Chapter 15
What is the best advice for the nurse to give a client who is starting an exercise program?
"Exercise for 20 minutes or more 3 to 5 days a week."
A client who has been exercising says to the nurse, "My skin is so hot!" What is the nurse's best response?
"Your body is trying to lower your temperature."
What should the nurse teach a client who is on bed rest ?
Immobility will lead to deconditioning of muscles.
Which of the following patients are exhibiting manifestations of chronic fatigue? (Select all that apply.)
A 42 year old who has experienced muscle pain, insomnia, and continuous fatigue for 6 months A 56 year old who is receiving chemotherapy for cancer and feels fatigue even with additional naps A 75 year old who has shortness of breath from heart failure, sleeps 8 hours nightly, and awakens tired
The nurse is caring for several clients on the acute care floor. Which of the following clients are at risk for the development of allergic responses to latex? (Select all that apply)
A client with a history of atopic reactions. A client with a history of food allergies. A client with a history of delayed hypersensitivity reactions.
A client is in the emergency department with a severe type I IgE-mediated hypersensitivity reaction. What pharmacologic treatment should the nurse prepare to administer in this acute phase? (Select all that apply)
Epinephrine An antihistamine Systemic corticosteroids
Which of the following assessment findings does the nurse expect in patients who have been performing aerobic or isometric exercise on a regular basis? (Select all that apply.)
Improved glucose tolerance Improved insulin sensitivity Increased bone density
How will the nurse explain the changes in blood flow during exercise to a client?
"Blood vessels to skeletal muscles dilate during exercise."
A parent brings a 6-month-old infant to the primary care physician to treat the infant's third respiratory infection since birth. What explanation will the nurse give for the order to administer intravenous immunoglobulin (IVIG)?
"IVIG supplements the infant's immunity to prevent recurrent infection."
A nurse is evaluating the progress of a patient with chronic fatigue syndrome. Which of the following statement by the patient indicates successful symptom management?
"My schedule includes yoga and a weekly club meeting
A nurse is evaluating the progress of a patient with chronic fatigue syndrome. Which of the following statement by the patient indicates successful symptom management?
"My schedule includes yoga and a weekly club meeting."
A client asks the purpose of an exercise stress test. What is the nurse's best response?
"The test is used to measure aerobic fitness."
A 5-year-old child is experiencing itchy, watery eyes and an increased respiratory rate with some inspiratory wheezes. He has been outside playing in the yard and trees. The mother asks, "Why does he get like this?" The health care worker's best response is:
"This is what we call a type I hypersensitivity reaction and usually occurs a few minutes after exposure to his allergen. It is primarily caused by mast cells in his body."
A client asks what exercise to engage in to increase endurance. What is the nurse's best response?
"You should perform aerobic exercise on a regular basis."
The nurse is helping to create an exercise plan for a 55-year-old client who has resolved to become more physically fit. What is this client's maximal heart rate?
165 beats per minute
A physician is providing care for several clients on a hospital-based medical ward. Which client is most likely to experience chronic fatigue?
51-year-old woman admitted for exacerbation of her multiple sclerosis.
A client presents to the Urgent Care with erythematous, papular, and vesicular lesions associated with intense pruritus and weeping. The client states he was in the woods and thinks he may have come in contact with poison ivy .The reaction may be classified as:
Allergic contact dermatitis
A patient will be receiving a bone graft from an unrelated individual. Which of the following types of graft does the nurse inform the patient that he or she will be receiving?
Allograft
What statement accurately explains types of muscle fibers?
Activity influences the distribution of type I and type II muscle fiber.
An infant is suspected of having a severe combined T- and B-cell immunodeficiency disorder. Which of the following effects on the infant makes early detection a priority?
Administering live attenuated virus vaccines can be fatal.
Which of the following should the nurse include in a teaching care plan concerning aerobic exercise?
Adults need to exercise for 20 to 60 minutes three days a week.
The primary care provider of a 41-year-old client with a diagnosis of diabetes mellitus has recommended that he begin a program of isometric exercise in an effort to control his blood glucose levels. Which additional benefit is the client likely to see over time?
