Med -Surg - Chapter 31, 32, 66

The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the client?

"Can you tell me what concerns you most about dying?"

Which of the following is a medical condition that is an example of a humoral immune response?

Asthma

A nurse is caring for a client in the clinic. Which sign or symptom may indicate that the client has gonorrhea?

Burning on urination

Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy?

Respiratory and Urinary

When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask?

Blood transfusion?

Which condition is associated with impaired immunity relating to the aging client?

Breakdown and thinning of the skin

A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which reason?

Exposure to foreign antigens may cause altered immune function.

A client taking abacavir has developed fever and rash. What is the priority nursing action?

Report to HCP

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 appendix

The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses?

Immunosenescence

A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand?

Neutrophils

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?

T-cell lymphocytes survey proteins in the body and attack the invading antigens.

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."

A client has been admitted with primary syphilis. Which signs or symptoms should the nurse expect to see with this diagnosis?

A painless genital ulcer that appeared about 3 weeks after unprotected sex

Which of the following medications are used to suppress viral load of the HSV-2 infection?

Acyclovir (Zovirax)

A 47-year-old male client presented to the medical unit and the health care team suspects tuberculosis (TB). The nurse is admitting the client to a reverse isolation room. QuantiFERON testing and chest x-ray are pending. Urinalysis results are negative. No other testing was performed prior to admission to isolation. The client denies any chest pain, shortness of breath (SOB), or respiratory difficulty. The client presents with productive yellow sputum.

Airbourne precautions Sputum sample

Which of the following cell types are involved in humoral immunity?

B

Activation of a natural immunity response is enhanced by physical and chemical barriers. Which of the following is a physical barrier, which the nurse knows can be altered by illness, nutrition, or lifestyle?

Cilia of the respiratory tract

A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?

Foul-smelling discharge from the penis

The nurse educator is discussing pathogens responsible for various sexually transmitted infections. When teaching about bacterial vaginosis (BV), the nurse educator is correct when stating the overgrowth of which bacteria is responsible for this infection?

Gardnerella vaginalis

While caring for a patient with pneumocystis pneumonia, the nurse assesses flat, purplish lesions on the back and trunk. What does the nurse suspect these lesions indicate?

Kaposi's sarcoma

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 tissue

A client is admitted with cellulitis and experiences a consequent increase in white blood cell count. During what process will pathogens be engulfed by white blood cells that ingest foreign particles?

Phagocytosis

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?

Vascular lesions

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

A nurse would perform handwashing instead of using an alcohol-based product for which situation?

When hands are visibly soiled from client care

How often should women diagnosed with human papillomavirus (HPV) have Pap smears?

Yearly

A nurse knows that more than 50% of clients with CVID develop the following disorder.

pernicious anemia

An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking properly. When assessing the client for dehydration, the nurse would expect to find:

tachycardia

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

The nurse is instructing the family on home care of a client with shingles. The family member asks whether their teenage children should stay in a different room. What is the best response by the nurse?

"Have they had chickenpox or the varicella vaccine?"

The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported 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 client may have cryptococcal meningitis and will need to be evaluated by the health care provider."

An adolescent informs the school nurse that she is afraid of contracting an STI but her boyfriend does not want to use condoms. What is the best response by the nurse?

"The use of condoms is one of the best ways to reduce the risk of acquiring an STI."

What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response?

Corticosteroids

The nurse has admitted a new client to the unit. This client has an open draining sore on the leg. What diagnostic test would the nurse anticipate being ordered?

Culture and Sensitivity

The nurse is assessing a client in the emergency department who grimaces and reports swelling of the testicles, burning on urination and a green discharge from the penis. The nurse suspects the client will be diagnosed with which infection?

Gonnorhea

A woman infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV?

Gynecologic problems

When describing the effects of treatment for phagocytic cell disorders, which of the following would the nurse include as being the most successful?

Hematopoietic stem cell transplantation

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

The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?

Older client who previously had chicken pox

A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have?

Passive

The infection control nurse collects data that indicates an increase in the number of clients in the hospital with multidrug-resistant infections. What priority education should healthcare providers receive?

Performing hand hygiene

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells.

In the immune response cycle, lymphocytes interfere with disease by picking up specific antigens from organisms to alter their function during which stage of an immune response?

Proliferation

Painless chancres are associated with which systemic disease?

Syphilis

A client taking fosamprenavir reports "getting fat." What is the nurse's best action?

Teach the client about medication side effects

When a hospitalized client requires contact precautions, which responses is necessary?

The client should be placed in a private room when possible.

The nurse is assessing a client who reports stiff joints and alopecia. While taking the client's health history, the client reports having multiple sexual partners in the past 6 months and finding a lesion on her labia about 1 month before today's appointment. What should the nurse anticipate based on the signs and symptoms presented?

The client will require treatment for the secondary stage of syphilis.

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.

Telangiectasia is the term that refers to

Vascular lesions caused by dilated blood vessels

The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what?

