Immunity
A 64-year-old male client, who leads a sedentary lifestyle, and a 31-year-old female client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. As the nurse, you would know that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why? A) The male client because of his age B) The male client because of his lifestyle C) The female client because of her age D) The female client because of her lifestyle
A 64-year-old male client, who leads a sedentary lifestyle, and A) The male client because of his age
A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client? A) Anemia and granulocytopenia B) Numbness in the extremities C) Alterations in the renal function D) Pancreatitis
A) Anemia and granulocytopenia
A client visits the nurse complaining of diarrhea every time he eats. The client has AIDS and wants to know what he can do to stop having diarrhea. What should the nurse advise? A) Avoid fibrous foods, lactose, fat, and caffeine. B) Encourage large, high-fat meals. C) Reduce food intake. D) Increase the intake of iron and zinc.
A) Avoid fibrous foods, lactose, fat, and caffeine.
A client comes to the clinic and informs the nurse that he had a mild case of the flu a couple of months ago and "hasn't felt well since." The client tells the nurse that he is fatigued and it gets worse after any physical activity and a recurrent sore throat and joint pain. What does the nurse recognize these symptoms may indicate? A) Chronic fatigue syndrome B) Rheumatoid arthritis C) Ulcerative colitis D) Recurrent flu
A) Chronic fatigue syndrome
The nurse understands that which cells circulate throughout the body looking forvirus-infected cells and cancer cells? A) Natural killer cells B) Cytokines C) Interleukins D) Interferons
A) Natural killer cells
A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection? A) Naturally acquired active immunity B) Artificially acquired active immunity C) Naturally acquired passive immunity D) Artificially acquired passive immunity
A) Naturally acquired active immunity
You are caring for a client with a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected? A) Protein electrophoresis B) Enzyme-linked immunosorbent assay C) T-cell and B-cell assays D) Plasmapheresis
A) Protein electrophoresis
The clinic nurse is caring for a client with an allergic disorder who has received the first sensitizing dose of a new drug. What nursing action is most important at this point? A) Assess the client for reduced urine output. B) Monitor the client for reactions. C) Assess the client for reduced appetite. D) Monitor the client for increased heart rate.
B) Monitor the client for reactions..
A client has had mumps when he was 9 years old. He had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect? A) Artificially acquired active immunity B) Naturally acquired active immunity C) Passive immunity D) Natural passive immunity
B) Naturally acquired active immunity
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay with positive results twice. What is the next step for the nurse to explain to the patient for confirmation of the diagnosis? A) Perform the p24 antigen test for confirmation of diagnosis. B) Perform a Western blot test for confirmation of diagnosis. C) Perform a polymerase chain reaction test for confirmation of diagnosis. D) Perform a T4-cell count for confirmation of diagnosis.
B) Perform a Western blot test for confirmation of diagnosis.
A client on antiretroviral drug therapy is discussing with the nurse that sometimes he "forgets to take his meds for a few days." What should the nurse inform the client can occur when the medications are not taken as prescribed? A) The funding for the medications will cease if the client is not taking the meds correctly. B) The client is risking the development of drug resistance and drug failure. C) The client will have to take the drugs intravenously to ensure compliance. D) The client will have to take higher doses of the antiviral medications.
B) The client is risking the development of drug resistance and drug failure.
A client has been diagnosed with HIV and has been placed on antiretroviral therapy. What does the nurse inform the client will be required for determining the progression of the disease as well as guiding drug therapy? A) The client will be required to stop the medication for 2 weeks and then have laboratory studies drawn to determine if the antiretroviral therapy has cured the disease. B) Viral load and T4-cell counts will be performed every 2 to 3 months. C) More antiretroviral medication will be added every 2 to 3 months. D) The Western blot test will be monitored every 6 months to see if the virus is still present.
B) Viral load and T4-cell counts will be performed every 2 to 3 months.
The nurse is instructing a client with chronic fatigue syndrome about what type of dietary sources are the best to eat to supply eicosapentaenoic acid (EPA). What statement by the client demonstrates the instruction is understood? A) "I will eat shrimp at least twice a week." B) "I love crab cakes and will be sure to make them once a week." C) "Fresh salmon is one of my favorites, and I will eat it twice a week." D) "Lobster is expensive, but I will eat it once a week."
C) "Fresh salmon is one of my favorites, and I will eat it twice a week."