An increase in his basal metabolic level.
People with congestive heart failure need to be on a closely monitored exercise regimen. What is the reason for this?
Anaerobic metabolism, coupled with vasoconstrictor response, can cause an increased afterload on the heart.
Some members of the population are so sensitive to certain antigens that they react within minutes by developing itching, hives, and skin erythema, followed shortly thereafter by bronchospasm and respiratory distress. What is this near immediate reaction commonly known as?
Anaphylactic reaction
Organ rejection is a complication of organ transplantation caused when recipient immune cells do which of the following?
Attack the donor cells
Select the statement that best describes autoimmune disease.
Autoimmune diseases represent a disruption in self-tolerance that results in damage to body tissues by the immune system.
Which of the following types of a hypersensitivity reaction involves failure of the development of self-tolerance?
Autoimmune reaction
A client who takes daily sodium warfarin (Coumadin) states he is going to start exercising daily. What is the best advice for the nurse to give the client?
Beneficial
A nurse monitors a 68-year-old patient starting an exercise program. For which of the following manifestations would the nurse stop the activity?
Breathlessness begins within 5 minutes
The nurse is working with a client who is at risk for cardiovascular disease. The nurse is helping the client implement an exercise routine. Which form of exercise should the nurse recommend to promote the greatest impact on the client's cardiovascular system?
Brisk walking on a treadmill
A patient has a rare autosomal recessive disorder that renders the patient severely susceptible to infections, bleeding tendencies, partial oculocutaneous albinism, and progressive neurologic dysfunction. Which of the following is the name of this disorder?
Chediak-Higashi (CHS) syndrome
A patient is suspected of having a T-cell immunodeficiency. Which of the following procedures will help diagnose this disorder?
Clinical presentation and family history
How will the nurse teach the client to apply her "target heart rate"?
Exercise until 85 to 90% of the target heart rate is achieved.
A client suspects they may have developed an allergic response to latex. What most common allergic response would the nurse expect to find?
Contact dermatitis
The nurse is caring for several patients with symptoms of chronic fatigue. Which of the following manifestations does not correlate with a diagnosis of chronic fatigue syndrome (CFS)?
Cough with blood-tinged sputum
A primary health provider (PHP) recommends that patients routinely engage in light to moderate exercise. Which of the following explanations of benefits corresponds with the patient's condition?
Crohn's disease; exercise reduces inflammation
Which of the following complications of immobility will the nurse observe first in a patient placed on bed rest for 3 days?
Diuresis
Which of the following will the nurse assess in order to determine that a patient has activity intolerance?
Dyspnea during activity
A nurse is evaluating a patient's response to instruction about exercise. Which of the following levels of activity meets the recommendations by the American College of Sports Medicine for a 50-year-old patient? Select all that apply.
Heart rate reaches 110 when exercising five times a week. Heart rate reaches 140 when exercising three times a week.
A patient is being treated for an anaphylactic reaction after eating shrimp. Which of the following classes of antibodies mediates the anaphylaxis?
IgE
The nurse is performing an admission assessment to a rehabilitation unit. Which of the following assessment tools should she utilize to determine an alert patient's normal activities, perceived level of activity tolerance, or level of fatigue?
Human Activity Profile
The immune system typically responds to invaders of all types in our body. However, it can also cause tissue injury and disease. What is this effect called?
Hypersensitivity action
A patient with common variable immunodeficiency (CVID) is admitted to the hospital for treatment. Which of the following types of treatment will the nurse be administering to the patient?
IV immunoglobulin
Which of the following assessment findings indicates a positive respiratory response to exercise?
Increased alveolar perfusion
Which of the following assessment findings is a positive outcome of treatment with diet and exercise for hypercholesterolemia?
Increased high-density lipoproteins
A patient is attempting to perform isometric exercise daily. Which of the following effects will the patient expect from this repeated exercise?
Increased muscle mass
The nurse teaches that what is an expected outcome of aerobic exercise?
