Exam 1 - Med Surg 2
When evaluating a client's knowledge about use of antihistamines, which of the following statements made by the patient would indicate to the nurse a knowledge deficit?
"If I am pregnant, I should take half the dose." pg. 1040
The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?
Intradermal pg. 1033
Which of the following is considered the most serious manifestation of angioneurotic edema?
Laryngeal swelling pg. 1047
Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?
Liquids pg.
Which cells present the antigen to T cells and initiate the immune response?
Macrophages pg. 1030
What is the function of the thymus gland?
Programs T lymphocytes to become regulator or effector T cells. pg. 971
Which condition is associated with impaired immunity relating to the aging client?
Renal function decreases pg. 979
A client taking abacavir has developed fever and rash. What is the priority nursing action?
Report to the health care provider. pg. 1007
Patient teaching about mild allergic responses should include information about the onset of symptoms. The nurse tells the patient that if exposure to an allergen occurs around 8:00 AM, he should expect a mild or moderate reaction by what time?
10:00 AM pg. 1037
A patient comes to the clinic with pruritus and nasal congestion after eating shrimp for lunch. The nurse is aware that the patient may be having an anaphylactic reaction to the shrimp. These symptoms typically occur within how many hours after exposure?
2 hours pg. 1037
A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?
AIDS pg. 994
Which condition is associated with impaired immunity relating to the aging client?
Breakdown and thinning of the skin pg. 978
What organ is considered lymphoid tissue?
Spleen pg. 971
A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function?
Surgical removal of the appendix pg. 1556
The inflammatory response needs to be balanced so that what is helpful does not become harmful if mediators are secreted in excess. Which of the following are the primary mediators in an inflammatory response?
T cells and cytokines pg. 972
Which type of hypersensitivity reaction involves immune complexes forming when antigens bind to antibodies?
Type III pg. p. 1032-1033.
A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse demonstrates a need for a review of transmission routes by identifying which body fluid as a means of transmission?
Urine pg.
A client with AIDS has become forgetful with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms
AIDS dementia complex (ADC) pg. 1012
During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess?
Acquired immunity pg.
While visiting the pediatric clinic with her 2 year old, a mother picks up a brochure about immunizations and asks about active and passive acquired immunity to childhood diseases. The nurse explains that immunizations are which of the following and why?
Active acquired immunity, because the person's own body develops defenses pg. 972
A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected?
Assess for ataxia using the finger-to-nose test and heel-to-shin test pg. 979
A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have?
The nurse ensures a written consent is obtained prior to testing. pg. 1005
A client with chronic mucocutaneous candidiasis, an autosomal recessive disorder, asks the nurse, "Will my children have this disease?" Which response by the nurse is appropriate?
"All of your children will be carriers of the recessive gene but may not develop the disease." pg. 990
A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?
"Although AIDS is an immune deficiency, your child's condition is different from AIDS." pg. 994
A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?
"I can eat whatever I want as long as it's low in fat." pg. 995
A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse?
"It is important that you continue to take your medication to avoid an acute exacerbation." pg. 1056
The nurse is working with a parent whose child has just been diagnosed with selective immunoglobulin A deficiency. The parent asks the nurse, "Does this mean that my child is going to die?" How should the nurse respond?
"Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract." pg. 987
There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency.
"Your immune system was most likely affected by an underlying disease process." pg. 994
A patient with HIV has been on antiretroviral therapy (ART) for 6 months. The patient comes to the clinic with home medications and the nurse observes that there are too many pills in the container. What does the nurse know about the factors associated with nonadherence to ART? (Select all that apply.)
- Active substance abuse - Depression - Lack of social support pg. 1006
Which assessment finding(s) are likely to cause noncompliance with antiretroviral treatment? Select all that apply.
Active substance abuse pg. 1006
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?
Administer epinephrine, as ordered, and prepare to intubate the client, if necessary. pg. 1037
When do most perinatal HIV infections occur?
After exposure during delivery pg. 1000
The nurse is evaluating a client's readiness for allergy skin testing. The nurse determines that the testing will need to be postponed when it is revealed that the client took which classification of medication the night before?
Antihistamine pg. 1036
A client has been having joint pain and swelling in the left foot and is diagnosed with rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and the client has significant joint destruction. What type of disease is this considered?
Autoimmune pg. 1054
A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid:
Avoid alcohol pg. 1041
Your client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?
