Med-surge Exam 1

When teaching a patient with HIV infection about transmission of the virus to others, which statement made by the patient would indicate a need for further teaching?

"I will need to isolate any tissues I use so as not to infect my family."

A patient was recently diagnosed with a sinus infection and prescribed a 10-day course of an antibiotic. After 3 days the patient felt back to normal and informed the nurse that he decided to stop the antibiotics and save the rest of the antibiotics in case he gets another infection. Which statement would the nurse include when providing education to the patient?

"If you are prescribed antibiotics, you should complete the entire course of treatment because you may create drug resistance by stopping early."

The nurse is teaching a patient with a latex allergy about preventing and treating allergic reactions. Which patient statement indicates a need for further teaching?

"My reactions are not severe; I will not need an EpiPen."

A pregnant woman is newly diagnosed with human immunodeficiency virus (HIV) infection is upset. What would the nurse teach this patient about her baby's risk of being born with HIV infection?

"Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection."

Which statement is most appropriate to include when teaching a patient ways to minimize the effects of seasonal allergic rhinitis?

"You should sleep in an air-conditioned room."

Factors associated with an increase in reemerging infections include

- international travel. - poor immunization rates. -poor sanitation standards. - not completing a full course of antibiotics.

The trajectory of chronic illness includes:

- period of crisis - episodes of exacerbations and stability -a gradual return to an acceptable way of life - symptoms that can be controlled by proper treatment

Which patients are at most risk for pressure injuries?

-A patient with right sided-paralysis and fecal incontinence -A young adult patient with paraplegia after a gunshot wound -A morbidly obese patient who has an open abdominal wound

The nurse is performing an assessment for an older adult patient suspected of elder mistreatment. Which assessment findings would lead the nurse to notify social services?

-Agitation -Depression -Weight loss -Hypernatremia

A patient is admitted to the emergency department (ED) with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. If the nurse suspects the patient is at risk for HIV infection, what nursing assessments will help identify HIV as the cause of the patient's manifestations?

-Assessment of sexual behavior -Assessment of drug and syringe use

A nurse is teaching a patient how to promote healing following abdominal surgery. What would be included in the teaching?

-Be sure to wash hands before changing the dressing to avoid infection. -Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. -Notify the health care provider of redness, swelling, and increased drainage.

A female patient with incontinence arrives early for appointments and social events so there is ready access to the restroom. Which task of the chronically ill is the patient demonstrating?

-Controlling the symptoms -Preventing social isolation -Preventing and managing a crisis

A healthy older adult patient requests a "flu shot" during an office visit. When assessing the patient, what other vaccinations would the nurse ask the patient about receiving?

-Shingles -Pneumonia

A heterosexual patient is concerned that they may contract human immunodeficiency virus (HIV) from a bisexual partner. What would the nurse include when teaching about preexposure prophylaxis?

-Use condoms for risk-reducing sexual relations. -Take emtricitabine and tenofovir (Truvada) regularly. -Have regular HIV testing for the patient and partner.

What would the nurse teach patients in an assisted living facility in order to decrease their risk for antibiotic resistant infection?

-Wash hands frequently. -Take antibiotics as prescribed. -Take the antibiotic until it is gone.

A nurse is discharging an older adult patient who is homeless. Which actions demonstrate the nurses understanding of the needs of this population:

-ask the patient if they have a social worker or case manager -inquires id the patient has concerns about staying in the local shelter -informs the patient that the hospital will call with his culture test results next week

A patient has a history of hypertension and type 1 diabetes. the patient exercises and eats a healthy diet. Which factors will most likely have a positive impact on biologic aging?

-exercise -social support -good nutrition -coping resources

Interventions to prevent health care-associated infections include

-following hand-washing protocols. -decontaminating equipment used for patient care.

When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods?

-grapes -bananas -potatoes -tomatoes

The patient asks the nurse why they need viral load testing. The nurse responds that an undetectable HIV viral load

-is the goal of HIV therapy. -means that someone is unable to sexually transmit HIV.

