Med surge Test 3 ch. 32 & 33

Which client does the nurse recognize as most likely to be diagnosed with non-Hodgkin's lymphoma rather than Hodgkin's lymphoma?

A 55-year-old client with an immunosuppression disorder

There is an older adult, male client, who leads a sedentary life style, and a younger adult, female client, who has a very stressful and active life style. They both require a vaccine against a particular viral disorder. The nurse knows 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

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.

The nurse is caring for a client with Hodgkin's disease who has developed anemia. What would the nurse expect to be ordered for this client?

Transfusions

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."

The nurse is caring for a client newly admitted to the unit with a diagnosis of lymphangitis. What interventions would the nurse institute to help promote the resolution of the lymphangitis?

-Note the response to antibiotic therapy. -Apply warm soaks/compresses to the area. -Elevate the area. -Encourage independent activities of daily living.

The nurse is sending a client to be fitted for a compression garment for the treatment of lymphedema after having a mastectomy and node dissection. What does the nurse inform the client that will do to decrease the edema? Select all that apply.

-Prevents tissue refilling with an excess volume of lymph -Increases local tissue pressure -Decreases the stretching of the skin -Helps muscles to propel lymphatic drainage

A client calls the clinic and informs the nurse that her boyfriend was diagnosed with infectious mononucleosis and wonders how long it would be before she got it. What does the nurse inform the client that the incubation period is for infectious mononucleosis?

30 to 50 days

A client had a left radical mastectomy with an axillary node dissection 6 months ago and is having a large amount of edema in the left arm down to the fingers. What should the nurse inform the client is the reason for the edema?

An accumulation of lymphatic fluid that results from impaired lymph circulation.

A client has just been admitted to the unit with a diagnosis of Hodgkin's disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis?

Are you experiencing fever, chills, or night sweats?

A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?

Artificially acquired active immunity

A teenaged client has been brought to the clinic by his mother and is suspected of having an immune system disorder. What tests would the nurse expect to be ordered for this young client?

Complete blood count with differential

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.

A client asks the nurse about the importance of taking supplements to maximize immune function. The client is healthy and does not have any medical problems. What is the best information to give to the client?

Eating a moderate diet that is balanced and varied will maximize immune function.

The nurse is performing a physical assessment on a client with a suspected lymphatic disorder. What would be the nurse's primary assessment for all clients with lymphatic disorders?

Enlargement of the lymph glands

A client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?

How to apply an elastic sleeve or stocking

A client has been diagnosed with non-Hodgkin's lymphoma but has no symptoms at this time. The client has received radiation and chemotherapy with responsiveness to this treatment. How would this disease be classified according to the lack of symptoms and responsiveness to treatment?

Indolent

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

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

Natural killer cells

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

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

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 immunity transferred by the mother

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells

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.

The nurse is caring for the client with infectious mononucleosis that has inflammation of the pharyngeal mucosa. What foods or liquids would be best to offer to this client?

Vanilla pudding and iced tea