Avoid antihistamines and cold preparations for 48 to 72 hours before the test.
Which of the following would the nurse prioritize as the most important action for the patient to take to prevent anaphylaxis?
Avoid potential allergens pg. 1037
The nurse is evaluating the plan of care for a client with an allergic disorder who has a nursing diagnosis of deficient knowledge related to measures for allergy control. Which of the following would indicate to the nurse that the outcome has been met?
Client identifies methods for reducing exposure risk to allergens. pg. 1043
More than 50% of individuals with this disease develop pernicious anemia:
Common variable immunodeficiency (CVID) pg. 990
Which of the following is associated with impaired immunity in the aging patient?
Decreased renal function pg. 979
A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring?
Delayed hypersensitivity response pg. 1038
A client presents to the clinic with complaints that he began to itch and break out in hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?
Diphenhydramine pg. 1047
A client calls the clinic and asks the nurse if using oxymetazoline nasal spray would be alright to relieve the nasal congestion he is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications?
Do not overuse the medication as rebound congestion can occur. pg. 1040
When assessing the skin of a client with allergic contact dermatitis, the nurse would most likley expect to find irritation at which area?
Dorsal aspect of the hand pg. 1046
A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?
Dyspnea, bronchospasm, and/or laryngeal edema. pg. 1037
When a patient experiences an allergic reaction, the nurse should initially assess for:
Dyspnea, bronchospasm, and/or laryngeal edema. pg. 1038
The nurse is obtaining a medication history from a patient with allergic rhinitis. The patient states, "I've been on numerous medications over the years and nothing seems to work. Plus I get so tired and sleepy from them." The nurse documents the medications used in the patient's medical record: Diphenhydramine 50 mg orally twice a day Hydroxyzine 25 mg orally three times a day Chlorpheniramine 4 mg orally every 6 hours Fexofenadine 60 mg orally twice a day When reviewing the list, which medication would the nurse identify as causing the least sedation?
Fexofenadine pg. 1041
When administering intravenous gamma globulin infusion, the nurse recognizes that which of the following complaints, if reported by the client, may indicate an adverse effect of the infusion?
Flank pain pg. 991
Nursing students are reviewing various medications that can be used to treat allergic disorders. The students demonstrate understanding of the information when they identify which of the following as an intranasal corticosteroid?
Fluticasone pp. 1040-1041.
T-cell deficiency occurs when which gland fails to develop normally during embryogenesis?
Thymus pg. 992
A client with AIDS is brought to the clinic by their family. The family. The family tells the nurse that the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?
HIV encephalopathy pg. 1012
When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic?
HIV-1 is more prevalent than HIV-2 subtypes pg. 1004
Which term refers to an incomplete antigen?
Hapten pg. p. 1029-1030.
A nurse practitioner working in a dermatology clinic explained to a group of nursing students that the pathophysiology of an allergic response involves a chain of events that includes responses from lymphocytes, IgE, mast cells, and basophils. The nurse mentioned that the most important chemical mediator involved in the response is:
Histamine. pg. 1030
A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. Which of the following would the nurse identify as a common cause of anaplhylaxis? Select all that apply?
Milk, Eggs and Shrimp pg. 1037
A mother has brought her child to the clinic for a wellness check. While talking with the nurse, the mother asks the nurse to suggest a diet that will maximize the immune function of her growing children. What dietary pattern should the nurse suggest?
Moderate diet that is balanced and varied pg. 980
A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed?
Pernicious anemia pg. 988
A majority of clients with CVID develop which type of anemia?
Pernicious pg. 990
A mother brings her young child to the clinic for an evaluation of an infection. The mother states, "He's been taking antibiotics now for more than 2 months and still doesn't seem any better. It's like he's always sick." During the history and physical examination, which of the following would alert the nurse to suspect a primary immunodeficiency?
Ten ear infections in the past year pg. 989
Reproductive health education for women who are HIV-positive includes recommending which of the following contraceptives?
The female condom pg. 1000
Telangiectasia is the term that refers to
Vascular lesions caused by dilated blood vessels pg. 992
The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. A clinical manifestation is telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what?
Vascular lesions caused by dilated blood vessels pg. 992
Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?
Vascular lesions pg. 992
What test will the nurse assess to determine the client's response to antiretroviral therapy?
