NUR2120 CH 32- 37
A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of his last tetanus shot, which he tells the nurse was more than 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what? (CH36) A) An antibody B) An antigen C) A bacteria D) A virus
A) An antibody The structural part of the invading or attacking organism that is responsible for stimulating antibody production is called an antigen. For example, an antigen can be a small patch of proteins on the outer surface of the microorganism. Not all antigens are naturally immunogenic, and these must be coupled to other molecules to stimulate the immune response. A single bacterium or large molecule, such as diphtheria or tetanus toxin, may have several antigens, or markers, on its surface, thus inducing the body to produce a number of different antibodies. Bacteria are microorganisms. A virus is an organism that can cause disease.
The nurse is discussing nutritional needs for a postmenopausal patient. What dietary increase should the nurse recommend to the patient? (CH32) A) Calcium B) Iron C) Salt D) Vitamin K
A) Calcium Postmenopausal women should be encouraged to observe recommended calcium and vitamin D intake, including calcium supplements, if indicated, to slow the process of osteoporosis. Iron and vitamin K need not be increased unless there are signs of deficiency. Salt should be eaten in moderation, not increased, to prevent hypertension.
The nurse is assessing a pregnant client who has come to the prenatal clinic for a scheduled visit. The nurse notes bruising to the client's wrists and upper arms. The client denies domestic, intimate partner violence. What is the nurse's best action? (CH32) A) Conduct another screening at the client's next prenatal visit B) Reassure the client domestic violence can be a one-time occurrence C) Offer the client a counseling session for trauma D) Speak to the client's partner about the bruises
A) Conduct another screening at the client's next prenatal visit. All women should be screened for domestic violence. For women who are pregnant, screening should occur over the course of the pregnancy including at the first visit, at least once per trimester and at the postpartum check-up. Domestic violence is rarely a one-time occurrence. The nurse should not provide reassurance in this way to the client. The client has denied domestic violence; therefore, it would be inappropriate to offer any services for trauma unless the client has indicated a reason this intervention is warranted. Asking to speak to the client's partner about the assessment findings would be a breach of the client's confidentiality. This is only an option if the nurse has obtained the client's consent and with the client present during the nurse's discussion with the partner.
Which term refers to a failure of one or both or both of the testes to descend into the scrotum? (Ch34) A) Cryptorchidism B) Hydrocele C) Varicocele D) Phimosis
A) Cryptorchidism Cryptorchidism is the failure of one or both of the testes to descend into the scrotum. Hydrocele is a collection of fluid, generally in the tunica vaginalis of the testes. Varicocele is an abnormal dilation of the veins of the pampiniform venous plexus in the scrotum. Phimosis is a condition in which the foreskin is constricted so that is cannot be retracted over the glans.
A 48-year-old man has presented to the outpatient radiology department for a scheduled transrectal ultrasound (TRUS). The nurse in this department should be aware that this patient has likely had: (CH32) A) Elevated prostate-specific antigen (PSA) B) Evidence of erectile dysfunction (ED) C) Urinary retention D) A history of infertility
A) Elevated PSA TRUS is performed in light of abnormalities detected by digital rectal examination and in those with elevated PSA levels. It is not indicated in cases of ED, retention, or infertility.
Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that: (CH36) A) filter bacteria from tissue fluid. B) increase the efficacy of antibiotics. C) eliminate cancer cells. D) program T lymphocytes.
A) Filter bacteria from tissue fluid. The tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral and nasal passages, they can become infected and locally inflamed.
The nurse is providing an educational event at the local community center on prostate cancer. A 53-year-old male attendee asks about the prevention and detection of prostate cancer. What information should the nurse provide to this man that would assist in the early identification of prostate cancer? (CH32) A) Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly B) Have a transrectal ultrasound every 5 years C) Perform monthly testicular self-examinations D) Have a complete blood count (CBC) yearly, including blood urea nitrogen (BUN) and creatinine assessment
A) Have a digitial rectal examination and prostate-specific antigen (PSA) test done yearly The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and the PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won't identify changes in the prostate gland due to its location in the body. A transrectal ultrasound and CBC with BUN and creatinine assessment are usually done after diagnosis to identify the extent of disease and potential metastases.
A client has a known allergy to peanuts, meaning that the client's immune system has identified peanuts as a foreign invader and has produced specific cells to attack if the client should come in contact with peanuts again. The formation of these specific cells is known as: (CH36) A) humoral response. B) cell-mediated response. C) inflammatory response. D) memory response.
A) Humoral response The B-cell lymphocytes mature in the bone marrow and migrate to the spleen and other lymphoid tissues such as the lymph nodes. When stimulated by T cells, the B cells become either plasma or memory cells. Plasma cells produce antibodies. Formation of antibodies is called a humoral response
A 65-year-old man complains to his health care provider that, when he urinates, he has to start and stop several times over a period of minutes in order to fully empty his bladder. The nurse is aware that this is not uncommon in men over the age of 60. This "double voiding" is directly related to which of the following? (CH34) A) Hyperplasia of the prostate gland B) Thickening of the seminiferous tubules C) Fibrotic changes of the corpora cavernosa D) Hypogonadism
A) Hyperplasia of the prostate gland
The nurse is assessing the breast of a female patient and observes a prominent venous pattern on the left breast. What does the nurse understand that this can be indicative of? (Ch33) A) Increased blood supply required by a tumor B) Infection C) Ulceration of the nipple D) Thrombus formation
A) Increased blood supply required by a tumor. A prominent venous pattern can signal increased blood supply required by a tumor.
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: (CH36) A) infection because the spleen removes bacteria from the blood. B) bleeding because the spleen synthesizes vitamin K. C) acidosis because the spleen maintains acid-base balance. D) anemia because the spleen produces red blood cells.
A) Infection because the spleen removes bacteria from the blood. One function of the spleen is to remove bacteria from circulation; therefore, the client will be more susceptible to infection.
A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client? (Ch33) A) This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. B) The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days. C) The potential for transmission to her sexual partner will be eliminated if condoms are used every time she and her partner have sexual intercourse. D) The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex.
A) This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.
