6. AUTOIMMUNE (Ch. 69, NCLEX) <aquila2883, theh00ker, MsHarley299, YCR_88>

What is the NORMAL BUN lab value?

7 to 20 mg/dL

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth

A, D, E ~ The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

What is the NORMAL CREATININE lab value?

0.6 to 1.2 mg/dL males 0.5 to 1.1 mg/dL females

A nurse is caring for a client who has had rheumatoid arthritis (RA) for 5 years. Which laboratory value requires the most immediate intervention by the nurse? a. White blood cell count (WBC), 3800/mm3 b. Hemoglobin (Hg), 10.6 g/dL c. Blood urea nitrogen (BUN), 16 mg/dL d. Creatinine, 3.2 mg/dL

D ~ Clients with RA usually have pancytopenia, or a decrease in all cell types. WBC and hemoglobin are low, consistent with this condition. BUN is normal. Creatinine is very high; this indicates renal disease. This client may have renal consequences of his or her RA, which should be investigated.

An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).

D ~ Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the clients TB test could be a false negative.

A client is suspected to have rheumatoid arthritis. Which manifestations does the nurse assess this client carefully for? a. Crepitus when the client moves the shoulders b. Numbness and tingling in the clients fingers c. Client has cool feet, with weak pedal pulses d. Low-grade fever, fatigue, anorexia with weight loss

D ~ Low-grade fever is common with rheumatoid arthritis because of the inflammatory response. Fatigue, anorexia, and weight loss are also common symptoms. Impaired neurologic status, popping sounds with range of motion (ROM), and poor circulation are not common symptoms of rheumatoid arthritis.

The nurse is instructing a client about management of discoid lupus erythematosus (DLE). Which statement indicates that the client requires additional teaching? a. I will be sure to apply sunscreen whenever I am outside. b. I will apply small amounts of the steroid cream to my face twice a day. c. I will take Plaquenil (hydroxychloroquine sulfate) with breakfast each morning. d. Steroids weaken the immune system, so I will wash my hands frequently.

D ~ Steroid creams used for the treatment of discoid lupus will not weaken the immune system because they should be applied in small amounts to affected areas. The client will be more sensitive to sun exposure while using the steroid cream, so sunscreen should be used whenever the client goes outside. The client should use only small amounts of the cream on her face. Plaquenil should be taken with meals or a glass of milk.

What is the NORMAL HEMOGLOBIN lab value?

Men: 13.5 to 17.5 Women: 12.0 to 15.5

What is the NORMAL WBC lab value?

4,500 to 11,000

A clients white blood cell count is 7500/mm3. Calculate the expected range for this clients neutrophils. (Record your answer using whole numbers separated with a hyphen; do not use commas.) ______/mm3

4125-5625/mm3 The normal range for neutrophils is 55% to 75% of the white blood cell count. 7500*0.55 = 4125 7500*0.75 = 5625 So the range would be expected to be 4125/mm3 to 5625/mm3.

The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestation? a) an exaggerated sense of well-being b) slurring of words when excited c) visual hallucinations d) inappropriate laughter

A Explanation: A client with multiple sclerosis may have a sense of optimism and euphoria, particularly during remissions. Euphoria is characterized by mood elevation with an exaggerated sense of well-being. Inappropriate laughter, slurring of words, and visual hallucinations are uncharacteristic of euphoria.)

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? a) Edrophonium b) Carbachol c) Pyridostigmine d) Ambenonium

A Explanation: Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma)

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? a) limiting fluid intake to 1,000 mL/day b) setting a regular time for elimination c) using an elevated toilet seat d) eating a diet high in fiber

A Explanation: Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position.)

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? a) Establish a regular voiding schedule. b) Insert an indwelling urinary catheter. c) Limit fluid intake to 1,000 mL/day. d) Administer prophylactic antibiotics, as prescribed.

A Explanation: Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence.)

Which is an initial sign of Parkinson's disease? a) tremor b) bradykinesia c) rigidity d) akinesia

A Explanation: The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia.)

What assessment findings would the nurse expect to find with a client with progressive myasthenia gravis? a) Muscle weakness, difficulty swallowing, double vision, and difficulty speaking b) Muscle pain, difficulty speaking, headaches, and arthritic changes c) Muscle inflammation, choking when eating, nearsightedness, and painful joints d) Atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving

A Explanation: With myasthenia gravis there is a disturbance in nerve transmission to the muscles. The signs and symptoms in this answer reflect this neuromuscular impairment. The other answers include signs and symptoms not related to neuromuscular impairment, such as atrophy, muscle inflammation, headaches, and arthritic changes.)

An expected nursing intervention for a patient diagnosed with Bell's palsy would be which of the following? A) Applying a protective eye shield B) Encouraging the patient to eat on the affected side C) Avoiding analgesics D) Avoiding brushing of the teeth

A Feedback: Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected. The patient is encouraged to eat on the unaffected side, due to swallowing difficulties. Analgesics are used to control the facial pain. The patient should continue to provide self-care including oral hygiene.

When developing a plan of care for a patient with Guillain-Barre' syndrome, the nurse knows that which of the following nursing interventions would receive priority? A) Using the incentive spirometer as prescribed B) Maintaining the patient on bed rest C) Assisting the patient with activities of daily living D) Determining abnormalities of cognitive function

A Feedback: Impaired gas exchange would be the priority. Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions aimed at enhancing physical mobility and preventing a deep vein thrombosis are utilized. Assisting the patient with activities of daily living is important but would not be the priority nursing intervention. Guillain-Barre' does not affect cognitive function or level of consciousness.

What basic information will the nurse caring for a patient recently diagnosed with multiple sclerosis (MS) provide to him? A) It is a degenerative disease of the nervous system. B) It usually occurs more frequently in men. C) It has an acute onset. D) It is caused by a bacterial infection.

A Feedback: Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system (CNS) characterized by the occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not known; it affects twice as many women as men.

When assessing a patient with myasthenia gravis, the nurse would be correct in questioning the patient regarding which of the following clinical manifestations? A) Weakness associated with fatigue B) Headache that worsens at night C) Projectile vomiting without nausea D) Diaphoresis

A Feedback: Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Generalized weakness affects all the extremities and the intercostal muscles, resulting in varying decreasing vital capacity and respiratory failure. The other manifestations listed are not symptomatic of myasthenia gravis.

When examining a patient with Guillain-Barre' syndrome, the nurse would expect to assess which of the following clinical manifestations? A) Paresthesias of the hands and feet B) Hyperactive deep tendon reflexes C) Hypotension D) Descending weakness

A Feedback: Sensory symptoms of Guillain-Barre' include paresthesias of the hands and feet, and pain related to the demyelinization of sensory fibers. Other clinical manifestations include hyporeflexia and loss of deep tendon reflexes. A classic feature of Guillain-Barre' is ascending weakness.

The nurse would expect to document which of the following in a patient with myasthenia gravis undergoing a Tensilon test? A) Positive Tensilon test B) Negative Tensilon test C) Positive sweat test D) Negative sweat test

A Feedback: The patient in myasthenic crisis improves immediately following administration of edrophonium chloride (Tensilon). Sweat tests are used in diagnosing cystic fibrosis, not myasthenia gravis.

The nurse would expect to find which of the following symptoms when assessing a 38-year-old patient diagnosed with multiple sclerosis? A) Vision changes B) Absent deep tendon reflexes C) Tremors at rest D) Flaccid muscles

A Feedback: Vision changes, such as diplopia, nystagmus, and blurred vision are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive, not absent. Babinski's sign may be positive. Tremors at rest aren't characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in patients with multiple sclerosis. Affected muscles are spastic rather than flaccid.

The nurse teaching a patient with trigeminal neuralgia about factors that precipitate an attack would be correct in teaching him to avoid: A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking liquids at room temperature

A Feedback: Washing the face should be avoided if possible due to the fact that this activity can trigger an attack of pain in a patient with trigeminal neuralgia. Exposing the skin to sunlight is not harmful to this patient. Using artificial tears and drinking liquids at room temperature are appropriate behaviors.

A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.

A ~ Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

A client with rheumatoid arthritis had abdominal surgery and has returned to the postoperative nursing unit. The client is unable to use the incentive spirometer correctly, demonstrating limited lung volume and fatiguing easily. What action by the nurse takes priority? a. Notify the physician immediately. b. Have respiratory therapy re-instruct the client. c. Assess for pain and medicate if necessary. d. Let the client rest for a few hours.

A ~ Clients with rheumatoid arthritis can have cervical spine involvement resulting in subluxation. This may lead to decreased respiratory function and can be life threatening. This client was recently intubated for an operation and so is at higher risk for this problem. The nurse should notify the physician immediately and continue assessing the client.

