exam 2 med surge prep u lvl 5-8
CHAPTER 37 LVL 5-8
CHAPTER 37 LVL 5-8
Which is a primary chemical mediator of hypersensitivity? Histamine Heparin Bradykinin Serotonin
ANSWER 1 Histamine is a primary chemical mediator of hypersensitivity. Secondary mediators include serotonin, heparin, and bradykinin.
What intervention is a priority when treating a client with HIV/AIDS? Monitoring psychological status Assessing neurologic status Assessing fluid and electrolyte balance Monitoring skin integrity
ANSWER 3 Fluid and electrolyte deficits are a priority in monitoring clients with HIV/AIDS, and assessment of fluid loss and electrolyte imbalance is essential. Skin integrity should be monitored but is a lower priority. Neurologic and psychological status should also be monitored, but this is not as high a priority as fluid and electrolyte imbalance.
CHAPTER 35 LVL 5-8
CHAPTER 35 LVL 5-8
Chapter 39
Chapter 39
Which is a major manifestation of Wiskott-Aldrich syndrome? Bacterial infection Ataxia Episodes of edema Thrombocytopenia
ANSWER 1
The nurse knows the best strategy for latex allergy is epinephrine from an emergency kit. corticosteroids. antihistamines. avoidance of latex-based products.
ANSWER 4 The best strategy available for latex allergy is to avoid latex-based products, but this is often difficult because of their widespread use. Antihistamines and an emergency kit containing epinephrine should be provided to these clients, along with instructions about emergency management of latex allergy.
A client with AIDS has developed cytomegalovirus (CMV) retinitis and is receiving treatment with foscarnet. The nurse would monitor for which possible adverse drug effects? Select all that apply. Neutropenia Hypercalcemia Hyperphosphatemia Seizures Hypomagnesemia
ANSWER
An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated? Helper T cells Macrophages B cells Cytotoxic T cells
ANSWER 4 Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis (disintegration) and by releasing cytolytic enzymes and cytokines. Lymphokines can recruit, activate, and regulate other lymphocytes and white blood cells. These cells then assist in destroying the invading organism.
An instructor is describing the process of bone development. Which of the following would the instructor describe as being responsible for the process of ossification? Osteoblasts Cortical bone Osteoclasts Cancellous bone
answer 1 Osteoblasts secrete bone matrix (mostly collagen), in which inorganic minerals, such as calcium salts, are deposited. This process of ossification and calcification transforms the blast cells into mature bone cells, called osteocytes, which are involved in maintaining bone tissue. Cortical bone is dense hard bone found in the long shafts; cancellous bone is spongy bone found in the irregular rounded edges of bone.
A nurse is preparing an in-service presentation about primary immunodeficiencies. When describing these conditions, what would the nurse need to integrate into the presentation? Overall, these conditions more commonly affect females. Primary immunodeficiencies are more common than secondary immunodeficiencies Most cases are typically diagnosed in infancy. The conditions appear to predominate in males after adolescence.
ANSWER 3 Most primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1. A large fraction of primary immunodeficiencies are not diagnosed until adolescence or early adulthood when the gender distribution equalizes. Secondary immunodeficiencies are more common than primary immunodeficiencies.
A client is admitted with a tentative diagnosis of acquired immunodeficiency syndrome (AIDS). The client undergoes biopsies of facial lesions and the preliminary report indicates Kaposi's sarcoma. Which action by the nurse is most appropriate? Inform the client of the biopsy results and support the client emotionally. Tell the client that Kaposi's sarcoma is common in people with AIDS. Pretend not to notice the lesions on the client's face. Explore the client's feelings about facial disfigurement.
ANSWER 4 The nurse should help the client explore his or her feelings about facial disfigurement because facial lesions can contribute to decreased self-esteem and an altered body image. Discussing AIDS with a client whose diagnosis isn't final may be inappropriate and doesn't provide emotional support. Pretending not to notice visible lesions ignores the client's concerns. The health care provider, not the nurse, should inform the client of the biopsy results.
A health care provider prescribed fluticasone for a client with a severe case of allergic rhinitis. The client took a first dose on February 2. What is the latest date by which the drug will be fully effective? February 6 February 15 February 12 February 9
ANSWER The full benefit of fluticasone (Flonase) should occur no later than 14 days after the first dose. The drug was initiated on February 2. Thirteen days later would be February 15.
The client asks the nurse how to determine a cause for rhinitis. What diagnostic test will the nurse explain to the client that will identify the cause of rhinitis? total serum IgE test intradermal skin test radioallergosorbent test peripheral blood count
ANSWER Increased IgE levels are a positive indicator of allergic rhinitis. Skin and provocation tests can yield false-positive and false-negative results.
A client is receiving ganciclovir as part of the treatment for cytomegalovirus retinitis. What would the nurse monitor the results of the client's laboratory tests for? Neutropenia Hypercalcemia Thrombocytopenia Hypophosphatemia
ANSWER 1 A common reaction to ganciclovir is severe neutropenia. Hypocalcemia and hyperphosphatemia are associated with foscarnet. Ganciclovir is not associated with thrombocytopenia.
The client presents to the health care provider's office with an allergic reaction. The health care provider documents the client's condition as a nonatopic, IgE-mediated response. What allergic reaction is this client experiencing? A latex allergy Eczema Asthma Rhinitis
ANSWER 1 A latex allergy does not have the genetic component and organ specificity as do the other choices. It is classified as nonatopic.
While interviewing a client with an allergic disorder, the client tells the nurse about an allergy to animal dander. The nurse knows that animal dander is what type of substance? Complete protein antigen Immunoglobulin T-lymphocyte Chemical mediator
ANSWER 1 Animal dander is considered a complete protein antigen. Immunoglobulins are antibodies formed by lymphocytes and plasma cells. Chemical mediators are substances released by the mast cells upon stimulation by an antigen. T-lymphocytes assist the B cells in producing antibodies.
