Rasmussen Adult 2 Exam 3 with NCLEX questions

When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? "Condoms should be used when lesions are present on the penis." "Always position the condom with a space at the tip of an erect penis." "Make sure it fits loosely to allow for penile erection." "Use adequate lubrication, such as petroleum jelly."

"Always position the condom with a space at the tip of an erect penis." Positioning the condom with a space at the tip of the erect penis allows for the collection of semen at the tip of the condom.Condoms must be used by HIV-infected people at all times for sexual activity, with or without the presence of lesions. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. Lubricants should be water-based only. Oil-based lubricants, for example, petroleum-based lubricants (such as petroleum jelly), can increase the likelihood of breakage and slipping of latex condoms due to loss of elasticity caused by these lubricants. Oil may also create tiny holes in the latex. Oil-based lubricants may be considered desirable for people who are in relationships not requiring condom use and who wish to avoid certain additives and preservatives often found in other lubricants.

A client diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The client asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? "This will not make any difference in the viral load." "Blood concentrations will be decreased, which will lead to increased viral replication." "If only one dose of medication is missed, this will not make a difference." "This will cause an increase in opportunistic infections."

"Blood concentrations will be decreased, which will lead to increased viral replication." When doses are missed, blood concentrations become lower than what is needed for inhibition of viral replication (often called the inhibitory concentration). Teach clients the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART.When the inhibitory concentration is too low, the organism can replicate and produce new organisms that are resistant to the drugs being used. It does not cause an increase in opportunistic infections but places the client at increased risk for developing one. Therefore, it does make a difference and is critical to ensure that highly active antiretroviral therapy (HAART) doses are not missed, delayed, or administered in lower-than-prescribed dosages in the inpatient setting.

In discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? "Have you had sex with men or women or both?" "I hope you use condoms to protect your partners." "You must tell me all of your partners' names, so I can let them know about possibly having AIDS." "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know."

"Have you had sex with men or women or both?" The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate."I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. Asking for information in the name of the public health department is not straightforward, and the tone of this entire statement is judgmental. Judgmental statements to clients by healthcare providers (HCPs) can impede the collaborative relationship and communication between client and HCP.

The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address? "When I injected heroin, I was exposed to HIV." "I don't understand how the antiretroviral drugs work." "I remember to take my antiretroviral drugs almost every day." "My sex drive is weaker than it used to be since I started taking my antiretroviral medications."

"I remember to take my antiretroviral drugs almost every day." It is important that clients take these drugs consistently, because inconsistent use of antiretroviral medications can lead to unsuccessful therapy and the development of drug-resistant HIV strains. The nurse would immediately assess the reasons why the client does not take the medications daily and then would implement a plan to improve adherence.The nurse would assess whether the client is still injecting drugs and would make certain the client understands the risks for infection with another strain of HIV or other blood borne pathogens and the risk for spreading HIV, but this does not need to be addressed immediately. The nurse must provide further education about how the medications work and assess how the lack of knowledge or decreased libido influences compliance, but this does not need to be addressed immediately.

The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery of his AIDS by his family? "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" "Is there somewhere private in the home where we can go and talk?" "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick." "It is your duty to protect your family members from getting AIDS."

"Is there somewhere private in the home where we can go and talk?" A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. The nurse needs to have a private conversation with the client to discover the client's wishes.The client has a right to privacy and can make the decision whether to post handwashing signs; caution signs invade the client's right to privacy. Protection from infection is important, but stating that the family members should know about the disease is not respectful of the client's right to privacy. The nurse suggesting that it is the client's responsibility to protect his or her family from getting AIDS is an intimidating statement. It is the client's right to make the decision whether to inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently.

Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? "I told family members they need to wash their hands when they enter and leave the room." "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." "Yes, I understand the reasons why I have to wear gloves when I bathe the client." "The client's spouse told me she got HIV from a blood transfusion."

"The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse.Instruction on handwashing to family members or friends is not a breach of confidentiality. Understanding the reasons for wearing gloves recognizes Standard Precautions in direct care and is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.

The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? "I need to know my HIV status, so I must get tested before caring for any clients." "Putting on a gown and gloves will cover up the itchy sores on my elbows." "Washing my hands and putting on a gown and gloves is what I must do before starting care." "I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client's genitals."

"Washing my hands and putting on a gown and gloves is what I must do before starting care." Standard Precautions include hand hygiene and whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes.Knowing HIV status is important for preventing transmission of HIV, but is not part of the Standard Precaution Protocol. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of a gown and gloves. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.

A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? "With this treatment, I probably cannot spread this virus to others." "This treatment does not kill the virus." "This medication prevents the virus from replicating in my body." "Research has shown the effectiveness of this therapy if I do not forget to take any doses."

"With this treatment, I probably cannot spread this virus to others." HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids.HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance.

Nursing Diagnosis for an aneurysm

*A risk for Ineffective tissue perfusion (Renal/peripheral) *A risk for fluid volume decrease

HIV Stage 1: Acute primary infection

1-4 weeks • S+S = fever (raised temperature) • body rash • sore throat • swollen glands • headache • upset stomach • joint aches and pains • muscle pain.

Steps to draw up insulin

1. Wash hands 2. Gently rotate NPH insulin bottle 3. Wipe off tops of insulin vials with alcohol wipe 4. Draw back amount of air into the syringe that equals total dose 5. Inject air equal to NPH dose into NPH vial. 6. Inject air equal to regular dose into regular vial 7. Invert regular insulin bottle and withdraw regular insulin dose 8. Without adding more air to NPH vial, carefully withdraw NPH dose.

A patient at an STI clinic is a worried-looking 28-year-old gay man who until a month ago was in a long-term mutually monogamous relationship. He became inebriated at a party last night and went home with a new acquaintance. Consensual unprotected sex occurred several times, and the patient was both a top and bottom partner. Upon awakening, the partner was gone. This morning, the patient is concerned about STI and HIV risks. His last HIV test, performed two weeks ago, was negative. He does not know how to contact the partner from last night, and he asks whether he should have another ELISA or that new "fast test" performed today. 1. Does the patient have cause for concern? Why or why not? 2. What will you tell him about testing today? 3. Is he a candidate for pre-exposure prophylaxis today? Why or why not? 4. Is he a candidate for post-exposure prophylaxis today? Why or why not? 5. What other teaching or considerations are needed at this time?