The nurse is caring for an older patient who has been receiving antiretroviral therapy (ART) for HIV infection for many years. The nurse is aware that complications of long-term ART use include

-osteoporosis. -insulin resistance. -cardiovascular disease.

Which patient has the greatest risk for delayed wound healing?

A 52-year-old obese woman with type 2 diabetes

Which patient would the nurse plan to administer round-the-clock antipyretic drugs?

A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F

A nurse is interested in providing care for persons with chronic illnesses. where would the nurse identify that most chronic illnesses are managed?

A community setting

Demographic trends among older Americans in the United States suggest:

A growth in racial and ethnically diverse populations

The nurse is supervising assistive personnel (AP) providing hygiene care to older adult residents in a care facility. What behavior indicates further AP education is required?

A negative attitude based on the age of the patient

The nurse is providing care for a patient who has been living with human immunodeficiency virus (HIV) infection for several years. Which assessment finding would the nurse recognize as being a sign of an acute exacerbation of the disease?

A sharp decrease in the patient's CD4+ count

A nurse is caring for an adult who sustained a severe traumatic injury following a motor vehicle accident. Which type of practice setting will the nurse prepare the patient for on discharge?

Acute rehabilitation

The nurse is developing a plan of care for an older adult patient. What must the nurse include in the plan of care?

Additional time related to declining energy reserves.

A patient with Alzheimer's disease has increased evidence of dementia and physical deterioration. Which would be the best assistance to recommend to the caregiver spouse who is exhausted?

Adult day care

The nurse teaches the staff that standard precautions would be used when providing care for which type of patient?

All patients regardless of diagnosis

Which patient is most at risk for developing a pressure injury?

An older patient who is septic, bedridden, and incontinent

A patient is diagnosed with chronic obstructive pulmonary disease (COPD). At what point should the nurse begin to include the patient's spouse in the teaching around the management of the disease?

As soon as possible

The assistive personnel (AP) is assisting the patient with Crohn's disease with perineal care. The AP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse?

Assess the patient and vaginal drainage.

What is the most appropriate nursing intervention to help patients with HIV adhere to their treatment plan?

Assess the patient's routines and find adherence cues that fit into their life circumstances.

Which action is aligned with the 4M model of am age-friendly health system?

Assessing if the patient needs a mobility device, such as a walker.

Which action is a priority for a newly admitted patient?

Assessing the patient's mental status

A patient has a compression dressing to promote healing of an ankle sprain. What is a priority nursing assessment?

Assessment of the patient's circulation distal to the location of the dressing

Association between HLA antigens and diseases is most often found in what disease conditions?

Autoimmune disorders

Which criterion must a 65-year-old person meet in order to qualify for Medicare funding?

Being entitled to social Security Benefits

Which order should a nurse question in the plan of care for an older adult, immobile stroke patient with a pink, clean stage 3 pressure injury?

Clean the wound daily with a cytotoxic solution.

A nurse was accidently stuck with a needle used on a patient with human immunodeficiency virus (HIV) infection. After reporting the incident, what care would the nurse receive first?

Combination antiretroviral therapy

The patient is diagnosed with vancomycin-resistant enterococci (VRE) infection in a surgical wound. What infection precautions would the nurse use to prevent transmission of the infection to others?

Contact precautions

A nurse who is providing care for an older adult patient recognizes the need to maximize the patient's mobility during recovery from surgery. What accurately describes the best rational for the nurse's actions?

Continued activity prevents deconditioning.

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend to promote wound healing?

Custard

An older adult patient is transferred from the nursing home with a black wound on the coccyx. What immediate wound therapy does the nurse anticipate providing the patient?

Debride the nonviable, eschar tissue to allow healing

A patient with human immunodeficiency virus (HIV) infection is being taught by the nurse about health promotion activities such as good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the reason for these interventions?

Delaying disease progression

A nurse is interviewing an older adult patient. What is the priority nursing action during the interview process?

Ensure all assistive devices are in place.

