NCLEX Immune 69 questions

Indinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV). The nurse has reinforced instructions to the client regarding ways to maximize absorption of the medication. Which statement by the client indicates an adequate understanding of the use of this medication?

"I need to take the medication with water but on an empty stomach. To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal such as cornflakes with skim milk and sugar. It is not to be administered with a large meal. The medication should be stored at room temperature and protected from moisture because moisture can degrade the medication

The home care nurse is assigned to care for the client who returned home following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs to reinforce instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should do which action?

Cover the crutch pads with cloth. The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Telling the client that the crutches must be immediately removed from the house is inappropriate and may alarm the client. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may not be appropriate considering this client's injury. No reason exists to contact the PHCP at this time.

Which findings should cause the nurse to postpone administration of an immunization and do further data collection? Select all that apply

Immune deficiency disease Familial history of severe allergic response to the immunization Immune deficiency disease or immunosuppressive therapy require postponement of vaccination and checking with primary medical provider. Allergic responses to substances by the client or family members should be investigated. Being over 60 years of age is not a reason to postpone or cancel immunization. Axillary temperature of 99 is not febrile. A negative tuberculin skin test for tuberculosis is expected and normal. Having insulin-dependent diabetes mellitus places a person at risk for some conditions such as pneumonia and influenza, making immunizations more important.

The client recently diagnosed with toxoplasmosis asks the nurse, "What is toxoplasmosis? How did I get it, and what do I have to do to get rid of it"? Which information should the nurse include in the response? Select all that apply.

Toxoplasmosis is treated with sulfadiazine. Pregnant people should not empty litter boxes. Toxoplasmosis is an organism found in rare pork. Toxoplasmosis may cause a severe inflammatory response. Treatment for toxoplasmosis includes pyrimethamine, folinic acid, and sulfadiazine for as long as 6 weeks. The organism is found in undercooked meats such as pork and venison. Symptoms range from flulike symptoms to severe inflammatory responses and may cause central nervous system (CNS) symptoms. Pregnant women should not empty litter boxes because cat feces are often sources of toxoplasmosis. Toxoplasmosis is caused by a protozoan called Toxoplasmosis gondii. Spores can remain in the environment for up to a year.

The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching?

"I should not use insect repellent because it will attract the ticks." In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, one should avoid heavily wooded areas or areas with thick underbrush. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

The nurse is assisting with the administration of immunizations at a health care clinic. The nurse should understand that immunization provides which protection?

Acquired immunity from disease Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases.

The client diagnosed with stage I Lyme disease asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which treatment should be included in the care plan?

A 3- to 4-week course of oral antibiotic therapy A 3- to 4-week course of oral antibiotic therapy is recommended during stage 1. Later stages of Lyme disease may require therapy with intravenous antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.

The client reports to the health care clinic to obtain testing regarding human immunodeficiency virus (HIV) status after being exposed to an individual who is HIV positive. The test results are reported as negative and the client tells the nurse that he feels so much better knowing that he has not contracted HIV. The nurse should explain the test results to the client, including which information?

A negative HIV test is not considered accurate during the first 6 months after exposure. A test done for HIV should be repeated. There might be a lag period after the infection occurs and before antibodies appear in the blood. Therefore, a negative HIV test is not considered accurate during the first 6 months after exposure

The nurse is assisting in developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. Which nursing intervention should be included in the plan of care to manage this symptom?

Administer an antipyretic at bedtime. For clients with AIDS who experience night fever and night sweats, it is useful to offer an antipyretic at bedtime. It is also helpful to keep a change of bed linens and night clothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Options 1, 3, and 4 are important interventions, but they are unrelated to the subject of fever and night sweats.

The client diagnosed with pemphigus is being seen in the clinic regularly. The nurse should plan care based on which description of this condition?

An autoimmune disease that causes blistering in the epidermis Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. During the initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.

Which individual is least at risk for the development of Kaposi's sarcoma?

An individual working in an environment where exposure to asbestos exists Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It is seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma.Client Needs: Physiological IntegrityCognitive Ability:

The nurse is instructing the client with a diagnosis of systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which primary foods? Select all that apply.

Beef Cheese The client with SLE is at risk for cardiovascular disorders, such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce intake of salt, fat, and cholesterol

The client calls the emergency department and tells the nurse that he received a bee sting to the arm. The client states that he has received bee stings in the past and is not allergic to bees but the site is painful and asks the nurse how to alleviate the pain. Which primary action should the nurse instruct the client to take?