A nurse is reviewing the history of a client diagnosed with erectile dysfunction. Which information would the nurse interpret as indicating that use of a PDE-5 inhibitor would be contraindicated. (CH34) A) use of nitroglycerin for angina B) history of heart attack 2 years ago C) hypertension controlled with medications D) use of antiseizure medications
A) Use of nitroglycerin for angina PDE-5 inhibitors should not be taken if the client is taking nitrate medications, such as nitroglycerine or isosorbide mononitrate, or if the client has high uncontrolled blood pressure, coronary artery disease, or a heart attack within the past 6 months. Use of antiseizure medications can cause erectile dysfunction.
Which term describes an opening between the bladder and the vagina? (CH33) A) Vesicovaginal fistula B) Cystocele C) Rectocele D) Rectovaginal fistula
A) Vesicovaginal fistula A vesicovaginal fistula may occur because of tissue injury sustained during surgery, vaginal birth, or a disease process. A cystocele is a downward displacement of the bladder toward the vaginal orifice. A rectocele is a bulging of the rectum into the vagina. A rectovaginal fistula is an opening between the rectum and the vagina.
While caring for a client who is being treated for severe pelvic inflammatory disease (PID), the nurse insists on keeping the client in a semi-sitting position. The nurse advises this in order to: (CH33) A) facilitate pelvic drainage and minimize the upward extension of the infection. B) prevent nosocomial infections to other clients. C) prevent movement that may increase pain. D) facilitate easy distraction of the client.
A) facilitate pelvic drainage and minimize the upward extension of the infection. While caring for a client hospitalized with PID, the nurse has to reduce the risk of the systemic spread of pathogenic microorganisms. The client must be advised to keep the upper body elevated; this facilitates pelvic drainage and minimizes the upward extension of infection.
A 33-year-old female client with three children has had a follow-up mammogram after an abnormal BSE. Mammogram findings reveal incidental microscopic abnormal tissue growth in the left breast lobules. The physician orders tamoxifen for the client. The nurse understands that the physician is implementing which primary prevention modality to treat this client? (CH33) A) Long-term surveillance B) Chemoprevention C) Prophylactic mastectomy D) Radiation therapy
B) Chemoprevention Chemoprevention is a primary prevention modality that aims at preventing the disease before it starts.
A 33-year-old man with AIDS is being treated for cytomegalovirus retinitis and has been prescribed ganciclovir. The nurse who is participating in this patient's care should recognize that this treatment necessitates which of the following assessments? (CH37) A) Daily assessment of the patient's orientation and cognition B) Close monitoring of the patient's WBC differential C) Ultrasound bladder scanning D) Auscultation of the patient's apical heart rate
B) Close monitoring of the patient's WBC differential. A common adverse reaction to ganciclovir is severe neutropenia. As a result, it is important to monitor the patient's neutrophil levels. The use of ganciclovir does not create a direct need for neurological, respiratory, or genitourinary assessment, although each of these systems may be affected by HIV infection.
A nurse is teaching a group of college-aged men about the risks of Chlamydia trachomatis and Neisseriae gonorrhoeae. A participant has implied that men do not need to be particularly concerned about these diseases since the health consequences for men are comparatively minor. The nurse counters that men may in fact become infertile because these diseases can cause: (CH35) A) Priapism B) Epididymitis C) Incarcerated hernias D) Hydrocele
B) Epididymitis In men younger than 35 years of age, the major cause of epididymitis or orchitis is C. trachomatis. Both conditions can result in infertility. Priapism, hernias, and hydrocele are not sequelae of C. trachomatis and N. gonorrhoeae.
A nurse practitioner who works for Planned Parenthood is responsible for health education seminars. During these presentations, the nurse always discusses the symptoms of the most common STI among young, sexually active people. This is: (CH35) A) Candidiasis. B) Human papillomavirus. C) Endocervicitis. D) Salpingitis.
B) Human papillomavirus At least 50% of sexually active men and women acquire genital HPV infection at some point in their lives.
Which test is an x-ray study of the uterus and the fallopian tubes after injection of a contrast agent? (CH32) A) Laparoscopy B) Hysterosalpingography C) Hysteroscopy D) Endometrial ablation
B) Hysterosalpingography Hysterosalpingography is an x-ray study of the uterus and the fallopian tubes after injection of a contrast agent. Laparoscopy allows the pelvic structures to be visualized. A hysteroscopy allows direct visualization of all parts of the uterine cavity be means of a lighted optical instrument. Endometrial ablation is the destruction of the uterine lining.
Which statement is true regarding hormonal contraception? (CH32) A) It increases the risk of benign breast cancer. B) It increases the risk for venous thromboembolism. C) Fetal anomalies are a concern. D) It increases the risk of uterine cancer.
B) It increases the risk for venous thromboembolism Clients taking hormonal contraception have an increased risk for venous thromboembolism, but their risk for benign breast cancer and uterine cancer is decreased. Fetal anomalies are not a concern.
Which nursing assessment finding is most significant in determining the plan of care in a client with erectile dysfunction? (CH34) A) Age B) Medication use C) Sexual history D) Undescended testicle
B) Medication use Certain medications such as antihypertensive drugs, antidepressants, narcotics, etc. can cause sexual dysfunction in men. Impotence is not a normal part of aging. Undescended testicle is not indicative of ED. Sexual history is not indicative of ED.
A patient has been admitted to a medical unit with respiratory symptoms that are characteristic of tuberculosis. When transporting the patient to radiology for a chest x-ray, the nurse has applied a mask that covers the patient's nose and mouth. This action addresses which component of the chain of infection? (CH35) A) Causative organism B) Mode of exit C) Portal of entry D) Susceptible host
B) Mode of exit. A mask blocks the exit of airborne microorganisms from an infected patient's respiratory system. It does not address the causative organisms or the host's susceptibility. Masks worn by staff and caregivers would address the mode of entry.
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? (Ch36) A) Artificially acquired active immunity B) Naturally acquired active immunity C) Passive immunity D) Natural passive immunity
B) Naturally acquired active immunity Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid. Passive immunity is acquired when ready-made antibodies are given to a susceptible person.
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? (CH36) A) Eosinophils B) Neutrophils C) B cells D) Monocytes
B) Neutrophils Neutrophils (polymorphonuclear leukocytes [PMNs]) are the first cells to arrive at the site where inflammation occurs. Eosinophils and basophils, other types of granulocytes, increase in number during allergic reactions and stress responses.