A nurse knows to advise a patient who is taking Atarax, an over-the-counter (OTC) antihistamine, to be aware of the serious potential side effect of: Seizures. Epigastric distress. Photosensitivity. Urinary retention.
ANSWER 1 Atarax is the only OTC antihistamine that has the potential serious side effect of tremors and seizures.
A pediatric client is recovering from an anaphylactic reaction to an allergen which brought him to the ED. The client's mother is quite concerned with the potential reoccurrence of her child's reaction. In attempting to narrow down the possible allergen, it is important to consider that clinical manifestations generally correlate with: route of exposure. systemic effects. skin reactions. respiratory symptoms.
ANSWER 1 Clinical manifestations generally correlate with the manner in which the allergen enters the body. For example, inhaled allergens usually cause respiratory symptoms, including nasal congestion, runny nose, sneezing, coughing, dyspnea, and wheezing. Inhaled allergens often trigger asthma.
The maximum intensity of histamine occurs within which time frame after contact with an antigen? 5 to 10 minutes 15 to 20 minutes 30 to 35 minutes 40 to 45 minutes
ANSWER 1 Histamine's effects peak 5 to 10 minutes after antigen contact. The other time frames are inaccurate.
The nurse is caring for a client experiencing an anaphylactic reaction. The nurse prepares for the maximum intensity of histamine response to occur within which time frame? 5 to 10 minutes 15 to 20 minutes 30 to 35 minutes 40 to 45 minutes
ANSWER 1 Histamine's effects peak 5 to 10 minutes after antigen contact. The other time frames are inaccurate.
A client comes to the clinic with a rash. While inspecting the client's skin, the nurse determines that the rash is medication-related based on which finding? Rash has several large raised areas. Rash is localized to a body area. Rash is pale in color. Rash has developed gradually.
ANSWER 1 In general, drug reactions appear suddenly, have a particularly vivid color, and manifest with characteristics more intense than the somewhat similar eruptions of infectious origin. Therefore, the appearance of several large raised areas would suggest a drug reaction.
T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do? T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person. T-cell and B-cell lymphocytes respond to the body's invasion by macrophages. T-cell and B-cell lymphocytes react to the body's lack of B12 . T-cell and B-cell lymphocytes distinguish harmful treatments from curative treatments.
ANSWER 1 T-cell and B-cell lymphocytes are the primary participants in the immune response. They distinguish harmful substances and ignore those natural and unique to a person. Options B, C, and D are incorrect.
The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as angioneurotic edema. urticaria. pitting edema. contact dermatitis.
ANSWER 1 The area of skin demonstrating angioneurotic edema may appear normal, but often has a reddish hue and does not pit. Urticaria (hives) is characterized as edematous skin elevations that vary in size, shape, and itch, which cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema, the result of increased interstitial fluid, is associated with disorders such as congestive heart failure.
The nurse is conducting discharge teaching for a client who is being discharged from the emergency department after an anaphylactic reaction to peanuts. Which education should the nurse include in the teaching? Select all that apply. Avoiding allergens Wearing a medical alert bracelet Use of sedatives to treat reactions Desensitization to allergen
ANSWER 1-2 reactions should make every attempt to strictly avoid the allergen. Additionally, they should wear a medical alert bracelet and carry an emergency kit containing epinephrine for injection to prevent the onset of the reaction on exposure. Sedatives are not used to treat anaphylactic reactions, and desensitization is not used for peanut allergies.
The nurse is planning care for a client with atopic dermatitis. Which information will the nurse include when teaching the client self-care for the condition? Select all that apply. Use a mild soap when bathing. Apply a skin cream that contains glycerol. Crusting of lesions is a sign of healing. Take antihistamines early in the day. Wear clothing made of cotton.
ANSWER 1-2-5 Atopic dermatitis is a type I immediate hypersensitivity disorder involving IgE antibodies that causes dry, pruritic, hypersensitive skin. It often begins with small, red, pruritic papules that stimulate intense itching, leaving erythematous, excoriated areas of skin. This often triggers an "itch-scratch cycle" where rubbing or scratching the skin causes further irritation, redness, and skin breakdown. Treatment of clients with atopic dermatitis involves avoidance of irritative agents, use of anti-inflammatory topical agents, and moisturization of the skin. The client should be advised to use mild soap when bathing and to wear clothing made of cotton. Thick cream moisturizers and emollients that contain glycerol should be used as these will keep the skin hydrated. Antihistamines may be used however should be taken at bedtime because they are sedating. The presence of purulence or honey-colored crusts suggests S. aureus infection and antibiotics are needed to eradicate infection.
The nurse is teaching a client how to self-administer epinephrine using an EpiPen autoinjector. What information should be included in the teaching? Select all that apply. Hold the EpiPen autoinjector against the thigh for 10 seconds. The needle should be at a 30 degree angle. After administering the injection, massage the area for 10 seconds. Grasp the EpiPen autoinjector pointing upward. Jab the EpiPen autoinjector firmly into the outer thigh. The buttocks can be used as an injection site.
ANSWER 1-3-5 The EpiPen autoinjector is administered pointing downward not upward. The EpiPen autoinjector is firmly jabbed into the outer thigh to ensure the needle pierces the skin. The needle needs to be at a 90-degree angle, not at a 30-degree angle. The medication may not work as well if the injection is given in the buttocks. The preferred site is the thigh to avoid hitting bone, nerves, vessels or organs. Massaging the area for 10 seconds after administering the injection increases the speed of absorption. Holding the EpiPen autoinjector against the thigh for 10 seconds gives the medication time to be fully administered.
Which term refers to an incomplete antigen? Antibody Hapten Allergen Antigen
ANSWER 2 A hapten is an incomplete antigen. An allergen is a substance that causes manifestations of allergy. An antigen is a substance that induces the production of antibodies. An antibody is a protein substance developed by the body in response to and interacting with a specific antigen.
