Davis 19/22 Caring for Patients with immune Disorders
A patient exposed to pollen dust is seen at the medical clinic with acute symptoms of dyspnea and shortness of breath. Which other symptoms might the nurse observe in this patient? Select all that apply.
1. Angioedema 2. Hoarseness and stridor 3. Swelling below surface of skin around mouth/eyes
The nurse is caring for a patient with Graves' disease. Arrange the events in the order that they lead to this condition.
1. Autoantibody binds to thyroid stimulating hormone receptor site 2. binding results in continual stimulation of thyoid cells 3. thyroid hormone is produced 4. normal feedback system doesn't work 5. Patient exhibits severe herthyroidism
A patient who is exposed to animal dander reports nasal discharge and watering eyes. The nurse observes edema around the mouth and eyes. Which medications would be most beneficial in relieving the patient's symptoms? Select all that apply.
1. Decongestants 2. Antihistamines
The nurse is reviewing the laboratory and diagnostic reports of a patient with allergic rhinitis. Which findings of the patient support the diagnosis?
1. Eosinophils 8% 2. Positive reaction for scratch tests
A student nurse obtains a used needle stick during a clinical rotation. After a Rapid HIV test is negative, the student asks the progression of the HIV illness should the virus have been contracted. List the sequence of events in order based on the illness progression.
1. Viral Transmission 2. Acute viral infection 1-2 weeks 3. Seroconversion 4. Asymptomatic chronic infection 5. Symptomatic/AIDS 6. Death
The nurse is teaching a patient diagnosed with type IV hypersensitivity. Which statements made by the patient indicate effective teaching? Select all that apply.
1. Wear medical alert bracelet 2. Use Epi injection if there is an allergic response
The nurse is starting a patient on chemotherapy. What is the priority teaching point for the patient and family? Select all that apply.
1. hand washing 2. refrain from having turtles/reptiles 3. Take antibiotics/antivirals
During an annual visit a client with in the asymptomatic stage of HIV says "I'm not sure if I want to go on. My lover has left me and I'm afraid to be near anyone. I feel like a recluse. It doesn't seem like life is worth living anymore." How should the nurse respond? Select all that apply.
1. have you thought about hurting yourself 2. I can tell you feel alone 3. Do you have friends or family that you are close too
The nurse is caring for a patient receiving immunosuppressive therapy. Which assessment findings indicate the presence of an infection? Select all that apply.
1. hypotension/tachycardia 2. increased leukocytes 3. adventitious breath sounds 4. Lesions on skin
The nurse is making assignments for the nursing unit considering priorities for infection control. Which patient should not be assigned to the nurse caring for a patient with a contagious infectious disease?
1. undergoing chemo 2. receiving radiation therapy 3. kidney transplant 4. surgical removal of spleen
The nurse is preparing to provide care for a client with symptomatic chronic infection of HIV. Which actions should the nurse take in planning care? Select all that apply.
1.hand washing 2.ensure drugs are administered 3.small, frequent meals 4.nonjudgemental 5.provide referals to social services
A client and his partner come to the clinic explaining that they are having a hard time remembering to take for all of the HIV medications that have been prescribed. They ask if they can eliminate one or two. What should the nurse explain about antiretroviral therapy?
Adherence rate of greater or equal to 95% is essential to achieve viral suppression
The nurse is teaching a client with HIV about opportunistic infections (OI). Which statement should be included in the teaching session? Select all that apply.
Avoid toxoplasmosis by not cleaning litter box Avoid 3rd world travel and large crowds to prevent TB Use condoms during sexual encounters to avoid syphilis
The nurse is teaching a client with AIDS about the importance of compliance with the prescribed multi-drug therapy. Which statement best explains why more than one antiretroviral medication is necessary?
Combination of meds keeps the virus from reproducing
The nurse is caring for a patient with a latex allergy. Which action should the nurse take to prevent a reaction?
Cover skin with cloth before applying BP cuff
The nurse in the emergency department is caring for a newly admitted patient. Analyze the information and determine which priority action the nurse should take at 1030.
Deliver the Epi dose
A nurse checks the medication administration record of a client with HIV and finds that protease inhibitors (PIs) have been prescribed. Which adverse effects should the nurse be monitoring for? Select all that apply.
Diabetes mellitus Hyperlipidemia Lipodystrophy
A young adult tells the nurse, "My roommate is HIV-positive. What precaution should I take so that I do not get the infection?" What should the nurse tell the client?
Do not share personal grooming items
A neighbor approaches a nurse asking about a "quick test" for HIV diagnosis. What should the nurse explain about the Rapid Test?