The nurse is preparing a discharge teaching plan for a client who has had a prostatectomy. Which of the following would be appropriate to include? (CH34) A) Using a bearing down motion to promote complete bladder emptying when voiding B) Performing perineal exercises frequently throughout the day C) Engaging in strenuous exercise to strengthen abdominal muscles D) Waiting to urinate for 5 to 10 minutes after feeling the initial urge
B) Performing perineal exercises frequently throughout the day. After a prostatectomy, the client should be instructed in how to perform perineal exercises and to perform them hourly throughout the day, each day. In addition, the client should avoid bearing down (straining) to urinate because of the increased risk for hematuria. He should also avoid strenuous exercise, which increases the tendency to rebleed. The client should be instructed to urinate as soon as he feels the first urge to do so.
When the nurse places the patient in the stirrups for a pelvic exam she observes a bulge caused by rectal cavity protrusion. What does the nurse know this protrusion is called? A) Cystocele B) Rectocele C) Uterine prolapse D) Hemorrhoids
B) Rectocele Childbirth trauma may have affected the posterior vaginal wall, producing a bulge caused by rectal cavity protrusion (rectocele). Trauma to the anterior vaginal wall during childbirth may have resulted in incompetency of the musculature, and a bulge caused by the bladder protruding into the submucosa of the anterior vaginal wall (cystocele) may be seen. The cervix and uterus may descend under pressure through the vaginal canal and be seen at the introitus (uterine prolapse). Hemorrhoids would not cause a bulge in the pelvic region.
Which of the following would the nurse expect to find when assessing the breasts of a client with fibrocystic breast disease? (CH33) A) Nipple retraction B) Soft mass C) Enlarged lymph nodes D) Skin dimpling
B) Soft mass The characteristic breast mass of fibrocystic disease is soft to firm, movable, and unlikely to cause nipple retraction. Nipple retraction, enlarged lymph nodes, and skin dimpling are more commonly associated with breast cancer.
The client states to the nurse that he is very anxious about having prostate cancer ever since his prostate-specific antigen (PSA) test came back elevated. The client asks, "Which diagnostic test produces definitive results if cancer is present?" The nurse is most correct to state which of the following? (CH32) A) Transrectal ultrasonography B) Tissue biopsy C) Tumor marker studies D) Digital rectal exam
B) Tissue biopsy Obtaining an actual piece of the tissue and analyzing it for cancer is a definitive test when cancer is found. A transrectal ultrasonography is a test to view the prostate gland from different angles. This test provides additional data on the status of the prostate gland. The tumor marker studies include the prostate-specific antigen (PSA) level. This antigen indicates a potential problem but is not definitive. PSA elevations have been noted for reasons other than cancer. A digital rectal exam provided data on the shape, size, and texture of the prostate gland.
Which is the most common type of prostate surgery? (Ch34) A) Retropubic prostatectomy B) Transurethral resection of the prostate C) Suprapubic prostatectomy D) Perineal prostatectomy
B) Transurethral resection of the prostate Transurethral resection of the prostate, or TURP, is the most common procedure used and can be carried out through endoscopy. Suprapubic, perineal, and retropubic prostatectomies are surgical procedures for the prostate, but they are not the most common.
A client comes to the clinic reporting urinary symptoms. Which statement would most likely alert the nurse to suspect benign prostatic hyperplasia (BPH)? (Ch34) A) "I've had a fever and noticed I've been running to the bathroom more often." B) "I'm waking up at night to urinate and I've noticed some burning, too." C) "I've had trouble getting started when I urinate, often straining to do so." D) "I've had some pain in my lower abdomen lately and felt a bit sick to my stomach."
C) "I've had trouble getting started when I urinate, often straining to do so." Symptoms that might alert the nurse to BPH include difficulty initiating urination and abdominal straining with urination. Although fever, urinary frequency, nocturia, pelvic pain, nausea, vomiting, and fatigue may be noted, they also may suggest other conditions such as urinary tract infection. Fever, nausea, vomiting, and fatigue are general symptoms that can accompany many conditions.
The nurse is seeing a client who came into the sexual health clinic after discovering condylomata along her labia. The client states, "This makes no sense, I don't even know who I got this from and I have been so careful!" What is the nurse's best response? (CH35) A) "If you make a list of your sexual partners over the past month you should be able to narrow down the person who is the source of your infection." B) "If a condom was used during all sexual contacts, it is unlikely the warts that you have were caused by the human papillomavirus (HPV)." C) "It sounds like you are feeling angry. Let's talk more about human papillomavirus (HPV) and strategies to stay healthy while you are being treated." D) "You are high risk simply because you are sexually active with more than one partner. Do you know how many partners all your partners have had?"
C) "It sounds like you are feeling angry. Let's talk more about human papillomavirus (HPV) and strategies to stay healthy while you are being treated." In many cases, clients are angry about having warts from HPV and do not know who infected them because the incubation period can be long and partners may have no symptoms. Acknowledging emotional distress that occurs when a sexually transmitted infection is diagnosed and providing support and facts are important nursing actions. The client in this case is clearly feeling angry and overwhelmed. The nurse should first provide empathy and help the client focus on information regarding treatment in a solution focused way. Discussing the number of sexual partners and risk factors is important in prevention; however, given the client's emotional state the alternative responses would not be helpful and supportive. In addition, to inform the client that if a condom was used the virus cannot be transmitted is incorrect. Transmission can also occur through skin-on-skin contact in areas not covered by condoms.
A nurse is conducting a comprehensive assessment of a 73-year-old male patient. When performing an assessment of this patient's genitourinary system, the nurse should anticipate which of the following age-related changes? (CH32) A) Increased difference in the size between the patient's testicles B) Atrophy of the patient's penis C) A scrotum that hangs lower than that of younger men D) Erythema on the skin of the penile shaft
C) A scrotum that hands lower than that of a younger man. As men age, the prostate gland enlarges, prostate secretion decreases, the scrotum hangs lower, the testes become smaller and less firm, and pubic hair becomes sparser. The penis does not typically atrophy, and the size difference between the testicles does not increase. Erythema on the shaft of the penis is an abnormal finding in patients of all ages.