1.) ANS: Yes, he does have cause for concern. He had unprotected receptive sex with a person whose HIV status is not known. Although not common, HIV can be transmitted with one sexual encounter, and he relates that sexual intercourse occurred more than once. 2.)ANS: None of the available tests can demonstrate whether HIV was transmitted within the past 24 hours. The "rapid test" still requires 21 days to avoid providing a false negative. The fact that he had a negative result 2 weeks ago is still within the window of false negatives for transmission with his previous partner. He should be offered HIV RNA particle testing today along with 4th generation antibody-antigen testing for that purpose. The results are ready within 24 hours. 3.)ANS: No, pre-exposure prophylaxis is not appropriate here. First, he has already been potentially exposed. Second, his circumstances do not indicate a continuing risk with known partners. 4.)ANS: Yes, he is a candidate for non-occupational exposure that occurred less than 36 hours ago. After testing but even before test results are known, he should be offered post-exposure prophylaxis . 5.)ANS: Even with post-exposure prophylaxis, he should continue to try and contact last night's partner and determine his HIV status, although this may not be possible. Ask him whether he frequently drinks alcohol and if alcoholism might be a possibility. Provide him with information about local support groups for alcoholism. Remind him of the transmission routes for HIV. Although he has been in a mutually monogamous relationship, that is no longer the case and unprotected intercourse is dangerous. Discuss with him the importance of returning to clinic for serial testing after post-exposure prophylaxis has been completed. Include pre-exposure prophylaxis discussion as a possibility for him in the future if he continues to test negative and is likely to have sex with a partner (partners) who are either HIV positive or whose status is not known. Provide him with condoms and strongly encourage him to use them with any sexual encounter.

When should you use Lispro?

15 minutes prior/after eating

How fast do manifestations of HIV occur?

2-4 weeks

When is HIV considered AIDS?

A count less than 200 with a complication. An example would be a count under 200 and PCP.

A nurse is caring for a client who is suspected of having HIV. Which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply.) A. Western blot B. Indirect immunofluorescence assay C. CD4+ T-lymphocyte count D. CD4+ T-lymphocyte percentage of total lymphocytes E. Cerebrospinal fluid (CSF) analysis

A,B A. CORRECT: Positive results of a Western blot test confirm the presence of HIV infection. B. CORRECT: Positive results of an indirect immunofluorescence assay confirm the presence of HIV infection. C. INCORRECT: CD4+ T-lymphocyte count assists with classifying the stage of HIV infection. D. INCORRECT: CD4+ T-lymphocyte percentage of total lymphocytes assists with classifying the stage of HIV infection. E. INCORRECT: CSF analysis can be used to confirm meningitis.

A nurse working in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he has had a cough along with nausea and diarrhea. His temperature is 38.1° C (100.6° F) orally. The client is afraid he has HIV. Which of the following actions should the nurse take? (Select all that apply.) A. Perform a physical assessment. B. Determine when current symptoms began. C. Teach the client about HIV transmission. D. Draw blood for HIV testing. E. Obtain a sexual history.

A,B,E A. CORRECT: The nurse should perform a physical assessment to gather data about the client's condition. This is an appropriate action by the nurse. B. CORRECT: The nurse should gather more data to determine whether the clinical manifestations are acute or chronic. This is an appropriate action by the nurse. C. INCORRECT: Teaching the client about HIV transmission is not an appropriate action by the nurse at this time. This is not a priority action for the nurse to include at this time. D. INCORRECT: Drawing blood for HIV testing is not an appropriate action by nurse at this time. This is not a priority action for the nurse to include at this time. E. CORRECT: The nurse should obtain a sexual history to determine how the virus was transmitted. This is an appropriate action by the nurse.

A nurse is assessing a client for HIV. Which of the following are risk factors associated with this virus? (Select all that apply.) A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult woman E. Occupational exposure

A,D,E A. CORRECT: Perinatal exposure is a risk factor associated with HIV. Women who are pregnant should take cautionary measures to prevent HIV exposure. B. INCORRECT: Women who are pregnant should be tested for HIV, but pregnancy is not a risk factor associated with this virus. C. INCORRECT: Having a monogamous sex partner is not a risk factor associated with the HIV virus. D. CORRECT: Being an older adult woman is a risk factor associated with the HIV virus due vaginal dryness and the thinning of the vaginal wall. E. CORRECT: Occupational exposure, such as being a health care worker, is a risk factor associated with the HIV virus.

3. A nurse is providing information to a client newly diagnosed with rheumatoid arthritis (RA). Which of the following statements by the nurse is appropriate? A. "You may experience morning stiffness when you get out bed." B. "You may experience abdominal pain." C. "You may experience weight gain." D. "You may experience low blood sugar."

A. "You may experience morning stiffness when you get out bed."

1. A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (Select all that apply.) A. Recent influenza B. Decreased range of motion C. Hypersalivation D. Decreased blood pressure E. Pain at rest

ABE 1. A. CORRECT: Exacerbating factors, such as a recent illness, are indicative of RA. B. CORRECT: Decreased ange of motion is indicative of RA. C. INCORRECT: Xerostomia is indicative of RA. D. INCORRECT: Blood pressure changes are not indicative of RA. E. CORRECT: Pain at rest is characteristic of RA.

A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate ? (Select all that apply.) A. Positive ANA B. Increased hemoglobin C. 2+ urine protein D. Increased serum C3 and C4 complement E. Elevated BUN

ACE A. CORRECT: A positive antinuclear antibody (ANA) titer is an expected finding in a client who has SLE. The ANA test identifies the presence of antibody produced against the client's own DNA. B. INCORRECT: Increased hemoglobin is not an expected finding in a client who has SLE. C. CORRECT: Increased urine protein is an expected finding due to renal involvement as a result of SLE. D. INCORRECT: Increased serum C3 and C4 are not expected findings in a client who has SLE. Findings would be decreased. E. CORRECT: Elevated BUN is an expected finding due to renal involvement in a client who has SLE.

Viral Load and CD4-T cells Untreated HIV infection

ACUTE: 2-12 weeks -- high viral load in blood at 6 weeks and drops -- HIV specific antibodies gradual increase -- CD4-T cells around 500 HIV ANTIBODIES WON'T BE DETECTABLE FOR SEVERAL WEEKS; NEED TO HAVE SERIAL TESTING** CHRONIC: 2-14 years -- low viral load in blood, gradual increase after 6 years -- HIV specific antibodies constant level remains -- CD4-T cells increasingly drops throughout years

This is the end stage of HIV infection. Without treatment, death occurs within 5 years.

AIDS

This stage of HIV is characterized by life-threatening opportunistic infections.

AIDS

During morning rounds, one of the unlicensed assistive personnel (UAP) makes a comment to another UAP that she is glad not to be assigned to that "nasty" patient with AIDS today. The patient has also remarked that this UAP is not very friendly, tries to avoid touching him, and even wears gloves to bring in his tray. 2. Should you force this UAP to provide care to this patient? Why or why not?