Done quickly to assess for presence/absence of HIV antibodies
A nurse is accidentally stuck with a needle used on an HIV-positive client. Which action of the nurse is most important for the nurse to take?
Ensure that an HIV test is conducted to ascertain seropositivity
A nurse is working at a booth at a community wellness fair and focusing on prevention of transmission. Which comment made by a participant requires correction?
HIV is seldom transmitted through IV drug use
A nurse is teaching a serodiscordant couple about safe HIV practices for prevention of transmission and early intervention of progression. Which statements should the nurse include? Select all that apply.
Important to use condoms Avoid eating raw eggs,meat ect S/S of disease
Which is true regarding viral load of HIV? Select all that apply.
It reflects the amount of viral replication Indicator of disease progression Inversely related to CD4+ lymph count
As the nurse performs an assessment on a client with AIDS, a rash is found (in the image). How should the nurse document the findings?
Lesions of Kaposi's sarcoma on the left shoulder and upper chest
The nurse caring for a patient with immune suppression from chemotherapy. Which protective device is most appropriate to wear into the patient's room when performing care? (surgical mask/googles/mask with eye protection)
Mask on left
A nurse is caring for a client newly diagnosed with HIV. Which statement by the client is most concerning?
My nurse was talking with another nurse outside my door and wondering if im bi-sexual
Which is a clinical manifestation of mycobacterial infection in an HIV-positive client?
Night sweats
The nurse is caring for a client with HIV, at the clinic for a routine exam. The client's weight is recorded below. What action should the nurse take next? 36 months ago: 178. 24 months ago: 175. 12 months ago: 173 Today: 152
Notify provider
The nurse on the medical unit is caring for a postoperative patient. Analyze the information and determine which priority action the nurse should take next.
Oxygen 100% nonrebreather mask
The nurse is caring for a patient with hay fever. The nurse identifies the condition as type I hypersensitivity reaction. What does this indicate?
Patient has develop rapid allergic reaction
A client with HIV arrives at the clinic with a fever of 101ᵒ F, a nonproductive cough, and fatigue. The client's CD4+ count is 184 cells/μL. How should the nurse interpret these findings?
Patient is disgnosed with AIDS
The condition of a patient with type I hypersensitivity progresses to anaphylactic shock and then respiratory arrest. Which intervention is of highest priority for this patient?
Performing endotracheal intubation
The nurse observes that an HIV-positive client has dyspnea on exertion, but the symptom is absent when the client is at rest. Which situation would cause these symptoms?
Pneumocystis carinii pneumonia
A nurse is listing the immunizations that an HIV-infected client should receive. Which statement is correct?
Pneumovax is given to an HIV-postive client with CD4+ greater than or equal to 200 every 5 years
An HIV-positive client with a CD4+ count of 225 comes to the clinic for an annual appointment and immunizations. Which immunization(s) should the nurse give today?
Pneumovax/Influenza vaccine
A patient diagnosed with anaphylaxis is treated with a beta agonist to decrease bronchospasms. Which assessment finding indicates effective outcome of the treatment?
RR 16 breaths/min
What is the first intervention that should be provided to treat a type III hypersensitivity reaction?
Removal of the offending medication
The nurse is admitting a male patient with immunosuppression to the medical-surgical unit. Which room would be the best to assign?
Room 204-A (Older male with COPD exacerbation)
The charge nurse is admitting a young-adult client with symptomatic chronic HIV infection. Which room should the client be assigned?
Room 448 (middle aged adult with appendicitis)
A patient has developed contact dermatitis from a latex allergy. Which treatment is most beneficial for this patient?
Skin creams containging steroids
The nurse is caring for a client with this skin condition. What is the earliest stage of HIV infection are they experiencing (pic not included)
Symptomatic chronic infection
The nurse is caring for a client with HIV. During ambulation, the client says, "I don't understand why I get so winded when I walk." How should the nurse reply?
The oneumocystis carinii pneumonia often causes shortness of breath with activity
A patient client with a hemoglobin of 6.2 g/dL who has type A blood receives blood from a donor with type AB blood. Which type of hypersensitivity reaction will most likely be seen in this patient?
Type II
The nurse is delegating care of a client with HIV to an unlicensed assistive personnel (UAP). The client has pneumocystis carinii pneumonia and genital herpes. Which precautions should the UAP take when delivering the meal trays and taking vital signs?
Universal precautions
The nurse is assessing a client coming to the clinic for a routine visit. Which clinical finding indicates that the status of an HIV-positive client is deteriorating and needs additional exploring?
Weight loss greater than 10%