A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse? A) "If you don't take your medication, you will become very ill." B) "Be sure to let the physician know after you stop your medications." C) "It is important that you continue to take your medication to avoid an acute exacerbation." D) "As long as you are not having symptoms, you can take a medication vacation."
C) "It is important that you continue to take your medication to avoid an acute exacerbation."
A client with AIDS is brought to the clinic by his family. The family tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms? A) Distal sensory polyneuropathy (DSP) B) Candidiasis C) AIDS dementia complex (ADC) D) Cytomegalovirus (CMV)
C) AIDS dementia complex (ADC)
The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client? A) Hives B) Itching C) Airway obstruction D) Diarrhea
C) Airway obstruction
The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client? A) Hives B) Itching C) Airway obstruction D) Diarrhea
C) Airway obstruction
Your client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client? A) Avoid red meat for 48 to 72 hours before the test. B) Avoid strenuous physical activity for 24 hours before the test. C) Avoid antihistamines and cold preparations for 48 to 72 hours before the test. D) Avoid sunlight for 48 to 72 hours before the test.
C) Avoid antihistamines and cold preparations for 48 to 72 hours before the test.
A client with AIDS has been tested for cytomegalovirus (CMV) with positive titers. What severe complication should the nurse be alert for with cytomegalovirus? A) Diarrhea B) Hearing impairment C) Blindness D) Fatigue
C) Blindness
A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection? A) Limit interactions with people who are not HIV infected. B) Limit interactions with people who are already HIV infected. C) Follow the same sexual precautions as someone who has been diagnosed with AIDS. D) Quit his job and admit himself to a hospital or a cancer treatment center.
C) Follow the same sexual precautions as someone who has been diagnosed with AIDS.
A client is given a dose of ketorolac (Toradol), a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do? A) Intubate the client. B) Perform an electrocardiogram (ECG). C) Assess the client's vital signs. D) Administer epinephrine.
D) Administer epinephrine.
A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide? A) Forced immunity B) Naturally acquired active immunity C) Passive immunity D) Artificially acquired active immunity
D) Artificially acquired active immunity
A client is taking oral corticosteroids after having an exacerbation of asthma. What should the nurse be sure to include when instructing the client how to take the medication? A) The medication will cause weight loss. B) The medication will cause drowsiness so do not drive. C) Take the medication on an empty stomach to increase absorption. D) Take the medication in the morning with food.
D) Take the medication in the morning with food.
A client is scheduled to have a prick test to determine what specific allergens are creating problems for the client. What should the nurse inform the client is involved with the testing? A) A concentrated form of the substance is applied to the skin and covered with an occlusive dressing for 48 hours and then examined. B) A dilute solution of an antigen is injected intradermal and observed for a wheal. C) The skin will be scratched, and applying a small amount of the liquid test antigen to the scratch, usually on the back. D) The client will taste several different possible antigens and observe for wheals.
. C) The skin will be scratched, and applying a small amount of the liquid test antigen to the scratch, usually on the back.
A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response? A) "It means you are very sensitive to something inside of yourself." B) "It is a hyperimmune response to something in the environment that is usually harmless." C) "It is a muted response to something in the environment." D) "It is a harmless reaction to something in the environment."
." B) "It is a hyperimmune response to something in the environment that is usually harmless."
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states he is allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies? A) Apply an allergy bracelet and flag the chart. B) Tape an Epipen to the head of the bed. C) Inform the client not to take any medications with those substances in them. D) Call the physician.
A) Apply an allergy bracelet and flag the chart.
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states he is allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies? A) Apply an allergy bracelet and flag the chart. B) Tape an Epipen to the head of the bed. C) Inform the client not to take any medications with those substances in them. D) Call the physician.
A) Apply an allergy bracelet and flag the chart.
When an attenuated toxin is administered to a client, the B lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this? A) Artificially acquired active immunity B) Passive immunity C) Natural immunity D) Naturally acquired active immunity
A) Artificially acquired active immunity
A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring? A) Delayed hypersensitivity response B) Anaphylactic reaction C) Sensitization D) An immediate hypersensitivity response
A) Delayed hypersensitivity response
A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring? A) Delayed hypersensitivity response B) Anaphylactic reaction C) Sensitization D) An immediate hypersensitivity response
A) Delayed hypersensitivity response
A client is scheduled for diagnostic skin testing in 1 week. What should the nurse be sure to instruct the client prior to the scheduled appointment? A) Do not take prescribed or over-the-counter antihistamines or cold preparations for at least 72 hours before testing. B) Do not take antihypertensive medications the morning of the scheduled skin testing. C) Do not take nonsteroidal anti-inflammatory (NSAID) medications for 1 week prior to the scheduled skin testing. D) Prior to having the skin test, have the client take an over-the-counter histamine prophylactically for any possible reaction that could cause anaphylaxis.
