis. The symptoms of painful head, painful chewing, and pain when the auricle is moved all indicate external otitis, frequently caused by compacted cerumen.
25. What must a patient do following a left vitrectomy? a. Remain flat in bed for 48 hours. b. Position self in a face-down position for 4 to 5 days. c. Assume a side-lying position with the left side down for 3 days. d. Keep head upright and cushioned with pillows for 24 hours.
b. Position self in a face-down position for 4 to 5 days. Following a vitrectomy, the patient must assume a face-down position or turn the face to the right side for 4 to 5 days.
27. What is the first indication of macular degeneration? a. The loss of peripheral vision b. The loss of central vision c. The loss of color discrimination d. Eye fatigue
b. The loss of central vision. Macular degeneration is characterized by the slow loss of central and near vision
9.A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially which liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely? a. Use a straw b. Tuck chin when swallowing c. Take a sip of liquid with each bite d. Turn head to the left
b. Tuck chin when swallowing. The patient should sit at a 90-degree angle with the head up and chin slightly tucked.
4. Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurological problem? a. "Do you have any sensations of pins and needles in your feet?" b. "Does the pain radiate from your back into your legs?" c. "Can you describe the sensations you are having?" d. "Do you ever have any nausea or dizziness?"
c. "Can you describe the sensation you are having?" For patients with suspected neurological conditions, the presence of many symptoms or subjective data may be a sign. Questions are not beneficial and may allow the patient to give misinformation. Questions should be specific.
23. When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report? a. Any color visible on the grid b. Fading of the edges of the grid c. Any distortion of the grid d. Movement of the black dot
c. Any distortion of the grid. Amsler grid, a diagnostic tool for retinal disorders, requires that the patient look at the dot on the grid and report any distortion in the grid lines.
6. The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four response, brainstem reflexes, motor response, and respiration. How are these results reported? a. As a sum of the scores of the four categories b. As part of the Glasgow coma scale c. As individual scores in each category d. As progressive scores during a 24-hour period
c. As individual scores in each category. The FOUR score coma scale assesses the patient in four categories: eye response, brainstem reflexes, motor response respiration. The scores are reported as individual scores in each category. It is frequently done in conjunction with coma scale, not part of it.
19. What should the nurse advise the 20 year old to do who has been put on cefaclor (Ceclor) for a resistant otitis media? a. Store suspension at room temperature. b. Discontinue drug when symptoms abate. c. Avoid alcoholic beverages. d. Take with meals only.
c. Avoid alcoholic beverages. Drinking alcohol is discouraged while on Ceclor. The drug should be taken in its entirety and stored in the refrigerator. The drug can be taken with or without meals.
31. The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to: a. damaged tympanic membrane. b. protective buildup of cerumen. c. damage of the fine hair cells in the organ of Corti. d. rupture of the oval window.
c. Damage of the fine hair cells in the organ of Corti. Long-term exposure to loud noises can damage the fine hair cells in the organ of Corti, which causes a conductive hearing loss.
25. The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage from the nose. What is the most appropriate nursing response to this assessment? a. Cleanse nose with a soft cotton-tipped swab b. Gently suction the nasal cavity c. Gently wipe nose with absorbent gauze d. Ask patient to blow his nose
c. Gently wipe nose with absorbent gauze. The patient's ear and nose are checked carefully for signs of blood and serous drainage, which indicate that the spinal fluid is escaping. No attempt should be made to clean out the orifice or to blow the nose. The drainage can be tested for the presence of glucose, which would confirm that the fluid is spinal fluid.
6. Four hours after a stapedectomy, the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response? a. A large percentage of stapedectomies are not successful. b. It will take at least 10 days for the graft to heal. c. Hearing will not return until edema subsides. d. Hearing will improve after irrigation of the ear.
c. Hearing will not return until edema subsides. Hearing improvement will not be noted until edema subsides and the packing is removed.
17. The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone: a. equally in both ears. b. as a shrill noise. c. louder in his affected ear. d. very faintly.
c. Louder in his affected ear. A conductive hearing loss can be diagnosed by the Weber test. A person with a conductive loss will hear the noise louder in his affected ear.
27. What is the basic problem that prompts most of the early signs of Alzheimer disease? a. Changes in mood b. Misplacing things c. Memory loss that disrupts daily life d. Problems with words in speaking
c. Memory loss that disrupts daily life. Memory loss that disrupts daily life is the basic problem that prompts most of the early signs of AD.
17. What is the nurse aware of when assessing a person with a craniocerebral injury? a. Most injuries of this type are irreversible b. Open injuries are always more serious than closed injuries c. Signs and symptoms may not occur until several days after the trauma d. Trauma to the frontal lobe is more significant than to any other area
c. Signs and symptoms may not occur until several days after the trauma. If a patient who has been conscious for several days after head injury loses consciousness or develops neurologic symptoms, a subdural hematoma should be suspected.
13. What should a patient who has had a cataract repair avoid? a. The use of eye patches b. The use of sunglasses c. The lifting of heavy objects d. Reading for long periods of time
c. The lifting of heavy objects. Postcataract patients should avoid any activity that increases the intraocular pressure, such as lifting heavy objects, stooping, and bending.