Viral load pg. 1005
A client is scheduled to begin immunotherapy. The nurse would explain that the client will receive injections initially at which interval
Weekly pg. 1043
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:
Western blot test for confirmation of diagnosis. pg. 1005
The majority of patient with primary immunodeficiency are in which age group?
Younger than 20 pg. 987
The nurse has four clients that come to the clinic for healthcare. Which client has the highest risk factor for HIV infection?
a 26-year-old inmate who receives tattoos in prison p. 1000-1001.
A treatment option for severe combined immune deficiency (SCID) includes
a stem cell transplant. pg. 992
Which allergic reaction is potentially life threatening?
angioedema pg. 1048
The best treatment for latex allergy is
avoidance of latex-based products. pg. 1051
A client has begun sensitivity testing to determine the allergen which caused an anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more sensitive to allergens?
back pg. 1035
Kaposi sarcoma (KS) is diagnosed through
biopsy. pg. 1011
A nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate?
candidiasis pg. 1016
What types of cells are the primary targets of the healthy immune system? Select all that apply.
infectious cells foreign cells cancerous cells pg. 970
A nurse knows that more than 50% of clients with CVID develop the following disorder.
pernicious anemia pg. 990
The lower the patient's viral load,
the longer the survival time. pg. 1006
Ataxia refers to
uncoordinated muscle movement. pg. 992
A nurse is assessing a client with a primary immunodeficiency. Afterward the nurse documents that the client displayed ataxia. The nurse makes this documentation because the client has
uncoordinated muscle movements. pg. 992
A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which of the following symptoms? Choose all that apply.
• Shaking chills • Flank pain • Tightness in the chest pg. 991
Contact dermatitis is considered a type IV hypersensitivity reaction. The nurse is aware that this classification is characterized by which of the following?
A delayed-type hypersensitivity that is mediated by T cells pg. 1046
The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed?
"I can take my child to the beach, as long as we play in the sand rather than swim in the water." pg. 995
The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed?
"I will be sure to eat lots of fresh fruits and vegetables every day." pg. 995
A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?
"If I notice tingling in my lips or mouth, gargling may help the symptoms." pg. 1043
A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response
"It is a hyperimmune response to something in the environment that is usually harmless." pg. 1030
A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?
"It is a hyperimmune response to something in the environment that is usually harmless." pg. 1030
A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse?
"The full benefit of the medication may take up to 2 weeks to be achieved." pg. 1041
The nurse receives a phone call at the clinic from the family of a patient with AIDS. They state that the patient started "acting funny" after complaining of headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?
"The patient may have cryptococcal meningitis and will need to be evaluated by the physician." pg. 1012
A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which statement?
"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling." pg. 992
When a nurse infuses gamma globulin intravenously, the rate should not exceed
3 mL/min. pg. 991
The nurse is caring for a client experiencing an anaphylactic reaction. The nurse prepares for the maximum intensity of histamine response to occur within which time frame?
5 to 10 minutes pg. 1030
The patient presents to the health care provider's office with an allergic reaction. The doctor documents the patient's condition as a nonatopic, IgE-mediated response. The nurse knows that the reaction is:
A latex allergy. pg. 1036
A 10-year-old boy has been brought to the emergency department (ED) by ambulance in apparent anaphylaxis after accidentally eating a snack bar that contained peanuts. The ED nurse should be aware that this patient's signs and symptoms are attributable to:
A massive release of histamine
A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do?
Administer epinephrine. pg. 1037
What nursing intervention helps reduce itchiness or prevent the client from scratching the skin would you institute with a client who has an allergic reaction and tends to itch due to histamine release?
Advise the client to use distracting techniques. pg.
Which of the following is the most severe form of hypersensitivity reaction?
Anaphylaxis pg. 973
The nurse is creating a discharge teaching plan for a client with a latex allergy. Which information should be included? Select all that apply.
Avoidance of latex-based products Administration of antihistamines Administration of emergency epinephrine pg. 1051
Which of the following cell types are involved in humoral immunity?
B lymphocytes pg. 972
A client with a history of allergic rhinitis comes to the clinic for an evaluation. The client is prescribed triamcinolone. Which of the following would the nurse include when teaching the client about this drug?
Be aware that some nasal burning and itching may occur. pg. 1040
Students are reviewing information about hypersensitivity disorders in preparation for class discussion the next day. The students demonstrate understanding of the material when they identify which of the following as a type IV hypersensitivity disorder?