ANS: Although this may seem like rewarding the UAP for insufficient care, do not assign her to this patient by herself. It is likely that she will need time to consider her actions as well as to become more familiar with what protection is needed. In the mean time, this patient deserves better care. After education, when you do assign her to this patient, or any other one who is known to have HIV/AIDS, provide care to the patient together and model caring and safe behavior.

1. Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? a. Activating the viral enzyme "integrase" within the infected host's cells b. Binding of the virus to the CD4+ receptor and either of the two co-receptors c. Clipping the newly generated viral proteins into smaller functional pieces d. Fusing of the newly created viral particle with the infected cell's membrane

ANS: B Entry inhibitors work by binding to and blocking the CCR5 receptors on CD4+ T-cells, the main target of HIV. In order to successfully enter and infect a host cell, the virus must have its gp120 protein attached to the CD4 receptor and have its gp41 bound to the CD4+ T cell's CCR5 receptor. Viral binding to both receptors is required for infection. By blocking the HIV's attachment to the CCR5 receptor, infection is inhibited.

1. With which activities does the nurse teach unlicensed assistive personnel (UAP) and nursing students caring for a client who is HIV positive to wear gloves to prevent disease transmission? (Select all that apply.) a. Applying lotion during a back rub b. Brushing the client's teeth c. Emptying a Foley catheter reservoir d. Feeding the client e. Filing the client's fingernails f. Providing perineal care

ANS: B, C, F

1. A client diagnosed with AIDS who is receiving combination antiretroviral therapy (cART) now has a CD4+ T-cell count of 525 cells/mm3. How will the nurse interpret this result? a. The client can reduce the dosages of the prescribed drugs. b. The virus is resistant to the current combination of drugs. c. The client no longer has AIDS. d. The drug therapy is effective.

ANS: D A client diagnosed with AIDS meets the criteria for Stage 3 category of HIV infection. Even when this client's CD4+ T-cell count increases as a result of therapy, the diagnosis of AIDS remains. The fact that the T-cell count has risen indicates that the combination of drugs used for therapy is effective; however, the dosages are not decreased.

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg

ANS: D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.

During morning rounds, one of the unlicensed assistive personnel (UAP) makes a comment to another UAP that she is glad not to be assigned to that "nasty" patient with AIDS today. The patient has also remarked that this UAP is not very friendly, tries to avoid touching him, and even wears gloves to bring in his tray. 3. What should you say to the patient?

ANS: First apologize that he has not been receiving appropriate care. Ask him to report any uncaring behavior to you or any other RN as soon as it occurs.

During morning rounds, one of the unlicensed assistive personnel (UAP) makes a comment to another UAP that she is glad not to be assigned to that "nasty" patient with AIDS today. The patient has also remarked that this UAP is not very friendly, tries to avoid touching him, and even wears gloves to bring in his tray. 4. Who will you assign to care for this patient today?

ANS: If you know the staff well, reassign the patient to a UAP who is known to have provided adequate care in a respectful manner to other patients who were known to be HIV positive. If you are less familiar with the staff, ask for a volunteer. In either case, lighten the newly assigned UAP's duties somewhat for today.

During morning rounds, one of the unlicensed assistive personnel (UAP) makes a comment to another UAP that she is glad not to be assigned to that "nasty" patient with AIDS today. The patient has also remarked that this UAP is not very friendly, tries to avoid touching him, and even wears gloves to bring in his tray. 1. How will you address this issue with the UAP?

ANS: Stress to the UAP that health care workers have an ethical responsibility to provide quality care to all patients regardless of their HIV status. Remind her that failure to provide such care is viewed as not performing her job adequately. Review Standard Precautions with the UAP (see Chapter 23). Also remind her that if a patient has a known communicable disease, the proper personal protective equipment would be provided. If there is an information course or sensitivity course for this issue available, ensure that she attends. If such a course is not available, report the problem to human resources (without revealing the UAP's name at this time) and suggest that a review may be needed for all UAP. An additional approach used in similar situations by some institutions is peer counseling to promote caring attitudes and behaviors.

During morning rounds, one of the unlicensed assistive personnel (UAP) makes a comment to another UAP that she is glad not to be assigned to that "nasty" patient with AIDS today. The patient has also remarked that this UAP is not very friendly, tries to avoid touching him, and even wears gloves to bring in his tray. 5. What if any ethical issues are in play here? (You may need to review the principles of ethics in Chapter 1).

ANS: There are several ethical principles to ensure respect for the individual. The one most violated here is social justice, which demands that all patients be treated equally and fairly regardless of age, gender identity, sexual orientation, religion, race, ethnicity, or education. This is the minimum ethical behavior expected by anyone working in health care. Beneficence, which is the obligation of the nurse or any health care worker, to do good for the patient. The actions of the UAP toward the patient did not promote beneficence. Nonmaleficence, which is the prevention of harm and promotion of the patient's well-being, was seriously violated in the described situation. Well-being is emotional and psychosocial, as well as physical.

Clinical Manifestations and Complications of HIV

Acute Infection: - Flu like symptoms (HA, fever, myalgias, diarrhea, diffuse rash, swollen lymph nodes, sore throat) - Recover in about 2 weeks, counts go up, can take 10 years for symptoms if left untreated Chronic HIV infection: (time from untreated to HIV diagnosis) - Asymptomatic - Symptomatic --- When drops below 500 --- High viral load (when viral load increases s/s show) --- Opportunistic infections risk increased: Cancer (kaposi's sarcoma); Wasting syndrome can happen (can see all the bones) AIDS diagnosis -- goal is to decrease viral load as much as possible - THERE'S NO CURE FOR HIV/AIDS. - Even w/ a zero detectable viral load you can still spread infection**

S+S hypoglycemia

An irregular heart rhythm Fatigue Pale skin Shakiness Anxiety Sweating Hunger Irritability Tingling sensation around the mouth Crying out during sleep Confusion, abnormal behavior or both, such as the inability to complete routine tasks Visual disturbances, such as blurred vision Seizures Loss of consciousness

Labs for RA

Anti-CCP antibodies - Positive ☐☐ This test detects antibodies to cyclic citrullinated peptide (anti-CCP). The result is positive in most people who have rheumatoid arthritis, even years before symptoms develop. The test is more sensitive for RA than rheumatoid factor (RF) antibodies. RF antibody ☐☐ Diagnostic level for rheumatoid arthritis is 1:40 to 1:60 (expected reference range 1:20 or less). ☐☐ High titers correlate with severe disease. ☐☐ Other autoimmune diseases also can increase RF antibody. Erythrocyte sedimentation rate (ESR) - Elevated ☐☐ The increase is associated with the inflammation or infection in the body. ☐☐ 20 to 40 mm/hr is mild inflammation. ☐☐ 40 to 70 mm/hr is moderate inflammation. ☐☐ 70 to 150 mm/hr is severe inflammation. ☐☐ Other autoimmune diseases also can increase ESR antibody. ■■ C-reactive protein (may be done in place of ESR) - Positive ☐☐ This test is useful for diagnosing disease or monitoring disease activity, and for monitoring the response to anti-inflammatory therapy. ■■ Antinuclear antibody (ANA) titer (antibody produced against one's own DNA) ☐☐ A positive ANA titer is associated with RA (it is normally negative at 1:20 dilution). ☐☐ Other autoimmune diseases also can increase ANA. ■■ Elevated WBCs ☐☐ WBC count may be elevated during an exacerbation secondary to the inflammatory response. ☐☐ Decreased RBCs due to anemia.