An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response? (CH36) A) T cells directly attack the foreign pathogen. B) A circulating lymphocyte containing an antigenic message returns to the nearest lymph node. C) B lymphocytes produce antibodies that are specific to the pathogen. D) Granulocytes and macrophages engulf and destroy the invading agents.
C) B lymphocytes produce antibodies that are specific to the pathogen. The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific antigen. T cells are more closely associated with cellular immunity, and the action of circulating lymphocytes containing antigenic messages is associated with the proliferation stage that precedes the humoral and cellular response. Phagocytic immunity is associated with the actions of granulocytes and macrophages.
A nurse practitioner examines a patient suspected of having endometriosis. The nurse knows that although a definitive diagnosis could not be made without diagnostic treatment (transvaginal ultrasound), the most frequent symptom is: (CH33) A) Dysuria. B) Low back pain. C) Chronic pelvic pain. D) Dyspareunia.
C) Chronic pelvic pain. Chronic pelvic pain is the most frequent symptom of endometriosis. Low back pain, dyspareunia, dysuria, dyschezia, dysmenorrhea, and menorrhagia are among the common complaints. The level of pain associated with endometriosis is not necessarily correlated with the stage of endometriosis.
Which assessment finding is most important in determining which client has a higher risk for developing testicular cancer? (Ch34) A) Previous sexually transmitted infection (STI) B) Low sperm count C) Cryptorchidism as an infant D) Family history of cancer
C) Cryptorchidism as an infant Caucasian men who have had cryptorchidism as an infant, regardless of whether an orchiopexywas performed, are at higher risk for incidence of testicular cancer. STIs, low sperm count, and family history of general cancers are not indicative of testicular cancer risk.
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte. (CH36) A) Helper T cell B) Suppressor T cell C) Cytotoxic T cell D) Memory T cell
C) Cytotoxic T cell The cytotoxic T cells (also known as killer T cells) attack the antigen directly and release cytotoxic enzymes and cytokines.
The client is asking if there is a pill that can be ordered to control the symptoms of menopause. Which assessment finding is most important in determining nursing care in association with hormone replacement therapy? (CH33) A) Presence of kyphosis B) Symptoms of hot flashes C) Family history of breast cancer D) History of osteoporosis
C) Family history of breast cancer The risk of endometrial or breast cancer in women prescribed HRT may outweigh the benefits of relieving symptoms of menopause and preventing kyphosis or hip fractures associated with osteoporosis.
Nursing students are reviewing information about the age-related changes in the reproductive system and their effects. The students demonstrate a need for additional study when they identify which of the following as an expected change? (Ch32) A) Decreased bone formation B) Increased vaginal pH C) Increased labial thickness D) Decreased vaginal lubrication
C) Increased labial thickness Age-related changes include a thinning of the labia, decreased bone formation, increased vaginal pH, and decreased vaginal lubrication.
The nurse is assessing an older adult female who has not seen her physician in 2 years. The nurse is assisting the patient into a gown and notices that the patient has edema and pitting of the skin on the right breast. What does the nurse understand is the significance of this finding? (CH33) A) It may result from inflammation due to mastitis while the patient is breastfeeding. B) This finding is not uncommon and is significant only when of recent origin. C) It may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance, a classic sign of advanced breast cancer. D) This finding is most likely related to benign cysts of the breast in the nipple area.
C) It may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance, a classic sign of advanced breast cancer. Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange peel appearance (peau d'orange)—a classic sign of advanced breast cancer.
Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment? (CH37) A) Active substance abuse B) Depression C) Past substance abuse D) Lack of social support
C) Past substance abuse Factors associated with nonadherence include active substance abuse, depression, and lack of social support, as well as neurocognitive impairment, low health literacy, stressful life events, high levels of alcohol consumption, homelessness, poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to medications. Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment.
A young male patient of a free clinic has been diagnosed with gonorrhea and has begun treatment. The nurse at the clinic is providing the man with relevant health education and has emphasized the importance of using condoms. The man replies, "I can't stand using condoms because I can't feel anything if I use one. I'll have to think about that." The nurse should consequently identify which of the following nursing diagnoses? (CH35) A) Anxiety related to diagnosis with an sexually transmitted infection (STI) B) Ineffective coping related to necessary health promotion measures C) Risk for infection transmission related to lack of STI prevention measures D) Deficient knowledge about the disease and risk for spread of infection
C) Risk for infection transmission related to lack of STI prevention measures. This patient's ambivalence about important protective measures is suggestive of a risk for infection transmission. There is no indication that he lacks knowledge or is experiencing anxiety or ineffective coping.
A client with vaginitis complains of itching and burning of the perineum. Which suggestion would be most appropriate to relieve the client's symptoms? (Ch33) A) Use a pure vinegar douche daily. B) Use skin protectants containing zinc oxide. C) Take sitz baths frequently. D) Avoid yogurt with active lactobacilli cultures.
C) Take sitz bath frequently Sitz baths are recommended to relieve the client's itching and burning as well as relieve swelling of the vulva and perineum. Skin protectants containing zinc oxide promote healing. A vinegar (1 to 2 tablespoons) and water (1 pint) douche daily may be used to combat the vaginitis when the client is symptomatic. Taking Lactobacillus acidophilus in capsule form or eating yogurt containing active cultures of lactobacilli can help restore normal vaginal microorganisms.
A community health nurse who works in an impoverished neighborhood has witnessed an increase in the incidence and prevalence of syphilis among underprivileged and homeless members of the community. The nurse is aware that syphilis often goes untreated because of what characteristic of the disease? (Ch35) A) The early signs and symptoms of the disease are similar to a common cold or influenza. B) The latent period between infection and the appearance of symptoms can last up to 3 years. C) The lesions that accompany initial infection disappear spontaneously within several weeks. D) The signs and symptoms of syphilis do not directly involve the genitourinary (GU) system.
C) The lesions that accompany initial infection disappear spontaneously within several weeks. Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless lesion at the site of infection is called a chancre. Untreated, these lesions usually resolve spontaneously within about 2 months. The disease becomes multisystemic but does involve the GU system.
