Adult Health I - Exam 1
A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have?
The nurse ensures a written consent is obtained prior to testing. pg. 1005
The nurse evaluates teaching as effective when a female client states that she will
Use sunscreen when outdoors. pg. 350
Which of the following would be inconsistent as a common side effect of chemotherapy?
Weight Gain pg. pp. 332-334.
altered level of consciousness
When a patient in NOT oriented, DOES NOT follow commands, or NEEDS persistent stimuli to achieve a state of alertness.
The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?
A 65-year-old client who had chicken pox when he was 12 years old pg. 1779
A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?
A cell-mediated response pg. 971
During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess?
Acquired immunity pg.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention?
Administering metoclopramide and dexamethasone as ordered pg. 332
Which of the following is the most severe form of hypersensitivity reaction?
Anaphylaxis pg. 973
A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis is appropriate for this client?
Anticipatory grieving pg. 361
When an attenuated toxin is administered to a client, the B lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this?
Artificially acquired active immunity pg.
A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected?
Assess for ataxia using the finger-to-nose test and heel-to-shin test pg. 979
A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?
Assure the client that this is a normal reaction pg. 984
Which type of vaccine uses the client's own cancer cells, which are killed and prepared for injection back into the client?
Autologous pg. 337
Which of the following advice does the nurse offer clients who are undergoing unsealed radiation therapy to reduce exposure?
Avoid kissing and sexual contact. pg.
The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?
Avoid spicy and fatty foods. pg.349
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?
Avoiding using soap on the irradiated areas pg. 347
Which of the following cell types are involved in humoral immunity?
B lymphocytes pg. 972
An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response?
B lymphocytes produce antibodies that are specific to the pathogen. pg.
You are working on a transplant unit and you know to carefully monitor your clients. What is the rationale for closely monitoring clients taking immunosuppressive drugs?
Because of an increased risk of respiratory or urinary system infection pg.
The patient diagnosed with thrombocytopenia is at risk for which of the following adverse effects:
Bleeding pg. 333
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?
Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis pg. 321
Which occurs when fluid accumulates in the pericardial space and compresses the heart?
Cardiac tamponade pg. 315
Which primary cancer treatment goal is prolonged survival and containment of cancer cell growth?
Control pg. 321
Which of the following is associated with impaired immunity in the aging patient?
Decreased renal function pg. 979
While administering cisplatin (Platinol-AQ) to a client, the nurse assesses swelling at the insertion site. The first action of the nurse is to
Discontinue the intravenous medication. pg. 335
The nurse is caring for a client newly diagnosed with cancer. Which of the following therapies is used to treat something other than cancer?
Electroconvulsive therapy pg. 321
Which of the following protective responses begin with the B lymphocytes?
Humoral pg. 972
What organ is considered lymphoid tissue?
Spleen pg. 971
The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis?
The injection area swells if the client has developed antibodies against the antigen. pg. 588
The nurse is evaluating the client's risk for cancer and recommends changes when the client states she
eats red meat such as steaks or hamburgers every day pg. 316
A patient with cancer who developed neutropenia several days ago has consequently been placed in a single-bed room that has positive pressure. His daughter has just come to visit her father after arriving from her home in another state and has asked you for his room number. You notice that the daughter has reddened eyes, sniffles, and a dry cough. What instruction should you provide to the daughter?
"Even though it might be difficult, it's best for your father's health if you get well before visiting him in person, since he's so vulnerable right now."
When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask?
"Have you ever received a blood transfusion?" pg. 982
A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?
"I floss my teeth every morning." pg. pp. 346-356.
A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed?
"I guess the doctor could not remove the entire tumor." pg. 322
Which statement by a client undergoing external radiation therapy indicates the need for further teaching?
"I'm worried I'll expose my family members to radiation." pg. 328
A nurse is explaining treatment options to a client diagnosed with an immune dysfunction. Which statement by the client accurately reflects the teaching about current stem cell research?
"Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, and clinical trials using stem cells are underway in clients with a variety of disorders with an autoimmune component." pg. 978
A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery?
"Tumor removal will promote comfort." pg. 323
A client is informed that his white blood cell count is low and that he is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse?
"White blood cells are produced in the bone marrow." pg. 970
The nurse is conducting a screening for familial predisposition to cancer. Which element should the nurse note as a possible indication of hereditary cancer syndrome?
An aunt and uncle diagnosed with cancer pg. 315
Which should a nurse thoroughly evaluate before a bone marrow transplant (BMT) procedure?
Blood studies pg. 336
Which condition is associated with impaired immunity relating to the aging client?
Breakdown and thinning of the skin pg. 978
The drug interleukin-2 is an example of which type of biologic response modifier?
Cytokine pg. 321
A patient will be having an endoscopic procedure with a diagnostic biopsy. What type of biopsy does the nurse explain will remove an entire piece of suspicious tissue?
Excisional biopsy pg. 322
A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which of the following reasons?
Exposure to foreign antigens may cause altered immune function. pg. 982
A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?
Extravasation pg. 331
What foods should the nurse suggest that the patient consume less of in order to reduce nitrate intake because of the possibility of carcinogenic action?
Ham and bacon pg. 316
Which type of cells destroys antigens already coated with antibody?
Null pg. 976
Which type of surgery is used in an attempt to relieve complications of cancer?
Palliative pg. 323
A patient is admitted with an infected leg, and the nurse notes an increase in his white blood cell (WBC) count. The nurse is aware that, during the immune response, pathogens are engulfed by WBCs that ingest foreign particles. What is this process known as?
Phagocytosis pg.
What is the function of the thymus gland?
Programs T lymphocytes to become regulator or effector T cells. pg. 971
During which stage of the immune response does the circulating lymphocytes containing the antigenic message return to the nearest lymph node?