An older adult client is scheduled for knee replacement surgery. Which statement by the client indicates a need for further preoperative instruction? a. I need to keep my leg positioned away from my body. b. I may have a continuous passive motion machine for a few days. c. I may need more pain medicine than I did with my hip replacement. d. I probably can get back to work within 2 to 3 weeks.

A ~ Dislocation is not a problem with knee replacement surgery, so the client does not need to keep his or her leg abducted. The other statements indicate accurate understanding of the instructions.

A client with a history of rheumatoid arthritis will be starting drug therapy with etanercept (Enbrel). What is most important for the nurse to teach the client? a. The correct technique for subcutaneous injections b. How to self-monitor blood glucose levels c. How to set up and prime the IV tubing d. How to calculate the dosage based on symptoms

A ~ Enbrel is a parenteral medication that is given by subcutaneous injection. The client and/or the family will need to be taught how to give a subcutaneous injection correctly. Blood glucose levels should not be affected by this medication. The medication is not administered IV. Drug dosages are not changed and recalculated by the client.

A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis

A ~ Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.

A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. It increases the elimination of T lymphocytes from circulation. b. It inhibits cytokine production in most lymphocytes. c. It prevents DNA synthesis, stopping cell division in activated lymphocytes. d. It prevents the activation of the lymphocytes responsible for rejection.

A ~ Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.

The nurse is teaching a community health class about health promotion techniques. Which statement by a student indicates a strategy to help prevent the development of osteoarthritis? a. I will keep my BMI under 24. b. I will switch to low-tar cigarettes. c. I will start jogging twice a week. d. I will have a family tree done.

A ~ Obesity increases the stress on weight-bearing joints and contributes to the development of degenerative joint disease. Smoking does not decrease risk for osteoarthritis. Jogging increases the risk because of increased wear and tear on the joints. There is a genetic link to osteoarthritis; creating a family tree might help the client discover if there is any familial link but will not help prevent the disorder.

A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes

A ~ Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. Avoid large crowds and people who are ill. b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed. d. You have a higher risk of developing cancer.

A ~ Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils

A ~ The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.

The nurse is caring for a postoperative client on the medical-surgical unit following a total left hip replacement the previous day. During the assessment, the nurse notes that the clients left leg is cool, with weak pedal pulses. What is the nurses first action? a. Assess circulatory status of the right leg. b. Notify the surgeon immediately. c. Measure leg circumference at the calf. d. Check for bilateral Homans signs.

A ~ The symptoms may represent impaired circulation or may be normal for this client. Before the surgeon is notified, the status of the nonoperative leg should be assessed and assessment findings on both legs compared with the clients baseline. Homans sign (pain in the calf on dorsiflexion of the foot) is not always indicative of a deep vein thrombosis and should not be evaluated until other assessments are made. Measuring calf circumference would provide additional data related to deep vein thrombosis.

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells

A, B, C ~ The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization

A, B, D, E ~ The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.

The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.

A, C, D, E ~ Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.

A nurse is collecting data on a client with rheumatoid arthritis. The nurse looks at the client's hands and notes these characteristic deformities. The nurse identifies this deformity as: Refer to figure. 1. Ulnar drift 2. Rheumatoid nodules 3. Swan neck deformity 4. Boutonniere deformity

Answer: 1 Rationale: All of the conditions identified in the options can occur in rheumatoid arthritis. Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints.

A health care provider aspirates synovial fluid from a knee joint of a client with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to indicate which finding? 1. Cloudy synovial fluid 2. Presence of organisms 3. Bloody synovial fluid 4. Presence of irate crystals

Answer: 1 Rationale: Cloudy synovial fluid is diagnostic of rheumatoid arthritis. Organisms present in the synovial fluid are characteristic of a septic joint condition. Bloody synovial fluid is seen with trauma. Urate crystals are found in gout.

A nurse determines that the neutropenic client needs further discharge teaching if which of the following statements is made by the client? 1. "I will include plenty of fresh fruits in my diet." 2. "If I develop a fever over 100° F, I will call my doctor." 3. "Petting my dog is fine as long as I wash my hands after doing so." 4. "My husband will just have to take over cleaning the cat's litter box."

Answer: 1 Rationale: Fresh fruits and vegetables are eliminated from the diet to avoid the introduction of pathogens. Fever of 100.4° F or greater should be reported immediately. Feeding and petting cats and dogs are fine as long as handwashing follows. Handling pet excrement must be avoided to avoid exposure to pathogens.

The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. Which client population is at most risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

Answer: 1 Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; individuals having multiple surgeries; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts.

The camp nurse prepares to instruct a group of children about Lyme disease. Which of the following information would the nurse include in the instructions? 1. Lyme disease is caused by a tick carried by deer. 2. Lyme disease is caused by contamination from cat feces. 3. Lyme disease can be contagious by skin contact with an infected individual. 4. Lyme disease can be caused by the inhalation of spores from bird droppings.

Answer: 1 Rationale: Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by Ixodes ticks can be infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse suggest to assist the client in performing activities of daily living? 1. Provide supportive care with hygiene needs. 2. Provide meals and snacks with high protein, high calorie, and high nutritional value. 3. Provide small, frequent meals. 4. Offer low microbial food.

Answer: 1 Rationale: Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options 2, 3, and 4 are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option 2 will assist the client in maintaining appropriate weight and proper nutrition. Option 3 will assist the client in tolerating meals better. Option 4 will decrease the client's risk of infection.

The nurse is assessing a client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection? 1. "Did you have chicken pox as a child?" 2. "How many sexual partners have you had?" 3. "Did you use an electric blanket on your side?" 4. "Why don't you try docosanol cream (Abreva) on your lesions?"

Answer: 1 Rationale: The client has the symptoms of herpes zoster, or shingles, which is caused by the same organism as chicken pox. Asking about sexual partners is inappropriate for this disorder. An electric blanket use does not cause this type of lesions. Abreva is used on herpes simplex I (cold sores).

A nurse is doing discharge teaching with a client who has sickle cell disease. The nurse instructs the client to avoid which factor that could precipitate a sickle cell crisis? 1. Infection 2. Mild exercise 3. Fluid overload 4. Warm weather

Answer: 1 Rationale: The client should avoid infections, which can increase metabolic demand and cause dehydration, precipitating a sickle cell crisis. The client should also avoid dehydration from other causes. Warm weather and mild exercise do not need to be avoided, but the client should take measures to avoid dehydration during these conditions. Fluids are important to prevent dehydration. Finally, the client should avoid being in areas of high altitude, or flying in a nonpressurized aircraft because of lesser oxygen tension in these areas.

The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

Answer: 1 Rationale: The client with immune deficiency has inadequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

A nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse understands that which problem is a priority for the client? 1. Infection 2. Inability to cope 3. Lack of information about the disease 4. Feeling uncomfortable about body changes

Answer: 1 Rationale: The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority problem is infection. The question presents no data indicating that options 2, 3, or 4 are a problem.

A nurse is providing dietary instructions to a client with systemic lupus erythematosus. Which of the following dietary items would the nurse instruct the client to avoid? 1. Steak 2. Turkey 3. Broccoli 4. Cantaloupe

Answer: 1 Rationale: The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake.

A client calls the health care clinic and tells the nurse that he was bitten by a tick. The client is concerned and asks the nurse about the first signs of Lyme disease. The nurse informs the client that stage 1 of Lyme disease is characterized by: 1. Skin rash 2. Painful joints 3. Tremors and weakness 4. Headaches and blurred vision

Answer: 1 Rationale: The hallmark of stage 1 of Lyme disease is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bullseye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage 1, most infected people develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. Options 2, 3, and 4 are not the first symptoms related to Lyme disease.

The client with acquired immunodeficiency syndrome has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that which of the following procedures will be done to confirm whether these lesions are due to Kaposi's sarcoma? 1. Skin biopsy 2. Lung biopsy 3. Western blot 4. Enzyme-linked immunosorbent assay

Answer: 1 Rationale: The skin biopsy is the procedure of choice to diagnose Kaposi's sarcoma, which frequently complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay and Western blot are tests to diagnose human immunodeficiency virus status.

A client with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a nursing diagnosis of Impaired Gas Exchange written in the plan of care. Which of the following indicates that the expected outcome of care has not yet been achieved? 1. The client limits fluid intake. 2. The client has clear breath sounds. 3. The client expectorates secretions easily. 4. The client is free of complaints of shortness of breath.