The nurse is outlining the female internal reproductive structures on a diagram. Where on the diagram would the nurse highlight the typical site of ovum fertilization? (Ch32) A) The nurse would highlight the uterus. B) The nurse would highlight the cervix. C) The nurse would highlight the fallopian tube. D) The nurse would highlight the ovaries.
C) The nurse would highlight the fallopian tubes The nurse would highlight the fallopian tubes as the site of ovum fertilization. Once fertilized, the fertilized egg moves to the uterus for implantation. The cervix is the lower, narrowed neck portion leading to the center of the uterus. The ovaries release the ovum, which is swept into the fallopian tubes.
The nurse is caring for a client who is ordered a sentinel lymph node biopsy. The physician explained the procedure and desired outcome. Which statement, made by the client, indicates a need for further instruction? (CH33) A) The procedure allows for an understanding of the spread of cancer cells. B) The procedure allows for conservation of breast tissue. C) The procedure removes all cancer from the body. D) The procedure includes minimal surrounding tissue damage.
C) The procedure removes all cancer from the body. Sentinel lymph node mapping involves identifying the first (sentinel) lymph nodes through which the breast cancer cells would spread to regional lymph nodes in the axilla. Validating the lack of lymph node metastasis allows the surgeon to preserve more breast tissue, axillary tissue and chest muscle. Further instruction would be needed to explain that the sentinel lymph node biopsy does not remove cancer from the body.
A nurse provides care on a surgical unit where a large number of patients are admitted following breast cancer surgery. The nurse is aware that breast cancer surgery creates a significant risk of disturbed body image. When should the nurse anticipate that this risk will be the highest? (CH33) A) When the patient is faced with the prospect of leaving the unit after discharge B) When the patient is admitted to the PACU from the operating room C) When the patient sees her incision for the first time D) When the patient is met on the unit by her husband or partner
C) When the patient sees her incision for the first time. Patients who have undergone mastectomy often find it very difficult to view the surgical site for the first time. No matter how prepared the patient may think she is, the appearance of an absent breast can be very emotionally distressing. The risk of disturbed body image is relevant at all times but is more likely during this event than in post-anesthetic recovery, meeting with a life partner, or being discharged home.
Which statement made by a client with a chlamydial infection indicates understanding of the potential complications? (CH35) A) "I'm glad I'm not pregnant; I'd hate to have a malformed baby from this disease." B) "I hope this medicine works before this disease gets into my urine and destroys my kidneys." C) "If I had known a diaphragm would put me at risk for this, I would have taken birth control pills." D) "I need to treat this infection so it doesn't spread into my pelvis because I want to have children some day."
D) "I need to treat this infection so it doesn't spread into my pelvis because I want to have children some day." Chlamydia is a common cause of pelvic inflammatory disease and infertility. It doesn't affect the kidneys or cause birth defects. It can cause conjunctivitis and respiratory infection in neonates exposed to infected cervicovaginal secretions during delivery. Use of a diaphragm isn't a risk factor.
The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? (CH37) A) "I will wash my hands whenever I get home from work." B) "I will make sure to have my own toothbrush and tube of toothpaste at home." C) "I will avoid contact with people who are sick or who have recently been vaccinated." D) "I will be sure to eat lots of fresh fruits and vegetables every day."
D) "I will be sure to eat lots of fresh fruits and vegetables every day." The client should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection
A nurse is conducting a health promotion class for a group of younger middle-aged men. When discussing the need for a digital rectal exam, the nurse would recommend this exam for every man over age: (CH34) A) 35. B) 40. C) 45. D) 50.
D) 50. The DRE is recommended as part of the regular health checkup for every man older than 50 years of age; it is invaluable in screening for cancer of the prostate gland.
A patient with genital herpes is having an acute exacerbation. What medication would the nurse expect to be ordered to suppress the symptoms and shorten the course of the infection? (CH35) A) Clotrimazole (Gyne-Lotrimin) B) Metronidazole (Flagyl) C) Podophyllin (Podofin) D) Acyclovir (Zovirax)
D) Acyclovir (Zovirax) Acyclovir (Zovirax) is an antiviral agent that can suppress the symptoms of genital herpes and shorten the course of the infection. It is effective at reducing the duration of lesions and preventing recurrences. Clotrimazole is used in the treatment of yeast infections. Metronidazole is the most effective treatment for trichomoniasis and other bacterial infections. Podophyllin is used to treat external genital warts.
The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response? (CH36) A) Nonsteroidal anti-inflammatory B) Angiotensin-converting enzyme inhibitors (ACE-I) C) Diuretics D) Corticosteroids
D) Corticosteroids The nurse obtains a history of immunizations, recent and past infectious diseases, and recent exposure to infectious diseases. The nurse reviews the client's drug history because certain drugs, such as corticosteroids, suppress the inflammatory and immune responses. Nonsteroidal anti-inflammatory medication does not suppress the inflammatory and immune responses of Crohn's disease. An ACE-I prevents the conversion of angiotensin I to angiotensin II and does not suppress the inflammatory or immune response. Diuretics also do not suppress the immune response but help reduce excess fluid from the kidneys.
A client is admitted with a tentative diagnosis of acquired immunodeficiency syndrome (AIDS). The client undergoes biopsies of facial lesions and the preliminary report indicates Kaposi's sarcoma. Which action by the nurse is most appropriate? (CH37) A) Tell the client that Kaposi's sarcoma is common in people with AIDS. B) Pretend not to notice the lesions on the client's face. C) Inform the client of the biopsy results and support the client emotionally. D) Explore the client's feelings about facial disfigurement.
D) Explore the client's feelings about facial disfigurement. The nurse should help the client explore his or her feelings about facial disfigurement because facial lesions can contribute to decreased self-esteem and an altered body image. Discussing AIDS with a client whose diagnosis isn't final may be inappropriate and doesn't provide emotional support. Pretending not to notice visible lesions ignores the client's concerns. The health care provider, not the nurse, should inform the client of the biopsy results.