A) Do not take prescribed or over-the-counter antihistamines or cold preparations for at least 72 hours before testing.
What type of cytokine will attract neutrophils and monocytes to remove debris? A) Lymphokines B) Cytotoxic T cells C) Suppressor T cells D) Regulator T cells
A) Lymphokines
You are caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders? A) Progressive tissue damage without any verifiable etiology B) Absence of a triggering event C) Profound fatigue with no identifiable cause D) Affects only older adults and infants less than 3 months
A) Progressive tissue damage without any verifiable etiology
A client comes to the clinic and informs the nurse that he feels as though he has allergies. What laboratory test results will be a positive indicator for an allergic disorder? A) Radioallergosorbent blood test (RAST) of 3 B) WBC of 7000/mm3 C) Neutrophils 60% D) Eosinophils 6%
A) Radioallergosorbent blood test
A client will be taking the tumor necrosis factor inhibitor, infliximab (Remicade), for the treatment of rheumatoid arthritis. Prior to beginning this therapeutic regimen, what screening should the client have? A) Screening for tuberculosis B) Screening for peptic ulcer disease C) Screening for syphilis D) Screening for rubella
A) Screening for tuberculosis
The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm3 and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse? A) The client has converted from HIV infection to AIDS. B) The client has advanced HIV infection. C) The client's T4-cell count has decreased due to the Pneumocystis pneumonia. D) The client has another infection present that is causing a decrease in the T4-cell count.
A) The client has converted from HIV infection to AIDS.
A client informs the nurse that he is very allergic to poison ivy but loves to go camping and has several camping trips planned for the summer months. What suggestions can be made to protect against poison ivy? A) Calamine lotion prior to the exposure of the poison ivy and any time skin gets wet B) Bentoquatam 5% (Ivy Block) applied 15 minutes prior to exposure and every 4 hours C) Vinegar and water applied to the skin every 2 hours D) Take diphenhydramine (Benadryl) 50 mg prior to the camping trip.
B) Bentoquatam 5% (Ivy Block) applied 15 minutes prior to exposure and every 4 hours
A client informs the nurse that he is very allergic to poison ivy but loves to go camping and has several camping trips planned for the summer months. What suggestions can be made to protect against poison ivy? A) Calamine lotion prior to the exposure of the poison ivy and any time skin gets wet B) Bentoquatam 5% (Ivy Block) applied 15 minutes prior to exposure and every 4 hours C) Vinegar and water applied to the skin every 2 hours D) Take diphenhydramine (Benadryl) 50 mg prior to the camping trip.
B) Bentoquatam 5% (Ivy Block) applied 15 minutes prior to exposure and every 4 hours
A client calls the clinic and asks the nurse if using Afrin nasal spray would be alright to relieve the nasal congestion he is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications? A) Report white patches in the mouth because Afrin can cause a fungal infection. B) Do not use Afrin for longer than 3 to 5 days in a row or rebound congestion can occur. C) Taper the dose when discontinuing the medication. D) Do not operate machinery or drive while using Afrin nasal spray.
B) Do not use Afrin for longer than 3 to 5 days in a row or rebound congestion can occur.
A male client is having sexual relations with another male as well as using methamphetamine and has contracted HIV. What concern does the nurse have for this client? A) The client is a drug addict and needs to stop using. B) The client may infect other people because of his drug use. C) The client may develop AIDS in a shorter period of time. D) The client will remain HIV positive for a longer period of time.
C) The client may develop AIDS in a shorter period of time.
A client comes to the clinic to see the physician with the complaint of "I think I ate something that I am allergic to." What symptoms would be appropriate for the nurse to ask the questions about? A) Nasal congestion and coughing B) Hives and itching C) Sneezing and runny nose D) Diarrhea and abdominal cramping
D) Diarrhea and abdominal cramping
A client comes to the clinic to see the physician with the complaint of "I think I ate something that I am allergic to." What symptoms would be appropriate for the nurse to ask the questions about? A) Nasal congestion and coughing B) Hives and itching C) Sneezing and runny nose D) Diarrhea and abdominal cramping
A client comes to the clinic to see the physician with the complaint of "I think I ate something that I am allergic to." What symptoms would be appropriate for the nurse to ask the questions about? A) Nasal congestion and coughing B) Hives and itching C) Sneezing and runny nose D) Diarrhea and abdominal cramping
A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse? A) "The doctor could prescribe anti-inflammatory drugs." B) "The doctor could prescribe antipyretic drugs." C) "The doctor could prescribe antineoplastic drugs." D) "The doctor could prescribe antihypertensive drugs."