Vascular lesions caused by dilated blood vessels

Kaposi sarcoma (KS) is diagnosed through

biopsy

Where are white blood cells produced?

bone marrow

A patient is being treated in the intensive care unit for sepsis related to ventilator-associated pneumonia. The patient is on large doses of three different antibiotics. What severe outcome should the nurse monitor for in the lab studies?

bone marrow suppression

Based on the nurse's base knowledge of primary immunodeficiencies, how would the nurse complete this statement? Primary immunodeficiencies

develop early in life after protection from maternal antibodies decreases.

The six elements necessary for infection include a causative organism, a reservoir of available organisms, a portal or mode of exit from the reservoir, a mode of transmission from reservoir to host, a susceptible host, and

mode of entry into the host

The nurse teaches the parent of a child with chickenpox that the child is no longer contagious to others when

the vesicles and pustules have crusted.

A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

thirst or irritability.

The nurse is meeting with the mother of an 11-year-old girl to provide decision making support and education regarding human papillomavirus (HPV) vaccination. The mother states, "I am confused about why my 11 year old needs to be protected from a sexually transmitted infection. She is so young and not sexually active. Why does she need the vaccination now?" What is the nurse's best response?

"The vaccination helps to prevent cervical cancer in adult women. It works better if she has it before she becomes sexually active. Let's talk about some of the concerns you have about the vaccination"

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."

During flu season, a nurse is teaching clients about the chain of infection. What components are considered "links" in this chain? Select all that apply.

Agent> host > entry

A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?

An induration of 12mm

A client has been diagnosed with acquired immune deficiency syndrome (AIDS). Which statement correctly describes a secondary immune deficiency?

An interference develops in an already developed immune system.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?

An isolation room three doors from the nurses' station

A long-term care facility is the site of an outbreak of infectious diarrhea. The nurse educator has emphasized the importance of hand hygiene to staff members. The use of alcohol-based cleansers may be ineffective if the causative microorganism is identified as what?

C-diff

A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used?

Digestive enzymes destroy its protein structure.

Which blood test confirms the presence of antibodies to HIV?

Enzyme-linked immunosorbent assay (ELISA)

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?

Epogen

A group of students are reviewing class material on sexually transmitted infections in preparation for a test. The students demonstrate understanding of the material when they identify which of the following as the cause of condylomata?

Human papilloma virus

The nurse is admitting a patient with severe diarrhea. What is the most important element of assessment for this patient?

Hydration status

Which of the following is a lack of one or more of the five immunoglobulins?

Hypogammaglobulinemia

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?

Immunosuppressive agents

The nurse is caring for a client with genital herpes experiencing a reoccurrence. Which nursing diagnosis would be the priority?

Impaired Skin Integrity

A 2-year-old is brought to the clinic by her mother who tells the nurse her daughter has diarrhea and the child is complaining of pain in her stomach. The mother says that the little girl had not eaten anything unusual, consuming homemade chicken strips and carrot sticks the evening prior. Which bacterial infection would the nurse suspect this little girl of contracting?

Salmonella

The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (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 each medication

Which organism is responsible for impetigo?

Staphylococcus aureus

A client suspected of having human immunodeficiency virus (HIV) asks the nurse what causes AIDS. What is the best response by the nurse?

The human immunodeficiency virus

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.

A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. What client need should in the nurse focus on when planning this client's care?

fluid replacement

A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to:

infection because the spleen removes bacteria from the blood.

What does the nurse understand will result if the patient has a deficiency in the normal level of complement?

Increased susceptibility to infection

The nurse is completing the admission assessment on a client with renal failure. The client states, "I was diagnosed with impetigo yesterday." Which is the appropriate nursing intervention?

Initiate contact isolation protocol.

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

A nurse is preparing an in-service presentation about primary immunodeficiencies. When describing these conditions, what would the nurse need to integrate into the presentation?

Most cases are typically diagnosed in infancy.

A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client?

diarrhea and abdominal pain

A nurse is caring for a male client with gonorrhea. The client asks how he can reduce his risk of contracting another sexually transmitted disease (STD). The nurse should instruct the client to:

wear a condom every time he has intercourse.

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

A client at the walk-in clinic reports exposure to human immunodeficiency virus (HIV). The client wants to know the precise sources through which the HIV infection is transmitted. What is the nurse's best response?

Semen

Nursing students are reviewing information about infectious diseases and events associated with infection. Students demonstrate understanding of the information when they identify the incubation period as which of the following?

Time between exposure and onset of symptoms

Why would it be important for the nurse to question the client about sexual practices, history of substance use disorder, and the client's lifestyle during the interview process?

To determine if the client has practices that the client at risk for acquired immunodeficiency syndrome (AIDS)

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 symptoms? Select all that apply.

Flank pain, shaking chills, tightness in the chest.

After teaching a group of students about sexually transmitted infections (STIs), the instructor determines that additional teaching is necessary when the students identify which STI as curable with treatment?

Genital herpes