Nursing care for HIV

Assess risk factors (sexual practices, IV drug use). Monitor fluid intake/urinary output. Obtain daily weights to monitor weight loss. Monitor nutritional intake. Monitor electrolytes. Assess skin integrity (rashes, open areas, bruising). Assess the client's pain status. Monitor vital signs (especially temperature). Assess lung sounds/respiratory status (diminished lung sounds). Assess neurological status (confusion, dementia, visual changes).

Which nursing activity can the nurse delegate to a home health aide? Changing the dressing for a client with a low absolute neutrophil count Assisting with bathing for a client with chronic rejection of a liver transplant Teaching a client with bacterial pneumonia how to take the prescribed antibiotic Assessing incisional tenderness for a client who had a recent kidney transplant

Assisting with bathing for a client with chronic rejection of a liver transplant Assisting with bathing for a client with chronic rejection of a liver transplant can be delegated to the home health aide.Changing the dressing for a client with a low absolute neutrophil count requires strict sterile technique by a licensed RN and should not be delegated because of the high risk for infection. Teaching about medications and assessments is within the scope of practice of the professional RN.

In what type of disorder do small antigens may bond with healthy tissue. The body then produces antibodies that attack the healthy tissue. This may be triggered by toxins, medications, bacteria, and/or viruses.

Autoimmune disorder

A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following clinical findings should the nurse anticipate? A. Swelling of joints of the fingers B. Pallor of toes with cold exposure C. Feet become reddened with ambulation D. Client report of intense feeling of heat in the fingers

B A. INCORRECT: Swelling, pain, and joint tenderness are clinical findings in a client who has SLE and is not specific to an episode of Raynaud's phenomenon. B. CORRECT: Pallor of the extremities occurs in Raynaud's phenomenon in a client who has SLE and has been exposed to cold or stress. C. INCORRECT: The extremities becoming red, white, and blue when exposed to cold or stress is characteristic of an episode of Raynaud's phenomenon in a client who has SLE. D. INCORRECT: A client report of intense pain in the hands and feet is characteristic of an episode of Raynaud's phenomenon in a client who has SLE.

A nurse is providing teaching about self-care to a client who has SLE. Which of the following statements by the client indicates a need for further teaching? A. "I should avoid sun exposure." B. "I will apply powder to any skin rash." C. "I should use a mild hair shampoo." D. "I will call my doctor if I have a cough."

B. CORRECT: This statement requires further teaching because the client should apply steroid-based creams to skin rashes.

A nurse is providing teaching to a client who has a new prescription for prednisone (Deltasone). Which of the following should be included in the teaching? (Select all that apply.) A. Hypotension can occur. B. Weight gain is expected. C. Abdominal striae may appear. D. Loss of appetite may be present. E. Moon facies may be evident.

BCE A. INCORRECT: Increased blood pressure is an adverse effect while taking this medication. B. CORRECT: Prednisone causes fluid retention which results in weight gain. C. CORRECT: Prednisone causes weight gain, especially in the abdomen, and can result in the appearance of abdominal striae. D. INCORRECT: An increase in appetite is an adverse effect while taking this medication. E. CORRECT: Moon facies (rounding of the face due to an accumulation of fatty tissue) is an adverse effect while taking this medication.

2. A nurse is caring for a client who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose this disease? (Select all that apply.) A. Urinalysis B. Erythrocyte sedimentation rate (ESR) C. BUN D. Antinuclear antibody (ANA) titer E. WBC count

BDE 2. A. INCORRECT: A urinalysis is not a laboratory test used to diagnose rheumatoid arthritis. This test can used for detecting kidney failure. B. CORRECT: ESR is a laboratory test used to diagnose rheumatoid arthritis. This laboratory test will show an elevated result in clients who have rheumatoid arthritis. C. INCORRECT: A BUN is not a laboratory test used to diagnose rheumatoid arthritis. This test can be used for detecting kidney failure. D. CORRECT: ANA titer is a laboratory test used to diagnose rheumatoid arthritis. This laboratory test will show a positive result in clients who have rheumatoid arthritis. E. CORRECT: WBC count is a laboratory test used to diagnose rheumatoid arthritis. This laboratory test will show a decreased result in clients who have rheumatoid arthritis.

Patient has a AAA and UO is 40 ml/2hours. What lab should be checked?

BUN. Need to check how kidney is functioning becuase poor renal perfusion is suspected.

A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the client? Clean toothbrushes once a week. Bathe daily using an antimicrobial soap. Eat salad at least once a day. Wash dishes in cool water.

Bathe daily using an antimicrobial soap. Bathing daily and using an antimicrobial soap will help decrease the risk for opportunistic infections by reducing the number of bacteria found on the skin.Toothbrushes should be cleaned daily through the dishwasher or by rinsing in liquid laundry bleach. Salads and raw fruits and vegetables could be contaminated and should be avoided. Dishes should be washed in hot, soapy water or in a dishwasher.

Why is it necessary to maintain a blood glucose level no lower than about 60 mg/dL?

Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation.

A Hydroxychloroquine (used for SLE and RA) side effected that should be reported immediately?

Blurred vision

High cholesterol foods

Butter, full-fat dairy, lard, fatty meats (Sausage), coconut and palm oils

AMI (antibody mediated immunity) is mediated by what?

B‐lymphocytes

A nurse is caring for a client who has HIV and has been newly diagnosed with Burkitt's lymphoma. Which of the following HIV infection stages is the client in? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

C. Stage 3

What does HIV target?

CD4+ lymphocytes, also known as T-cells or T-lymphocytes.

Metformin

Causes GI upset. Oral hypoglycemic for type 2 diabetes. Does not require daily testing of sugar levels.

Which interventions does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)-related dementia? Select all that apply. Change the decorations in the home according to the season. Put the bed close to the window. Write out detailed instructions, and have the client read them over before performing a task. Ask the client what time he or she prefers to shower or bathe. Mark off the days of the calendar, leaving open the current date.