Answer: 1 Rationale: The status of the client with a nursing diagnosis of Impaired Gas Exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include that the client breathes easier, coughs up secretions effectively, and has clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

Answer: 1 Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply. 1. Use non-latex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Do not puncture rubber stoppers with needles. 5. Keep a latex-safe supply cart available in the client's area. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

Answer: 1 2 4 5 Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use non-latex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with a rubber stopper that requires puncture with a needle. It is not necessary to place the client in a private room.

A nurse is assisting in developing a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which of the following is the priority concern for this client? 1. Inability to care for self at home 2. Development of an infection 3. Lack of available support services 4. Isolation

Answer: 2 Rationale: Acquired immunodeficiency syndrome decreases the body's immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body's defense system. Opportunistic infections are a primary cause of death in people affected with AIDS. Therefore preventing infection is a priority of nursing care. Although the concerns in options 1, 3, and 4 may need to be addressed at some point in the care of the client, these are not the priority.

A nurse is providing instructions to a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. The nurse advises the client to do which of the following to increase comfort while minimizing symptoms? 1. Remove the plastic cover on the pillow. 2. Keep liquids on the nightstand at home. 3. Reduce fluid intake before bedtime. 4. Take an antipyretic after the fever spikes.

Answer: 2 Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to keep liquids on the nightstand at home. The client should keep a plastic cover on the pillow and place a towel over the pillowcase if needed also. The client should not decrease fluid intake, and the client should take an antipyretic before going to sleep and before the fever spikes.

The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate in the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wearing a gown and gloves to change the bed linens and gloves only for the bath

Answer: 2 Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

A client who is prescribed zidovudine (Retrovir) has been diagnosed with severe neutropenia. The nurse anticipates which intervention will be implemented? 1. The medication dose will be reduced. 2. The medication will be temporarily discontinued. 3. Prednisone will be added to the medication regimen. 4. Epoetin alfa (Epogen) will be added to the medication regimen.

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

A client with acquired immunodeficiency syndrome (AIDS) is taking zidovudine (Retrovir) 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. Which of the following would the nurse anticipate to be prescribed for the client? 1. Reduction in the medication dosage 2. Discontinuation of the medication 3. The administration of prednisone concurrent with the therapy 4. Administration of epoetin alfa (Epogen)

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

A client calls the office of his primary care health care provider and tells the nurse that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction, because the client's neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to: 1. Advise the client to soak the site in hydrogen peroxide. 2.Ask the client if he ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency room. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

Answer: 2 Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse would suspect that which of the following findings will be reported from this blood test? 1. Increased red blood cell count 2. Decrease of all cell types 3. Increased white blood cell count 4. Increased neutrophils

Answer: 2 Rationale: In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease of all cell types, probably caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.

A nurse is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1. Children in day care centers 2. Individuals with spina bifida 3. Individuals with cardiac disease 4. Individuals living in a group home

Answer: 2 Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work with manufacturing latex products; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, passion fruit, avocados, and chestnuts.

Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma? 1. A kidney transplant client 2. A male with a history of same-sex partners 3. A client receiving antineoplastic medications 4. An individual working in an environment where exposure to asbestos exists

Answer: 2 Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It isn't seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma.

A client with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine (Videx) therapy. The clinic nurse emphasizes what instruction to this client? 1. Take crackers and milk with each dose of the medication. 2. Come to the health care clinic to be seen by the health care provider. 3. Decrease the dose of the medication until the next clinic visit. 4. This is an uncomfortable but expected side effect of the medication.

Answer: 2 Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine (Videx). The client should be seen by the health care provider and be monitored for indications of developing pancreatitis. The reported symptoms are not the primary subject, and so the options directed toward explaining or managing them are not correct. The nurse should not encourage the client to alter the medication dose without first notifying the health care provider.

A client with acquired immunodeficiency syndrome (AIDS) is taking didanosine (Videx). The client calls the nurse at the health care provider's office and reports nausea, vomiting, and abdominal pain. Which of the following instructions would the nurse provide to the client? 1. This is an expected side effect of the medication. 2. Come to the office to be seen by the health care provider. 3. Take crackers and milk with the administration of the medication. 4. Decrease the dose of the medication until the next health care provider's visit.

Answer: 2 Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of developing pancreatitis, which include increased serum amylase in association with increased serum triglycerides, decreased serum calcium, and nausea, vomiting, or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. The client should be seen by the health care provider.

A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which of the following descriptions of this condition? 1. The presence of tiny red vesicles 2. An autoimmune disease that causes blistering in the epidermis 3. The presence of skin vesicles found along the nerve caused by a virus 4. The presence of red, raised papules and large plaques covered by silvery scales

Answer: 2 Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.

A clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse assesses for an early manifestation of Pneumocystis jiroveci infection by monitoring for which of the following at each client visit? 1. Fever 2. Cough 3. Dyspnea on exertion 4. Dyspnea at rest

Answer: 2 Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.

A nurse is providing information to a client with systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which of the following foods? 1. Chicken 2. Beef 3. Melons 4. Cauliflower

Answer: 2 Rationale: The client with SLE is at risk for cardiovascular disorders, such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce intake of salt, fat, and cholesterol.

A client is diagnosed with stage I of Lyme disease. In addition to the rash, the nurse would check the client for which manifestation? 1. Arthralgias 2. Flulike symptoms 3. Neurologic deficits 4. Enlarged and inflamed joints

Answer: 2 Rationale: The hallmark of stage I is the development of a skin rash at the tick bite site. The rash develops into a concentric ring that has a bullseye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. The other options listed occur in stage II (neurological deficits) or stage III (arthralgias and enlarged, inflamed joints).

The client is diagnosed with stage I of Lyme disease. The nurse assesses the client for which characteristic of this stage? 1. Arthralgias 2. Flu-like symptoms 3. Enlarged and inflamed joints 4. Signs of neurological disorders

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

A nurse is assigned to care for a client who returned home from the emergency department following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should: 1. Contact the health care provider (HCP). 2. Cover the crutch pads with cloth. 3. Call the local medical supply store, and ask for a cane to be delivered. 4. Tell the client that the crutches must be removed immediately from the house.

Answer: 2 Rationale: The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 4 is inappropriate and may alarm the client. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may not be appropriate, considering this client's injury. No reason exists to contact the HCP at this time.

A client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which of the following questions should the nurse ask next? 1. "Was the tick small or large?" 2. "When were you bitten by the tick?" 3. "Did you save the tick for inspection?" 4. "Did the tick bite anyone else in the family?"

Answer: 2 Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. The appropriate question by the nurse should elicit information related to when the tick bite occurred.

A nurse is assisting in the care of a client diagnosed with systemic lupus erythematosus (SLE). The nurse should administer which of the following prescribed medications that is needed to manage the condition? 1. Antidiarrheal 2. Corticosteroid 3. Antibiotic 4. Opioid analgesic

Answer: 2 Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory medications, corticosteroids, and immunosuppressants. The other options are not standard components of medication therapy for this disorder.

A client reports to the health care clinic to obtain testing regarding human immunodeficiency virus (HIV) status after being exposed to an individual who is HIV positive. The test results are reported as negative, and the client tells the nurse that he feels so much better knowing that he had not contracted HIV. The nurse explains the test results to the client, telling the client that: 1. There is no further need for testing. 2. A negative HIV test is considered accurate. 3. A negative HIV test is not considered accurate during the first 6 months after exposure. 4. The test should be repeated in 1 week.

Answer: 3 Rationale: A test done for HIV should be repeated. There might be a lag period after the infection occurs and before antibodies appear in the blood. Therefore a negative HIV test is not considered accurate during the first 6 months after exposure.

A nurse is assisting in developing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention should the nurse suggest including in the plan of care to manage this symptom? 1. Keep the call bell within reach for the client. 2. Administer a sedative at bedtime. 3. Administer an antipyretic at bedtime. 4. Provide a back rub and comfort measures before bedtime.

Answer: 3 Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer an antipyretic at bedtime. It is also helpful to keep a change of bed linens and night clothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Options 1, 2, and 4 are important interventions but they are unrelated to the subject of fever and night sweats.

A Cub Scout leader who is a nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellent because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants."

Answer: 3 Rationale: In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, one should avoid heavily wooded areas or areas with thick underbrush. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of the following? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions on the skin

Answer: 3 Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is: 1. A local rash that occurs as a result of allergy 2. A disease caused by overexposure to sunlight 3. An inflammatory disease of collagen contained in connective tissue 4. A disease caused by the continuous release of histamine in the body

Answer: 3 Rationale: SLE is an inflammatory disease of collagen contained in connective tissue. Options 1, 2, and 4 are not associated with this disease.