A) "The doctor could prescribe anti-inflammatory drugs."
A client presents to the clinic with complaints that he began to itch and break out in hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors? A) Diphenhydramine (Benadryl) B) Flunisolide (Nasalide) C) Beclomethasone dipropionate (Beconase) D) Pseudoephedrine hydrochloride (Sudafed)
A) Diphenhydramine (Benadryl)
You are caring for a client with chronic fatigue syndrome. What is a realistic nursing intervention when taking care of a client with this diagnosis? A) Educate the client about the disease process. B) Advise the client to avoid moderate exertion. C) Instruct the client to reduce the intake of potassium-rich foods. D) Advise the client to avoid being in crowds.
A) Educate the client about the disease process.
A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wartlike lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding? A) Testing the client for the presence of HIV B) Instructing the client to wear cotton underwear C) Having the client abstain from sexual activity for 6 weeks while the medication is working D) Using a medicated douche in order to keep the vaginal pH normal
A) Testing the client for the presence of HIV
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health? A) The client appears mildly ill, listless, and disheveled. B) The client has a blood pressure of 120/72 mm Hg. C) The client is alert and oriented to all spheres. D) The client has palpable peripheral pulses in the upper extremities.
A) The client appears mildly ill, listless, and disheveled.
A client comes to the clinic and states he has "broken out in hives and itching since eating strawberries this morning." The client states he has never had problems with strawberries before. What is the best response by the nurse? A) "It is probably not the strawberries that you are having an allergy to if you have eaten them before." B) "It is possible to develop an allergic reaction to something you have had prior exposure to previously." C) "Are you sure that you haven't had an allergic reaction before; this doesn't seem possible." D) "We will probably be admitting you to the hospital; this could cause respiratory arrest."
B) "It is possible to develop an allergic reaction to something you have had prior exposure to previously."
A parent of a child who has been having frequent bouts of tonsillitis brings the childback to the clinic for another sore throat. The parent asks the nurse, "What are tonsils good for anyway?" What is the best response by the nurse? A) "They really do not have a function and should be removed." B) "These tissues filter bacteria from tissue fluid." C) "The tissue acts as an emergency reservoir of blood." D) "The tissue removes blood and bacteria."
B) "These tissues filter bacteria from tissue fluid."
A 17-year-old client with a diagnosis of HIV presents at the public health clinic complaining of pharyngitis, rash on the palms and soles of his feet, and diarrhea. What would the nurse suspect the client is suffering from? A) AIDS dementia complex (ADC) B) Acute retroviral syndrome (ARS) C) Distal sensory polyneuropathy (DSP) D) AIDS-related complex (ARC)
B) Acute retroviral syndrome (ARS)
A client's immune system has the ability to protect itself from external invaders. What type of immune function is present when this occurs? A) Immunosuppression B) Immunocompetence C) An immune response D) Immune incompatibility
B) Immunocompetence
A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse? A) "If you don't take your medication, you will become very ill." B) "Be sure to let the physician know after you stop your medications." C) "It is important that you continue to take your medication to avoid an acute exacerbation." D) "As long as you are not having symptoms, you can take a medication vacation."
C) "It is important that you continue to take your medication to avoid an acute exacerbation."
A client has had a kidney transplant performed for end-stage kidney disease. What typeof immune response that T-cell lymphocytes perform is related to this type of surgery? A) Activation of the complement system B) Stimulation of colony-stimulating factors C) A cell-mediated response D) Naturally acquired active immunity
C) A cell-mediated response
The nursing instructor is discussing allergic reactions with her clinical group. What allergic reactions would the nursing instructor talk about? Select all that apply. A) Atypical B) Unmediated C) Cytotoxic D) Atopic E) Immune complex
C) Cytotoxic D) Atopic E) Immune complex
A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells? A) Etanercept (Enbrel) B) infliximab (Remicade) C) Epoetin alfa (Epogen) D) Adalimumab (Humira)
C) Epoetin alfa (Epogen)
A woman infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV? A) Rashes on the face, trunk, palms, and soles B) Muscle and joint pain C) Gynecologic problems D) Weight loss
C) Gynecologic problems
The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system? A) Stem cells B) Cytokines C) Lymphoid tissues D) Red blood cells
C) Lymphoid tissues
A client is scheduled to have a prick test to determine what specific allergens are creating problems for the client. What should the nurse inform the client is involved with the testing? A) A concentrated form of the substance is applied to the skin and covered with an occlusive dressing for 48 hours and then examined. B) A dilute solution of an antigen is injected intradermal and observed for a wheal. C) The skin will be scratched, and applying a small amount of the liquid test antigen to the scratch, usually on the back. D) The client will taste several different possible antigens and observe for wheals.
