nrsg 122 ch 36,38, 39,51

A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse?

"The doctor could prescribe anti-inflammatory drugs."

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

The clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient?

Fatigue

Which term refers to an incomplete antigen?

Hapten

An African American patient has been admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what area of the body would the nurse look for yellow discoloration?

Sclerae

Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues?

Scleroderma

An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned that he has melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of?

Senile lentigines

A nurse completes assessment of the skin of an 82-year-old resident in a nursing home. She notices the presence of multiple dilated capillaries radiating from a central arteriole. The nurse documents their presence on the electronic health record as:

Spider angiomas.

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

Proteins formed when cells are exposed to viral or foreign agents that are capable of activating other components of the immune system are referred to as

interferons.

The nurse is working with a client with allergies. What will the nurse use to confirm allergies and decrease the risk of anaphylaxis?

intradermal testing

A clinic nurse has been charged with the responsibility of teaching avoidance strategies to an adult patient who has allergic rhinitis. What measure should the nurse recommend to this patient? You Selected:

"If possible, make sure that no one smokes tobacco in your home."

A client with osteoarthritis expresses concerns that the disease will prevent the ability to complete daily chores. Which suggestion should the nurse offer?

"Pace yourself and rest frequently, especially after activities."

The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity?

"Your symptoms are a result of your body attacking itself."

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

The nurse is teaching health promotion to a class on osteoporosis prevention. The nurse determines that the participants understand the teaching when they identify that clients need how much sun exposure to synthesize sufficient vitamin D?

5 to 30 minutes twice a week

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? You Selected:

Administer epinephrine.

A client has breast cancer. The nurse is concerned about a compromised immune system in this client for which reason?

Antineoplastic drug therapy

The 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.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau's line

During an allergic reaction, histamine is released in about 15 minutes. The patient usually takes an antihistamine that has an affinity for bronchiolar smooth muscle cells (an H2 receptor). Which of the following is most likely the drug described?

Benadryl

A 29-year-old woman who gave birth to her first child yesterday had a particularly long labor but vaginally delivered a healthy infant. The nurse notes during this morning's assessment that the woman now has petechiae on her face. The nurse should understand that these lesions are a result of what process?

Broken blood capillaries

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.

Cytotoxic T cell

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included?

Delaying exercise for at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided.

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?

Dermis

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? You Selected:

Do not overuse the medication as rebound congestion can occur.

The nurse is preparing a patient with a suspected latex allergy for the radioallergosorbent test (RAST). Which of the precautionary steps is most important for the nurse to follow? You Selected:

Emergency equipment should be available.

The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?

Has a weight gain of 5 pounds

An occupational health nurse is assessing a woman who experienced an anaphylactic reaction to a dip that contained crab during an office celebration. Because the woman promptly self-administered epinephrine, her status has normalized and she is now resting in a colleague's office. What action should the nurse perform?

Have the woman transported to a nearby emergency department.

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?

Herpes zoster

The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding?

Hirsutism

Contact with a pathogen has precipitated a cutaneous immune reaction on a nurse's hands. The nurse would understand that this reaction primarily involves the action of what component of the integumentary system?

Langerhans cells

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?

Lichenification

A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule?

Patch test

The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding?

Pearly white substance that is attached to the hair shaft that is not removed with brushing

What intervention is a priority for a client diagnosed with osteoarthritis?

Physical therapy and exercise

The nurse is assessing a patient with a primary skin lesion called a macule. What does the nurse understand is a clinical example of this lesion?

Port-wine stains

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?

Pustule

A client is diagnosed with multiple site cancers and has received whole-body irradiation. The nurse is concerned about a compromised immune system in this client for which reason?

Radiation destroys lymphocytes.

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

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.

The nursing student is learning about the elderly and the instructor is discussing physical changes associated with the aging process. What would the instructor tell the student about common changes in the skin associated with the aging process?

The elderly have skin atrophy.

The nurse's assessment of an older adult patient who is postoperative day 1 following orthopedic surgery reveals scrotal edema. A review of the patient's recent documentation indicates that the patient is likely fluid overloaded. Why are areas such as the scrotum particularly susceptible to edema?

The vascularity and thin dermis of the scrotum make it prone to edema.

Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage?

Tophi

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the: You Selected:

Upper left quadrant of the abdomen.

The nurse is reviewing various medications with a client that can be used to treat allergic disorders. What medication will the nurse identify as an intranasal corticosteroid?

fluticasone

The nurse is caring for a client exposed to peanuts with a known allergy. What assessment is considered the most serious manifestation of angioneurotic edema?

laryngeal swelling

The nurse is teaching a client about allergic rhinitis and its triggers. What is the most common trigger for the respiratory allergic response?

plant pollen

The nurse is teaching a client with osteoarthritis about the disease. What is the most important client focus for disease management?

strategies for remaining active

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

A 60-year-old man with several health problems and a history of increasing joint stiffness over the past several months is being assessed for the presence of rheumatic diseases. Which of the following laboratory findings is most clearly suggestive of an inflammatory process?

Erythrocyte sedimentation rate (ESR) of 22 mm/hr (normal 0 to 20 mm/hr)

A patient has had rheumatoid arthritis for over 10 years, and the health care provider has now ordered cyclophosphamide (Cytoxan) for treatment of the disease. The nurse must be alert to what side effects of this medication when administering an immunosuppressant?

Infection

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

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

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells.

A man is working in the field beside his house and sustains a deep scratch from an old tool left in the field. The man develops a virulent staphylococci infection of the right leg. The circulating lymphocyte containing the antigenic message returns to the nearest lymph node. What is this known as?

Proliferation stage

The nurse is assessing the periwound skin of an African American client for inflammation. The nurse determines that inflammation is present when which characteristic is noted?

Purple-gray cast

A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection?

Through the mucous membranes of the throat

The nurse documenting an acute open wound should include which characteristic(s)? Select all that apply.

Wound size Periwound skin Wound bed

A nurse is managing the care of a client with osteoarthritis. What is the appropriate treatment strategy the nurse will teach the about for osteoarthritis?

administration of nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of

anemia.

The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as

angioneurotic edema.

Three female students share an apartment. They notice after several months that their menstrual cycles are coordinating. What is speculated to be responsible for the synchronization of their monthly cycles?

apocrine secretions

The best treatment for latex allergy is

avoidance of latex-based products.

The nurse is administering intravenous vancomycin. What will the nurse initially assess the client for if an allergic reaction occurrs?

dyspnea, bronchospasm, and/or laryngeal edema

Which immunity type becomes active as a result of infection by a specific microorganism?

naturally acquired active immunity

When conducting a skin assessment, the nurse notes a purple macular lesion on the client's right upper extremity. The nurse differentiates the lesion as a petechia or ecchymosis based on

size.