A patient who had a breast reduction arrives for a follow-up appointment at the clinic. The nurse, observing excess soft pink tissue at the surgical incision site, determines which complication is present?

Excess granulation tissue

A patient was exposed to the human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection?

Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea

The nurse manager has noted a recent increase in the number of hospital care-associated infections (HAIs) on the unit. Which nursing action would be a priority in response to this increase?

Frequent and thorough hand washing

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What early signs and symptoms will the nurse teach the patient to report that may indicate an infection?

General malaise and fatigue

A patient in the unit has a 103.7°F temperature. Which intervention would be most effective in restoring normal body temperature?

Giving antipyretics on an around-the-clock schedule

The nurse is teaching a community health class about the prevention of antibiotic-resistant infections. What would be included in the teaching plan?

Hand washing can prevent many infections.

A patient with systemic lupus erythematosus is receiving plasmapheresis to treat an acute attack. What assessment findings indicate that the patient has developed complications related to the procedure?

Hypotension, paresthesias, and dizziness

Newborns are protected for the first 3 months of life from bacterial infections because of the maternal transmission of

IgG.

An 85-year-old patient has a score of 16 on the Braden Scale. What should the nurse include in the plan of care?

Implementing a 1-hour turning schedule with skin assessment.

The nurse is monitoring the effectiveness of antiretroviral therapy (ART) for a patient with human immunodeficiency virus (HIV) infection. What laboratory result indicates ART is effective?

Increased CD4+ T-cell count

The nurse is assessing an older adult patient. Which immunologic response would the nurse assess related to age?

Increased autoimmune response.

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. What laboratory finding suggests the patient has a bacterial infection?

Increased number of band neutrophils

A patient is prescribed acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which priority parameter would the nurse monitor, other than temperature, if the patient requires this medication?

Intake and output

A patient with an autoimmune disease will be treated with plasmapheresis. What would the nurse teach the patient about this treatment?

It will remove the IgG autoantibodies and antigen complexes from the plasma.

A patient received penicillin V potassium intramuscular (IM) causing a systemic anaphylactic reaction. What manifestations would the nurse observe initially?

Itching and edema

An older adult patient admitted with an irregular heart rhythm has a lower blood level of medication than expected. which common cause of medication errors made by older adults should the nurse suspect?

Lack of financial resources to obtain prescribed medications.

Which intervention would the nurse include in the plan of care for a patient who is paraplegic with a stage 3 pressure injury?

Maintain protein intake of at least 1.25 g/kg/day.

A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, what is the nurse's priority action?

Monitor for signs and symptoms of an adverse reaction.

A frail older adult with chronic heart failure is cared for in the home by her only child. Which problem is most indicated by the caregiver's failure to provide companionship or social stimulation?

Neglect

Which factors place the patient at increased risk for severe COVID-19?

Obesity -Cigarette smoking -Chronic kidney disease

A patient with an allergy to bee stings was just stung by a bee. After applying oxygen, removing the stinger, and administering epinephrine, the nurse notes the patient is hypotensive. What would be the nurse's first action?

Place the patient recumbent and elevate the legs.

The nurse notes a patient with an infection has chills. Which intervention should the nurse include in the plan of care?

Provide a light blanket.

Which action would the nurse include in the plan of care for a patient with pneumonia who has a fever of 103°F?

Provide acetaminophen every 4 hours to maintain consistent blood levels.

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse notes thick, white, malodorous wound drainage. How would the nurse document this drainage?

Purulent

Nursing interventions directed at health promotion in the older adult are mainly focused on:

Reducing risk for illness or injury

A patient being tested for multiple allergies develops localized redness and swelling in reaction to a patch skin test. Which intervention by the nurse would have the highest priority?

Remove the patch and extract from the skin.

Assistive personnel (AP) report a patient has a reddened area on the coccyx. After assessing the area, what action would the nurse include in the plan of care?

Reposition every 2 hours.

A patient is seen in the emergency department for a sprained ankle. What interventions would the nurse plan to include in the patient's care?