Change the decorations in the home according to the season. Put the bed close to the window. Ask the client what time he or she prefers to shower or bathe. Mark off the days of the calendar, leaving open the current date. Changing decorations according to the season and using a calendar to mark off the days will help to keep the client oriented. Keeping the bed close to the window may help keep the client oriented. The client should be included in planning the daily schedule.Directions to the client need to be short and uncomplicated, and not detailed.

Diabetic foot care

Check feet daily, no lotion between toes, a podiatrist will trim nails straight across, wear shoes and socks at all times, cotton socks

Nursing management of an aneurysm

Check vitals, abdomnial size, cap refill, foot mottling, edema, surgical site checked frequently, function/drainage of an NG tube

HIV subjective data assessment

Chills Rash Anorexia, nausea, weight loss Weakness and fatigue Headache and sore throat Night sweats

What is an often silent and long stage (10+ years) of HIV where we see a dramatic loss of immunity, the viral load increases ond CD4+ cells are destroyed?

Chronic asymptomatic infection

The nurse is assigned to care for four clients. Which client does the nurse assess first? Client with human immune deficiency virus (HIV) and Kaposi's sarcoma who has increased swelling of a sarcoma lesion on the right arm Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature Client who has been admitted to receive a monthly dose of serum immune globulin to treat Bruton's agammaglobulinemia Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count

Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature The temperature elevation of the client with a history of liver transplantation indicates that infection may be occurring, and is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated.Information regarding the HIV-positive client with Kaposi's sarcoma and the client with Bruton's agammaglobulinemia indicates that these clients' physiologic statuses are relatively stable. It is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count.

Objective data for RA

Clinical findings depend on the area affected by the disease process Joint swelling and deformity, warmth, and erythema. Finger, hands, wrists, knees, and foot joints are generally affected. Finger joints affected are the proximal interphalangeal and metacarpophalangeal joints. Joints may become deformed merely by completing ADLs. Ulnar deviation, swan neck, and boutonniere deformities are common in the fingers. Subcutaneous nodules

What is an important part of ART (antiretroviral therapy)

Compliance to schedule!

Young, female patient with HIV is taking efavirenz, what education do they need.

Continue to use contraception because this medication may cause birth defects.

Tx of an Aneurysm

Control HTN with meds Surgical (only done after several tests) Pharm = diuretics, anti hypertensives, analgesica, stool softener, prop. hydrochloride. Activity = Avoid raising BP! STOP SMOKING

A nurse is completing discharge instructions with a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? A. "I will wear gloves while changing the pet litter box." B. "I will rinse raw fruits with water before eating them." C. "I will wear a mask when around family members who are ill." D. "I will cook vegetables before eating them."

D. "I will cook vegetables before eating them."

A nurse is admitting a client who has suspected SLE. Which of the following clinical findings supports this diagnosis? A. Weight loss B. Petechiae on thighs C. Increased hair growth D. Alopecia

D. Alopecia

Type 1 Diabetes and blindness

Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

Which diabetics should not use metformin

Diabetics with impaired kidney function due to lactic acidosis.

Subjective data for LUPUS

Fatigue/malaise Alopecia Blurred vision Malaise Pleuritic pain Anorexia/weight loss Depression Joint pain, swelling, tenderness

Risk factors for RA

Females (3:1) 20-50 yo Genetic predisposition Epstein-Barr virus Stress Environmental factors

Lupus Risk factors

Females/African American-Asian-Native American/age 20-40

A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? Fluconazole (Diflucan) Trimethoprim/sulfamethoxazole (Bactrim) Rifampin (Rifadin) Acyclovir (Zovirax)

Fluconazole (Diflucan) Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. Candidiasis is a fungal infection.Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. Rifampin (Rifadin) is used for treatment of tuberculosis. Acyclovir (Zovirax) is an antiviral agent.

Thrombosis

Formation of a clot

Thrombus

Formed clot that stays where it was found

Which factor relates most directly to a diagnosis of primary immune deficiency? History of viral infection Full-term infant surfactant deficiency Contact with anthrax toxin Corticosteroid therapy

Full-term infant surfactant deficiency Genetic mutation causes surfactant deficiency; this is a primary immune deficiency. Primary immunodeficiency diseases (PI) are a group of more than 250 rare, chronic disorders in which part of the body's immune system is missing or functions improperly.Viral infection can cause a secondary immune deficiency. Anthrax and medical therapy are examples of a secondary immune deficiency.

Primary immune response disorders

HIV

Which factors are possible transmission routes for human immune deficiency virus (HIV)? Select all that apply. Breast-feeding Anal intercourse Mosquito bites Toileting facilities Oral sex

HIV can be transmitted via breast milk from an infected mother to the child. Anal intercourse not only allows seminal fluid to make contact with the mucous membranes of the rectum, but it also tears the mucous membranes, making infection more likely. Oral sexual contact exposes the mucous membranes to infected semen or vaginal secretions.HIV is not spread by mosquito bites or by other insects. It is not transmitted by casual contact. Sharing toilet facilities does not cause transmission of HIV.

HIV medications

Highly active antiretroviral therapy (HAART) involves using three to four HIV medications in combination with other antiretroviral medications to reduce medication resistance, adverse effects, and dosages. ■■ Infusion inhibitors - enfuvirtide (Fuzeon) Blocks the fusion of HIV with the host cell ■■ Entry inhibitors - maraviroc (Selzentry) ■■ Nucleoside reverse transcriptase inhibitors (NRTIs) - zidovudine (Retrovir) Interfere with the virus's ability to convert RNA into DNA ■■Non-nucleoside reverse transcriptase inhibitors (NNRTIs) - delavirdine (Rescriptor) and efavirenz (Sustiva) ☐☐ Inhibit viral replication in cells ■■ Protease inhibitors - atazanavir (Reyataz), nelfinavir (Viracept), saquinavir (Invirase), and indinavir (Crixivan) ☐☐ Inhibit an enzyme needed for the virus to replicate ■■ Integrase inhibitors - raltegravir (Isentress) ■■ Antineoplastic medication - interleukin (Interferon) Immunostimulant that enhances the immune response and reduces the production of cancer cells (used commonly with Kaposi's sarcoma)

An HIV positive client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? Therapeutic highly active antiretroviral therapy (HAART) level Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot Positive Papanicolaou (Pap) test Improved CD4+ T-cell count and reduced viral load

Improved CD4+ T-cell count and reduced viral load Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication.Therapeutic HAART level is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. ELISA and Western blot, if positive, indicate that the client is HIV positive (a fact already known for this client) and do not indicate response to prescribed medication. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication.

Phlebitis

Inflammation in the wall of the vein without clot formation. Reddened streak over a vein.

Symptoms of HIV may look similar to what illness?