Increased use of oxygen for energy
The nurse is teaching a new mother about caring for her baby and reducing the risk for infection. On which of the following does the nurse base the knowledge of passive immunity?
Infants are protected at birth from infection by maternal IgG.
Which of the following is the most common type of immunoglobulin deficiency, affecting 1 in 400 to 1 in 1000 persons?
Inherited selective IgA deficiency
A client diagnosed with the autoimmune disorder, Hashimoto's thyroiditis, asks the nurse what they have done to cause this disorder. What knowledge by the nurse should the response be based upon?
It is a result of the loss of immunolgic self-tolerance.
Disuse of a muscle and muscle atrophy contribute to the weakening and wasting of muscle tissue. What else do they contribute to?
Joint contractures
Many types of fatigue are reported by clients with a wide variety of disease disorders. What is an identified cause of fatigue in clients with forced immobility, neuromuscular disorders, and wasting syndromes?
Loss of muscle mass, muscle strength, and endurance
A patient has common variable immunodeficiency (CVID),a form of humoral primary immunodeficiency. Which of the following alterations in serum levels would the nurse expect to see?
Low serum IgG levels
A patient with hereditary angioneurotic edema (HAE) is experiencing an attack. Which of the following priority interventions should the nurse be prepared to administer?
Maintaining a patent airway
A client has developed a type 1 hypersensitivity reaction. The nurse recognizes that a secondary or late-phase response:
May occur 2 to 8 hours after the primary or initial-phase response and lasts for several days
A theory that has been postulated to describe the mechanisms by which infectious agents or other foreign substances trigger an immune response against autoantigens is known as what?
Molecular mimicry
Systemic lupus erythematosus is best characterized by which one of the following?
Most patients have antinuclear antibodies present in their blood.
Which disorder does the nurse know is considered to be an autoimmune disease?
Myasthenia gravis
While getting up out of bed for the first time after surgery, a patient reports feeling dizzy and faint. Which of the following conditions is the patient most likely experiencing?
Orthostatic intolerance
The nurse is caring for an infant wih DiGeorge syndrome. Which of the following organs does the nurse know will be underdeveloped or absent?
Parathyroid and thymus glands
The nurse is caring for several patients who have chronic fatigue. Which of the following interventions is the appropriate match for the cause of the patients' fatigue?
Patients with end-stage renal disease receiving erythropoietin
The cell responsible for migrating to the site of an infection and enveloping invading microorganisms is which of the following?
Phagocyte
After a week in which a client worked four 12-hour shifts and went home to two children with the flu, the client is feeling fatigued. How should this client's fatigue be categorized?
Physiologic
What statement is true concerning the use of ATP by skeletal muscles?
Skeletal muscles use ATP at a rapid rate during exercise.
Which of the following statements is true considering nutrition and hydration status with exercise?
Proteins are necessary for rebuilding tissues in the body.
A patient has been told to increase aerobic exercise. Which of the following activities could the patient choose?
Running
A major complication of prolonged bed rest is an increase risk of kidney stones. The nurse knows that this is is most likely related to which of the following?
Saturation of urine with calcium salts
Skeletal muscles with fast-twitch fibers are better suited for which type of activity?
Sprinting
A patient with a long history of "hay fever" has recently begun a series of immunotherapy (allergy shots). How will this treatment potentially achieve a therapeutic effect?
Stimulating production of IgG to combine with antigens
A client who has been exercising for a few weeks begins to sweat as soon as he exercises. What will the nurse determine from this assessment?
The client is reacting normally.
A client with cirrhosis has just received a liver transplant. Tissue rejection can be best prevented by what means?
Suppression of CD8+ cytotoxic T cells
A client with a diagnosis of cirrhosis has experienced an acute rejection of a donor liver. Which of the following cells is responsible for the rejection of the client's transplanted organ?
T cells
An infant has a rare autosomal recessive disorder, ataxia-telangiectasia, that has recently been diagnosed. Which of the following developmental milestones assists in diagnosing this disorder?