A nurse practitioner is assessing the size and position of a patient's uterus and ovarian structures. To perform this assessment, the nurse has informed the patient that bimanual palpation will be performed. How will the nurse perform this assessment? (CH32) A) Insert one finger in the patient's vagina and one in the rectum and palpate for lesions. B) Using two hands, palpate the patient's ovaries simultaneously. C) Insert the index finger of each hand into the patient's vagina and palpate simultaneously. D) Insert fingers of one hand into the vagina and palpate outside with the other hand.
D) Insert fingers of one hand into the vagina and palpate outside with the other hand. During bimanual palpation, the practitioner inserts two lubricated fingers from one hand into the vagina of the patient, while the other hand compresses from the outside to assess the reproductive organs
When a female client demonstrates a wartlike growth near the nipple, causing bloody nipple discharge, the client is exhibiting signs of which disease process? (CH33) A) Paget disease B) Acute mastitis C) Fibroadenoma D) Intraductal papilloma
D) Intraducatal papilloma Intraductal papilloma is a wartlike growth that often involves the large milk ducts near the nipple, causing bloody nipple discharge. Surgery usually involves removal of the papilloma and a segment of the duct where the papilloma is found. Paget disease is a malignancy of mammary ducts with early signs of erythema of nipple and areola. Acute mastitis is demonstrated by nipple cracks or abrasions along with reddened and warm breast skin and tenderness. Fibroadenoma is characterized as the occurrence of a single, nontender mass that is firm, mobile, and not fixed to breast tissue or chest wall.
A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby: (CH36) A) Antibodies reside in the plasma B) Antibodies are released into the bloodstream C) B-lymphocytes respond to a specific antigen D) Lymphocytes migrate to areas of the lymph node
D) Lymphocytes migrate to areas of the lymph node. Lymphocytes migrate to areas other than those programmed to become plasma cells.
A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised? (Ch36) A) Specific immunity B) Passive immunity C) Adaptive immunity D) Natural immunity
D) Natural immunity Natural immunity, which is nonspecific, provides a broad spectrum of defense against and resistance to infection. It is considered the first line of host defense following antigen exposure, because it protects the host without remembering prior contact with an infectious agent.
What severe complication does the nurse monitor for in a patient with ataxia-telangiectasia? (CH37) A) Acute kidney injury B) lung disease C) Neurologic dysfunction D) Overwhelming infection
D) Overwhelming infection Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination), telangiectasia (vascular lesions caused by dilated blood vessels), and immune deficiency. The immunologic defects reflect abnormalities of the thymus. The disorder is characterized by some degree of T-cell deficiency, which becomes more severe with advancing age. Immunodeficiency is manifested by recurrent and chronic sinus and pulmonary infections, leading to bronchiectasis.
A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect? (CH37) A) Mycobacterium avium complex B) Legionella C) Cytomegalovirus D) Pneumocystis jiroveci
D) Pneumocystis jiroverci Although mycobacterium, legionella, and cytomegalovirus may cause the signs and symptoms described, the most common infection in people with AIDS is pneumocystitis pneumonia caused by pneumocystis jiroveci. It is the most common opportunistic infection associated with AIDS.
A nurse has assessed a woman in the hospital emergency department who was struck several times in the face by her intimate partner. As the woman is having her facial injuries assessed, she tells the nurse she does not want to return home. Which action should the nurse take? A) Call a shelter where the woman can stay B) Contact a 24-hour hotline for the client C) Provide the woman with a safety plan D) Provide the woman with a list of phone numbers for shelters
D) Provide the woman with a list of phone numbers for shelters. The nurse can provide teaching, resources and support to the client when managing domestic abuse. This should include information about possible shelters that she can access while decided her next plan of action if she does not want to return to the abusing intimate partner. The client must independently make the decision to go to a shelter, without the perception of pressure to make this decision from the health care provider. For this reason, it is important that the client call the shelter on her own accord. The nurse should not call the 24-hour hotline for the client. This is a resource for victims of violence to utilize when needing emotional support or developing a plan to leave the abusive situation. A safety plan is a tool that the nurse can assist the client in developing if she decides to return home. The plan needs to be individualized to meet the client's unique needs for her situation, the nurse should not provide a premade plan.
Which statement accurately reflects current stem cell research? (CH36) A) Stem cell transplantation cannot restore immune system functioning. B) Stem cell transplantation has been performed in the laboratory only. C) Clinical trials are underway only in clients with acquired immune deficiencies. D) The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.
D) The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Stem cells comprise only a small portion of all types of bone marrow cells. Research conducted with mouse models has demonstrated that once the immune system has been destroyed experimentally, it can be completely restored with the implantation of just a few purified stem cells. Stem cell transplantation has been carried out in human subjects with certain types of immune dysfunction, such as severe combined immunodeficiency. Clinical trails are underway in clients with a variety of disorders with an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis.
Hydrocele (CH32)
accumulation of fluid within scrotum
Candidias
yeast infection Dysuria related to inflammation of urinary meatus. Thick-white curd like (Cottage cheese) and odorless Treatment: Topical containing azole, terconalze
Atypical hyperplasia increases a women's risk for breast cancer about how many times compared with that of the general population? (CH33) A) 4 B) 2 C) 6 D) 8
A) 4
Cystocele (CH32)
bulging of the bladder into the vagina
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do? (CH33) A) Inform the physician immediately. B) Squeeze the nipple to check for drainage. C) Check the area after the next menses. D) Put a heating pad on the area to reduce inflammation.
A) Inform the physician immediately The client should notify the physician immediately because a breast lump may be a sign of breast cancer. The client shouldn't squeeze the nipple to check for drainage until the physician examines the area. The client shouldn't wait until after the next menstrual period to inform the physician of the breast lump because prompt treatment may be necessary. Placing a heating pad on the area would have no effect on a breast lump.
A patient asks the nurse if there are any available nonsurgical options to terminate a pregnancy if she is only 2 weeks pregnant. What information should the nurse provide to the patient about a medication that blocks progesterone? (CH32) A) Mifepristone (RU-486, Mifeprex) is used only in early pregnancy to terminate a pregnancy nonsurgically. B) Methotrexate is used only in early pregnancy to terminate a pregnancy nonsurgically. C) Clomiphene (Clomid) is used only in early pregnancy to terminate a pregnancy nonsurgically. D) Birth control pills can be used to terminate the pregnancy.
