Exam 3 - NUR 211
1. What is type 1 hypersensitivity?
1. IgE-mediated; quick onset after exposure (ALLERGIC)
15. What is a major risk factor of rheumatoid arthritis?
15. family hx of 1st degree relatives
16. What should you address regarding treatment of rheumatoid arthritis?
16. chronic pain
17. What medications are given for treatment of RA?
17. NSAIDS, prednisone, DMARDS
18. What is the most common treatment for RA?
18. methotrexate, prior to beginning treatment, the client should receive a TB test
19. Why does the patient need to get a TB skin test?
19. should be done prior to initiation of immunosuppressive meds to rule out TB
1. What is type 2 hypersensitivity?
2. cytotoxic/ antibody mediated
20. What are some non-pharmacological interventions for RA?
20. adequate nutrition, PT, emotional support, exercise, diversional activities, splint extremity
22. What is A SIGN OF LUPUS?
22. butterfly-shaped rash across bridge of nose and cheeks
23. What should patients with lupus avoid?
23. direct exposure to sunlight and encourage use of sunscreen
24. What should pts with lupus cleanse their skin with?
24. mild soap and water
25. What is the nursing diagnoses associated with HIV/AIDS?
25.impaired skin integrity due to diarrhea and altered nutrition
26. On antiretroviral treatment, HIV viral loads of 200 copies/mL or higher are associated with potential treatment failure, what might this mean?
26. the current ART regimen is no longer effective and needs to be changed
27. What type of HIV testing does the CDC strongly recommend?
27. rapid testing because results are highly accurate and it can be done in a variety of settings and available within 20 minutes
28. How are in-home HIV tests done?
28. using saliva
29. What should you follow a negative rapid HIV test with?
29. a risk assessment to determine the need for repeat tests
1. What is type 3 hypersensitivity?
3. immune complex/ IgG/ IgM mediated (IMMUNE COMPLEX DEPOSITION)
30. Positive rapid tests can be disclosed to the pt but they must be confirmed with what?
30. a standard HIV assay, this necessitates a blood draw and a return appointment to get results
31. What is megace use to treat?
31. loss of appetite and wasting syndrome in AIDS clients
32. What does megace promote?
32. significant weight gain
33. What type of diet is recommended for HIV/AIDS patients?
33. high calorie and high protein diet (limit soft drinks) as well as ensure drinks
1. What is type 4 hypersensitivity?
4. delayed or cell-mediated (DELAYED)
40. With prednisone what is important?
40. take with food, monitor blood glucose levels because it can alter them
41. What is the most common treatment for allergic rhinitis?
41. antihistamines
42. What does AZT or ART have to do with?
42. HIV/AIDS
43. What should you not use when practicing safe sex?
43. oil based lubricant such as petroleum jelly
5. What is the most common form of respiratory allergy?
5. allergic rhinitis
6. What medicines are given for allergic rhinitis?
6. antihistamines, anticholinergic, corticosteroids (worse case), decongestants
7. What do antihistamines help?
7. relieve itching, sneezing, runny nose, doesn't relieve congestion
8. What should you avoid using before wearing latex gloves?
8. oil-based hand creams and lotions before putting on latex gloves, bc prep breaks down latex
1. The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply. A. Obtain a signed consent. B. Initiate a 22-gauge IV. C. Assess the client's lungs. D. Check for allergies. E. Hang a keep-open IV of D5W.
A
12. Which data, obtained during the nurse's assessment of the patient, indicates that the patient in the neurologic intensive care unit with an increased intracranial pressure (ICP) is deteriorating? A. Presence of fixed unresponsive pupils B. Sluggish reaction of pupil in response to light C. Brisk constriction of pupil in response to light D. Slight constriction in the opposite pupil in response to light
A
12. Which of the following is a disease condition associated with type 2 hypersensitivity? A. All of the answers are correct B. Myasthenia Gravis C. Graves' disease D. Autoimmune hemolytic anemia
A
14. Which medication is an osmotic diuretic that the nurse would prepare to administer when needing to lower a patient's intracranial pressure (ICP)? A. Mannitol B. Cimetidine C. Dexamethasone D. Hypertonic saline
A
16. Which signs and symptoms are early clinical manifestations of increased intracranial pressure (ICP)? A Disorientation and restlessness. B. Increased pulse and respirations . C. Decerebrate posturing. D. Loss of corneal reflex.