A client diagnosed with Lyme disease says to the nurse, "I heard this disease can affect the heart. Is this true?" The nurse should make which response to the client? 1. "Where did you get your information?" 2. "Yes, that's true but it rarely ever occurs." 3. "It can, but you will be monitored closely for cardiac complications." 4. "It primarily affects the joints with the occasional facial paralysis."

Answer: 3 Rationale: Stage 2 of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. The serious problems that occur in this stage include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. The remaining options are either untrue or do not effectively address the client's concern.

A nurse reads the chart of a client who has been diagnosed with stage 3 Lyme disease. Which clinical manifestation supports this diagnosis? 1. A generalized skin rash 2. A cardiac dysrhythmia 3. Complaints of joint pain 4. Paralysis of a facial muscle

Answer: 3 Rationale: Stage 3 develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage 2. A rash occurs in stage 1. Paralysis of the extremity where the tick bite occurred is not a characteristic of Lyme disease.

A client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse would focus on which of the following first until additional help arrives? 1. Preparing a dose of epinephrine (Adrenalin) 2. Preparing a dose of a corticosteroid 3. Maintaining a patent airway 4. Telling the client to obtain a Medic-Alert bracelet

Answer: 3 Rationale: The initial priority of the nurse would be to maintain a patent airway. Once additional helps arrives, the client would likely receive epinephrine and corticosteroids. The topic of the Medic-Alert bracelet should be deferred until the client is stable.

A client arrives at the health care clinic requesting to be tested for Lyme disease. The client tells the nurse that he removed the tick and flushed it down the toilet. Which nursing action is appropriate? 1. Refer the client for a blood test immediately. 2. Inform the client that the tick is needed to perform a test. 3. Arrange for the client to return in 4 to 6 weeks to be tested. 4. Ask the client to describe the size, shape, and color of the tick.

Answer: 3 Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. Options 1, 2, and 4 are inaccurate.

Indinavir (Crixivan) is prescribed for a client with human immunodeficiency virus (HIV). The nurse has provided instructions to the client regarding ways to maximize absorption of the medication. Which of the following, if stated by the client, indicates an adequate understanding of the use of this medication? 1. "I need to take the medication with my large meal of the day." 2. "I need to store the medication in the refrigerator." 3. "I need to take the medication with water but on an empty stomach." 4. "I need to take the medication with a high-fat snack."

Answer: 3 Rationale: To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal such as cornflakes with skim milk and sugar. It is not to be administered with a large meal. The medication should be stored at room temperature and protected from moisture because moisture can degrade the medication.

The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed? 1. Antibiotic 2. Antidiarrheal 3. Corticosteroid 4. Opioid analgesic

Answer: 3 Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. The incorrect options are not standard components of medication therapy for this disorder.

A client calls the emergency department and tells the nurse that he received a bee sting to the arm while weeding a garden. The client states that he has received bee stings in the past and is not allergic to bees. The client states that the site is painful and asks the nurse for advice to alleviate the pain. The nurse tells the client to first: 1. Take two acetaminophen (Tylenol). 2. Place a heating pad to the site. 3. Apply ice and elevate the site. 4. Lie down and elevate the arm.

Answer: 3 Rationale: When a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. Pain may be alleviated by the application of an ice pack and elevating the site. A heating pad will increase discomfort at the site. Acetaminophen may be taken by the client to assist in alleviating discomfort, but this would not treat the injury at a local level. Lying down and elevating the arm may have some effect on reducing edema at the site but will not directly assist in alleviating the pain at the site of injury.

A client is positively diagnosed with stage 1 Lyme disease. The client asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which of the following will be part of the treatment plan? 1. Ultraviolet light therapy 2. No treatment unless symptoms develop 3. Treatment with intravenous (IV) penicillin G 4. A 3- to 4-week course of oral antibiotic therapy

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

A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which of the following nursing actions is appropriate? 1. Refer the client for a blood test immediately. 2. Inform the client that there is not a test available for Lyme disease. 3. Tell the client that testing is not necessary unless arthralgia develops. 4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

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

The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that immunization provides which of the following? 1. Protection from all diseases 2. Innate immunity from disease 3. Natural immunity from disease 4. Acquired immunity from disease

Answer: 4 Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases.

The home care nurse is ordering dressing supplies for a client who has an allergy to latex. The nurse asks the medical supply personnel to deliver which of the following? 1. Elastic bandages 2. Adhesive bandages 3. Brown Ace bandages 4. Cotton pads and silk tape

Answer: 4 Rationale: Cotton pads and plastic or silk tape are latex-free products. The items identified in the incorrect options are products that contain latex.

The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

Answer: 4 Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy.

The nurse interprets that the client who is prescribed zalcitabine (Hivid) is experiencing an adverse effect of this medication when which event is reported by the client? 1. Diarrhea 2. Tinnitus 3. Burning with urination 4. Numbness in the legs

Answer: 4 Rationale: Peripheral neuropathy is an adverse effect associated with the use of zalcitabine, which manifests initially as numbness and burning sensations in the extremities. They may progress to sharp shooting pains or severe continuous burning if the medication is not withdrawn. The other options are not associated with use of this medication.

Which client is at the highest risk for systemic lupus erythematous (SLE)? 1. An Asian male 2. A white female 3. An African-American male 4. An African-American female

Answer: 4 Rationale: SLE affects females more commonly than males. It is more common in African-American females than in white females.

A nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse further checks for which of the following that is also indicative of the presence of SLE? 1. Emboli 2. Ascites 3. Two hemoglobin S genes 4. Butterfly rash on cheeks and bridge of nose

Answer: 4 Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE. Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many conditions but are not associated with SLE.

A nurse is reviewing the medical record of a young female client who is suspected of having systematic lupus erythematosus (SLE). Which of the following would the nurse expect to note documented in the record that is related to this diagnosis? 1. Presence of two hemoglobin S genes in the blood cell report 2. Ascites noted in the abdomen 3. Recurrent emboli 4. Butterfly rash on cheeks and bridge of the nose

Answer: 4 Rationale: SLE primarily occurs in females 10 to 35 years of age and is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE. Option 1 is found in sickle cell anemia. Options 2 and 3 are found in many conditions but are not usually noted in SLE.

A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous? 1. Weight gain 2. Subnormal temperature 3. Elevated red blood cell count 4. Rash on the face across the bridge of the nose and on the cheeks

Answer: 4 Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

A client with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client verbalized to increase intake of foods such as: 1. Raw fruits and vegetables 2. Hot soup 3. Peanut butter 4. Puddings

Answer: 4 Rationale: The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables. The client is encouraged to take in foods that are mild, nonabrasive, and easy to swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs, and desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating.

A nurse is assisting in preparing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure should the nurse include in the plan? 1. Dairy products with each snack and meal 2. Red meat daily 3. Adding spices to food to make the taste more palatable 4. Foods that are at room temperature

Answer: 4 Rationale: The client with AIDS experiencing nausea should avoid fatty products, such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous foods should be avoided because they aggravate nausea. Foods are best tolerated either cold or at room temperature.

A client who is human immunodeficiency virus (HIV) positive has had a Mantoux skin test. The results show a 7-mm area of induration. The nurse evaluates that this result is: 1. Negative 2. Borderline 3. Uncertain 4. Positive

Answer: 4 Rationale: The client with HIV is considered to have positive results on Mantoux skin testing with an area of 5 mm of induration or greater. The client without HIV is positive with induration greater than 10 or 15 mm if the client is at low risk. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is also possible for the client infected with HIV to have false negative readings because of the immunosuppression factor.

A client is diagnosed with an immune deficiency. The nurse focuses on which of the following as the highest priority when providing care to this client? 1. Encouraging discussion about emotional impact of the disorder 2. Identifying historical factors that placed the client at risk 3. Providing emotional support to decrease fear 4. Protecting the client from infection

Answer: 4 Rationale: The client with immune deficiency has inadequate immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. The other options are also part of the plan of care but are not the highest priority.

A client with human immunodeficiency virus (HIV) who has contracted tuberculosis (TB) asks the nurse how long the medication therapy lasts. The nurse responds that the duration of therapy would likely be for at least: 1. 6 total months and at least 1 month after cultures convert to negative 2. 6 total months and at least 3 months after cultures convert to negative 3. 9 total months and at least 3 months after cultures convert to negative 4. 9 total months and at least 6 months after cultures convert to negative

Answer: 4 Rationale: The client with tuberculosis who is coinfected with HIV requires that antitubercular therapy last longer than usual. The prescription is usually for a total of 9 months and at least 6 months after sputum cultures convert to negative.