Rest, ice, compression, and elevation

In which situation would the nurse suspect elder mistreatment?

Sacral pressure injury on a patient who lives at home

A patient with diabetes has been chronically ill with a severe lung infection requiring corticosteroids and antibiotics. What condition would the nurse monitor for related to the patient's condition?

Secondary immunodeficiency

A nurse is caring for a patient who has a pressure injury that is treated with debridement, irrigations, and moist gauze dressings. How would the nurse expect healing to occur?

Secondary intention

An 82-year-old man is being cared for at home by his family. A pressure injury on his right buttock measures 1 × 2 × 0.8 cm, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form?

Stage 3

The nurse is providing postoperative care for a patient with human immunodeficiency virus (HIV) infection who had an appendectomy. What type of precautions would the nurse implement to prevent HIV transmission?

Standard precautions

A patient has a hemoglobin level of 8.2 g/dL and hematocrit of 28% and is receiving a transfusion of packed red blood cells. The patient reports back pain, chills, and has a fever during the transfusion. What is the priority nursing action?

Stop the transfusion.

The patient with inflammation reports fatigue, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way?

Systemic response

A patient is ordered cardiac rehabilitation following cardiac bypass surgery. The nurse recognizes this as:

Tertiary prevention to reduce the progression of heart disease

The nurse is administering medication to an older adult patient. Which consideration most related to aging would the nurse monitor when administering medications?

The ability of the medication to metabolize.

Which statement by the patient who had an organ transplant would indicate that the patient understands teaching about immunosuppressive medications?

The lower doses of my medications can prevent rejection and minimize the side effects."

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight redness at the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make?

The patient has a normal inflammatory response.

A patient has human immunodeficiency virus (HIV) infection and the viral load is reported as undetectable. What patient teaching would the nurse provide related to this laboratory study result?

The patient has the virus but the infection is well controlled.

The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching would the nurse provide to the patient regarding the healing process?

The wound will be left open and heal from the edges inward.

A surgical unit's quality improvement committee notes the number of new catheter-associated urinary tract infections (CAUTIs) increased over the past 6 months. The nurse understands that this means:

There is a need to review unit practices.

A parent does not want their child to have any extra immunizations for diseases that no longer occur. What teaching about immunization would the nurse provide the parent?

There is a reemergence of some of the infections, such as pertussis.

A patient has been diagnosed with human immunodeficiency virus (HIV) infection. What information about antiretroviral therapy with multiple drugs would the nurse provide to the patient to improve adherence?

Viral replication will be inhibited.

The nurse assessing a patient with a chronic leg wound finds redness and edema. The patient reports pain at the wound site. What would the nurse expect to be ordered to assess the patient's systemic response?

WBC count and differential

The nurse is planning discharge for a frail older adult patient covered under Medicare Part A health insurance. Which medical supply would be covered if needed?

Walker

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective?

White blood cell (WBC) count of 8500/ìL; temperature of 98.4°F

The nurse caring for a patient with HIV who has been on ART for many years plans care with the knowledge that the patient

can develop other chronic conditions at an earlier age than someone without HIV.

. A patient with a low number of monocytes would have a decreased ability to

capture antigens by phagocytosis and present them to lymphocytes.

The most common cause of secondary immunodeficiencies is

drugs.

The nurse would be alerted to possible anaphylactic shock after a patient has received IM penicillin by the development of

edema and itching at the injection site.

A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse explains that plasmapheresis is used in treatment to

exchange her plasma that contains antinuclear antibodies with a substitute fluid.

The nurse tells a friend who asks him to administer his allergy shots that

immunotherapy should only be administered in a setting where emergency equipment and drugs are available.

Opportunistic diseases in HIV infection

occur in the presence of immunosuppression.

When working with a patient who has suspected tuberculosis, the nurse would

place the patient on airborne precautions.

In a type I hypersensitivity reaction the primary immunologic disorder appears to be

release of chemical mediators from IgE-bound mast cells and basophils.

A basic principle to consider when planning treatment for HIV is

using a combination of drugs from more than one class.