26. How would the nurse instruct a patient with Parkinson disease to improve activity level? a.use a soft mattress to relax the spine b. To walk with a shuffling gait to avoid tripping c. To walk with hands clasped behind back to help balance d. To sit in hard chair with arms for posture control
c. To walk with hands clasped behind back to help balance. The patient with Parkinson disease can improve the activity level by sleeping on a firm mattress without a pillow curvature, hold hands clasped behind to keep better balance, and keep the arms from hanging stiffly at the side. the feet to avoid tripping and "freezing."
10. The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK: a. reshapes the central cornea. b. makes partial-thickness radial incisions in the cornea. c. removes some internal layers of the cornea. d. implants intracorneal rings.
c. removes some internal layers of the cornea. The LASIK procedure removes some of the internal layers of the cornea affecting the central zone of vision.
16. What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously and obeys commands for movement? a. 8 b. 10 c. 11 d. 12
d. 12 The Glasgow coma scale was developed in 1974, and it consists of three parts of the neurologic assessment:eye response, and best verbal response. This patient gets a 4 for eye opening, a 2 for in-comprehensible speech, and a demand.
11. What does the cataract treatment of phacoemulsification involve? a. "Drying" the cataract with hypertonic saline b. Removing the lens through the anterior capsule c. The insertion of a new lens d. Breaking the cataract with ultrasound
d. Breaking the cataract with ultrasound. Phacoemulsification uses ultrasound to break up the cataract.
13. To be diagnosed as having AIDS, the patient must be HIV-positive, have a compromised immune systemwith immune system disease or recent organ transplant, and present with which of the following? a. Opportunistic infection b. A positive ELISA or Western blot test c. Weight loss, fever, and generalized lymphedema d. CD4+ lymphocyte count less than 200 mm3
d. CD4+ lymphocyte count less than 200 mm3. The 1993 expanded case definition of AIDS includes all HIV-infected people who have CD4+, T-lymphocyte count cells/mm3; this includes all people who have one or more of these three clinical conditions: pulmonary tuberculo pneumonia, or invasive cervical cancer, and it retains the 23 clinical conditions listed in the 1987 AIDS case definition.
1. What are the two divisions of the nervous system? a. Somatic and the autonomic b. Cerebellum and the brainstem c. Medulla oblongata and the diencephalon d. Central and the peripheral
d. Central and the peripheral. The central and the peripheral are the two divisions of the nervous system. The autonomic and the somatic are the peripheral nervous system.
21. What do miotic eye drops do for a patient with glaucoma? a. Dilate the pupil and sharpen vision. b. Lubricate and moisten the dry eye. c. Irrigate the surface of the eye. d. Constrict the pupil and open the canal of Schlemm.
d. Constrict the pupil and open the canal of Schlemm. Miotic eye drops allow the pupil to constrict and open the canal of Schlemm to drain the excess fluid.
5. What is the cardinal sign of increased intracranial pressure in a brain injured patient? a. Pupil changes b. Ipsilateral paralysis c. Vomiting d. Decrease in the level of consciousness
d. Decrease in the level of consciousness. Collection of objective data includes a change in level of consciousness. A change in the level of consciousness is increased intracranial pressure.
15. What is the nurse assessing when asking the patient, "Who is the president of the United States?" during a level consciousness assessment? a. Orientation b. Memory c. Calculation d. Fund of knowledge
d. Fund of knowledge. Fund of knowledge is tested by questions such as "Who is the president?" or asking about current events.
3. One of the housekeepers splashes a chemical in the eyes. What should be the first priority? a. Transport to a health care provider immediately. b. Cover the eyes with a sterile gauze. c. Irrigate with H2O for 5 minutes. d. Irrigate with normal saline solution for 20 minutes.
d. Irrigate with normal saline solution for 20 minutes. Burns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush immediately after burn exposure.
20. How should the nurse advise a patient who has severe vertigo from labyrinthitis? a. Lean against a wall and not head forward until vertigo lessens. b. Bend at the waist and take several deep breaths. c. Drink an iced drink slowly. d. Lie immobile and hold the head in one position until the vertigo lessens.
d. Lie immobile and hold the head in one position until the vertigo lessens. Lying immobile and holding the head in one position will lessen vertigo.
11.A family member of a patient who has just suffered a tonic clonic seizure is concerned about the patient's deep behavior called? a. Convalescent period b. Neural recovery period c. Sombulant period d. postictal period
d. Postictal period. Seizures are followed by a rest period of variable length, called a postictal period.
2. The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient? a. The patient would be considered totally blind. b. This patient probably has some light perception, but no usable vision. c. This patient has some usable vision, which enables function at an acceptable level. d. The nurse would need to determine how this patient's visual impairment affects normal functioning.
d. The nurse would need to determine how this patient's visual impairment affects normal functioning. "Legal blindness" refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient.
26. How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy? a. The procedure will destroy the retina, which is not getting enough blood supply. b. The procedure will reduce edema in the macula of the eye. c. The procedure will vaporize fatty deposits that appear in the retina. d. The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.
d. The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema. Photocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels and to destroy new vessels.
13. Which symptom is specific to migraine headaches? a. Tachycardia b. They become worse in the evening c. They involve the entire head d. They are preceded by an aura
d. They are preceded by an aura. Migraine headaches are unusual in that signs and symptoms occur before the acute attack.
2. What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions? a. Somatic motor nerve b. Visceral sensory nerve c. Abducens nerve d. Vagus nerve
d. Vagus nerve. The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal cavities. It is responsible sensations and will accelerate peristalsis when stimulated.