A client is diagnosed with stage 1 Lyme disease. The nurse checks the client for which hallmark characteristic of this stage? 1. Signs of neurological disorders 2. Enlarged and inflamed joints 3. Headache 4. Skin rash

Answer: 4 Rationale: The hallmark of stage 1 is the development of a skin rash that occurs within 2 to 30 days of infection, generally at the site of the tick bite. The remaining options are not initially related to this pathology.

A nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse would inform the students that which of the following is an unsafe behavior? 1. Abstinence 2. Mutual monogamy 3. Use of latex condoms 4. Use of natural skin condoms

Answer: 4 Rationale: The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through. Abstinence is the safest way to avoid HIV infection. The next most reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of the HIV virus as long as the condom is used properly and remains in place and intact.

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial? a) weekly visits by another person with MS b) regular exercise c) psychotherapy d) day care for the granddaughter

B Explanation: An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients)

When teaching a client about levodopa-carbidopa therapy for Parkinson's disease, a nurse should include which instruction? a) "Report any eye spasms." b) "Be aware that your urine may appear darker than usual." c) "Stop taking this drug when your symptoms disappear." d) "Take this medication at bedtime."

B Explanation: Levodopa-carbidopa, used to replace insufficient dopamine in the client with Parkinson's disease, may cause harmless darkening of the urine. The drug doesn't cause eye spasms, although blurred vision is an expected adverse effect. The client should take levodopa-carbidopa shortly before meals, not at bedtime, and must continue to take it for life.)

A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction? a) "My family will take care of me. I've given my daughter durable power of attorney for health care." b) "I don't really need to sign anything. I'm depending on my physician to tell my family what to do if something bad happens." c) "I've signed the advance directive papers and will fight to maintain the highest quality of life until my time comes." d) "I know that I'll eventually be unable to make decisions. Signing an advance directive now will save my family grief."

B Explanation: The client requires additional teaching if the client states that he/she will depend on the physician to tell the family what to do in regards to his/her health. The client should not rely on the physician to tell the family what to do. The best way for the client to convey his/her health care wishes is to put them in writing in an advance directive. The client stating that he/she has designated his/her daughter to make health care decisions when the client cannot, that the client has signed an advance directive, or that the client knows an advance directive will help when he/she is unable to make decisions indicate that the client has made decisions about his/her end-of-life care.)

Which is an expected outcome for a client with Parkinson's disease who has had a pallidotomy? a) reduced emotional stress b) improved functional ability c) better appetite d) increased alertness

B Explanation: The goal of a pallidotomy is to improve functional ability for the client with Parkinson's disease. This is a priority. The pallidotomy creates lesions in the globus pallidus to control extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by the pallidotomy, the client may experience a secondary response of an improved emotional response, but this is not the primary goal of the surgical procedure. The procedure will not improve alertness or appetite.)

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent: a) fluid overload. b) contractures. c) dry mouth. d) ascites.

B Explanation: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.)

A patient with Guillain-Barre' has had arterial blood gases (ABGs) drawn. Which of the following ABG values indicates that the patient's status is deteriorating? A) pH 7.37 B) PaCO2 60 C) HCO3 24 D) Oxygen saturation of 94%

B Feedback: A PaCO2 of 60 places the patient with Guillain-Barre' in an acidotic state due to hypoventilation from respiratory muscle weakness. The pH, HCO3, and oxygen saturation are within normal levels.

The physician has ordered a Tensilon test to rule out myasthenia gravis. The nurse knows that which of the following medications would be used to counteract the side effects of the Tensilon? A) Baclofen (Lioresal) B) Atropine (AtroPen) C) Epinephrine (Adrenalin) D) Narcan (Naloxone)

B Feedback: Atropine 0.4 mg controls the side effects of Tensilon, which include bradycardia, sweating, and cramping. Baclofen is a skeletal muscle relaxant used in the treatment of multiple sclerosis. Epinephrine is used in the treatment of anaphylaxis, cardiac arrest, and bronchospasm. Narcan is used to reverse the narcotic-induced respiratory depression.

Upon admission, the physician orders baclofen (Lioresal) for a patient diagnosed with multiple sclerosis. The nurse knows that which of the following is an expected outcome of this medication? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Limited severity and duration of exacerbations

B Feedback: Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Anticholinesterase agents increase muscle strength in the upper extremities. Corticosteroids limit the severity and duration of exacerbations.

Bell's palsy is a disorder of cranial nerve VII. What are the clinical manifestations of the disorder? A) Tinnitus B) Facial paralysis C) Pain at the base of the tongue D) Diplopia

B Feedback: Bell's palsy is characterized by facial dysfunction, weakness, and paralysis.

It is important to frequently monitor the patient with Guillain-Barre' syndrome when ascending paralysis is occurring. When assessing the patient for bulbar muscle weakness, the nurse should be alert to which of the following clinical manifestations? A) Decreased level of consciousness B) Inability to clear secretions C) Hypersensitivity of hands and feet D) Increased intracranial pressure

B Feedback: Bulbar muscle weakness related to demyelinization of the glossopharyngeal and vagus nerves results in an inability to swallow or clear secretions. Guillain-Barre' does not affect cognitive function or level of consciousness. Sensory symptoms include paresthesias of the hands and feet related to demyelinization of the sensory fibers. Guillain-Barre' does not cause increased intracranial pressure.

A nurse caring for a patient with possible bacterial meningitis in the ICU knows that which of the following assessment findings would be expected for a patient with bacterial meningitis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities

B Feedback: Clinical manifestations of bacterial meningitis include positive Brudzinski's sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski's sign. Positive Homan's sign (pain upon dorsiflexion of the foot) and negative Romberg's sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the patient with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities and is not an initial assessment to rule out bacterial meningitis.

When teaching the patient with multiple sclerosis how to reduce fatigue, the nurse should tell him to: A) Take a hot bath. B) Rest in an air-conditioned room. C) Increase the dose of muscle relaxants. D) Avoid naps during the day.

B Feedback: Fatigue is a common symptom in patients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the patient with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

The nurse assessing a patient with multiple sclerosis understands that due to the pathophysiology of this disease process which of the following is the expected primary finding on the MRI? A) Subarachnoid hemorrhage B) Presence of multiple plaques C) Atrophy of the caudate nuclei D) Presence of a tumor

B Feedback: MRI is the primary diagnostic tool for visualizing plaques, documenting disease activity, and evaluating the effect of treatment. A subarachnoid hemorrhage would be seen on an MRI from a ruptured aneurysm. Atrophy of the caudate nuclei is seen in Huntington's disease. The presence of a tumor indicates brain tumor.

A patient with trigeminal neuralgia is taking Tegretol (carbamazepine) to alleviate pain associated with this disorder. It is important to teach the patient that which of the following side effects may occur from taking this medication? A) Skin discoloration B) Drowsiness C) Insomnia D) Tinnitus

B Feedback: Side effects of Tegretol include nausea, dizziness, drowsiness, and aplastic anemia. The patient must also be monitored for bone marrow depression during long-term therapy. Skin discoloration, insomnia, and tinnitus are not side effects of Tegretol.

A 42-year-old woman diagnosed with metastatic cancer has developed trigeminal neuralgia. She is taking carbamazepine (Tegretol) for pain relief. Which of the following applies to this medication? A) The medication should be taken on an empty stomach. B) Thee patient should be monitored for bone marrow depression.. C) Side effects include renal dysfunction. D) The medication should be taken in maximum dosage form to be effective.

B Feedback: The anticonvulsant agents carbamazepine (Tegretol) and phenytoin (Dilantin) relieve pain in most patients diagnosed with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals. Carbamazepine is taken with meals and should be gradually increased until pain relief is obtained.

The nurse is caring for an older adult client who will be discharged home to live with an adult daughter. The client will be given prescriptions for four new medications for rheumatoid arthritis. How does the nurse ensure that the client will be able to take the medications correctly at home? a. Monitor the client self-administering medications while in the hospital. b. Include the clients daughter when teaching the client about the medications. c. Provide the client with pamphlets and information about all the medications. d. Make a chart showing which medications the client should take at different times.

B ~ Because the client will be living with the daughter, she should be included in the teaching plan about the medications. Providing pamphlets or charts about the medications does not ensure that the client knows how to take them correctly at home. Self-administering medications may or may not be permitted by hospital policy and might be helpful, but including the daughter would be the best option.