Apply ice and elevate the site When a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. Pain may be alleviated by the application of an ice pack and elevating the site. A heating pad will increase discomfort at the site. Acetaminophen may be taken by the client to assist in alleviating discomfort, but this would not treat the injury at a local level. Lying down and elevating the arm may have some effect on reducing edema at the site but will not directly assist in alleviating the pain at the site of injury.

The client arrives at the health care clinic requesting to be tested for Lyme disease. The client tells the nurse that he removed the tick and flushed it down the toilet. The nurse should respond with which most appropriate action?

Arrange for the client to return in 4 to 6 weeks to be tested. There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. Options 1, 2, and 4 are inaccurate.

The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which should be the appropriate nursing action?

Ask the client if they ever sustained a bee sting in the past. In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

The nurse is reviewing the medical record of the client who is suspected of having systematic lupus erythematosus (SLE). Which sign should the nurse expect to be documented in the record that is most related to this diagnosis?

Butterfly rash on cheeks and bridge of the nose SLE primarily occurs in females 10 to 35 years of age and is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE. Option 4 is found in sickle cell anemia. Options 1 and 2 are found in many conditions but are not usually noted in SLE.

The nurse is collecting data on a client complaining of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse should further check for which manifestation that is also indicative of the presence of SLE?

Butterfly rash on the cheeks and bridge of the nose Systematic lupus erythematosus is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE. Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many conditions but are not associated with SLE.

The client is diagnosed with stage I of Lyme disease. The nurse should check the client for which characteristic of this stage?

Flu-like symptoms The hallmark of stage I is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance. The lesion enlarges up to 50 cm to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Arthralgia and joint enlargements are most likely to occur in stage III. Neurological deficits occur in stage II.

The nurse is assisting in developing a plan of care for the client with immunodeficiency. The nurse should determine that which problem is a priority for the client?

Infection The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority problem is infection. The question presents no data indicating that inability to cope, lack of information about the disease, and feeling uncomfortable about body changes are problems.

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?

Lyme disease is caused by a tick carried by deer. Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by Ixodes ticks can be infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings.

Which symptoms should the nurse anticipate and monitor for in clients diagnosed with stage 4 human immunodeficiency virus (HIV) infection? Select all that apply.

Lymphoma Kaposi's sarcoma Candidiasis of the esophagus Lymphoma; Kaposi's sarcoma; and candidiasis of the esophagus, trachea, or lung are classified as clinical stage 4 HIV infection symptoms. Asymptomatic infection is a clinical stage 1 symptom. Recurrent upper respiratory infections are characteristic of stage 2 HIV infection as is the unintentional weight loss of less than 10%.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse implement to assist the client in performing activities of daily living?

Provide supportive care with hygiene needs. Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options 1, 2, and 4 are important interventions for the client with AIDS but do not address the subject of activities of daily living.

The nurse is reinforcing dietary instructions to a client diagnosed with systemic lupus erythematosus. Which dietary items should the nurse most instruct the client to avoid?

Steak The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake.

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse incorporate in the plan during the bathing of this client?

Wearing a gown and gloves Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

The nurse reinforces home care instructions to a client diagnosed with systemic lupus erythematosus and instructs the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching?

"I should take hot baths because they are relaxing." To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

The nurse determines that the client diagnosed with neutropenia needs further teaching if which statement is made by the client?

"I will include plenty of fresh fruits in my diet." Fresh fruits and vegetables are eliminated from the diet to avoid the introduction of pathogens. Fever of 100.4° F or greater should be reported immediately. Feeding and petting cats and dogs are fine as long as hand washing follows. Handling pet excrement must be avoided to avoid exposure to pathogens.

The client diagnosed with Lyme disease tells the nurse, "I heard this disease can affect the heart. Is this true?" The nurse should make which response to the client?

"It can, but you will be monitored closely for cardiac complications." Stage II of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. The serious problems that occur in this stage include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. The remaining options are either untrue or do not effectively address the client's concern.

The client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which question should the nurse ask next?

"When were you bitten by the tick?" There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. The appropriate question by the nurse should elicit information related to when the tick bite occurred.