Contact dermatitis pg. 1046
The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response?
Corticosteroids pg. 1502
A client with allergic rhinitis is prescribed a mast cell stabilizer. Which of the following would the nurse expect to be used?
Cromolyn sodium pg. 1040
A client suspected of having HIV has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?
ELISA pg. 1005
Injected allergens are used for "hyposensitization" and may produce systemic reactions that can be harmful. Which of the following medications should be on hand in case of an adverse reaction?
Epinephrine pg. 1043
A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells?
Epoetin alfa (Epogen) pg. 897
A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?
For their immunosuppressant effects pg. 982
The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?
Lymphoid tissues pg. 970-971.
Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?
Histamine pg. p. 1029-1030
A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen?
IV gamma globulin administration pg. 992
Nursing students are reviewing information about the various types of primary immunodeficiencies. The students demonstrate understanding of the material when they identify which of the following as an example of a primary immunodeficiency involving B-lymphocyte dysfunction?
IgA deficiency pg. 987
A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?
IgE pg. 1030
When describing the immunoglobulin most likely involved with allergic reactions, which of the following would the nurse address?
IgE pg. 1030
There are several types of reactions to latex. The nurse knows to be most concerned about laryngeal edema with the following reaction:
IgE-mediated hypersensitivity. pg. 1049
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. Which of the following would the nurse expect to be started?
Immunosuppressive agents pg. 992
After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which of the following?
Jabs the autoinjector into the outer thigh at a 90-degree angle pg. 1039
The nurse is aware that the most prevalent cause of immunodeficiency worldwide is
Malnutrition pg. 994
A nurse is preparing an in-service presentation about primary immunodeficiencies. When describing these conditions, which of the following would the nurse need to integrate into the presentation?
Most cases are typically diagnosed in infancy pg. 987
Histamine release in anaphylaxis causes which of the following?
Nasal congestion pg. 1030
Ataxia-telangiectasia is a disorder characterized by the following. Choose all that apply.
Neurologic symptoms that usually occur before 5 years of age IgA deficiency in 40% of individuals pg. 992
A patient has had a "stuffy nose" and obtained Afrin nasal spray. What education should the nurse provide to the patient in order to prevent "rebound congestion"?
Only use the Afrin for 3 to 4 days once every 12 hours. pg. 1040
Health teaching about food allergies includes advising patients about the food products that cause the most severe reactions and result in the highest patient death rates. Which of the following foods fit that category?
Peanut and tree nuts pg. 1048
What is the most common cause of anaphylaxis?
Penicillin pg. 1036
A patient is suspected to have an immunodeficiency disorder. The physician orders a nitroblue tetrazolium reductase (NTR) test to diagnose this patient. What does the nurse suspect that this disorder is related to?
Phagocytic cells pg. 988
A patient is admitted with an infected leg, and the nurse notes an increase in his white blood cell (WBC) count. The nurse is aware that, during the immune response, pathogens are engulfed by WBCs that ingest foreign particles. What is this process known as?
Phagocytosis pg.
Which type of contact dermatitis requires light exposure in addition to allergen contact?
Photoallergic pg. 1046
Preventive health education includes informing patients about the symptoms associated with allergic rhinitis. The nurse is aware that the most common trigger to this respiratory allergic response is:
Plant pollen. pg. 1038
During which stage of the immune response does the circulating lymphocytes containing the antigenic message return to the nearest lymph node?
Proliferation pg. 973
Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy?
Respiratory or urinary system infections pg. 994
An infant is born to a mother who had no prenatal care during her pregnancy. What type of hypersensitivity reaction does the nurse understand may have occurred?
Rh-hemolytic disease pg. 1032
A client comes to the clinic reporting nasal congestion and states, "I've been using an over-the-counter nasal spray that seemed to help at first, but then I got even more congested than before I started the medication. I continued the nasal spray, but it seems to be worse." The nurse suspects which of the following?
Rhinitis medicamentosa pg. 1044
A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines?
Sedation pg. 1040
The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply.
Semen Breast milk Blood Vaginal secretions pg. 1021
A patient with a history of allergies comes to the clinic for an evaluation. The following laboratory test findings are recorded in a patient's medical record: Total serum IgE levels: 2.8 mg/mL White blood cell count: 5,100/cu mm Eosinophil count: 4% Erythrocyte sedimentation rate: 20 mm/h The nurse identifies which result as suggesting an allergic reaction?