A client is admitted for a total hip replacement. Past medical history includes diabetes mellitus type 2, a heart attack 5 years ago, and allergies to sulfa drugs. The client currently takes insulin on a sliding scale and celecoxib (Celebrex). Before administering the clients medications, which action by the nurse is most appropriate? a. Take the clients blood pressure in both arms. b. Call the physician to clarify the orders. c. Schedule a preoperative electrocardiogram. d. Review the clients laboratory values.

B ~ Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs are thought to cause serious adverse reactions such as myocardial infarction and renal problems. This client already has coronary artery disease and a past myocardial infarction, so the nurse should discuss the order with the physician before giving the medication. Reviewing laboratory results could indicate renal impairment, but taking the clients blood pressure and scheduling an electrocardiogram (ECG) would not take priority over discussion with the physician.

A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

B ~ During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.

The nurse is working with a client who will be taking 20 mg of prednisone daily for rheumatoid arthritis. Which precautions does the nurse give the client about taking this medication? a. Take this medication at bedtime because it will make you sleepy. b. Take calcium and vitamin D supplements daily. c. Eat a high-fiber diet with lots of lean meats. d. Wash your face twice a day with an antibacterial soap.

B ~ Long-term steroid use is associated with many complications, including diabetes, infection, and osteoporosis, among others. The client should be instructed to take calcium and vitamin D supplements to help prevent osteoporosis. Prednisone does not cause constipation, so increased fiber would not be helpful. Prednisone should be taken in the morning because it may interfere with sleep if taken at bedtime. Washing the face with antibacterial soap may cause skin dryness and breakdown.

A female client with rheumatoid arthritis has taken Rheumatrex (methotrexate) for the past year to control her symptoms. The client comes to the clinic and tells the nurse that a home pregnancy test was positive. What is the nurses best response? a. You need to schedule a prenatal appointment with your obstetrician right away. b. Stop taking Rheumatrex immediately. Ill tell the physician you are pregnant. c. Continue taking the Rheumatrex, and increase the dose if you have a flare. d. See a genetic counselor to determine whether your baby will have rheumatoid arthritis.

B ~ Rheumatrex is highly teratogenic and should not be taken during pregnancy. A prenatal appointment should be made right away, but the first priority is to stop taking methotrexate. Genetic counseling is not appropriate because the counselor will not be able to determine whether the baby will develop rheumatoid arthritis.

The nurse is working with a client who has severe rheumatoid arthritis in her hands. The client states that she is frustrated at mealtime because it is difficult for her to manage cups and silverware. What is the nurses best response? a. Ill have the nursing assistants set up your meal trays while you are in the hospital. b. Lets see if the occupational therapist can provide you with some utensils that are easier for you to use. c. Ill arrange for a home nursing assistant to help you with your meals after you are discharged from the hospital. d. Lets see if the physical therapist can suggest some muscle strengthening exercises for you.

B ~ The client wishes to be more independent at mealtimes; adaptive eating utensils from the occupational therapist will help her meet this goal. Muscle-strengthening exercises will not be as effective for the clients mealtime needs. The client wishes to remain as independent as possible, so a home nursing assistant should not be suggested.

The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling

B ~ The recipients immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.

A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

B, C, D, E ~ Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.

The nurse is teaching a client with rheumatoid arthritis (RA) about joint protection principles. What information does the nurse include? (Select all that apply.) a. Use smaller joints to rest the larger ones. b. Hold objects with two hands, not one. c. Sit most often in a reclining chair. d. Use assistive-adaptive devices. e. Bend at your knees to lift objects.

B, D, E ~ Clients with RA should use large joints to protect smaller ones, should hold objects with two hands instead of one, should sit in chairs with straight backs, should not bend at the waist but rather bend the knees while keeping the back straight, and should use assistive-adaptive devices wherever possible.

While assessing a patient, the nurse concludes that the patient has a severe form of scleroderma. Which symptoms in the patient support the nurse's conclusion? A. Althralgia B. Digit necrosis C. Joint contractures D. Periungual lesions E. Sausage-like fingers

B, D, E ~ Severe scleroderma is characterized by digit necrosis, the death of cells in the fingers. Periungual lesions (vasculitis lesions around the nail beds) is another symptom of severe scleroderma. Sausage-like fingers are the symptoms that may occur in severe scleroderma due to edema formation in the upper and lower extremities and face. Althralgia and joint contractures are common symptoms of scleroderma.

Which nursing diagnosis takes the highest priority for a client with Parkinsonian crisis? A. Imbalanced nutrition: less than body requirements B. Impaired urinary elimination C. Ineffective airway clearance D. Risk for injury

C Explanation: In parkinsonian crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of an ineffective airway clearance takes the highest priority. Although imbalanced nutrition: less than body requirements, impaired urinary elimination, and risk for injury are also appropriate nursing diagnoses, they are not immediately life-threatening.)

Which of the following clinical manifestations would alert the nurse caring for a patient with Guillain-Barré syndrome that his status is deteriorating? A) Tidal volume of 500 mL B) Residual lung volume of 1200 mL C) Vital capacity of 11 mL/kg D) Oxygen saturation of 97%

C Feedback: A vital capacity of 12 to 15 mL/kg in a patient with Guillain-Barre' means that the patient's condition has deteriorated to the point that he may need to be mechanically ventilated. Thus, a vital capacity of 11 mL/kg is a warning. The tidal volume, residual lung volume, and oxygen saturation are within normal values. Breathing in a Guillain Barre' patient would become increasingly labored as the paralysis ascended toward the intercostals and diaphragm.

Which of the following schedules would be most appropriate for the care of a 28-year-old female hospitalized with a diagnosis of myasthenia gravis? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest

C Feedback: Myasthenia gravis is characterized by extreme muscle weakness, which generally worsens after effort and improves with rest. The schedule for procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the patient may be too exhausted to eat. Procedures should also be avoided at bedtime.

A 37-year-old teacher is hospitalized with complaints of weakness, incoordination, dizziness, and loss of balance. The diagnosis is multiple sclerosis (MS). Which of the following signs and symptoms, revealed during the history and physical assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinski's reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

C Feedback: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski's reflex is found in MS. Abdominal reflexes are absent with MS.

The nurse knows that plasmapheresis is being utilized in the treatment of the patient with Guillain-Barre' syndrome for which of the following reasons? A) Removal of anti-acetylcholine receptor antibodies B) Reduction in the number of bacteria in the bloodstream C) Decrease in antibodies attacking peripheral nerve myelin D) Removal of potassium and fluid

C Feedback: Plasmapheresis and IV immunoglobulin (IVIG) are used to directly affect the peripheral nerve myelin antibody level. Both therapies decrease circulating antibody levels and reduce the amount of time the patient is immobilized and dependent on mechanical ventilation. In myasthenia gravis, plasmapheresis is used to remove anti-acetylcholine receptor antibodies. Antibiotics reduce the number of bacteria in the bloodstream. Hemodialysis removes fluid and potassium.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: A. increase the dose of muscle relaxants. B. take a hot bath. C. rest in an air-conditioned room. D. avoid naps during the day.

C Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity)

A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. Blood urea nitrogen (BUN) of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr

C ~ A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.

A client returns to the medical-surgical unit after a total hip replacement with a large wedge-shaped pillow between his legs. The clients daughter asks the nurse why the pillow is in place. What is the nurses best response? a. It will help prevent bedsores from developing. b. It will help prevent nerve damage and foot drop. c. It will keep the new hip from becoming dislocated. d. It will prevent climbing out of bed if he becomes confused.

C ~ Adduction of the operative leg beyond the midline could dislocate the new hip. The wedge pillow will help prevent this from happening. The wedge will not prevent bedsores from developing because it does not prevent pressure. The pillow will not prevent foot drop, because it is placed between the legs. The pillow is not a restraining device, and it will not prevent the client from climbing out of bed.

The nurse has taught a client with lupus about skin protection in the clinic. Later, the nurse sees the client at an outdoor music festival. Which observation by the nurse indicates that the client requires further instruction? a. Client is wearing a thin, long-sleeved shirt. b. Client is wearing a hat with a full brim. c. Client is discussing her new perm. d. Client is seen applying sunscreen twice.

C ~ Alopecia is common; the client should use gentle shampoo and avoid any harsh chemical treatments, such as a permanent wave. The other observations show good skin protection practices by the client.

The nurse is caring for a pregnant client who is taking Humira (adalimumab) to control symptoms of rheumatoid arthritis. The client mentions the pain and inconvenience of the subcutaneous injections and asks, While Im pregnant, can I take this drug by mouth instead? What is the nurses best response? a. I will ask the physician to write a prescription for you today. b. Humira takes much longer to work when it is given orally. c. Humira can be given only by subcutaneous injection. d. You can switch from Humira to oral leflunomide (Arava).

C ~ Humira is given by subcutaneous injection only. Arava causes birth defects; clients taking it must be on strict birth control and must inform their health care providers if pregnancy occurs.

The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

C ~ Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. Inflammatory is not a type of immunity.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

C ~ Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

The nurse is caring for a client who has a history of severe rheumatoid arthritis. The client becomes combative and abusive to the staff when she is unable to perform personal care independently. What is the best statement the nurse can make to the client at this time? a. I will have to restrain your hands if you cannot keep them to yourself. b. I will ask your doctor for a psychiatrist to talk to you about anger management. c. You seem frustrated. Would you like to try to dress again in a few minutes? d. Would you like me to get an order for medication to help you settle down?

C ~ The client is acting out her frustration over her chronic illness and loss of use of her hands. The nurse should acknowledge this frustration. Allowing the client to make decisions regarding care will help the client regain some sense of control and will help improve self-esteem. Requesting sedation, suggesting psychiatric therapy, or threatening use of restraints is not appropriate, because the client is expressing frustration over the situation.

The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance

C ~ The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should: a) give the client a muscle relaxant. b) have the UAP keep a steady pull on the client to promote forward ambulation. c) assist the UAP with getting the client back in bed. d) explain how to overcome a freezing gait by telling the client to march in place.

D Explanation: Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.)

When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis? a) Increased weakness. b) Diaphoresis. c) Increased salivation. d) Improved muscle strength after I.V. administration of edrophonium chloride.

D Explanation: Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In cholinergic crisis, I.V. edrophonium chloride, a cholinergic agent, does not improve muscle weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in cholinergic crises.)

Which goal is the most realistic for a client diagnosed with Parkinson's disease? a) to cure the disease b) to begin preparations for terminal care c) to stop progression of the disease d) to maintain optimal body function

D Explanation: Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. However, many clients live for years with the disease: and it would not be appropriate to start planning terminal care at this time)

The primary nursing goal for a client with myasthenia gravis is to: a) provide psychological support and reassurance. b) promote comfort and relieve pain. c) ensure a safe environment. d) maintain respiratory function.

D Explanation: In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure. Providing a safe environment and emotional support are secondary goals. Pain is not commonly associated as a problem of myasthenia gravis.)

A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy? a) alertness b) appetite c) mood d) muscle rigidity

D Explanation: Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson's disease.)

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory alkalosis d) Respiratory acidosis

D Explanation: Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.)

Which of the following nursing interventions would be included in the care plan for a patient admitted with MS? A) Encourage the patient to void 1 hour after drinking. B) Order a low-residue diet. C) Provide total assistance as needed with all activities of daily living. D) Instruct the patient on daily muscle stretching.

D Feedback: A patient diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The patient should participate in daily muscle stretching to help alleviate and relax muscle spasms.

The nurse recognizes that corticosteroid therapy, when used in the treatment of Guillain-Barre' syndrome, reduces the inflammation and edema associated with this neuromuscular disorder. It is most important for the nurse to monitor which of the following lab values for the patient on corticosteroid therapy? A) pH of urine B) Hemoglobin C) Serum potassium D) Serum glucose

D Feedback: Corticosteroid therapy increases the blood glucose level. Corticosteroids have an effect on insulin and can produce symptoms related to glucose intolerance.

The nurse is caring for a patient recently diagnosed with myasthenia gravis whose CT scan reveals an enlarged thymus gland. Which additional assessment data would be consistent with the diagnosis of myasthenia gravis? A) Decreased sensation in the hands and feet B) Incoordination of gait C) Facial numbness causing slurred speech D) Generalized weakness of the extremities

D Feedback: Generalized weakness affects all the extremities and the intercostal muscles, resulting in decreasing vital capacity and respiratory failure in the myasthenia gravis patient. Myasthenia gravis is purely a motor disorder with no effect on sensation or coordination.

Which of the following is a clinical manifestation associated with Guillain-Barré syndrome? A) Vertigo B) Ptosis of the eyelid C) Diminished taste for food D) Vocal paralysis

D Feedback: Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness).

The nurse teaching a patient recently diagnosed with myasthenia gravis should tell him that it is caused by: A) Genetic dysfunction B) Upper and lower motor neuron lesions C) Decreased conduction of impulses in an upper motor neuron lesion D) A lower motor neuron lesion

D Feedback: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It isn't a genetic disorder. Combined upper and lower neuron lesions generally occur as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord causes decreased conduction of impulses at an upper motor neuron.

The nurse is caring for a recently diagnosed patient with myasthenia gravis whose CT scan reveals an enlarged thymus gland. Which additional assessment parameter should the nurse complete to confirm the diagnosis of myasthenia gravis? A) Passive range of motion of the neck B) Check of deep tendon reflexes C) Application of painful stimuli to legs D) Visual screening using the Snellen chart

D Feedback: Patients with myasthenia gravis commonly exhibit diplopia (double vision) and ptosis. Using the Snellen chart enables the nurse to assess both of these clinical manifestations. Performing passive range of motion on the neck indicates whether or not the patient has nuchal rigidity, which is a clinical manifestation of meningitis, not myasthenia gravis. Checking deep tendon reflexes is not specific to myasthenia gravis. Application of painful stimuli assesses level of consciousness but also is not specific to myasthenia gravis.

Which of the following primary manifestations is the nurse most likely to assess in a patient diagnosed with MS? A) Dementia B) Bradykinesia C) Contracture deformities D) Difficulty in coordination

D Feedback: The primary symptoms most commonly reported with patients who have MS are difficulties with coordination, spasticity of the extremities, and loss of coordination. Secondary symptoms of MS include contracture deformities and rarely dementia.

The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells

D ~ Suppressor T cells help prevent hypersensitivity to ones own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.

The nurse is teaching a client who has osteoarthritis ways to slow progression of the disease. Which statement indicates that the client understands the nurses instruction? a. I will eat more vegetables and less meat. b. I will avoid exercising to minimize wear on my joints. c. I will take calcium with vitamin D every day. d. I will start swimming twice a week.

D ~ Swimming is an excellent form of exercise for clients with arthritis because it involves minimal weight bearing and stress on the joints from gravity. Eating more vegetables will not decrease the progression of osteoarthritis. Taking calcium with vitamin D will decrease the risk of osteoporosis, not osteoarthritis. Gentle exercise is important to help slow progression of the disease.

What is the most common type of a secondary immunodeficiency disorder? a) Drug induced b) Stress induced c) Related to hypofunction of the immune system d)Malnutrition induced

a) Drug-induced - Immunosuppressive therapy is prescribed for pts to treat autoimmune disorders or to prevent transplant rejection. Immunosuppression is also a side effect of cancer chemotherapy. Generalized leukopenia often results, leading to a decreased humoral and cell-mediated response. Therefore, secondary infections are common in immunosuppressed patients. -Stress may alter the immune response. This response involves the interrelationships between the nervous, endocrine, and immune systems. -Hypofunction of the immune system exists in young children and older adults. With age there is a decrease in the levels of immunoglobulin, involution of the thymus, and decreased number of T cells. -Malnutrition alters cell-mediated immune responses. With a long-standing protein deficiency, there is atrophy of the thymus gland, decreased lymphoid tissue, and increased susceptibility to infection.

What are considered methods of improving safety for blood transfusions? (Select all that apply.) a) Careful selection of blood donors b) Use of microaggregate filters for blood administration c) Close monitoring of the patient receiving a blood transfusion d) Administering blood within 6 hours of refrigeration e) Refrigerating blood until 1 hour before administration f) Carefully checking donor and recipient numbers before administering blood

a), b), c) & f) Careful selection of blood donors is an important method of improving safety for blood transfusions. Also important is careful typing and cross-matching of blood from donor to recipient. Use of microaggregate filters for blood administration is an important method of improving safety for blood transfusions. Filters are important to trap small particles or precipitates to keep them from entering the patient's bloodstream. The patient receiving a blood transfusion needs to be monitored closely, especially early in the transfusion, for signs or symptoms of a transfusion reaction. The most severe reactions occur within the first 15 minutes of the start of the transfusion. Moderate reactions can occur anytime during the first 90 minutes. Carefully checking donor and recipient numbers before administering blood is an important method of improving safety for blood transfusions. Mismatched blood has a high rate of transfusion reactions and can have very serious consequences for the patient. -It is important to administer blood within 4 hours of refrigeration; blood components may be administered within 6 hours of refrigeration. -Blood that is to be transfused must be refrigerated until 1 hour before administration. This is done at the blood bank, not on the nursing unit. If the blood cannot be administered within that time frame, it must be returned to the blood bank.