A) Mifepristone (RU-486, Mifeprex) is used only in early pregnancy to terminate a pregnancy nonsurgically. Mifepristone (Mifeprex), formerly known as RU-486, is a medication used only in early pregnancy (up to 49 days from the last menstrual period) to induce abortion. It works by blocking progesterone.
Which term refers to the surgical removal of one or both testes? (Ch34) A) Orchiectomy B) Circumcision C) Vasectomy D) Hydrocelectomy
A) Orchiectomy Orchiectomy is required when the testicle(s) has been damaged. Circumcision is excision of the foreskin, or prepuce, of the glans penis. Vasectomy is ligation and transection of part of the vas deferens to prevent the passage of sperm from the testes. Hydrocelectomy describes the surgical repair of a hydrocele, a collection of fluid in the tunica vaginalis.
Which of the following is the medication of choice for early syphilis? (CH35) A) Penicillin G benzathine B) Doxycycline C) Tetracycline D) Rocephin
A) Penicillin G benzathine A single dose of penicillin G benzathine intramuscular injection is the medication of choice for early syphilis or early latent syphilis of less than 1 year's duration. Patients who are allergic to penicillin are usually treated with doxycycline or tetracycline. Rocephin is not the medication of choice for syphilis.
Which of the following is the obstructive and irritative symptom complex caused by benign prostatic hypertrophy? (Ch34) A) Prostatism B) Prostatitis C) Prostaglandin D) Prostatectomy
A) Prostatism Symptoms of prostatism include increased frequency of urination, nocturia, urgency, dribbling, and a sensation that the bladder has not completely emptied. Prostatitis is an inflammation of the prostate gland. Prostaglandins are physiologically active substances present in tissues with vasodilator properties. Prostatectomy refers to the surgical removal of the prostate gland.
A patient had a pessary inserted for long-term treatment of a prolapsed uterus. As part of a teaching plan, the nurse would advise the patient to: (CH33) A) see her gynecologist to remove and clean the pessary at regular intervals. B) keep the insertion site clean and dry. C) avoid sexual intercourse. D) avoid climbing stairs as much as possible.
A) See her gynecologist to remove and clean the pessary at regular intervals. A pessary should be removed, examined, and cleaned by a health care provider at prescribed intervals. At this time, the vaginal wall should be examined for pressure points or signs of irritation.
Which immunoglobulin assumes a major role in bloodborne and tissue infections? (CH36) A) IgA B) IgG C) IgM D) IgD
B) IgG IgG assumes a major role in bloodborne and tissue infections. IgA protects against respiratory, gastrointestinal, and genitourinary infections. IgM appears as the first immunoglobulin produced in response to bacterial and viral infections. IgD possibly influences B-lymphocyte differentiation.
The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following? (CH36) A) Serum, which depletes the body's store of immunoglobulins B) Plasma, which depletes the body's store of catecholamines C) Plasma, which depletes the body's store of calcitonin D) Serum, which depletes the body's store of glucagon
A) Serum, which depletes the body's store of immunoglobulins Major burns cause impaired skin integrity and compromise the body's first line of defense. Loss of large amounts of serum occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. Loss of serum or plasma does not deplete the body of catecholamines (adrenal gland), calcitonin (thyroid gland), or glucagon (pancreas).
T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do? (CH36) A) T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person. B) T-cell and B-cell lymphocytes respond to the body's invasion by macrophages. C) T-cell and B-cell lymphocytes react to the body's lack of B12 . D) T-cell and B-cell lymphocytes distinguish harmful treatments from curative treatments.
A) T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person. T-cell and B-cell lymphocytes are the primary participants in the immune response. They distinguish harmful substances and ignore those natural and unique to a person. Options B, C, and D are incorrect.
Which should be included as part of the home care instructions for a client with epididymitis and orchitis? (Ch34) A) Take prescribed antibiotics B) Undertake lifting exercises C) Apply ice to the area after scrotal swelling subsides D) Resume sexual intercourse
A) Take prescribed antibiotics Home care for a client with epididymitis and orchitis includes instructions to continue administering prescribed antibiotics and to take Sitz baths, apply local heat after scrotal swelling subsides, avoid lifting, and refrain from sexual intercourse until symptoms are relieved.
Which structure is referred to as the vulva? (CH32) A) external female genitalia B) clitoris C) mons pubis D) vagina
A) External female genitalia
While examining the introitus, the nurse practitioner asks the client to "bear down." The nursing student observing the examination knows that the nurse practitioner is assessing the client for which condition? (CH32) A) Uterine prolapse B) Colorectal cancer C) Female genital mutilation D) Human papillomavirus
A) Uterine prolapse The introitus is the vaginal orifice. Uterine prolapse occurs when the cervix and uterus descend under pressure through the vaginal canal and can be seen at the introitus. To identify such protrusions, the examiner asks the client to "bear down." Examinations for colorectal cancer or female genital mutilation do not improve when the client bears down. A Pap test reveals atypical cells; the liquid method allows for human papillomavirus testing. This procedure does not require the client to bear down.
A 58-year-old patient has been diagnosed with acute prostatitis after seeking care for severe perineal pain. The patient's severe leukocytosis has prompted the care team to admit him to the medical unit of the hospital for treatment. The nurse should anticipate that this patient's treatment regimen will include which of the following? (Ch34) A) Insertion of a suprapubic catheter B) Administration of IV antibiotics C) Intermittent urinary catheterization every 2 to 4 hours D) Administration of beta-adrenergic blockers to relax the prostate
B) Administration of IV antibiotics Acute prostatitis may require the administration of IV antibiotics to resolve the existing infection and prevent sepsis. Intermittent catheterization would be contraindicated due to the potential for trauma. A suprapubic catheter is not normally necessary. Beta-adrenergic blockers do not resolve the signs and symptoms of acute prostatitis.
Which treatment involves implantation of interstitial radioactive seeds under anesthesia to treat prostate cancer? (Ch34) A) Hormone therapy B) Brachytherapy C) Teletherapy D) Chemotherapy
B) Brachytherapy Brachytherapy involves the implantation of interstitial radioactive seeds under anesthesia. Hormone therapy for advanced prostate cancer suppresses androgenic stimuli to the prostate by decreasing the level of circulating plasma testosterone or interrupting the conversion to or binding of DHT. Teletherapy involves 6 to 7 weeks of daily radiation treatments. High-dose ketoconazole (HDK) lowers testosterone through its abilities to decrease both testicular and endocrine production of androgen.