A
19. The nurse is providing diet-related advice to a male client following a cerebrovascular accident (CVA) . The client wants to minimize the volume of food and yet meet all nutritional elements. What suggestion should the nurse give to the client about controlling the volume of food intake? A. Provide thickened commercial beverages and fortified cooked cereals. B. Include dry or crisp foods and chewy meats. C. Always serve hot or tepid foods. D. Provide a high-fat diet.
A
2. The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention? A. Assess the client's body weight and ask what the client has been able to eat B. Place in contact isolation and don a mask and gown before entering the room C. Check the HCP's orders and determine what lab tests will be done D. Teach the client about total parenteral nutrition and monitor the subclavian IV site
A
22. The nurse identifies the nursing diagnosis of impaired verbal communication for a client with expressive aphasia. Which intervention would help the client communicate? A. Provide a communication board, which includes common needs and phrases. B. Provide spontaneity in the client's schedule to stimulate conversation. C. Finish the client's sentences for them to prevent frustration. D. Prevent embarrassing the client by changing the subject if the client does not respond in a timely manner.
A
27. A client with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? A. Noncontrast computed tomography (CT) scan. B. Chest radiograph. C. Complete blood count (CBC). D. Electrocardiogram (EGG).
A
28. Which clinical manifestation is associated with a stroke on the right side of the brain? A. Impulsiveness B. Impaired speech C. Slow performance D. Paralyzed right side
A
29. A nurse is updating the health history of a patient who is being admitted to the hospital with an evolving stroke. Which question is most important for the nurse to ask the patient's support person? A. "What was the time of onset of symptoms?" B. "Is the patient taking any medication?" C. "Does the patient have any allergies?" D. "Has the patient ever had stroke symptoms before?"
A
3. The nurse is caring for a client who practices Catholicism and was newly diagnosed with cancer. The client states, "God is punishing me for my past sins." What is the best response by the nurse? A. "You sound upset. Would you like to talk about it?" B. "Why do you think God is punishing you?" C. "Would you like me to get someone from your church to visit you?" D. "You didn't get cancer as punishment"
A
34. A patient diagnosed with HIV has an HIV viral load test of 9,000 copies/mL. What should this test result suggest to the nurse? A. The current prescribed medication therapy is not effective B. The dose of prescribed medication can be reduced C. A less toxic medication needs to be prescribed D. The current prescribed medication therapy is effective
A
35. An RN is teaching a student nurse about the management of increased intracranial pressure in a patient who sustained a stroke. Which statement made by the student nurse indicates the need for further teaching? A. "The patient should be placed in a supine position." B. "The patient's head and neck should be in alignment." C. "The patient's bowel function status should be maintained." D. "The patient's temperature should be maintained between 96.8°F to 98.6°F."
A
4. The nurse caring for several clients on a surgical unit notes that one of the clients is Muslim. The nurse decides to remove all pork from the client's meal tray prior to delivering it to the room. What best describes the nurse's action? A. Stereotyping B. Cultural competence C. Honoring rituals D. Transcultural nursing
A
5. The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse administer to prepare the client? A. Prednisone, a glucocorticoid. B. Zithromax, an antibiotic. C. Ativan, a tranquilizer. D. Epogen, a biologic response modifier.