The primary health care provider prescribes fluconazole for the client. When administering this medication the nurse should explain to the client that it is prescribed to treat which opportunistic infection?

Candidiasis Fluconazole is a broad-spectrum antifungal medication. Candidiasis is a fungal infection that causes thrush and vaginal yeast infections, so fluconazole would be an appropriate medication to treat this. Cytomegalovirus and herpes simplex 1 are viral diseases, and mycobacterium tuberculosis is classified in the bacterial/mycobacterial category. Thus, fluconazole, an antifungal medication, would not be appropriate treatment.

The primary health care provider aspirates synovial fluid from a knee joint of a client diagnosed with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and should expect the results to best indicate which finding?

Cloudy synovial fluid Cloudy synovial fluid is diagnostic of rheumatoid arthritis. Organisms present in the synovial fluid are characteristic of a septic joint condition. Bloody synovial fluid is seen with trauma. Urate crystals are found in gout.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine therapy. The clinic nurse should reinforce which instruction to this client?

Come to the health care clinic to be seen by the primary health care provider Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. The client should be seen by the primary health care provider and be monitored for indications of developing pancreatitis. The reported symptoms are not the primary subject, and so the options directed toward explaining or managing them are not correct. The nurse should not encourage the client to alter the medication dose without first notifying the primary health care provider

The nurse reads the chart of the client who has been diagnosed with stage III Lyme disease. The nurse should determine that which sign/symptom best supports this diagnosis?

Complaints of joint pain Stage III develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage II. A rash occurs in stage I. Paralysis of the extremity where the tick bite occurred is not a characteristic of Lyme diseas

The nurse is assisting in the care of the client diagnosed with systemic lupus erythematosus (SLE). The nurse should most appropriately administer which prescribed medication to manage the condition?

Corticosteroid Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory medications, corticosteroids, and immunosuppressants. The other options are not standard components of medication therapy for this disorder.

The home care nurse is prescribing dressing supplies for the client who has an allergy to latex. The nurse should ask the medical supply personnel to deliver which items?

Cotton pads and silk tape Cotton pads and plastic or silk tape are latex-free products. The items identified in the incorrect options are products that contain latex.

A complete blood cell count is performed on the client with a diagnosis of systemic lupus erythematosus (SLE). The nurse should suspect that which finding will most likely be reported from this blood test?

Decrease of all cell types In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease of all cell types, probably caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.

The nurse is assisting in developing a plan of care for the pregnant client diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse should determine that which is the priority concern for this client?

Development of an infection Acquired immunodeficiency syndrome decreases the body's immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body's defense system. Opportunistic infections are a primary cause of death in people affected with AIDS. Therefore, preventing infection is a priority of nursing care. Although the concerns in options 1, 3, and 4 may need to be addressed at some point in the care of the client, these are not priorities.

The nurse should determine that which are risk factors for systemic lupus erythematous (SLE)? Select all that apply.

Female gender African-American origin Being in the childbearing years Systemic lupus erythematous affects females more commonly than males. It is more common in African-American females than in white females. The females are generally in the childbearing years.

A client is diagnosed with stage I Lyme disease. In addition to the rash, the nurse should check the client for which manifestation?

Flulike symptoms The hallmark of stage I is the development of a skin rash at the tick bite site. The rash develops into a concentric ring that has a bull's-eye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. The other options listed occur in stage II (neurological deficits) or stage III (arthralgias and enlarged, inflamed joints).

The nurse is assisting in preparing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure should the nurse most likely include in the plan?

Foods that are at room temperature The client with AIDS experiencing nausea should avoid fatty products, such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous foods should be avoided because they aggravate nausea. Foods are best tolerated either cold or at room temperature.

The nurse is assigned to care for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the primary health care provider's prescriptions. Which medication should the nurse expect to be prescribed to aid in long-term control?

Hydroxychloroquine Hydroxychloroquine, an antimalarial drug, aids in long-term control of SLE. Aspirin is not used in the treatment of SLE. Dehydroepiandrosterone (DHEA), a mild male hormone, is given to treat hair loss, joint pain, fatigue, and memory issues. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to reduce inflammation and control pain

The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding this diagnosis?

It is an inflammatory disease of collagen contained in connective tissue. SLE is an inflammatory disease of collagen contained in connective tissue. Options 1, 2, and 3 are not associated with this disease.