Serum IgE level pg. 1033
The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction?
Symptoms are localized to the area of exposure, usually the back of the hands. pg. 1050
The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? Select all that apply.
The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle. pg. 1006
The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis?
The injection area swells if the client has developed antibodies against the antigen. pg. 588
The nurse is conducting a community education program on allergies and anaphylactic reactions. The nurse determines that the participants understand the education when they make which statement about anaphylaxis?
The most common cause of anaphylaxis is penicillin. pg. 1036
Allergy testing has revealed that an elementary school-aged child has a severe hypersensitivity to insect stings. When conducting health education with the child's parents, the nurse should address which of the following subjects?
The need for the child to carry an EpiPen
What education should the nurse provide to the patient taking long-term corticosteroids?
The patient should not stop taking the medication abruptly and should be weaned off of the medication. pg. 1042
A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately?
Tickle in the throat pg. 991
When the nurse administers intravenous gamma-globulin infusion, she recognizes that which symptom, if reported by the client, may indicate an adverse effect of the infusion?
Tightness in the chest pg. 991
A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?
Type I pg. 1032
A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in her teaching plan?
Use a topical skin moisturizer daily. pg. 1047
A client is given a nursing diagnosis of social isolation related to withdrawal of support systems and stigma associated with AIDS. Which outcomes would indicate that the nurse's plan of care was effective? Select all that apply.
• Client demonstrates beginning participation in events and activities. • Client identifies appropriate sources of assistance and support. • Client verbalizes feelings related to the changes imposed by the disease. pg. 1020
A client with AIDS is exhibiting shortness of breath, cough, and fever. The nurse most likely would suspect infection with which of the following?
Pneumocystis jiroveci pg. 1010
A nurse comes to the employee health center for evaluation and is diagnosed with allergic contact dermatitis related to latex. Which of the following would the nurse most likely exhibit?
Blistering pg. 1051
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
Bone marrow transplantation pg. 992
A client with an allergic disorder calls the nurse and asks what treatment is available for allergic disorders. The nurse explains to the client that there is more than one treatment available. What treatments would the nurse tell the client about?
Desensitization pg. 1042
A client is diagnosed with common variable immunodeficiency (CVID). When assessing the client for possible infection, which of the following would the nurse identify as a least likely cause?
Pneumocystis jiroveci pneumonia pg. 990
The nurse completes a history and physical assessment on a patient with AIDS who was admitted to the hospital with respiratory complications. The nurse knows to assess for the most common infection in persons with AIDS (80% occurrence). This is:
Pneumocystis pneumonia. pg. 1010
Which intervention is the single most important aspect for the client at risk for anaphylaxis?
Prevention pg. 1037
Which of the following is a contraindication for immunotherapy?
Use of a beta-blocker pg. 1042
When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask?
"Have you ever received a blood transfusion?" pg. 982
A nurse is explaining treatment options to a client diagnosed with an immune dysfunction. Which statement by the client accurately reflects the teaching about current stem cell research?
"Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, and clinical trials using stem cells are underway in clients with a variety of disorders with an autoimmune component." pg. 978
A client is informed that his white blood cell count is low and that he is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse?
"White blood cells are produced in the bone marrow." pg. 970
A client comes in to get an EIA test done because the physician suspects AIDS. Which nursing action is essential before an EIA test is performed?
. Obtaining a general consent for medical care from the client pg. 1005
Antiretroviral medications should be offered to clients with T-cell counts less than
350 cells/mm3. pg. 1006
A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when he schedules a return visit for viral load testing at which time?
6 weeks pp. 1005-1006.
The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?
A 65-year-old client who had chicken pox when he was 12 years old pg. 1779
A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?
A cell-mediated response pg. 971
When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following?
Antibodies to HIV are not present in his blood. pg. 1005
When an attenuated toxin is administered to a client, the B lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this?
Artificially acquired active immunity pg.
A patient receiving antiretroviral therapy is complaining of "not urinating enough." What is the nurse's best action?
Assess BUN and creatinine. pg. 1006
The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care?
Assist with chest physiotherapy every 2 to 4 hours. pg. 1018
A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?
Assure the client that this is a normal reaction pg. 984
A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise?
Avoid fibrous foods, lactose, fat, and caffeine. pg. 1023
An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response?