A client visits the employee health department because of mild itching and a rash on both hands. What will the employee health nurse focus on during the assessment interview? life stressors the nurse may be experiencing chemical and latex glove use medication allergies laundry detergent or bath soap changes
ANSWER 2 Because the itching and rash are localized, the employee health nurse will suspect an environmental cause in the workplace. With the advent of standard precautions, many nurses have experienced allergies to latex gloves. Allergies to medications, laundry detergents, or bath soaps and dermatologic reactions to stress usually elicit a more generalized or widespread rash.
Which microorganism is known to cause retinitis in people with HIV/AIDS? Pneumocystis carinii Cytomegalovirus Cryptococcus neoformans Mycobacterium avium
ANSWER 2 Cytomegalovirus is a species-specific herpes virus. C. neoformans is a fungus that causes an opportunistic infection in clients with HIV/AIDS. M. avium is an acid-fast bacillus that commonly causes a respiratory illness. P. carinii is an organism that is thought to be protozoan, but believed to be a fungus based on its structure.
Ibuprofen affects the immune system by causing pancytopenia. neutropenia. hemolytic anemia. thrombocytopenia.
ANSWER 2 Ibuprofen causes leukopenia and neutropenia. Phenylbutazone causes pancytopenia. Cefuroxime sodium causes thrombocytopenia and hemolytic anemia.
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? tumor necrosis factor interferons colony-stimulating factor interleukins
ANSWER 2 Interferons are chemicals that primarily protect cells from viral invasion. They enable cells to resist viral infection and slow viral replication. They have been used as adjunctive therapy in the treatment of AIDS. Interferons also have been used to treat some forms of cancer such as leukemia because they stimulate NK cell activity. Interferon is administered parenterally because digestive enzymes destroy its protein structure.
Which chemical mediators initiate and mediate the inflammatory response? Cytokines Leukotrienes Complement Prostaglandins
ANSWER 2 Leukotrienes are chemical mediators from constituents of cell membranes. Cytokines are nonantibody proteins that act as intercellular mediators, as in the generation of the immune response. Prostaglandins are lipid-soluble molecules synthesized from constituents of cell membranes. Complement is a plasma protein associated with immunologic reactions.
What education should the nurse provide to the patient taking long-term corticosteroids? The patient should discontinue using the drug immediately if weight gain is observed. The patient should not stop taking the medication abruptly and should be weaned off of the medication. Corticosteroids are relatively safe drugs with very few side effects. The patient should take the medication only as needed and not take it unnecessarily.
ANSWER 2 Patients who receive high-dose or long-term corticosteroid therapy must be cautioned not to stop taking the medication suddenly. Doses are tapered when discontinuing this medication to avoid adrenal insufficiency.
Which condition is associated with impaired immunity relating to the aging client? Increase in peripheral circulation Breakdown and thinning of the skin Increase in humoral immunity Decrease in inflammatory cytokines
ANSWER 2 The aging process stimulates changes in the immune system. Age-related changes in many body systems also contribute to impaired immunity. Changes such as poor circulation, as well as the breakdown of natural mechanical barriers such as the skin, place the aging immune system at even greater disadvantage against infection. As the immune system undergoes age-associated alterations, its response to infections progressively deteriorates. Humoral immunity declines and the number of inflammatory cytokines increase with age.
Which of the following is accurate regarding acquired immunity? Select all that apply. Also know as innate immunity An immunologic response acquired during life but not present at birth Usually develops as a result of exposure to an antigen through immunization Can develop by contracting a disease A nonspecific immunity present at birth
ANSWER 2-3-4
A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply. Monitor international normalized ratio (INR) level. Insert an intravenous line. Administer Diphenhydramine. Have respiratory therapy provide an albuterol treatment. Give metoprolol.
ANSWER 2-3-4 Administering diphenhydramine reverses the effect of histamine. Inserting an intravenous line will allow access to administer medications quickly. Metoprolol is a medication used to treat hypertension or chest pain. Administering an albuterol treatment reverses histamine-induced bronchospasm. The international normalized ratio (INR) level is monitored for warfarin treatment.
Which term means a lack of one or more of the five immunoglobulins? Panhypoglobulinemia Agammaglobulinemia Hypogammaglobulinemia Telangiectasia
ANSWER 3
Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment? Active substance abuse Depression Past substance abuse Lack of social support
ANSWER 3 Factors associated with nonadherence include active substance abuse, depression, and lack of social support, as well as neurocognitive impairment, low health literacy, stressful life events, high levels of alcohol consumption, homelessness, poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to medications. Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment.
A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit? type III type IV type I type II
ANSWER 3 ( TYPE 1) There are four types of hypersensitivity responses, three of which are immediate. This is an example of Type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies
The nurse is teaching a client with allergic rhinitis about medications. What medication is a mast cell stabilizer used in the treatment of allergic rhinitis? tetrahydrozoline hydrochloride oxymetazoline hydrochloride pseudoephedrine hydrochloride intranasal cromolyn sodium
ANSWER 4 Intranasal cromolyn sodium is a mast cell stabilizer. Tetrahydrozoline hydrochloride, oxymetazoline hydrochloride, and pseudoephedrine hydrochloride are adrenergic agents.
CHAPTER 36 LVV 5-8
CHAPTER 36 LVV 5-8
Which is a circulatory indicator of peripheral neurovascular dysfunction? Cool skin Paralysis Weakness Paresthesia
answer 1 Indicators of peripheral neurovascular dysfunction related to circulation include pale, cyanotic, or mottled skin with a cool temperature. The capillary refill is more than 3 seconds. Weakness and paralysis are related to motion. Paresthesia is related to sensation.
Which serum level indicates the rate of bone turnover? Osteocalcin Aspartate aminotransferase Myoglobin Creatinine kinase
answer 1 Serum osteocalcin (bone GLA protein) indicates the rate of bone turnover. Serum myoglobin is assessed to evaluate muscle trauma. Serum enzyme levels of creatinine kinase and aspartate aminotransferase become elevated with muscle damage.