Which term means a lack of one or more of the five immunoglobulins? (CH37) A) Agammaglobulinemia B) Hypogammaglobulinemia C) Panhypoglobulinemia D) Telangiectasia
B) Hypogammaglobulinemia
A patient diagnosed with endometriosis asks for an explanation of the disease. What should the nurse explain to the patient? (CH33) A) She has developed an infection in the lining of her uterus. B) Tissue from the lining of the uterus has implanted in areas outside the uterus. C) The lining of the uterus is thicker than usual, causing heavy bleeding and cramping. D) The lining of the uterus is too thin because endometrial tissue has implanted outside the uterus.
B) Tissue from the lining of the uterus has implanted in areas outside the uterus. Endometriosis is a chronic disease affecting between 6% and 10% of women of reproductive age (Falcone & Lebovic, 2011) and consisting of a benign lesion or lesions that contain endometrial tissue (similar to that lining the uterus) found in the pelvic cavity outside the uterus.
When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask? (CH36) A) "Have you ever been treated for a sexually transmitted infection?" B) "When was your last menstrual period?" C) "Do you have abdominal pain or discomfort?" D) "Have you ever received a blood transfusion?"
D) "Have you ever received a blood transfusion?" A history of blood transfusions is obtained, because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function.
A client is diagnosed with hypertension. The client also reports skin discoloration, weight gain, and nausea. Which contraceptive preparations would the nurse practitioner recommend for this client? (CH32) A) Monophasic B) Biphasic C) Triphasic D) Progestin-only
D) progestin- only Progestin-only preparations are useful for women who have experienced estrogen-related side effects (e.g., headaches, hypertension, leg pain, chloasma or skin discoloration, weight gain, or nausea) when taking combination pills. Combined preparations can be monophasic, biphasic, and or triphasic. Monophasic preparations supply the same dose of estrogen and progestin for 21 days. Biphasic preparations and triphasic pills vary the amount of hormonal components during the cycle.
Uterine prolapse (CH32)
Uterus falling out of normal position
Bacterial Vaginosis (BV) (CH33)
a condition caused by an overgrowth of certain bacteria inhabiting the vagina. Malodorous vaginal discharge, "Fishy odor", grayish-white color Medication: Metronidazole
Variocele (CH32)
enlarged veins of the spermatic cord
Retrocele (CH32)
protrusion or herniation of rectum into vagina
Which is an early sign of Paget disease? (CH33) A) Increased pulse B) Nipple erythema C) Thickening of areola D) Fever
B) Nipple erythema Early signs of Paget disease include nipple and areola erythema. Late signs include thickening, scaling, and erosion of the nipple and areola.
A client presents with symptoms of menstrual difficulties and infertility. Which hormone is essential in the maintenance of the endometrium? (Ch32) A) Estrogen B) Progesterone C) Testosterone D) Prolactin
B) Progesterone Without a high level of progesterone, the endometrium (uterine lining) degenerates and shreds. Estrogen is a hormone that is essential for menstruation and prepares the uterus for pregnancy. Women produce testosterone, which maintains muscle mass, bone strength, and sex drive. Prolactin is produced by the pituitary gland and stimulates lactation.
A community health nurse is aware that a comprehensive assessment of a patient's immune system addresses nearly every system of the body. Which of the following assessment questions should the nurse prioritize in an assessment of a new patient's immune system? (CH36) A) "Have you had any recent unexplained weight loss or fatigue?" B) "Have you been consistent with taking your prescribed medications?" C) "Do you ever feel like your heart is racing or skips a beat?" D) "When was the last time that you visited your family doctor?"
A) "Have you had any recent unexplained weight loss or fatigue?" Weight loss and fatigue are associated with many of the health problems that result from an impaired immune response. Adherence to a medication regimen and history of care should also be assessed, but these are less directly linked to the signs and symptoms of immune dysfunction. Cardiac manifestations of impaired immune function are less common than symptoms involving other body systems.
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)? (CH37) A) Bone marrow transplantation B) Antibiotics C) Radiation therapy D) Removal of the thymus gland
A) Bone marrow transplantation Treatment options for SCID include stem cell and bone marrow transplantation.
The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed? (CH37) A) "I will let my neighbor have my pet iguana." B) "I will apply lotion following every bath to prevent dry skin." C) "I can take my child to the beach, as long as we play in the sand rather than swim in the water." D) "I will avoid letting my child drink any juice that has been sitting out for more than an hour."
C) "I can take my child to the beach, as long as we play in the sand rather than swim in the water." Parents should verbalize ways to plan for regular exercise and activity that does not pose a risk of infections. Immunocompromised clients should avoid touching sand or soil because of the high level of bacteria and increased risk of diseases such as toxoplasmosis.
The nurse is conducting a health history when a middle-aged client states that her last menstrual period was 6 months ago. Upon further questioning, the client also states that symptoms of hot flashes and mood fluctuations. Which question should the nurse ask next? (CH32) A) "Do you feel like hurting yourself?" B) "Are you finished having children?" C) "When was your first menstrual period?" D) "Are you taking any hormone replacement therapy?"
D) "Are you taking any hormone replacement therapy?" To ensure a thorough health history, a client who exhibits symptoms of perimenopause should be assessed for the use of hormone replacement therapy to alleviate the symptoms. This information adds to the data reported by the client. Asking if the client feels like hurting herself may be extreme with the report of mood fluctuations. Asking if the client is finished having children produces little additional data. Asking the first menstrual period is part of the health history but not the best question to ask after the client's statement.
A client is having prostate-specific antigen (PSA) testing done. Which result would the nurse identify as abnormal? (Ch34) A) 2.7 nanograms/milliliter B) 3.2 nanograms/milliliter C) 3.8 nanograms/milliliter D) 4.6 nanograms/milliliter
D) 4.6 nanograms/milliliter Normal prostate-specific antigen (PSA) levels are less than 4.0 nanograms/milliliter (ng/mL). A level of 4.6 ng/mL would be considered abnormal.