The child is beginning to walk.
How will the nurse teach the client to utilize metabolic equivalents when starting an exercise routine?
The client should understand that activities with higher metabolic equivalents have higher workloads.
What does the nurse teach is the principal factor that determines how long the client can exercise?
The client's heart and lung capacity
A client who is exercising has a blood pressure of 130/90 at the start of exercise and 150/95 during exercise. What statement is true concerning this assessment?
The client's mean arterial pressure has increased.
Which of the following assessment findings is a negative cardiac response to exercise?
The patient's diastolic blood pressure increases.
The mediators involved in type I hypersensitivity allergic responses are released from which of the following?
The primary healthcare provider prescribes new medications to treat a client with an autoimmune disorder. For which order would the nurse seek clarification?
The nurse knows that with aerobic exercise, which of the following changes is true with regard to blood pressure?
The systolic blood pressure increases while the diastolic pressure remains unchanged.
What is the purpose of the "Fatigue Severity Scale"?
The tool helps to measure activity tolerance from a client perspective.
Why is early diagnosis essential for an infant with severe combined immunodeficiency disorders (SCIDs)?
There is better opportunity for successful treatment
What should the nurse teach the client prior to ergometry?
This test evaluates cardiac function.
Children born to mothers who are infected with HIV are considered uninfected if the children become HIV antibody negative after 18 months of age, have no other laboratory evidence of HIV infection, and have not met the surveillance case definition criteria for AIDS in children.
True
The type of hypersensitivity reaction that is mediated by IgG or IgM antibodies directed against target antigens on specific host cell surfaces or tissues is also known as which of the following types of hypersensitivity reaction?
Type II
The nurse is caring for a patient with common variable immunodeficiency (CVID) disorder. Which of the following clinical manifestations of the disorder is common with this patient?
Viral pneumonia
Which of the following is an example of an isometric exercise?
Weight lifting
A 45-year-old patient is being tested for aerobic fitness on a bicycle ergometer. At which of the following events would the test be allowed to continue?
When the heart rate reaches 135 beats/min
A patient develops an immunodeficiency disorder after receiving chemotherapy for the treatment of lung cancer. The patient asks the nurse if he was born with this deficiency. Which of the following is the nurse's best response?
You have developed a secondary immunodeficiency disorder as a result of your chemotherapy."
A nurse informs her supervisor that she thinks she has developed an allergy to the latex gloves. A latex-specific serum IgE immunoassay has been performed with negative results. What definitive diagnostic test should be performed at this time?
A contact test.
A patient with common variable immunodeficiency (CVID) who is also deficient in IgA is being treated with IV immunoglobulin (IV Ig) in the hospital. For which of the following should the nurse closely monitor the client during treatment?
Anaphylaxis
Mismatched blood transfusion reaction with hemolysis of blood cells is an example of type II, _____ mediated hypersensitivity reaction
Antibody
Which of the following interventions will the nurse caring for a patient on bed rest implement to prevent deep-vein thrombosis (DVT)?
Anticoagulants and regular repositioning
Following a spider bite she received while camping, a 20-year-old woman presented to the emergency department with rash, edema, and fever and was subsequently diagnosed with serum sickness. Which statement best describes the physiologic rationale for the broad systemic effects of this event?
Antigen--antibody complexes have been deposited in a variety of locations throughout the body.
A child has experienced a "bee-sting" while at the park. The health care provider is walking by and notices the child has swelling around the eyes, lips, and face in general. What priority assessment should the nurse make at this time?
Assess and establish an open airway.
In a newborn, which antibody crosses the placenta to provide protection from infection?
IgG
Which treatment would be considered appropriate when managing the care of any client experiencing long term immobility?
Medication to prevent deep vein clotting
A patient has been on bed rest following an injury. Which of the following assessments indicates that the patient is experiencing complications of immobility?
Mental confusion
A parent of a 9-year-old brings the child into the emergency department with a possible food allergy reaction. Which of the following symptoms in a child of this age group would the nurse expect to assess?
Wheezing and stridor