A client undergoes an invasive joint examination of the knee. What will the nurse closely monitor the client for? Serous drainage Lack of sleep and appetite Signs of shock Signs of depression
answer 1 When the client undergoes an invasive knee joint examination, the nurse should inspect the knee area for swelling, bleeding, and serous drainage. An invasive joint examination does not cause lack of sleep or appetite, depression, or shock. The client may be in shock due to the injury itself.
A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply. Administer Diphenhydramine. Give metoprolol. Insert an intravenous line. Monitor international normalized ratio (INR) level. Have respiratory therapy provide an albuterol treatment.
answer 1-2-4 Administering diphenhydramine reverses the effect of histamine. Inserting an intravenous line will allow access to administer medications quickly. Metoprolol is a medication used to treat hypertension or chest pain. Administering an albuterol treatment reverses histamine-induced bronchospasm. The international normalized ratio (INR) level is monitored for warfarin treatment.
A client is having repeated tears of the joint capsule in the shoulder, and the health care provider orders an arthrogram. What intervention should the nurse provide after the procedure is completed? Select all that apply. Administer a mild analgesic. Actively exercise the area immediately after the procedure. Apply heat to the area for 48 hours. Apply a compression bandage to the area. Inform the client that a clicking or crackling noise in the joint may persist for a couple of days.
answer 1-4-5 The client having an arthrogram may feel some discomfort or tingling during the procedure. After the arthrogram, a compression elastic bandage may be applied if prescribed, and the joint is usually rested for 12 hours. Strenuous activity should be avoided until approved by the primary provider. The nurse provides additional comfort measures (e.g., mild analgesia, ice) as appropriate and explains to the client that it is normal to experience clicking or crackling in the joint for 24 to 48 hours after the procedure until the contrast agent or air is absorbed.
A client has an exaggerated convex curvature of the thoracic spine. What is this condition called? lordosis kyphosis scoliosis diaphysis
answer 2 Kyphosis is an exaggerated convex curvature of the thoracic spine. Lordosis is an excessive concave curvature of the lumbar spine. Scoliosis is a lateral curvature of the spine. Diaphyses are the long shafts of bones in the arms and legs.
Which of the following deformity causes a exaggerated curvature of the lumbar spine? Scoliosis Lordosis Steppage gait Kyphosis
answer 2 Lordosis is an exaggerated curvature of the lumbar spine. Scoliosis is a lateral curving deviation of the spine. Kyphosis is an increased forward curvature of the thoracic spine. Steppage gait is not a type of spinal deformity.
The nurse is completing the intake assessment of a client new to the allergy clinic. The client states that he was taking nose drops six times a day to relieve his nasal congestion. The nasal congestion increased, causing him to increase his usage of the nasal spray to eight times a day. But again the congestion worsened. The nurse communicates to the health care provider that the client experienced Tolerance to nose drops Rhinitis medicamentosa Atopic dermatitis Leukotriene modifier
answer 2 Rhinitis medicamentosa is a rebound reaction from overuse of sympathomimetic nose drops or sprays that worsen the congestion, causing the client to use more of the medication, thereby leading to more nasal congestion. This differs from tolerance, when more medication is needed to achieve the desired effect. Leukotriene modifiers are a category of medications used to treat allergies. Atopic dermatitis is a type I hypersensitivity involving inflammation of the skin evidenced by itching, erythema, and skin lesions.
Skull sutures are an example of which type of joint? Aponeuroses Synarthrosis Diarthrosis Amphiarthrosis
answer 2 Skull sutures are considered synarthrosis joints and are immovable. Amphiarthrosis joints allow limited movement, such as a vertebral joint. Diarthrosis joints are freely movable joints such as the hip and shoulder. Aponeuroses are broad, flat sheets of connective tissue.
The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as pitting edema. angioneurotic edema. urticaria. contact dermatitis.
answer 2 The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit. Urticaria (hives) is characterized as edematous skin elevations that vary in size and shape, itch, and cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema is the result of increased interstitial fluid and associated with disorders such as congestive heart failure.
*******Which nerve is being assessed when the nurses asks the client to dorsiflex the ankle and extend the toes?****** Radial Peroneal Median Ulnar
answer 2 The motor function of the peroneal nerve is assessed by asking the client to dorsiflex the ankle and to extend the toes, while pricking the skin between the great toe and center toe assesses sensory function. The radial nerve is assessed by asking the client to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. The median nerve is assessed by asking the client to touch the thumb to the little finger. Asking the client to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.
There are thousands of components of the musculoskeletal system that facilitate mobility and independent function. The function of skeletal muscle is promoting: movement of skeletal bones. involuntary function. All options are correct. organ function.
answer 2 The skeletal muscles promote movement of the bones of the skeleton.
The nurse is teaching a client about a vitamin that supports calcium's absorption. What vitamin is the nurse teaching the client about? Vitamin B12 Vitamin D Vitamin A Vitamin C
answer 2 To support the absorption of calcium from the gastrointestinal tract and increase the amount of calcium in the blood, there needs to be sufficient active vitamin D. Vitamin A is for eye health. Vitamin B12 is for anemia prevention. Vitamin C is used for skin and immune health.
A nurse is caring for a client with atopic dermatitis. Which suggestions for the client by the nurse would be appropriate? Select all that apply. Keep the room temperature at approximately 70 degrees Fahrenheit (21 degrees Celsius). Humidify the home when the heat is on during the winter. Use a strong antibacterial detergent for the laundry. Wear clothing made from synthetic fabrics. Apply topical moisturizers to the skin.
answer 2-3-5 The nurse would suggest that the client use a mild detergent for laundry and keep the room temperature between 68 to 72 degrees Fahrenheit (20 to 22 degrees Celsius) to decrease itching and scratching. Other suggestions include applying topical moisturizers to the skin, wearing clothes made from cotton fabrics, and humidifying the home when dry home heating is used during the winter.