Influenza with rash and sore throat

This is given once daily to help control the blood sugar level of those with diabetes. It consists of microcrystals that slowly release insulin, giving a long duration of action of 18 to 26 hours, with a "peakless" profile.

Insulin glargine (lantus)

In RA, when the synovial tissue becomes inflamed it may spread into the cartilage, bone, tendons, and ligaments that surround the joint. What does this cause?

Joint deformity and bone erosion may result from these changes, decreasing the joint's range of motion and function.

Patient education for Buerger's Disease

Lifestyle/diet/hygiene

Clients whose SLE is unable to be managed with immunosuppressants and corticosteroids may experience renal failure secondary to glomerulonephritis. This is a major cause of death, and a renal transplant may be necessary. What is this called?

Lupus nephritis (renal failure/glomerulonephritis)

What persists throughout the disease process of HIV?

Lymphadenopathy

Embolus

Mass circulating in blood stream

DVT

May have no symptoms! Can be warm or tender at the site.

Nursing actions for LUPUS/SLE

Monitor for periorbital and lower extremity swelling and hypertension. Monitor the client's renal status (creatinine, BUN).

Raynaud's

More common in women. Unknown cause. Higher risk if 15-30, live in cold climate, or have family history.

Secondary immune response disorders

Myasthenia gravis Ankylosing spondylitis (Marie-Strümpell disease) Fibromyalgia Polymyositis and dermatomyositis RA* (classified as connective tissue disorder) SLE* (vascular and connective tissue disorder)

Zidovudine, an HIV antiviral, these adverse effect should be reported immediately

Myopathy: Tiredness Muscle pain Weakness or if you have symptoms of severe anemia or neutropenia

Medications used for LUPUS

NSAIDs ■■ Used to reduce inflammation and arthritic pain. ■■ Nursing Considerations ☐☐ NSAIDs are contraindicated for clients who have renal compromise. ☐☐ Monitor for NSAID-induced hepatitis. Corticosteroids (prednisone [Deltasone]) ■■ Used for immunosuppression and to reduce inflammation. ■■ Nursing Considerations - Monitor for fluid retention, hypertension, and renal dysfunction. ■■ Client Education - Do not stop taking steroids or decrease the dose abruptly. Immunosuppressant agents - methotrexate and azathioprine (Imuran) ■■ Used to suppress the immune response. ■■ Nursing Considerations - Monitor for toxic effects (bone marrow suppression, increased liver enzymes). Antimalarial - hydroxychloroquine (Plaquenil) ■■ Used for suppression of synovitis, fever, and fatigue.

Medications for RA

NSAIDs (Treatment begins with NSAIDs.) ■■ NSAIDs provide analgesic, antipyretic, and anti-inflammatory effects. NSAIDs can cause considerable gastrointestinal (GI) distress. ■■ Nursing Considerations ☐☐ Request a concurrent prescription for a GI-acid lowering agent (histamine2-receptor antagonist, proton pump inhibitor) if GI distress is reported. ☐☐ Monitor for fluid retention, hypertension, and renal dysfunction. ■■ Client Education ☐☐ Instruct the client to Take the medication with food or with a full glass of water or milk. If taking routinely, H2‑receptor antagonist may also be prescribed. Observe for GI bleeding (coffee ground emesis; dark, tarry stools). Avoid alcohol, which can increase the risk of GI complications. Corticosteroids ■■ Corticosteroids (prednisone) are strong anti-inflammatory medications that may be given for acute exacerbations or advanced forms of the disease. They are not given for long-term therapy due to significant adverse effects (osteoporosis, hyperglycemia, immunosuppression, cataracts). ■■ Nursing Considerations ☐☐ Observe for Cushingoid changes. ☐☐ Monitor weight and blood pressure. ■■ Client Education ☐☐ Instruct the client to observe for changes in vision, blood glucose, and impaired healing. ☐☐ Instruct the client to avoid crowds. ☐☐ Instruct the client to follow the provider's prescription, such as alternate day dosing, tapering, and discontinuing medication. Disease modifying anti-rheumatic drugs (DMARDs) ■■ DMARDs work in a variety of ways to slow the progression of RA and suppress the immune system's reaction to RA that causes pain and inflammation. Relief of symptoms may not occur for several weeks. ■■ Antimalarial agent - hydroxychloroquine (Plaquenil) ■■ Antibiotic - minocycline (Minocin) ■■ Sulfonamide - sulfasalazine (Azulfidine) ■■ Biologic response modifiers - etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), and chelator penicillamine (Cuprimine) ■■ Cytotoxic medications - methotrexate (Rheumatrex), leflunomide (Arava), cyclophosphamide (Cytoxan), and azathioprine (Imuran). These medications can cause severe adverse effects.

Why should a type 2 diabetes mellitus who is prescribed glipizide (Glucotrol) not use NSAIDS

NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

Lipodystrophy

Not rotating injection sites. Tissue damage from using the same site over and over.

What to do FIRST when you think the AAA has ruptured

Obtain a BP

A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first? Obtain a 12-lead electrocardiogram (ECG). Call for a portable chest x-ray. Obtain blood cultures from two sites. Give cefazolin (Kefzol) 500 mg IV.

Obtain blood cultures from two sites. Antibiotics should be given as soon as possible to immunocompromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic.A 12-lead ECG can be obtained and calling for a portable chest x-ray can be done after other priority requests have been carried out.

Novolog

Onset of action = Approximately 15 minutes Peak = 1-2 hours Duration = 3-6 hours

NPH

Onset of action = Approximately 2-4 hours Peak = 4-8 hours Duration = 10-18 hours

Humulin R

Onset of action = Approximately 30-60 minutes Peak = 2-4 hours

S+S of RA

Pain areas: in the joints, back, or muscles Joints: stiffness, swelling, tenderness, or weakness Whole body: fatigue, anemia, or malaise Skin: lumps or redness Hand: bump on the finger or swelling Also common: flare, dry mouth, physical deformity, or sensation of pins and needles

Metformin is contraindicated for what type of patient?

Patients with kidney impairment

The nurse presents a seminar on human immune deficiency virus (HIV) testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention regarding HIV testing? Select all that apply. "I am 78 years old, and I was treated and cured of syphilis many years ago." "In 1986, I received a transfusion of platelets." "Seven years ago, I was released from a penitentiary." "I used to smoke marijuana 30 years ago, but I have not done any drugs since that time." "At 68, I am going to get married for the fourth time."

People who have had a sexually transmitted disease should be tested. People who are in or have been in correctional institutions such as jails or prisons and people who are planning to get married should be tested for HIV.HIV testing is recommended for clients who received a blood transfusion between 1978 and 1985. People who have used injectable drugs (not marijuana) should be tested.