Proliferation pg. 973
The nurse at the clinic explains to the patient that the surgeon will be removing a mole on the patient's back that has the potential to develop into cancer. The nurse informs the patient that this is what type of procedure?
Prophylactic pg. 323
Palliation refers to
Relief of symptoms of disease and promotion of comfort and quality of life. pg. 310
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication?
Serum potassium level of 2.6 mEq/L pg. 334
A nurse is administering daunorubicin (DaunoXome) to a patient with lung cancer. Which situation requires immediate intervention?
The I.V. site is red and swollen. pg. pp. 331-332.
The nurse is caring for a client is scheduled for chemotherapy followed by autologous stem cell transplant. Which of the following statements by the client indicates a need for further teaching?
"I hope they find a bone marrow donor who matches." pg. 336
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications?
Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive. pg. 978
The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response?
Corticosteroids pg. 1502
What intervention should the nurse provide to reduce the incidence of renal damage when a patient is taking a chemotherapy regimen?
Encourage fluid intake to dilute the urine. pg. 351
A side-effect of chemotherapy is renal damage. To prevent this, the nurse should:
Encourage fluid intake, if possible, to dilute the urine. pg. 333
brain death
Irreversible loss of all functions of the entire brain, including the brain stem.
A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?
Lymphocyte pg. 973
A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:
Lymphocytes migrate to areas of the lymph node pg. 973
The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?
Lymphoid tissues pg. 970-971.
The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents?
Macrophages pg. 972
A mother has brought her child to the clinic for a wellness check. While talking with the nurse, the mother asks the nurse to suggest a diet that will maximize the immune function of her growing children. What dietary pattern should the nurse suggest?
Moderate diet that is balanced and varied pg. 980
A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?
Natural immunity pg. 971
A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?
Naturally acquired active immunity pg.
An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?
Naturally acquired active immunity pg. 972
Which type of immunity becomes active as a result of infection by a specific microorganism?
Naturally acquired active immunity pg. 972
According to the tumor-node-metastasis (TNM) classification system, T0 means there is
No evidence of primary tumor pg. 321
Which of the following does a nurse have to assess during the bone marrow transplant (BMT) procedure?
Psychological status pg. 338
When the client complains of increased fatigue following radiotherapy, the nurse knows this is most likely to be related to which factor?
Radiation can result in myelosuppression. pg. 365
Which condition is associated with impaired immunity relating to the aging client?
Renal function decreases pg. 979
The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following?
Serum, which depletes the body's store of immunoglobulins pg. 982
Which of the following are true statements about effective radiation therapy? Select all that apply.
Slower-growing tissues at rest (muscle) are more radioresistant. Tumors that are well oxygenated are more sensitive to radiation. Tumors that are small in size and dividing rapidly are more sensitive. pp. 324-325.
A nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath. The nurse immediately
Stops the chemotherapeutic infusion pg. 331
A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function?
Surgical removal of the appendix pg. 1556
The inflammatory response needs to be balanced so that what is helpful does not become harmful if mediators are secreted in excess. Which of the following are the primary mediators in an inflammatory response?
T cells and cytokines pg. 972
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
The client appears mildly ill, listless, and disheveled. pg. 65
What should the nurse tell a client who is about to begin chemotherapy and is anxious about hair loss?
The client should consider getting a wig or cap prior to beginning treatment. pg. 350
Which statement accurately reflects current stem cell research?
The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. pg. 978
A client with metastatic pancreatic cancer underwent surgery to remove a malignant tumor in the pancreas. Despite the tumor being removed, the physician informs the client that chemotherapy must be started. Why might the physician opt for chemotherapy?
To prevent metastasis pg. 328
The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?
Tumor pressure against normal tissues pg. 313
A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells?
Epoetin alfa (Epogen) pg. 897
autoregulation
In the context of neuroscience, describes the ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial BP.
The Family Nurse Practitioner is conducting a physical examination of a client with an immunity disorder. What would be an important parameter to examine?
Inspect the pharynx for large, red tonsils.
When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care?
Inspect the skin frequently. pg. 325
Which of the following is a characteristic of a malignant tumor?
It gains access to the blood and lymphatic channels. pg. 313
A decrease in circulating white blood cells (WBCs) is referred to as
Leukopenia pg. 362
A nurse is performing a home visit for a client who received chemotherapy within the past 24 hours. The nurse observes a small child playing in the bathroom, where the toilet lid has been left up. Based on these observations, the nurse modifies the client's teaching plan to include:
chemotherapy exposure and risk factors. pg. 336
What types of cells are the primary targets of the healthy immune system? Select all that apply.
infectious cells foreign cells cancerous cells pg. 970
The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?
interferons pg. 976
A 64-year-old male client, who leads a sedentary life-style, and a 31-year-old female client, who has a very stressful and active life-style, require a vaccine against a particular viral disorder. As the nurse, you would know that in one of these clients the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?
The male client because of his age pg. 978
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?
Stage 3 pressure ulcer on the left heel pg. 364
While visiting the pediatric clinic with her 2 year old, a mother picks up a brochure about immunizations and asks about active and passive acquired immunity to childhood diseases. The nurse explains that immunizations are which of the following and why?
Active acquired immunity, because the person's own body develops defenses pg. 972
A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia?
Closely observe the client's skin for petechiae and bruising. pg. 363
A client with a brain tumor is undergoing radiation and chemotherapy for treatment of cancer. The client has recently reported swelling in the gums, tongue, and lips. Which is the most likely cause of these symptoms?
Stomatitis pg. 345
akinetic mutism
Unresponsiveness to the environment; The patient makes no movement or sound but sometimes opens their eyes.