C) The skin will be scratched, and applying a small amount of the liquid test antigen to the scratch, usually on the back.
You are caring for a client on tube feedings. The physician has ordered Osmolite HN as the feeding formula for the client. The family asks why the physician has ordered Osmolite HN instead of another formula to feed their family member. What is an important reason that tube-feeding formulas, such as Impact, Osmolite HN, or Perative, be recommended to clients? A) To suppress immune system function B) To block tumor necrosis factor C) To enhance the production of lymphocytes and NK cells D) To stimulate the immune system to attack tumor cells
C) To enhance the production of lymphocytes and NK cells
A client is informed that his white blood cell count is low and that he is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse? A) "White blood cells are produced in the plasma." B) "White blood cells are produced in the thymus gland." C) "White blood cells are produced in the lymphatic tissue." D) "White blood cells are produced in the bone marrow."
D) "White blood cells are produced in the bone marrow."
The nurse is instructing client's about the importance of taking the shingles vaccine. Which client would benefit from this vaccine? A) A 24-year-old client who is pregnant B) A 17-year-old client who will be attending college and living in a dormitory C) A 32-year-old client who has never had chickenpox D) A 65-year-old client who had chicken pox when he was 12 years old
D) A 65-year-old client who had chicken pox when he was 12 years old
A client who had sexual contact with a partner who is HIV+ recently develops flulike symptoms such as a low grade fever, headache, and muscle pain. What does the nurse suspect this client is experiencing? A) Pneumocystis pneumonia B) Influenza C) AIDS D) Acute retroviral syndrome
D) Acute retroviral syndrome
A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used? A) The taste of the medication is not palatable. B) The medication will work more rapidly parenterally. C) The medication, given orally, will cause diarrhea. D) Digestive enzymes destroy its protein structure.
D) Digestive enzymes destroy its protein structure.
A client with an allergic disorder is in treatment for his disorder. What might the treatment be? A) Autoimmune therapy B) Hypersensitive therapy C) Desensitization therapy D) Drug therapy for symptoms
D) Drug therapy for symptoms
A client asks the nurse about the importance of taking supplements to maximize immune function. The client is healthy and does not have any medical problems. What is the best information to give to the client? A) Instead of taking supplements, eat a lot of fruits and vegetables, and this will help maximize immune function B) Adopt a vegetarian diet and omit all meats, and you will maximize immune function. C) You should take a variety of vitamin and mineral supplements to maximize immune function. D) Eating a moderate diet that is balanced and varied will maximize immune function.
D) Eating a moderate diet that is balanced and varied will maximize immune function.
A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder? A) To decrease the body's risk of infection B) Because an autoimmune disease is a neoplastic disease C) So the client has strong drug therapy D) For their immunosuppressant effects
D) For their immunosuppressant effects
What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction? A) IgG B) IgA C) IgM D) IgE
D) IgE
The client is scheduled for a tilt-table test to assist in the diagnosis of chronic fatigue syndrome (CFS). What is the nurse's responsibility while the client is having the test? A) Diagnose the client's chronic fatigue syndrome. B) Position the client while monitoring the oxygen saturation. C) Perform venipuncture for glucose levels during testing. D) Position the client while monitoring blood pressure and pulse.
D) Position the client while monitoring blood pressure and pulse.
The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. A) Semen B) Urine C) Breast milk D) Blood E) Vaginal secretions
The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. A) Semen C) Breast milk D) Blood E) Vaginal secretions
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? A) A disorder where the body has too many immunoglobulins. B) A disorder where histocompatible cells attack the immunoglobulins. C) A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." D) A disorder where the body does not have enough immunoglobulins.
. C) A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self."