Complications of LUPUS/SLE

Pericarditis and myocarditis (instruct the client to report chest pain) - Inflammation of the heart, its vessels, and the surrounding sac can occur secondary to SLE.

Dx for HIV

Positive Western Blot test Positive ELISA test Positive/detectable result for viral load testing

In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency Potential for infection transmission related to recurring opportunistic infections High risk for inadequate nutrition related to acquired secondary immune deficiency and Candida albicans

Potential for infection transmission related to recurring opportunistic infections Protecting the client from further opportunistic infection such as Candida albicans is a priority. Secondary immune deficiencies are common and acquired as part of another disease or as a consequence of certain medications. The most common secondary immune deficiencies are caused by aging, malnutrition, certain medications, and some infections, such as HIV. The most common medications associated with secondary immune deficiencies are chemotherapy agents and immune suppressive medications, cancer, transplanted organ rejection, or autoimmune diseases.Loss of social contact is not a priority problem with an opportunistic infection. Mouth sores would be secondary concern because Candida Albicans causes the mouth sores. Nutrition will be affected because of Candida Albicans; however, it is not a priority.

What can exacerbate systemic lupus erythematosus

Pregnancy, infection, physical or mental stress, UV rays, certain medications, inactivity

Antidote for Heparin

Protamine sulfate

A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? Collaborate with the client to select foods that are high in calories. Provide oral care to the client before meals to enhance appetite. Assess the perianal area every 8 hours for signs of skin breakdown. Discuss the need to avoid foods that are spicy or irritating.

Provide oral care to the client before meals to enhance appetite. Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants.Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice, and would be done by licensed staff.

Measures the viral load and monitors HIV progression

Quantitative RNA

Which home health nurse should the nurse manager assign to care for an 18-year-old client with a kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)? RN who has worked for the home health agency for 5 years in maternal-child health RN who has extensive critical care nursing experience and has worked in home health for a year RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency

RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency The RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency has the experience and understanding of the needs of a posttransplantation client, as well as knowledge of cyclosporine, and would be the best choice.An RN who has worked for the home health agency for 5 years in maternal-child health, an RN who has extensive critical care nursing experience and has worked in home health for a year, and an RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit would not have specific knowledge and information on the care provided and medications used in posttransplantation clients.

Buerger's Disease

Rare, More common in men. Caused by arteries/veins where blood vessels become inflamed, swell, and are blocked with clots. This damages and destroys skin. STOP SMOKING!!!

Zidovudine, an HIV antiviral, side effects include

Rash Aplastic Anemia Blistering or peeling of the skin Hives Itching Difficulty breathing or swallowing Swelling of the eyes, face, tongue, lips, or throat

A patient has fruity breath and DKA is suspected, what type of insulin will they be given?

Regular

This has an onset of 30-60 minutes and should be given at a specific time before meals, typically 30 minutes. Always check the blood glucose level before administration.

Regular Insulin

Type 1 Diabetes and heredity

Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.

Raynaud's Dx

Rule out other conditions Primary = ANA test Secondary = Erythocyte Sedimentation rate

A "butterfly rash" is a dry red rash across the bridge of the nose and cheeks, can be seen with which disease

SLE (Lupus)

Autoimmune disorders

SLE, rheumatoid arthritis, vasculitis, multiple sclerosis, scleroderma (including Raynaud's phenomenon), and psoriasis.

Buerger's Disease Tx

STOP SMOKING Meds to dilate blood vessels or dissolve clots Intermittent compression Amputation

Tx for varicose veins

Scleratherapy

A client who is exposed to invading organisms recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client? Intact skin and mucous membranes Self-tolerance Inflammatory response against invading foreign proteins Antibody-antigen interaction

Self-tolerance Self-tolerance is the process of recognizing and distinguishing between the body's own healthy self cells and non-self proteins and cells. The presence of different proteins on cell membranes makes the process of self-tolerance possible.The body has some defenses to prevent organisms from gaining access to the internal environment, such as intact skin and mucous membranes; however, they are not perfect—invasion of the body's internal environment by organisms often occurs. Inflammation provides immediate protection against the effects of tissue injury and invading foreign proteins. The inflammatory response is immediate but short-term against injury or invading organisms; it does not provide true immunity. Seven steps, known as phagocytosis (See Figure 17-6), are needed to produce a specific antibody directed against a specific antigen. These steps are necessary whenever the person is exposed to that antigen.

Complications of RA

Sjogren's syndrome (triad of symptoms - dry eyes, dry mouth, and dry vagina). Caused by obstruction of secretory ducts and glands.

What type of medication would a patient with PAD (chronic buildup) recieve?

Statin

Patient taking metformin and scheduled to have an angiogram. What should you do?

Stop taking metformin 1-2 days prior due to reaction of the dyes needed in angiogram and medication.

S/S of AAA

Sudden, intense and persistent abdominal or back pain, which can be described as a tearing sensation. Pain that radiates to your back or legs. Sweatiness.

What is an autoimmune disorder in which an atypical immune response results in chronic inflammation and destruction of healthy tissue?

Systemic lupus erythematosus

What works together to form adaptive immunity?

T-cells work in concert with B-lymphocytes

Indications of infection

Tachycardia, increased neutrophils, and localized edema.

Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)? The dietary worker hands the disposable meal trays to the LPN assigned to the client. The social worker encourages the client to verbalize about stressors at home. A member of the housekeeping staff thoroughly cleans and disinfects the hallways near the client's room. The health care provider orders vital signs, including temperature, every 8 hours.

The dietary worker hands the disposable meal trays to the LPN assigned to the client. The dietary worker giving the meal tray to the LPN limits the number of health care personnel entering the room, thus reducing the risk for infection.Verbalizing stressors does not reduce the risk for infection. Cleaning of bathrooms, not hallways, at least once daily by housekeeping staff reduces risk for infection. Vital signs, including temperature, should be taken every 4 hours to detect potential infection, but this does not reduce the risk of infection.

Immunodeficiency

The inability to produce a normal complement of antibodies or immunologically sensitized T cells (cell-mediated immunity), especially in response to specific antigens.

The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority? Administer antibiotics as prescribed. Transfuse ordered packed red blood cells. Teach pursed-lip breathing. Encourage increased fluid intake.

Transfuse ordered packed red blood cells. Packed red blood cells increase hemoglobin molecules and increases sites at which oxygen can attach and improves gas exchange.Antibiotics treat infection and do not improve oxygenation. Mouth breathing does not improve oxygenation related to anemia. Fluid intake does not have an effect on improving oxygenation.

HIV Stage 3: Symptomatic HIV infection

Very susceptible to opportunistic disease/infections S+S= • weight loss • chronic diarrhea • night sweats • a fever • a persistent cough • mouth and skin problems • regular infections • serious illnesses or diseases.

Patient education for Raynaud's

Wear gloves when holding something cold, bundle up outdoors, warm your car, use indoor precautions, control stress, don't smoke, exercise

Rheumatoid arthritis RA

a chronic, progressive inflammatory disease that can affect tissues and organs but principally attacks the joints producing an inflammatory synovitis. It involves joints bilaterally and symmetrically, and it typically affects several joints at one time.

Aneurysm

an excessive localized enlargement of an artery caused by a weakening of the artery wall. 3 Types: Fusiform, Saccular, and Dissecting S+S = Depends on location. Hypotension, Tachycardia, Pallor, Cool/clammy skin, abdominal/back pain

Why is SLE often overlooked in older adults?

because many of the clinical manifestations mimic other disorders or may be associated with reports common to the normal aging process.

These medications can cause a glucose intolerance

betamethasone, prednisone and deflazacort.

Tx for Raynaud's

calcium channel blockers, vasodilators, nerve surgery, chemical injections

Patient has intermittent claudication, what should you assess?

check for pulses (legs/feet)

Raynaud's S+S

cold fingers/toes color changes in skin due to cold stress Numb/prickly feeling due to warmth or relief

Older adult clients are at an increased risk for fractures if they use what?

corticosteroid therapy

The natural course of RA

exacerbations and remissions.

Where is HIV found but not necessarily responsible/unlikely source for transmission?

feces, urine, tears, saliva, cerebrospinal fluid, cervical cells, lymph nodes, corneal tissue, and brain tissue

Secondary or specific immune antibody response

includes the activation of B cells and the memory cells (IgG, IgM, IgA, and IgE); and activation of T cells, cytotoxic (killer) cells, lymphokine-producing cells, helper cells, and suppressor cells (humoral immunity) to a specific antigen.

lymphadenopathy

is disease of the lymph nodes, in which they are abnormal in size, number, or consistency.

Primary Immune response

occurs when an antigen is initially introduced into the system. It involves both mast cell degranulation and activation of plasma proteins, that is, complement, clot-ting factors, and kinin—polypeptides that increase blood-flow and permeability of small blood capillaries.

Buerger's Disease S+S

pain, inflammation, fingers and toes turn pale when cold (Raynauds), painful sores on fingers and toes

S+S varicose veins

pain, swelling, skin ulcers

HIV Stage 2: The asymptomatic stage

the HIV virus may not reveal any other symptoms for up to 10 or even 15 years (depending on age, background and overall health).

What does RA typically affect first?

the upper joints

HIV risk factors

unsafe sex, rape, prostitution, occupational exposure, exposure to blood or contaminated needles

Causes of varicose veins

valvular incompetence

Nursing management of Venous thrombosis or thrombophlebitis

warm soaks, NSAID, tylenol, elevation, elastic support, anticoagulants, diet for hydration, bed rest with periods of elevation, monitor vitals, monitor for warmth/swelling/bleeding, change stockings every 24 hours (Hygeine)

Lab tests for lupus

■■ Autoantibodies ☐☐ Antinuclear antibody (ANA) titer (antibody produced against one's own DNA) - positive ANA titer in 90% of clients who have lupus (expected finding is negative ANA titer at 1:20 dilution) ■■ Anti-DNA - positive (not specific for SLE but positive in the vast majority of clients who have SLE) ■■ Extractable nuclear antibodies (ENAs) specific for selected parts of a cell's nucleus ☐☐ Anti-Smith (anti-Sm) - positive (highly specific for SLE) ☐☐ Anti-RO (SSA) - positive ☐☐ Anti-LA (SSB) - positive ☐☐ Anti-RNP - positive ☐☐ Anti-phospholipids (AP) - positive

HIV client education

■■ Instruct the client to practice good hygiene and frequent hand hygiene to reduce the risk of infection. ■■ Instruct the client to avoid crowded areas or traveling to countries with poor sanitation. ■■ Encourage the client to avoid raw foods, such as vegetables and meats. ■■ Instruct the client to avoid cleaning pet litter boxes to reduce the risk of toxoplasmosis. ■■ Encourage the client to keep the home environment clean and to avoid being exposed to family and friends who have colds or flu viruses.

Nursing interventions for Sjogren's syndrome

■■ Provide the client with eye drops and artificial saliva, and recommend vaginal lubricants as needed. ■■ Provide fluids with meals.

Patient education for LUPUS/SLE

■■ Teach the client the importance of taking immunosuppressants and corticosteroids as prescribed. ■■ Teach the client the importance of avoiding stress and illness.

Complications of HIV

●● Opportunistic Infections ◯◯ Bacterial diseases, such as tuberculosis, bacterial pneumonia, and septicemia (blood poisoning) ◯◯ HIV-associated malignancies, such as Kaposi's sarcoma, lymphoma, and squamous cell carcinoma ◯◯ Viral diseases, such as those caused by cytomegalovirus, herpes simplex, and herpes zoster virus ◯◯ Fungal diseases, such as PCP, candidiasis, cryptococcosis, and penicilliosis ◯◯ Protozoal diseases, such as pneumocystis jiroveci pneumonia (PCP), toxoplasmosis, microsporidiosis, cryptosporidiosis, isosporiasis, and leishmaniasis Wasting Syndrome Seizures (HIV encephalopathy)

Nursing care for RA

◯◯ Apply heat or cold to the affected areas as indicated based on client response. ■■ Morning stiffness (hot shower) ■■ Pain in hands/fingers (heated paraffin) ■■ Edema (cold therapy) ◯◯ Assist with and encourage physical activity to maintain joint mobility (within the capabilities of the client). ◯◯ Monitor the client for indications of fatigue.

Subjective data for RA

◯◯ Pain at rest and with movement ◯◯ Morning stiffness ◯◯ Pleuritic pain (pain upon inspiration) ◯◯ Xerostomia (dry mouth) ◯◯ Anorexia/weight loss ◯◯ Fatigue ◯◯ Paresthesias ◯◯ Recent illness/stressor ◯◯ Joint pain ◯◯ Lack of function

HIV - Care after discharge

◯◯ Refer the client to local AIDS support groups as appropriate. ◯◯ Home health service may be indicated for clients who need help with strengthening and assistance regarding ADLs. ◯◯ Home health services may also provide assistance with IVs, dressing changes, and total parenteral nutrition (TPN). ◯◯ Respiratory services may be consulted for providing portable oxygen. ◯◯ Long-term care facilities may be indicated for clients with chronic HIV. ◯◯ Hospice services may be indicated for clients who have a late stage of HIV. ◯◯ Food services may be indicated for clients who are homebound and need meals prepared.