The client who is diagnosed positive for human immunodeficiency virus (HIV) has had a tuberculin skin test. The results show a 7-mm area of induration. The nurse should interpret the test results as which response?

It is positive. The client with HIV is considered to have positive results on skin testing with an area of 5 mm of induration or greater. The client without tuberculin HIV is positive with induration greater than 10 or 15 mm if the client is at low risk. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is also possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor.

The nurse is providing instructions to the client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. The nurse should advise the client to do which action to best increase comfort while minimizing symptoms?

Keep liquids on the nightstand at home. For clients with AIDS who experience night fever and night sweats, it is useful to keep liquids on the nightstand at home. The client should keep a plastic cover on the pillow and also place a towel over the pillowcase if needed. The client should not decrease fluid intake, and the client should take an antipyretic before going to sleep and before the fever spikes.

The nurse should interpret that the client prescribed zalcitabine is experiencing an adverse effect of this medication when which event is reported by the client?

Numbness in the legs Peripheral neuropathy is an adverse effect associated with the use of zalcitabine, which manifests initially as numbness and burning sensations in the extremities. They may progress to sharp shooting pains or severe continuous burning if the medication is not withdrawn. The other options are not associated with use of this medication.

Which medications should the nurse expect to be prescribed to effectively reduce nasal edema and rhinorrhea (thin watery discharge from the nose)? Select all that apply.

Oxymetazoline Pseudoephedrine Oxymetazoline and pseudoephedrine are decongestants that reduce nasal edema and rhinorrhea. Corticotropin is an anti-inflammatory agent. Isoniazid is used in the treatment of tuberculosis. Terbutaline causes bronchodilation. Phenazopyridine is a urinary analgesic.

The client is diagnosed with an immune deficiency. The nurse focuses on which nursing responsibility as the highest priority when providing care to this client?

Protecting the client from infection The client with immune deficiency has inadequate immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. The other options are also part of the plan of care but are not the highest priority.

The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should determine that this has been confirmed by which finding?

Punch biopsy of the cutaneous lesions Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

The client is suspected of having systemic lupus erythematous (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of SLE?

Rash on the face across the nose and on the cheeks Skin lesions or a rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of SLE. Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

The client with a diagnosis of acquired immunodeficiency syndrome has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that which procedure will be done to confirm whether these lesions are due to Kaposi's sarcoma?

Skin biopsy The skin biopsy is the procedure of choice to diagnose Kaposi's sarcoma, which frequently complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay and Western blot are tests to diagnose human immunodeficiency virus status.

The nurse is explaining about antigens and antibodies when the client asks where antibodies come from. The nurse should include which areas as the most appropriate response? Select all that apply.

Tears Spleen Saliva Blood serum Lymph nodes Antibodies are found in tears, the spleen, saliva, blood, and lymph nodes. Each antibody is able to attach to the kind of antigen it is made for. The skin does not form antibodies but rather acts as a barrier.

A client diagnosed with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a client problem of impaired gas exchange written in the plan of care. Which indicates that the expected outcome of care has not yet been achieved?

The client limits fluid intake. The status of the client with a nursing diagnosis of impaired gas exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include that the client breathes easier, coughs up secretions effectively, and has clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

The client prescribed zidovudine has been diagnosed with severe neutropenia. The nurse anticipates which intervention should be implemented?

The medication will be temporarily discontinued. Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or neutropenia develops, treatment should be interrupted until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia

The nurse is collecting data on the client with a diagnosis of rheumatoid arthritis. The nurse looks at the client's hands and notes characteristic deformities. The nurse should identify this as which deformity? Refer to figure.

Ulnar drift All of the conditions identified in the options can occur in rheumatoid arthritis. Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints. A hallux valgus deformity is a deformity characterized by lateral deviation of the great toe. It is commonly called a bunion. A swan neck deformity is a deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it. A boutonniere deformity is a deformed position of the fingers or toes, in which the joint nearest the knuckle is permanently bent toward the palm while the farthest joint is bent back away.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking didanosine. The nurse reinforces instructions to the client to watch for which signs/symptoms that the medication may have caused the adverse effect of pancreatitis?

Vomiting and abdominal pain Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of developing pancreatitis, which include increased serum amylase in association with increased serum triglycerides; decreased serum calcium; and vomiting or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. Fatigue and aching joints are associated with hepatitis. Low grade fever and malaise is associated with cholecystitis. Dark urine and clay colored stools are associated with cirrhosis.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking zidovudine 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results indicate severe neutropenia. Which should the nurse next anticipate to be prescribed for the client?