Which of the following diagnostic studies are done to relieve joint pain due to effusion? Bone scan Arthrocentesis Biopsy Electromyography (EMG)
answer 3 Arthrocentesis (joint aspiration) is carried out to obtain synovial fluid for purpose of examination or to relieve pain due to effusion. EMG provides information about the electrical potential of the muscles and the nerves leading to them. A bone scan is performed to detect metastatic and primary bone tumors, osteomyelitis, certain fractures, and aseptic necrosis. A biopsy may be performed to determine the structure and composition of bone marrow, bone, muscle, or synovium to help diagnose specific diseases.
The client presents with an exaggeration of the lumbar spine curve. How does the nurse interpret this finding? Scoliosis Kyphosis Lordosis Dowager's hump
answer 3 Lordosis is an exaggeration of the lumbar spine curve.
A client visits the health care provider for a routine checkup. The history reveals that the client was diagnosed with a spinal curvature. Which region of the spine should the nurse assess for complications? Sacral Cervical Thoracic Lumbar
answer 3 The nurse should assess the thoracic region of the spine because a progressive curvature of more than 65 degrees in this region may lead to cardiopulmonary failure as well as less serious signs and symptoms, such as fatigue, back pain, decreased height, and cosmetic deformity. Although a curvature may affect any part of the spine, life-threatening complications aren't associated with curvature of the cervical, lumbar, or sacral regions.
Which term refers to mature compact bone structures that form concentric rings of bone matrix? Trabecula Cancellous bone Lamellae Endosteum
answer 3 latticelike bone structure
A client scheduled to undergo an electromyography asks the nurse what this test will evaluate. What is the correct response from the nurse? Bone density Metastatic bone lesions Muscle composition Muscle weakness
answer 4 Electromyography tests the electric potential of the muscles and nerves leading to the muscles. It is done to evaluate muscle weakness or deterioration, pain, disability, and to differentiate muscle and nerve problems. A bone biopsy is done to identify bone composition. Bone densitometry is done to evaluate bone density. A bone scan would be appropriate to detect metastatic bone lesions.
Which of the following is an example of a gliding joint? Hip Knee Joint at base of thumb Carpal bones in the wrist
answer 4 Gliding joints allow for limited movement in all directions and are represented by the joints of the carpal bones in the wrist. Hinge joints permit bending in one direction only and include the knee and elbow. The hip is a ball-and-socket joint. The joint at the base of the thumb is a saddle joint.
A client is prescribed montelukast as part of a treatment plan for an allergic disorder. The nurse understands that this drug belongs to which class? Nonsedating antihistamine Mast cell stabilizer Corticosteroid Leukotriene-receptor antagonist
answer 4 Montelukast is classified as a leukotriene-receptor antagonist. Cromolyn sodium is a mast cell stabilizer. Cetirizine, loratadine, and fexofenadine are nonsedating antihistamines. Beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, and triamcinolone are corticosteroids.
Which nursing instruction is most important to stress when teaching on calcium intake? Maintain diary sources of calcium intake. Eat green, leafy vegetables. Drink calcium- and vitamin D-fortified orange juice. Provide age-related calcium intake recommendations.
answer 4 Providing accurate and specific age-related daily calcium intake guidelines empowers clients to meet those recommendations in a manner that fits their lifestyle. It is also important to realize that calcium intake guidelines increase to 1200 mg/day for those older than age 50 years. Eating green, leafy vegetables is an important source of calcium as well as drinking fortified orange juice. Dairy sources also provide calcium intake in varying degrees.
A nurse performs a neurovascular assessment on a client 2 weeks after a wrist cast had been removed. The nurse documents in the client's chart that there is normal sensation in the ulnar nerve. What finger assessment test will the nurse perform on this client? Prick the top or distal surface of the index finger. Prick the skin midway between the thumb and second finger. Prick the top of the middle finger. Prick the distal fat pad on the small finger.
answer 4 See Table 40-2 in the text. The ulnar nerve runs near the ulnar bone and enters the palm of the hand. It branches to the fifth finger (small finger) and the ulnar side of the fourth finger.
The nurse is working on an orthopedic floor caring for a client injured in a football game. The nurse is reviewing the client's chart noting that the client has previously had an injured tendon. The nurse anticipates an injury between the periosteum of the bone and which of the following? Cartilage Joint Ligament Muscle
answer 4 Tendons attach muscles to the periosteum of bone. Joints are a junction between two or more bones. Ligaments connect two freely movable bones. Cartilage is a dense connective tissue used to reduce friction between two structures.
chapter 37 LVL 5-8
chapter 37 LVL 5-8
Maximum intensity of histamine occurs within which time frame following antigen contact? 5 minutes 15 minutes 45 minutes 30 minutes
ANSWER 2 Maximum intensity is reached within about 15 minutes after antigen contact. The other time frames are inaccurate.
A client with a history of anaphylactic reactions to insect stings has just been stung by a wasp. Place the steps in the correct order that the client will follow for self-administration of an EpiPen. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Inject the black tip into the outer thigh 2Massage the injection area 3Call the emergency medical response number (911) 4Remove the gray safety-release cap
answer (4-1-2-3) When using an EpiPen, the client removes it from the carrying tube, grasps the unit with the black tip pointed downward, forms a fist around the unit, and removes the gray safety-release cap. Then the client holds the black tip near the outer thigh and swings and injects it firmly into the outer thigh until hearing a click with the device perpendicular to the thigh. Next, the client holds the device firmly against the thigh for about 10 seconds, then removes it and massages the area for 10 seconds. Lastly, the client or another person calls 911 and seeks emergency medical attention.