The nurse is caring for a patient who has had an organ transplant. The patient inquires about rejection and medications used to prevent it. On what knowledge will the nurse's response be based? (Select all that apply.) a) Immunosuppressive therapy is helpful in slowing the process of graft rejection b) Tissue rejection usually occurs within 2 to 4 days of transplantation c) Antigenic determinants on the cells lead to graft rejection via the immune process d) Infection is a threat to the patient receiving immunosuppressive therapy e) Medications will be discontinued approximately 2 months after the transplant

a), c) & d) Immunosuppressive therapy is helpful in slowing the process of graft rejection. Immunosuppressive therapy agents typically used include corticosteroids, cyclosporine, and azathioprine. Antigenic determinants on the cells lead to graft rejection via the immune process. Therefore, recipient tissue is matched as closely as possible to donor tissue antigenic determinants before transplantation. Tissue matching leads to a better chance of success. Infection is a threat to the patient receiving immunosuppressive therapy. Meticulous aseptic technique is required when caring for a patient on immunosuppressive therapy. Prophylactic antibiotic therapy may be advisable, and good skin care is necessary. Visitors are limited; individuals with infection are not allowed at the bedside. -Tissue rejection does not occur immediately after transplantation. It takes several days after transplantation for vascularization to occur. Seven to 10 days after the blood supply is adequately established, sensitized lymphocytes appear in sufficient numbers for sloughing to occur at the site. -The immunosuppressive drug regimen is continued for many months and perhaps a lifetime after an organ transplant.

What is the most effective treatment for a hypersensitivity disorder? a) Symptom management b) Environmental control c) Immunotherapy d) Taking a detailed and thorough history

b) Environmental control - includes avoidance of the offending allergen, thereby removing the stimulus to which the patient reacts. -Symptom management is one of the treatments for a hypersensitivity disorder. It is a very important treatment, but choice #2 is the most effective tx. -Immunotherapy, or desensitization, is one of the treatments for a hypersensitivity disorder. This is the technique of assisting the body to develop immunity by way of injecting a diluted antigen, in a series of injections of increasing strength, over a 1- to 3-year period. -Taking a detailed and thorough history of pt with a hypersensitivity disorder is the most important diagnostic tool. It is, however, a tool, and not a tx for the disorder.

What is the technique of assisting the body to develop immunity by way of injecting a diluted antigen, in a series of injections of increasing strength, over a 1- to 3-year period? a) Immunization b) Immunotherapy c) Vaccination d) Anaphylaxis

b) Immunotherapy - technique of assisting body to develop immunity by way of injecting a diluted antigen, in a series of injections of increasing strength, over a 1- to 3-year period. The theory behind immunotherapy is to assist the individual to build a tolerance to the antigen without developing fever or increased signs and symptoms. It is also known as desensitization. -The theory behind immunization is that controlled exposure to a disease-producing pathogen develops antibody production while preventing disease. An individual is immunized with a vaccine or toxoid that is weakened, or attenuated, to reduce its strength without losing its ability to stimulate antibody production. -Vaccination is another term for immunization. -Anaphylaxis is a term that refers to a life-threatening response of the body. It is an exaggerated allergic response brought about by large amounts of immunoglobulins that respond to the presence of foreign agents.

What is the highest priority nursing diagnosis for the patient experiencing anaphylaxis? a) Anxiety b) Breathing pattern, ineffective c) Impaired tissue perfusion d) Impaired thought processes

b) Ineffective breathing pattern - Anaphylaxis is a life-threatening situation, b/c upper airway occlusion can occur from edema of the airway. -Anxiety is, of course, an important nursing diagnosis for the patient experiencing anaphylaxis; however, the anxiety itself is not life threatening. Although a high priority, it is not the highest priority in this case. -Impaired tissue perfusion not the highest priority in this case due to the risk of airway obstruction in the short term. -Impaired thought process would likely be due to hypoxia or decreased cardiac output. Although a significant nursing challenge, and a sign of higher priority nursing diagnoses, impaired thought processes are not the highest priority in this case.

What cells are responsible both for cell-mediated (cellular) immunity and protection of the body against viruses? a) B cells b) T cells c) NK cells d) Complement cells

b) T cells - Cell mediated immunity (cellular immunity) comes into play when an antigen activates T cells. Once the T cells have been sensitized, they are released into the blood and body tissues, where they remain indefinitely. On contact with the antigen to which they are sensitized, they will attach to the organism and destroy it. Cellular immunity is involved in resistance to infectious disease caused by viruses and some bacteria. -B cells mediate humoral immunity, producing antibodies in response to an antigen challenge. On first exposure to a given antigen, a primary humoral response is initiated. This response is generally slow in comparison to subsequent exposures. When a second exposure occurs, memory B cells cause a quick response, regardless of whether the first exposure was to an antigen or to immunization. -NK cells, or "natural killer" cells, are large, granular lymphocytes. -The complement system is a system of approximately 25 serum enzymatic proteins that interact with one another and with other components of the innate and adaptive immune systems. Normally inactive, when activated by antigen/antibody interactions, the system functions in a "step-by-step" series, destroying the cell membrane of many bacterial species and attracting phagocytes to the area.

Autoimmune disorders fall into which category of "inappropriate responses of the immune system?" a) Hyperactive responses against environmental antigens b) Inability to protect the body c) Failure to recognize the body as self d) Attacks on beneficial foreign tissue

c) Failure to recognize the body as self - ex: systemic lupus erythematosus (SLE). -Hyperactive responses against environmental antigens would be an allergy or allergic reaction. -Inability to protect the body is an immune deficiency disorder, such as acquired immunodeficiency syndrome (AIDS). -Attacks on beneficial foreign tissue include organ transplant rejection or a blood transfusion reaction.

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene, 25 mg P.O. daily. Which assessment finding indicates the medication is effective? A. Increased ability to sleep B. Relief from pain C. Relief from constipation D. Reduced muscle spasticity

d Dantrolene reduces muscle spacticity. It doesn't increase the ability to sleep or relieve constipation or pain.)

What is the most accurate statement regarding latex allergies? a) Fifty percent of health care workers regularly exposed to latex are sensitized b) Type IV contact dermatitis is a response to natural rubber latex proteins that occurs within minutes of contact c) Using oil-based creams or lotions before donning gloves is recommended d) A person with a latex allergy should be taught to wear a medic alert bracelet and carry an epinephrine pen

d) A person with a latex allergy should be taught to wear a medic alert bracelet and carry an epinephrine pen - The type I latex allergy is a response that can manifest itself anywhere from skin erythema to full-blown anaphylactic shock. An epinephrine pen may be required for immediate intervention. -Eight percent to 17% of health care workers regularly exposed to latex are sensitized. The increase in allergic reactions has coincided with the sharp increase in glove use related to the introduction of universal precautions (now known as Standard Precautions) against infectious diseases, which began in 1987. Type I allergic reaction is a response to natural rubber latex proteins that occurs within minutes of contact. This more serious type of latex allergy can result in anaphylactic shock. -Type IV contact dermatitis is caused by the chemicals used in the manufacturing process of latex gloves. It is a delayed reaction that occurs within 6 to 48 hours after exposure and begins with dryness, pruritus, fissuring, and cracking of the skin. This is followed by erythema, edema, and crusting at 24 to 48 hours. Chronic exposure can lead to skin changes; the dermatitis may extend beyond the area of physical contact with the allergen. -Using oil-based creams or lotions before donning gloves is not recommended, because lotions tend to break down the latex in the gloves and increase the likelihood of sensitization.

Which statement most accurately describes normal changes of aging of the immune system? a) The older adult has decreased susceptibility to infections b) Older adults have increased tear production c) Older adults have increased production of saliva and gastric secretions d) The thymus gland decreases in size and activity with age

d) The thymus gland decreases in size and activity with age - this is probably a primary cause of immunosenescence. Both T and B cells show deficiencies in activation, transit time through the cell cycle, and subsequent differentiation; however, the most significant alteration seems to involve the T cells. -The older adult has increased susceptibility to infections. In addition, s&s of infection in older adult are more subtle—and easily missed—-when compared with a younger adult. An older adult can have an infection without the presence of a fever. Changes in behavior, such as lethargy, fatigue, disorientation, irritability, and loss of appetite may be early signs of infection. -Older adults have decreased tear production; increases the risk of eye inflammation and infections. -Older adults have decreased production of saliva and gastric secretions, which increases the risk of gastrointestinal infections and may affect (slow) the absorption of certain medications that require an acidic environment.