A
5. The clinic nurse assesses a client with a history of transient ischemic attacks (TIA).This client is at increased risk for which disorder? A. Cerebrovascular accident (CVA). B. Aneurysm . C. Vasovagal syndrome. D. Myasthenia gravis
A
5. The nurse is caring for a dying client and the family. The male client is Muslim. Which intervention should the female nurse implement at the time of death? A. Allow the wife to stay in the room during postmortem care. B. Call the client's imam to perform last rites when the client dies. C. Place incense around the bed, but do not allow anyone to light it. D. Do not touch the body, and have the male family members perform care.
A
6. The nurse is conducting a teaching clinic for senior citizens about risk factors for stroke. Although the nurse includes all of the following as risk factors, which one presents the greatest risk for stroke? A. Hypertension. B. Heart disease . C. Diabetes. D. High cholesterol level.
A
7. Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? A. The blood will coagulate if left out of the refrigerator for greater than four (4) hours. B. The blood has the potential for bacterial growth if allowed to infuse longer. C. The blood components begin to break down after four (4) hours. D. The blood will not be affected; this is a laboratory procedure.
A
8. The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse's best response? A. Close the door and discuss the UAP's action after coming out of the room. B. Make the UAP come back outside the room and then reenter, closing the door. C. Say nothing to the UAP but report the incident to the nursing supervisor. D. Enter the client's room and discuss the matter with the UAP immediately.
A
8. What is a contraindication for the administration of tissue plasminogen activator (t-PA)? A Intracranial hemorrhage. B. Ischemic stroke . C. Age 18 years of age or older. D. Systolic blood pressure less than or equal to 160 mm Hg.
A
9. A client presents to the Emergency Department with right-sided weakness and slurred speech for the past 3 hours. What is the probable cause of the neurologic deficit? A Left-sided stroke. B. Right-sided stroke. C. Cerebral aneurysm. D. Transient ischemic attack
A
1. A nurse is working to develop cultural competence. Which activities would be appropriate for the nurse to engage in when exploring the nurse's own cultural awareness? Select all that apply. A. Critical reflection B. Feedback from colleagues C. Self-assessment D. Journal article research E. Client interviews
A, B, C
20. A nurse is planning a community-based stroke awareness/prevention health fair. Which activities would be most helpful to include? Select all that apply A. Smoking cessation B. Cholesterol screening C. BP screening D. Early warning signs of a stroke E. Education on food high in vitamin K F. Importance of taking aspirin daily if having a history of sinus tachycardia
A, B, C, D
26. The client diagnosed with a right-sided cerebrovascular accident (CVA) is admitted to the rehabilitation unit. Which interventions should be included in the nursing plan of care? (Select all that apply .) A. Position the client to prevent shoulder adduction. B. Refer the client to occupational therapy. C. Encourage the client to move the affected side. D. Perform quadriceps exercises five times a day. E. Instruct the client to hold the fingers in a fist.
A, B, C, D
8. Which interventions would help to facilitate patient safety during eating for a patient who has dysphagia? Select all that apply. A. Place food on the unaffected side of the mouth. B. Check mouth for pocketing of food. C. Place patient in a low Fowler's position. D. Help the patient to maintain a sitting position for 30 minutes after completing a meal. E. Help the patient to position the head in backward extension to promote swallowing
A, B, D
2. Which scenarios are examples of cultural competence? Select all that apply. A. attending a cultural diversity lecture series in the community B. Making arrangements for an acupuncturist to come to the hospital and provide pain relief for the client C. Explaining to the client that therapeutic touch is not as good as the use of traditional medicine D. Having a one-on-one conversation with a client regarding prayer needs and practies E. Performing a self assessment of one's own personal biases
A, B, D, E
10. When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply. A. Provide the patient a quiet and calm environment. B. Minimize procedures that potentially produce agitation. C. Facilitate an increased number of family visits to the patient. D. Encourage the patient's family to increase patient interactions. E. Observe the patient for signs of agitation or irritation and intervene.
A, B, E
7. Which interventions would be recommended for a client with dysphagia? (Select all that apply.) A Assist client with meals as needed. B. Place food on the affected side of mouth. C. Test gag reflex prior to offering food or fluids . D. Allow ample time to eat. E. Offer thickened liquids.