The nurse is reviewing the client's medications. What antihistamines are contraindicated for a client with narrow-angle glaucoma? Select all that apply. diphenhydramine loratadine cetirizine fexofenadine brompheniramine
ANSWER 1-23-5 Diphenhydramine, loratadine, brompheniramine, and cetirizine are antihistamines contraindicated with clients with narrow-angle glaucoma. The antihistamines have the potential to induce angle closure. Fexofenadine should be used cautiously in patients with hepatic or renal impairment.
Which group of mediators initiates the inflammatory response? Prostaglandins Lymphokines Leukotrienes Mast cells
ANSWER 3 Leukotrienes are a group of chemical mediators that initiate the inflammatory response. Lymphokines are substances released by sensitized lymphocytes when they contact specific organs. Mast cells are connective tissue that contains heparin and histamine in their granules. Prostaglandins are unsaturated fatty acids that have a wide assortment of biologic activity.
The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as contact dermatitis. urticaria. pitting edema. angioneurotic edema.
ANSWER 4 The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit. Urticaria (hives) is characterized as edematous skin elevations that vary in size and shape, itch, and cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema is the result of increased interstitial fluid and associated with disorders such as congestive heart failure.
A client taking antiretroviral therapy (ART) for stage 1 of HIV wants new medications because the CD4+ level is not much higher one year after initiation of therapy. The nurse knows that which response will be correct when educating the client about their disease? "It's possible that other medication would be more effective." "This means that medication doses have been skipped." "The viral load results can show improvement." "You are entering another stage of the illness."
ANSWER
The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? "I will be sure to eat lots of fresh fruits and vegetables every day." "I will make sure to have my own toothbrush and tube of toothpaste at home." "I will avoid contact with people who are sick or who have recently been vaccinated." "I will wash my hands whenever I get home from work."
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The nurse is teaching a client about a recent order for loratadine to help with seasonal allergies. What client statements indicate no further teaching is required? Select all that apply. "Sucking on ice chips will help if my mouth is dry." "It is recommended that I buy a humidifier for my bedroom." "Taking my medication on an empty stomach is a must." "Drinking two or three alcoholic drinks a week is okay." "Being careful driving is important after taking the medication."
ANSWER Client education includes instructing the client to take the medication on an empty stomach to prevent food from interfering with absorption. Avoid alcohol because the medication can cause increased drowsiness. A side effect is dry mouth, and sucking on ice chips will help. Being careful when driving is important because the medication can cause drowsiness. Using a humidifier will help decrease the negative symptoms associated with humidity.
A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include hypoglycemia. adrenal suppression. hypotension. diuresis.
answer 2 The nurse should instruct the client that side effects of oral corticosteroid therapy include adrenal suppression, fluid retention, weight gain, glucose intolerance, hypertension, and gastric irritation.
***********Which nerve is being assessed when the nurses asks the client to dorsiflex the ankle and extend the toes?******* Ulnar Median Radial Peroneal
answer 4 The motor function of the peroneal nerve is assessed by asking the client to dorsiflex the ankle and to extend the toes, while pricking the skin between the great toe and center toe assesses sensory function. The radial nerve is assessed by asking the client to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. The median nerve is assessed by asking the client to touch the thumb to the little finger. Asking the client to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.
A patient was seen in the clinic for hypertension and received a prescription for a new antihypertensive medication. The patient arrived in the emergency department a few hours after taking the medication with severe angioedema. What medication prescribed may be responsible for the reaction? Vasodilator Beta blocker Angiotensin receptor blocker
ANSWER Several frequently prescribed medications, such as angiotensin-converting enzyme inhibitors and penicillin, may cause angioedema. The nurse needs to be aware of all medications the patient is taking and be alert to the potential of angioedema as a side effect.
Which statement describes the clinical manifestations of a delayed hypersensitivity (type IV) allergic reaction to latex? They are localized to the area of exposure, usually the back of the hands. They can be eliminated by changing glove brands or using powder-free gloves. They occur within minutes after exposure to latex. They may worsen when hand lotion is applied before donning latex gloves.
ANSWER 1 Clinical manifestations of a delayed hypersensitivity reaction are localized to the area of exposure. Clinical manifestations of an irritant contact dermatitis can be eliminated by changing glove brands or using powder-free gloves. With an irritant contact dermatitis, avoid use of hand lotion before donning gloves; this may worsen symptoms, as lotions may leach latex proteins from the gloves. Described as a latex allergy, when clinical manifestations occur within minutes after exposure to latex, an immediate hypersensitivity (type I) allergic reaction has occurred.
What are expected client outcomes the nurse would include in a plan of care for a client with allergic rhinitis? Select all that apply. The client reports no symptoms of peripheral tingling The client controls outdoor precipitating factors The client will wear a dampened mask if dust is a problem The client develops cachexia The client's lungs will have occasional crackles or rhonchi
ANSWER 1-2-3 Wearing a dampened mask if there is a dust problem, reporting no symptoms of peripheral tingling, and controlling outdoor precipitating factors are all expected client outcomes that would be included in a plan of care. Lungs should be absent of crackles or rhonchi. Cachexia is seen in clients with a chronic illness, such as AIDS, chronic obstructive pulmonary disease, or heart failure.
The nurse is conducting discharge teaching for a client who is being discharged from the emergency department after an anaphylactic reaction to peanuts. Which education should the nurse include in the teaching? Select all that apply. Avoiding allergens Desensitization to allergen Use of sedatives to treat reactions Wearing a medical alert bracelet
ANSWER People who have experienced food, medication, idiopathic, or exercise-induced anaphylactic reactions should make every attempt to strictly avoid the allergen. Additionally, they should wear a medical alert bracelet and carry an emergency kit containing epinephrine for injection to prevent the onset of the reaction on exposure. Sedatives are not used to treat anaphylactic reactions, and desensitization is not used for peanut allergies.