Discontinuation of the medication Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

The nurse is assisting with identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?

Individuals with spina bifida Individuals at risk for developing a latex allergy include health care workers; individuals who work with manufacturing latex products; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, passion fruit, avocados, and chestnuts.

The clinic nurse periodically cares for the client diagnosed with acquired immunodeficiency syndrome. The nurse should assess for an early manifestation of Pneumocystis jiroveci infection by monitoring for which sign/symptom at each client visit?

Cough The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.

The nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse should inform the students that which behavior is most unsafe?

Use of natural skin condoms The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through. Abstinence is the safest way to avoid HIV infection. The next most reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of the HIV virus as long as the condom is used properly and remains in place and intact

Which interventions should be implemented in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply

1. Use nonlatex gloves. 2.Use medications from glass ampules. 4.Do not puncture rubber stoppers with needles. 5.Keep a latex-safe supply cart available in the client's area If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

A client is diagnosed with stage II Lyme disease. The nurse should check the client for which characteristic of this stage?

Nervous system disorders If untreated stage II of Lyme disease begins 2 to 12 weeks after the first stage with carditis and nervous system disorders such as meningitis, peripheral neuritis, or a facial paralysis similar to Bell palsy. Flulike symptoms, "bull's-eye" rash and stiffness in the joints are symptoms seen in stage I of the disease.

Which signs/symptoms should indicate to the nurse that the client is experiencing an anaphylactic reaction? Select all that apply.

Hives Stridor Dyspnea Urticaria Wheezing Hives are one symptom of anaphylaxis. Stridor, a high-pitched sound during inspiration, is a symptom. Dyspnea occurs as the airway swells. Urticaria is an allergic reaction with wheals that causes intense itching. Wheezing is a musical sound heard as the respiratory lumen narrows. Pallor is not specifically associated with an anaphylactic reaction.

The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. The nurse should determine that which client population is at risk for developing this type of allergy?

Hairdressers Individuals at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; individuals having multiple surgeries; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts.

The nurse is assisting with planning the care of a client with a diagnosis of immunodeficiency. The nurse should incorporate which intervention as a priority in the plan of care?

Protecting the client from infection The client with immunodeficiency has inadequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

The nurse is caring for the client diagnosed with systemic lupus erythematosus (SLE) that is affecting the hematopoietic system. Which data regarding signs and symptoms should the nurse anticipate collecting? Select all that apply.

Anemia Splenomegaly Lymphadenopathy Hematology is the study of blood and blood-forming tissues, which include the bone marrow, blood, spleen, and lymph system. Therefore, anemia is a hematological system issue, and it often occurs with SLE. Lymphadenopathy, or enlarged lymph nodes, and splenomegaly, or an enlarged spleen, are also issues of the hematological system and occur with SLE. Alopecia is loss of hair, which is a dermatological condition, as is discoid erythema. Raynaud's phenomenon is cardiopulmonary in origin causing pallor and diminished blood flow to fingers.

The nurse is assessing the client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection?

Did you have chicken pox as a child?" The client has the symptoms of herpes zoster, or shingles, which is caused by the same organism as chicken pox. Asking about sexual partners is inappropriate for this disorder. Use of an electric blanket does not cause this type of lesion. Docosanol is used on herpes simplex I (cold sores).

The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate?

Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable. A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Options 1, 2, and 3 are incorrect.

The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse should question the client about an allergy to which food items? Select all that apply

Kiwi Bananas Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy.

The client calls the health care clinic and tells the nurse that he was bitten by a tick. The client asks the nurse about the first signs of Lyme disease. The nurse should respond with which characteristic of stage 1 of Lyme disease?

Skin rash The hallmark of stage I of Lyme disease is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance (although some individuals do not develop a rash). The lesion enlarges up to 12 inches, and smaller lesions develop farther away from the original tick bite. It is important to note that in some individuals, a rash does not occur. In stage I, most infected people develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. Options 2, 3, and 4 are not the first symptoms related to Lyme disease.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client verbalizes the intent to increase intake of which food(s)?

Puddings The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables. The client is encouraged to take in foods that are mild, nonabrasive, and easy to swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs, and desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating.