211 Test 3
A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.
A
A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.
A
A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site
A
A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. I always wear long sleeves, pants, and a hat when outdoors. b. I try not to use cosmetics that contain any type of sunblock. c. Since I tend to sweat a lot, I use a lot of baby powder. d. Since I can't be exposed to the sun, I have been using a tanning bed.
A
A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.
A
A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. I don't need to go to the hospital after using it. b. I must carry two EpiPens with me at all times. c. I will write the expiration date on my calendar. d. This can be injected right through my clothes
A
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.
A
A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.
A
An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.
A
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? a protecting the client from infection b proving emotional support to decrease fear c encouraging discussion about lifestyle changes d Identifying factors that decreased the immune function
A
The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse
A
The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3
A
The nurse provides home care instructions to a client with SLE and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching? a "I should take hot baths because they are relaxing." b "I should sit whenever possible to conserve my energy." c "I should avoid long periods of rest because it causes joint stiffness." d "I should do some exercises, such as walking, when I am not fatigued."
A
A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important?a. Assess the clients bedside glucose reading .b. Instruct the client not to get up without help .c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight.
B
A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit
B
A patient has a bone density score of -2.8. What action by the nurse is best? a Asking the patient to complete a food diary b Planning to teach about bisphosphonates c Scheduling another scan in 2 years d Scheduling another scan in 6 months
B
An older patient is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3 (8.9 x 109/L), red blood cell count: 3.2/mm3 (3.2 x 1012/L), hemoglobin: 9 g/dL (90 g/L), hematocrit: 32%. What intervention by the nurse is most appropriate? a Instruct the patient ot avoid large crowds b Prepare to administer epoetin alfa c Teach the patient about foods high in iron d Tell the patient that all laboratory results are normal
B
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client
B
The nurse is teaching the parent of a 4-year-old child with a cast on the arm about care at home. What statement by the parent indicates a correct understanding of the teaching? a "I should have the affected limb hang in a dependent position." b "I will use an ice pack to relieve the itching." c "I should avoid keeping the injured arm elevated." d "I will expect the fingers to be swollen for the next 3 days."
B
The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? a Wear gloves b wear gown and gloves c wear a gown, gloves, and a mask d wear a gown and gloves to change the bed linens, and gloves only for the bath
B
The nurse should instruct a patient with a nondisplaced fractured left radius that the cast will need to remain in place for what amount of time? a two weeks b at least six weeks c until swelling of the wrist has resolved d until x-rays show complete bone fusion
B
Which action should the nurse take when repositioning the patient who has just had a laminectomy and discectomy? a Instruct the patient to move the legs before turning the rest of the body b Place a pillow between the patient's legs and turn the entire body as a unit c Have the patient turn by grasping the side rails and pulling the shoulders over d Turn the patient's head and shoulders first, followed by the hips, legs, and feet
B
A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. Be sure you get enough sleep at night. b. Eat plenty of high-protein, high-iron foods. c. Notify your provider at once if you get a fever. d. Weigh yourself every day on the same scale.
C
A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month
D
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly
D
After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? a "His masklike face makes it difficult to communicate, so I will use the white board." b "He should not socialize outside of the house due to uncontrollable drooling." c "This disease is associated with anxiety causing increased perspiration." d "He may have trouble chewing, so I will offer bite-sized portions."
D
The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)
D
The nurse is caring for an immobilized preschool child. What intervention is helpful during this period of immobilization? a Encourage wearing pajamas. b Let the child have a few behavioral limitations c Keep the child away from other immobilized children if possible. d Take the child for a "walk" by wagon outside the room
D
The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should questions the client about an allergy to which food item? a. Eggs b. Milk c. Yogurt d. Banana
D
The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjogren's syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity
D