********When do most perinatal HIV infections occur? After exposure during delivery In utero Through casual contact Through breastfeeding
ANSWER 1 Mother-to-child transmission of HIV-1 may occur in utero or through breastfeeding, but most perinatal infections are thought to occur after exposure during delivery.
The nurse is conducting a community education program on allergies and anaphylactic reactions. The nurse determines that the participants understand the education when they make which statement about anaphylaxis? The most common cause of anaphylaxis is penicillin. Systemic reactions include urticaria and angioedema. Anaphylactoid (anaphylaxis-like) reactions are commonly fatal. The most common food item that causes anaphylaxis is chocolate.
ANSWER 1 The most common cause of anaphylaxis is penicillin, accounting for about 75% of fatal anaphylactic reactions in the United States. Although possibly severe, anaphylactoid reactions are rarely fatal. Food items that are common causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Local reactions usually involve urticaria and angioedema at the site of the antigen exposure. Systemic reactions, which occur within about 30 minutes of exposure, involve cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.
The nurse is teaching a client about latex allergies. What route of exposure from latex products occurs from use of latex condoms? percutaneous mucosal parenteral cutaneous
ANSWER 2 Mucosal exposure can occur from the use of latex condoms, catheters, airways, and nipples. Parenteral exposure can occur from IV lines or hemodialysis equipment. Cutaneous exposure involves the wearing of latex gloves.
A client is prescribed montelukast as part of a treatment plan for an allergic disorder. The nurse understands that this drug belongs to which class? Nonsedating antihistamine Leukotriene-receptor antagonist Corticosteroid Mast cell stabilizer
answer 2 Montelukast is classified as a leukotriene-receptor antagonist. Cromolyn sodium is a mast cell stabilizer. Cetirizine, loratadine, and fexofenadine are nonsedating antihistamines. Beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, and triamcinolone are corticosteroids.
The nurse teaches the client with allergies about anaphylaxis, including which statement? The most common cause of anaphylaxis is penicillin. The most common food item that causes anaphylaxis is chocolate. Systemic reactions include urticaria and angioedema. Anaphylactoid (anaphylaxis-like) reactions are commonly fatal.
ANSWER 1 The most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the United States, is penicillin. Although possibly severe, anaphylactoid reactions are rarely fatal. Food items that are common causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Local reactions usually involve urticaria and angioedema at the site of the antigen exposure. Systemic reactions occur within about 30 minutes of exposure involving cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.
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? Naturally acquired active immunity A cell-mediated response Stimulation of colony-stimulating factors Activation of the complement system
ANSWER 2 A cell-mediated response occurs when T cells survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. An example of a cell-mediated response is one that occurs when an organ is transplanted. The complement system cooperates with antibodies to attract phagocytes and coat antigens to make them more recognizable for phagocytosis and stimulate inflammation and is not related to the surgery. Colony-stimulating factors prompt the bone marrow to produce, mature, and promote the functions of blood cells. Naturally acquired active immunity is a direct result of infection by a specific microorganism.
Which medication classification is known to inhibit prostaglandin synthesis or release? Antibiotics (in large doses) Nonsteroidal anti-inflammatory drugs (in large doses) Adrenal corticosteroids Antineoplastic agents
ANSWER 2 Nonsteroidal anti-inflammatory drugs include aspirin and ibuprofen. Antibiotics in large doses are known to cause bone marrow suppression. Adrenal corticosteroids and antineoplastic agents are known to cause immunosuppression.
A patient tells the nurse, "I was working out and lifting weights and now that I have stopped, I am flabby and my muscles have gone!" What is the best response by the nurse? "Your muscles were in a state of hypertrophy from the weight lifting but it will persist only if the exercise is continued." "While you are lifting weights, endorphins are released, creating increase in muscle mass, but if the muscles are not used they will atrophy." "Once you stop exercising, the contraction of the muscle does not regain its strength." "The muscle mass has decreased from the lack of calcium in the cells."
answer 1 Muscles need to exercise to maintain function and strength. When a muscle repeatedly develops maximum or close to maximum tension over a long time, as in regular exercise with weights, the cross-sectional area of the muscle increases. This enlargement, known as hypertrophy, results from an increase in the size of individual muscle fibers without an increase in their number. Hypertrophy persists only if the exercise is continued.
The nurse is taking an initial history of a new client with a musculoskeletal problem. Which factor is most important for the nurse to keep in mind for this assessment? Client's lifestyle Duration and location of discomfort or pain Client's age Any chronic disorder or recent injury
answer 4 The focus of the initial history depends on the nature of the musculoskeletal problem, whether the client has a chronic disorder or a recent injury. If the disorder is long-standing, the nurse obtains a thorough medical, drug, and allergy history. If the client is injured, the nurse finds out when and how the trauma occurred. The client's age, lifestyle, or duration and location of discomfort or pain, although important, have little influence on the focus of the initial history and assessment of the client.
The nurse working the medical-surgical floor knows that the nitroblue tetrazolium reductase (NTR) test is used to diagnose immunodeficiency disorders related to T lymphocytes Phagocytic cells B lymphocytes Complement
ANSWER 2 Diagnosis of phagocytic dysfunction is based on the health history, signs and symptoms, and laboratory analysis by the nitroblue tetrazolium reductase test, which indicates the cytocidal (causing death of cells) activity of the phagocytic cells. The others do not use the NTR test to assist with diagnosis.
A client on antiretroviral drug therapy informs the nurse about sometimes forgetting to take the medication for a few days. What should the nurse inform the client can occur when the medications are not taken as prescribed? The funding for the medications will cease if the client is not taking the meds correctly. The client is risking the development of drug resistance and drug failure. The client will have to take the drugs intravenously to ensure compliance. The client will have to take higher doses of the antiviral medications.
ANSWER 2 Clients who neglect to take antiretroviral drugs as prescribed risk development of drug resistance. When drug levels are not adequately maintained, viral replication and mutations increase. Funding will not cease for noncompliance. The medications are not all available in IV form. Taking a higher dose of the medication if missed does not resolve drug resistance.
A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised? Passive immunity Natural immunity Specific immunity Adaptive immunity
ANSWER 2 Natural immunity, which is nonspecific, provides a broad spectrum of defense against and resistance to infection. It is considered the first line of host defense following antigen exposure, because it protects the host without remembering prior contact with an infectious agent.
A client with AIDS has been tested for cytomegalovirus (CMV) with positive titers. What severe complication should the nurse be alert for with cytomegalovirus? hearing impairment fatigue blindness diarrhea
ANSWER 3 CMV can infect the choroid and retinal layers of the eye, leading to blindness. It does not lead to hearing impairment. Fatigue and diarrhea may occur but are not as critical as blindness.
The nurse is evaluating the plan of care for a client with an allergic disorder who has a nursing diagnosis of deficient knowledge related to measures for allergy control. What client statement will indicate to the nurse that the outcome has been met? Client states the need for coughing and deep breathing. Client demonstrates appropriate coping strategies for dealing with a chronic disorder. Client identifies methods for reducing exposure risk to allergens. Client reports an absence of symptoms associated with the allergy.
ANSWER 3 For the nursing diagnosis of deficient knowledge, the client's ability to identify methods for reducing the risk of allergen exposure indicates that the outcome has been met. The statement about coughing and deep breathing and an absence of symptoms would be appropriate for evaluating the nursing diagnosis of ineffective breathing pattern. Positive coping strategies would be an appropriate outcome for a nursing diagnosis of ineffective coping.
The nurse is admitting an older adult to a skilled nursing facility. What assessment parameters will the nurse expect to find with the musculoskeletal assessment? Select all that apply. increased muscle strength increase in height decreased endurance decreased range of motion joint stiffness
answer 3-4-5 Significant assessment findings of the musculoskeletal system in the older adult would include joint stiffness and decreased height, range of motion, muscle strength, and endurance. Older adults may have decreased height from osteoporosis and decreased muscle strength from atrophy.
A college student reports the onset of skin burning and hives when walking outdoors in cold weather. Which suggestions will the nurse make to limit this reaction from occurring? Select all that apply. Use a wetsuit when planning to go swimming in cold water. Avoid ingesting foods and beverages that are cold in temperature. Soak in a tub of tepid water when the itching and hives occur. Apply an over-the-counter topical corticosteroid to the areas every day. Take an over-the-counter antihistamine before going outdoors in cold weather.
answer 1-2-5 The client is describing cold urticaria, which is the development of wheals (hives) or angioedema due to exposure to cold. Mast cells release histamine and inflammatory mediators are stimulated in response to skin contact with cold objects, cold fluids, or cold air. It is an IgE-mediated atopic immune reaction. A wet suit can be used during swimming. Clients should understand that cold foods and beverages can stimulate oropharyngeal angioedema or anaphylaxis and should be avoided. Pretreatment with an antihistamine prior to predictable cold exposure is recommended, because clinical experience suggests that antihistamine pretreatment can prevent skin reactions and systemic reactions. Soaking in tepid water is not recommended to treat the hives and itching caused by cold urticaria. Over-the-counter corticosteroids are not recommended to treat the itching and hives caused by cold urticaria.
The nurse is conducting a community education program on allergies and anaphylactic reactions. The nurse determines that the participants understand the education when they make which statement about anaphylaxis? Anaphylactoid (anaphylaxis-like) reactions are commonly fatal. The most common cause of anaphylaxis is penicillin. The most common food item that causes anaphylaxis is chocolate. Systemic reactions include urticaria and angioedema.
answer 2 The most common cause of anaphylaxis is penicillin, accounting for about 75% of fatal anaphylactic reactions in the United States. Although possibly severe, anaphylactoid reactions are rarely fatal. Food items that are common causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Local reactions usually involve urticaria and angioedema at the site of the antigen exposure. Systemic reactions, which occur within about 30 minutes of exposure, involve cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.
The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as contact dermatitis. urticaria. angioneurotic edema. pitting edema.
answer 3 The area of skin demonstrating angioneurotic edema may appear normal, but often has a reddish hue and does not pit. Urticaria (hives) is characterized as edematous skin elevations that vary in size, shape, and itch, which cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema, the result of increased interstitial fluid, is associated with disorders such as congestive heart failure.
A client undergoes an arthroscopy at the outpatient clinic. After the procedure, the nurse provides discharge teaching. Which response by the client indicates the need for further teaching? "Elevating my leg will reduce swelling after the procedure." "I may notice some bruising or swelling in my knee." "My physician may prescribe pain pills after the procedure." "I should use my heating pad this evening to reduce some of the pain in my knee."
answer 4 The client requires additional teaching if he states that he'll use a heating pad to reduce pain the evening of the procedure. The client shouldn't use heat at the procedure site during the first 24 hours because doing so may increase localized swelling. Ice is indicated during this time. Elevating the extremity helps reduce swelling. The client may experience some discomfort after the procedure for which the physician may order medication. Bruising and swelling are common after an arthroscopy.
A client develops contact dermatitis in response to adhesive tape used to secure a dressing. The nurse interprets this reaction as an example of which type of hypersensitivity? Type II Type I Type III Type IV
ANSWER 4 An allergic reaction to adhesive tape leading to contact dermatitis is an example of a type IV hypersensitivity reaction. Type I hypersensitivity refers to anaphylaxis and is seen with allergic rhinitis, asthma, and penicillin or latex allergy. Type II hypersensitivity occurs when the system mistakenly identifies a normal body constituent as foreign, such as in myasthenia gravis, Goodpasture's syndrome, or Rh-hemolytic disease of the newborn. A Type III hypersensitivity reaction is associated with systemic lupus erythematosus, rheumatoid arthritis, and certain types of nephritis in which immune complexes are formed when antigens bind to antibodies.