A, C, D , E
11. A client presents to the Emergency Department with a body temperature of 104°F. Which interventions would be appropriate? (Select all that apply.) A. Cover the client with a fluid-circulating cooling blanket. B. Restrict fluids. C. Ensure a cool environment. D. Provide warmed intravenous fluids. E. Monitor intake and output.
A, C, E
3. Which factors would the nurse associate with influencing a patient's intracranial pressure (ICP) readings? Select all that apply. A. Posture B. Swallowing C. Drowsiness D. Temperature E. Carbon dioxide levels F. Intraabdominal pressure
A, D, E, F
14. What type of disease is rheumatoid arthritis?
AUTOIMMUNE
18. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? A. The client smokes a pack of menthol cigarettes daily. B. The client's blood pressure (BP) is chronically around 170/90 mm Hg. C. The client works at a desk and relaxes by watching television. D. The client is 25-30 pounds above the ideal weight.
B
2. The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective? A. A decrease in the white blood cells in the sputum. B. The client's symptoms are improving. C. No change in the chest x-ray. D. The skin test is now negative.
B
2. The nurse planning care for a client admitted with a stroke would include which interventions to support the client's sensorimotor needs? A. Provide complete care for the client. B. Encourage use of non-affected arm to feed self, bathe, and dress. C. Talk loudly and distinctly. D. Turn the television on loudly for stimulation.
B
20. The health care provider recommends a carotid endarterectomy for a client with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The client asks the nurse to describe the procedure. Which response by the nurse is most accurate? A. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." B. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." C. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque." D. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed ."
B
23. A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? A. "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." B. "The client is unaware of his left side. You should approach him on the right side." C. "The client is unaware of his right side. You need to encourage him to interact from this side." D. "This condition is temporary, and he will adjust."
B
24. A nurse is explaining the National Institutes of Health Stroke Scale (NIHSS) to a student nurse. Which statement indicates that the student nurse understands the purpose of performing the NIHSS? A. "The NIHSS helps to prevent a second stroke." B. "The NIHSS measures the severity of a stroke." C. "The NIHSS is used primarily for research data collection." D. "The NIHSS is an invasive procedure that measures stroke severity."
B
25. A 7-year-old with a head injury is hospitalized after losing consciousness . The last set of vital signs showed heart rate 48, blood pressure 148/74, and respiratory rate 12 and irregular. The nurse concludes these are symptoms of what potential problem? A. Cardiovascular disease. B. Increased intracranial pressure. C. Spinal cord injury. D. Typical for a sleeping child at this age.
B
3. A client recovering from a stroke is being discharged on oral warfarin sodium (Coumadin). During discharge teaching, which statement by the client would reflect an understanding of the effects of this medication? A. "I will stop taking this medicine if I notice any bruising." B. "I will eat my usual amount of spinach while I am taking this medicine." C. "It will be okay for me to eat anything, as long as it is low-fat."' D. "I'll check my blood pressure frequently while taking this medication."
B
3. The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? A. The client who had wisdom teeth removed a week ago. B. The nursing student who received a measles immunization two (2) months ago. C. The mother with a six (6)-week-old newborn. D. The client who developed an allergy to aspirin in childhood.
B
35. The Human Immunodeficiency Virus (HIV) mainly attacks what type of cells in the human body? A. Red Blood Cells B. CD4 positive cells C. Stem Cells D. Platelets
B
38. The nurse is teaching a patient newly diagnosed with HIV. Which patient statement indicates the need for additional teaching? A. "I know I can't donate blood anymore because I have HIV." B. "I know to use an oil-based lubricant to prevent giving the disease to my partner." C. "I know I have to practice safe sex with my partner." D. "I will not share my toothbrush or razor with my partner."
B
39. The physician orders a combination HIV antigen/antibody test on a patient. The patient was potentially exposed to HIV 3 weeks ago. What HIV antigen does this test assess for? A. GP120 B. p24 C. GP41 D. P35
B
4. A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (Activase). What is true regarding the use of this medication? A. Is indicated if the stroke symptoms have occurred within 6 hours or less. B. Is administered to dissolve the clot that is occluding the cerebral circulation. C. Has not been associated with serious complications. D. Is used to treat thrombotic and hemorrhagic strokes.
B
4. The 56-year-old client diagnosed with tuberculosis (Tb) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? A. "I will take my medication for the full three (3) weeks prescribed." B. "I must stay on the medication for months if I am to get well." C. "I can be around my friends because I have started taking antibiotics." D. "I should get a Tb skin test every three (3) months to determine if I am well."
B
4. The hospice care nurse is conducting a spiritual care assessment. Which statement is the scientific rationale for this intervention? A. The client will ask all of his or her spiritual questions and get answers. B. The nurse is able to explain to the client how death will affect the spirit. C. Spirituality provides a sense of meaning and purpose for many clients. D. The nurse is the expert when assisting the client with spiritual matters.
B
6. While doing a neurologic assessment of a patient who sustained a thrombotic stroke, the nurse records the score of a patient as 40 on a National Institutes of Health Stroke Scale (NIHSS). Which interpretation does this score indicate? A. Minor stroke B. Severe stroke C. Moderate stroke D. No stroke symptoms
B
8. The HCP orders two (2) units of blood to be administered over eight (8) hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse implement? A. Call the HCP to question the order because blood must infuse within four (4) hours. B. Retrieve the blood from the laboratory and run each unit at an eight (8)-hour rate. C. Notify the laboratory to split each unit into half-units and infuse each half for four (4) hours. D. Infuse each unit for four (4) hours, the maximum rate for a unit of blood.
B
37. A 30-year-old patient is in the Acute Stage of HIV. What findings below correlate with this stage of HIV? Select all that apply: A. CD4 level <500 cells/mm3 B. No present of Opportunistic Infections C. High viral load D. Patient reports flu-like symptoms E. Patient is asymptomatic
B, C, D
1. Which factors would the nurse consider prior to repositioning a patient with an increased intracranial pressure (ICP)? Select all that apply. A. Raise the head of bed above 30 degrees B. Take care to prevent extreme neck flexion of patient. C. Adjust body position to decrease ICP. D. Rotate the patient to a side-lying position to prevent skin breakdown. E. Follow protocol standards to maintain a head-up position for the patient
B, C, E
7. Which aspects of the medical history of a female patient are risk factors for stroke? Select all that apply. A. Chronic low back pain B. Current use of high-dose oral contraceptives C. History of long-standing hair loss D. History of migraine headaches with aura E. Past employment involving exposure to chemical dyes
B, D
15. Which clinical manifestations are characteristics of Cushing's triad? Select all that apply. A. Tachycardia B. Bradycardia C. Systolic hypotension D. Systolic hypertension E. Widening pulse pressure F. Narrowing pulse pressure
B, D, E
21. A patient with rheumatoid arthritis is experiencing articular involvement. The nurse recognizes these characteristic changes include... SATA A. Bamboo-shaped fingers B. Metatarsal head dislocation in feet C. Non-inflammatory pain in large joints D. Asymmetric involvement of small joints E. Morning stiffness lasting 60 minutes or more
B, E
1. The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client? A. A red area is a positive reading that means the client has tuberculosis. B. The skin test is the only procedure needed to diagnose tuberculosis. C. A positive reading means exposure to the tuberculosis bacilli. D. Do not get another skin test for one (1) year if the skin test is positive.
C
10. A client is receiving alteplase (Activase) following a stroke. Which effects are most likely attributed to this drug? A. Skin rash with urticaria. B. Wheezing with labored respirations. C . Bruising and epistaxis. D. Temperature elevation of 100.8 degrees
C
11. The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first? A. The client who is two-thirds of the way through a blood transfusion and has had no complaints of dyspnea or hives. B. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body. C. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood. D. The client diagnosed with Crohn's disease who is complaining of perineal discomfort.
C
11. When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include? A. BP, brain tissue, body mass index B. Glucose level, BP, and brain tissue C. BP, brain tissue, and cerebrospinal fluid D. BP, brain tissue, and ventricles of the brain
C
13. The mother of a preschool age client tells the nurse that the client has frequent fevers.What is the best response to the mother? A. "Your child's immunity is compromised." B. "Your child must be around people with illnesses." C. "Fevers are seen more frequently in children because of developing immunity." D. "This is unusual since common diseases of childhood rarely result in fevers."
C
14. The nurse is administering oxygen to a client experiencing a stroke in order to prevent hypoxia and hypercapnia. This intervention will also lessen the risk for which complication? A Fluid accumulation in the lungs. B. Pulmonary emboli. C. Increased intracranial pressure (ICP). D. Rebleeding.
C
16. Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg? A. Normal intracranial pressure (ICP) B. Increased ICP C. Decreased cerebral blood flow (CBF) D. Increased cerebral perfusion pressure (CPP)
C
17. A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? A. Encourage coughing and deep breathing. B. Position the client with the head turned toward the side of the brain tumor. C. Administer stool softeners. D. Provide sensory stimulation.
C
2. Which assessment would the nurse perform to determine whether the mannitol (Osmitrol) IV treatment had the desired outcome for a patient with a head injury? A. Increased BP B. Decrease in body temperature C. Decreased intracranial pressure D. Decreased serum blood glucose
C
21. Which finding is consistent with a left-hemispheric stroke? A. Impaired judgment B. Unilateral weakness of the left extremities C. Unilateral weakness of the right extremities D. Spatial-perceptual deficits
C
22. Which deficit is associated with left-hemispheric stroke? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks
C
23. How would the nurse explain a transient ischemic attack (TIA) to the spouse of a patient who just had a TIA? A. It is usually neurologically damaging. B. It is a signal of progressive brain damage. C. It can be a warning of an impending stroke. D. It is nothing to be concerned about because it is not a stroke.
C
24. A client has a stroke affecting the right hemisphere of the brain. Based on the knowledge of the effects of right brain damage, what is the priority nursing diagnosis for this client? A. Impaired physical mobility related to right hemiplegia . B. Impaired verbal communication related to speech-language deficits. C. Risk for injury related to denial of deficits and impulsiveness. D. Ineffective coping related to depression and distress about disability.
C
25. A patient was brought to the emergency department with a sudden onset of a severe headache different from any other headache previously experienced. Which type of stroke is most likely occurring based on these symptoms? A. Embolic stroke B. Thrombotic stroke C. Hemorrhagic stroke D. Transient ischemic attack (TIA)
C
27. The patient was exhibiting symptoms of a stroke for 45 minutes before the symptoms resolved. Which condition may this patient have experienced? A. Embolic brain stroke B. Acute brain infarction C. Transient ischemic attack D. Subarachnoid hemorrhage
C
36. Which statement below best describes the role of reverse transcriptase? A. It's an enzyme that helps cut up the long protein chains of HIV. B. It plays a key role in the maturity of the virus. C. Reverse transcriptase is an enzyme that turns viral RNA into viral DNA. D. Reverse transcriptase is an enzyme that allows the viral DNA to become part of the cell's DNA.
C
4. The client with O+ blood is in need of an emergency transfusion but the laboratory does not have any O+ blood available. Which potential unit of blood could be given to the client? A. The O- unit. B. The A+ unit. C. The B+ unit. D. Any Rh+ unit.
C
5. The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing? A. The client's first skin test indicates a purple flat area at the site of injection. B. The client's second skin test indicates a red area measuring four (4) mm. C. The client's previous skin test was read as positive. D. The client has never shown a reaction to the tuberculin medication.
C
5. The nurse observes that a patient may be demonstrating stoicism in response to pain. In order to adequately assess his pain, the nurse should implement which assessment technique? A. Ask the client to rate their pain utilizing the Wong-baker FACES scale B. Tell the client he will need to ask the nurse for PRN pain meds C. Assess the client for non-verbal signs/symptoms of pain D. Wait to assess the client until they complain of pain
C
6. The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? A. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the lab. B. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. C. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. D. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.
C
9. The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse's first response? A. Notify the laboratory and health-care provider. B. Administer the histamine-1 blocker, Benadryl, IV. C. Assess the client for further complications. D. Stop the transfusion and change the tubing at the hub.
C
9. Which food would be included in the diet for a patient who had a stroke and has dysphagia? A. Milkshakes B. Chicken soup C. Mashed potatoes D. Pureed cooked rice
C
2. The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? A. Type and crossmatch for red blood cells immediately (STAT). B. Initiate an IV with an 18-gauge needle and hang normal saline. C. Have the client sign a consent for an exploratory laparotomy. D. Notify the significant other of the client's admission.
C, D
4. Which findings support the use of thrombolytic agents for a patient diagnosed with a stroke? Select all that apply. A. The onset of symptoms was six hours ago. B. The patient had a hip replacement one week ago. C. There has been no head trauma for three months. D. The patient's BP is 180/100 mm Hg. E. There is a recent history of gastrointestinal (GI) bleeding. F. The CT scan is clear of hemorrhage.
C, D, F
1. A client with cerebral edema is prescribed intravenous mannitol (Osmitrol). What is the expected action of mannitol? A. Inhibit platelet aggregation. B. Prevent seizure activity. C. Reduce inflammation of brain tissue. D. Reduce fluid in the cerebral tissue.
D
1. The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding AIDS should be included? A. Females taking birth control pills are protected from becoming infected with HIV B. Protected sex is no longer an issue because there is a vaccine for the HIV virus C. Adolescents with a normal immune system are not at risk for developing AIDS D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV
D
10. The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which nursing task would be delegated to the UAP? A. Assess the urine output on a client who has had a blood transfusion reaction. B. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs. C. Auscultate the lung sounds of a client prior to a transfusion. D. Assist a client who received 10 units of platelets in brushing the teeth.
D
11. The principal antibodies involved in type 2 hypersensitivity are____ A. IgD and IgB B. IgA and IgC C. IgG and IgE D. IgG and IgM E. IgA and IgD
D
12. An elderly client admitted with pneumonia has a normal body temperature. The nurse realizes the reason for this inconsistency is based upon which rationale? A. The client does not have pneumonia. B. The client is losing body heat. C. The room is cold. D. The temperature is not a reliable indicator.
D
13. Which clinical manifestations would the nurse monitor to assess the development of increasing intracranial pressures in a patient who sustained a head injury and has a baseline Glasgow Coma Scale (GCS) score of 14? A. Increased systolic BP, increased pulse, GCS score of 12 B. Decreased diastolic BP, decreased pulse, and GCS score of 13 C. Increased systolic and diastolic BP, increased pulse, GCS score of 9 D. Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4
D
15. A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be appropriate for this client? A Frequent range-of-motion exercises to prevent contractures. B. Encourage independence with ADLs to promote self-esteem. C. Encourage family visitation to decrease anxiety. D. Absolute bed rest in a quiet, non-stimulating environment.
D
17. Which action would the nurse implement when a patient's assessment reveals an increased intracranial pressure (ICP) and the patient has a lumbar puncture scheduled? A. Prepare the patient and assist with the lumbar puncture. B. Reschedule the lumbar puncture for the next business day. C. Administer IV fluids before the lumbar puncture. D. Cancel the lumbar puncture and contact the prescribing provider.
D
18. When assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first? A. Dim vision B. Papilledema C. Body temperature D. Level of consciousness
D
19. Which assessment would the nurse teach a patient to report as part of the warning signs of stroke, using the mnemonic FAST? A. Footdrop B. Arm strength C. States disoriented D. Facial drooping
D
21. A client with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the client for which procedure? A. Intravenous heparin administration. B. Transluminal angioplasty. C. Surgical endarterectomy. D. Tissue plasminogen activator (tPA) infusion.
D
26. Which condition presents with a sudden onset of a headache, vomiting, and decreased level of consciousness? A. Embolic stroke B. Brain infarction C. Cerebral edema D. Hemorrhagic stroke
D
3. The public health department nurse is caring for the client diagnosed with active tuberculosis who has been placed on directly observed therapy (DOT). Which statement best describes this therapy? A. The nurse accounts for all medications administered to the client. B. The nurse must complete federal, state, and local forms for this client. C. The nurse must report the client to the Centers for Disease Control. D. The nurse must watch the client take the medication daily
D
30. A nurse is admitting a patient with a thrombotic stroke. The patient is NPO but is requesting a drink of water. Which response by a nurse is appropriate? A. "You can have a couple of ice chips to wet your mouth." B. "A barium swallow test is required for stroke patients before giving PO fluids." C. "We need to keep you NPO in case a procedure needs to be performed today." D. "It is not safe to allow you to have anything by mouth until a swallow assessment can be performed."
D
32. During the acute phase of stroke management, which nursing intervention is most important to decrease risk of aspiration? A. Placing an oral-pharyngeal airway at the bedside B. Elevating head of bed 30 degrees C. Placing suction equipment at the bedside D. Maintaining NPO status
D
33. A patient presents to the emergency department reporting a sudden onset of headache described as "the worst headache ever." The patient also reports nausea and visual disturbances. Which collaborative intervention would be a priority for the nurse? A. Obtain consent for lumbar puncture. B. Administer Zofran 4 mg Ondansetron (ODT) for nausea. C. Administer morphine sulfate 4 mg IV push (IVP). D. Prepare patient for transport to CT scan.
D
34. Which intervention would the nurse take when communicating with a patient suffering from aphasia following a stroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Finish the patient's sentences to minimize frustration associated with slow speech. D. Use simple, short sentences accompanied by visual cues to enhance comprehension.
D
5. Which statement is accurate about the recommendations for BP management after an ischemic stroke? A. A lower BP is a protective response to maintain cerebral perfusion. B. The BP must be lower than 160/70 mm Hg to receive fibrinolytic agents. C. Elevated BPs are expected after a stroke, and drug therapy should be initiated. D. Drugs to lower BP are recommended if the BP is 220/120 mm Hg or higher.
D
6. The client undergoing knee replacement surgery has a "cell saver" apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system? A. Infuse the drainage into the client when a prescribed amount fills the chamber. B. Attach an hourly drainage collection bag to the unit and discard the drainage. C. Replace the unit with a continuous passive motion (CPM) unit and start it on low. D. Have another nurse verify the unit number prior to reinfusing the blood.
D
7. The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement? A. Standard Precautions. B. Contact Precautions. C. Droplet Precautions. D. Airborne Precautions.
D
9. In a type 1 hypersensitivity reaction the primary immunologic disorder appears to be : A. binding of IgG to an antigen on a cell surface B. Deposit of antigen-antibody complexes in small vessels C. Release of cytokines used to interact with specific antigens D. Release of chemical mediators from IgE-bound mast cells and basophils
D
31. Which food items would be included in the diet plan for a patient being discharged from the hospital after recovering from a stroke? Select all that apply. A. Pizza B. French fries C. Cheeseburger D. Grilled chicken E. Vegetable soups
D, E
10. Type 2 hypersensitivity is sometimes called which of the following? A. None of the answers are correct B. A delayed-type reaction C. An immune complex reaction D. An allergic or immediate reaction E. Antibody-dependent cytotoxicity
E
13. Does rheumatoid arthritis affect more males or females?
FEMALES