B lymphocytes produce antibodies that are specific to the pathogen. pg.
A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client?
Bank autologous blood. pg. 890
You are working on a transplant unit and you know to carefully monitor your clients. What is the rationale for closely monitoring clients taking immunosuppressive drugs?
Because of an increased risk of respiratory or urinary system infection pg.
Which is usually the most important consideration in the decision to initiate antiretroviral therapy?
CD4+ counts pg. 1006
The nurse practitioner who is monitoring the patient's progression of HIV is aware that the most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is:
Chronic diarrhea. pp. 1010-1011.
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications?
Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive. pg. 978
There are many ethical issues in the care of clients with HIV or HIV/AIDS. What is an ethical issue healthcare providers deal with when caring for clients with HIV/AIDS?
Disclosure of the client's condition pg. 1025
A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which of the following reasons?
Exposure to foreign antigens may cause altered immune function. pg. 982
A patient has received the results of his HIV antibody test, which is positive. The nurse explains that this result means that:
He has been infected and has produced antibodies. pg. 1005
Which condition is an early manifestation of HIV encephalopathy?
Headache pp. 1011-1012.
Which of the following indicates that a client with HIV has developed AIDS?
Herpes simplex ulcer persisting for 2 months pg. 999
Which of the following protective responses begin with the B lymphocytes?
Humoral pg. 972
A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find?
Hypokalemia pg. 1015
A patient in the clinic states, "My boyfriend told me he went to the clinic and was treated for gonorrhea." While testing for the sexually transmitted infection (STI), what else should be done for this patient?
Inform the patient that it would be beneficial to test for HIV. pg. 1005
The Family Nurse Practitioner is conducting a physical examination of a client with an immunity disorder. What would be an important parameter to examine?
Inspect the pharynx for large, red tonsils.
Which substance may be used to lubricate a condom?
K-Y jelly pg.
The nurse teaches the client that reducing the viral load will have what effect?
Longer survival pg. 1005
A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?
Lymphocyte pg. 973
A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:
Lymphocytes migrate to areas of the lymph node pg. 973
The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents?
Macrophages pg. 972
The nurse advises a patient who has received a negative test result from his HIV antibody test that he:
May be infected but antibodies are not currently present. pg. 1005
A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?
Natural immunity pg. 971
A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?
Naturally acquired active immunity pg.
An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?
Naturally acquired active immunity pg. 972
Which type of immunity becomes active as a result of infection by a specific microorganism?
Naturally acquired active immunity pg. 972
Which type of cells destroys antigens already coated with antibody?
Null pg. 976
Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment?
Past substance abuse pg. 1006
A client with HIV will be started on a medication regimen of three medications. What drug will the nurse instruct the client about?
Reverse transcriptase inhibitors p. 998, 1006.
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as containing the genetic viral material?
Ribonucleic acid (RNA) pg. 1003
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Risk for injury pg. 1012
The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following?
Serum, which depletes the body's store of immunoglobulins pg. 982
You are caring for a client who has a diagnosis of HIV. Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications?
Side effects of drug therapy pg. 1024
Cryptococcus meningitis is suspected in a client with HIV. Which of the following would be consisted with cryptococcus meningitis? Select all that apply?
Stiff neck and seizures pg. 1012
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?
Stool specimen for ova and parasites pg. 1011
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
The client appears mildly ill, listless, and disheveled. pg. 65
The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm³, and the client has been diagnosed with pneumocystis pneumonia. What does this indicate to the nurse?
The client has converted from HIV infection to AIDS. pg. 1010
A 64-year-old male client, who leads a sedentary life-style, and a 31-year-old female client, who has a very stressful and active life-style, require a vaccine against a particular viral disorder. As the nurse, you would know that in one of these clients the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?
The male client because of his age pg. 978
Which statement accurately reflects current stem cell research?
The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. pg. 978
A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection?
Trimethoprim-sulfamethoxazole pg. 1013
A client has been diagnosed with HIV and has been placed on antiretroviral therapy. What does the nurse inform the client will be required for determining the progression of the disease as well as guiding drug therapy?
Viral load and T4-cell counts will be performed every 2 to 3 months pg. 1006
A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test?
Western blot assay pg. 1005
The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?
interferons pg. 976
A client who is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication will the client take for the treatment of this infection?
trimethoprim-sulfamethoxazole pg. 1013