A female client informs the nurse that she is considering beginning sexual relations and wants to know the best way to protect herself from a sexually transmitted infection and HIV. What is the best response by the nurse? A) "Using a condom (latex) and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV." B) "Using a diaphragm with spermicidal jelly will also kill the bacteria and viruses that transmit STIs and HIV." C) "Using a lamb skin condom will be the most effective way to decrease transmission of STIs and HIV." D) "Douching immediately after intercourse will be the most effective way to kill bacteria and viruses."
A) "Using a condom (latex) and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV."
A client comes to the clinic and informs the nurse that he feels as though he has allergies. What laboratory test results will be a positive indicator for an allergic disorder? A) Radioallergosorbent blood test (RAST) of 3 B) WBC of 7000/mm3 C) Neutrophils 60% D) Eosinophils 6%
A) Radioallergosorbent blood test (RAST) of 3
The nurse is collecting data from a client with the autoimmune disorder, endocarditis. What does the nurse recognize as symptom of an acute exacerbation? A) Temperature of 100.9° F B) Respiratory rate of 20 breaths/minute C) Constipation D) Nausea
A) Temperature of 100.9° F
A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have? A) The nurse ensures a written consent is obtained prior to testing. B) The nurse should send the client to have the blood drawn without informing him about the specific screening test. C) The nurse will call the client with the results of the test. D) The nurse will inform the client that the results will have to be reported to the Centers for Disease Control and Prevention (CDC).
A) The nurse ensures a written consent is obtained prior to testing.
A public health nurse is giving an informational presentation on HIV/AIDS at a nearby college. How would the nurse best define AIDS? A) Acquired immunodeficiency syndrome is an infection by the human immunodeficiency virus. B) Acquired immunodeficiency syndrome is a fatal infection that profoundly weakens the immune system. C) Acquired immunodeficiency syndrome is a sexually transmitted disease. D) Acquired immunodeficiency syndrome is an infectious disease transmitted in blood and body fluids.
B) Acquired immunodeficiency syndrome is a fatal infection that profoundly weakens the immune system.
A client has not responded to chemotherapy and radiation therapy. What option may be available for treatment for this client? A) If chemotherapy and radiation do not work, there is no other treatment. B) Aldesleukin C) Tumor necrosis factor inhibitors D) Colony-stimulating factor
B) Aldesleukin
A client has been having joint pain and swelling in the left foot and is diagnosed with rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and the client has significant joint destruction. What type of disease is this considered? A) An exacerbation of a previous disorder B) Autoimmune C) An alloimmunity disorder D) A cause-and-effect relationship
B) Autoimmune
A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client? A) Sign a refusal of blood transfusion form so the client will not receive the transfusion. B) Bank autologous blood. C) Ask people to donate blood. D) Using volume expanders in case blood is needed.
B) Bank autologous blood.
A client with Crohn's disease, an autoimmune disorder, informs the nurse that he has not had any symptoms of the disease in 8 months. What does the nurse understand this asymptomatic period is referred to? A) An exacerbation B) Remission C) A cure D) An acute inflammatory response
B) Remission
The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis? A) The client will have a productive cough. B) The injection area swells if the client has developed antibodies against the antigen. C) The injection area will become painful with induration if the client has antibodies against the antigen. D) The injection area will break out in a fine macular rash.
B) The injection area swells if the client has developed antibodies against the antigen.
A client is cutting vegetable for dinner and accidently cuts his finger. What response is desirable to destroy foreign agents such as microorganisms to prevent infection from developing in the finger? A) A cell-mediated response B) The release of antibodies C) The release of memory cells D) Passive immunity
B) The release of antibodies
Why would it be important for the nurse to question the client about sexual practices, history of substance abuse, and his lifestyle during the interview process? A) To find out if the client will be compliant with therapeutic treatments B) To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS) C) To determine if the client needs a referral to counseling services D) To determine what type of personality the client has
B) To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS)
Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply. A) T4/T8 ratio B) polymerase chain reaction C) Western blot D) p24 antigen test E) ELISA test
B) polymerase chain reaction D) p24 antigen test
A client requires a blood transfusion for anemia and informs the nurse that he refuses because he doesn't want to contract acquired immune deficiency syndrome (AIDS). What is the best response by the nurse? A) "It's always a possibility." B) "You don't want to die, do you?" C) "The blood is screened very carefully; the risk is 1 in 2,000,000. D) "If you don't have the transfusion, you are taking a greater risk."
C) "The blood is screened very carefully; the risk is 1 in 2,000,000.
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications? A) Administer the medications that the physician ordered. B) Call the pharmacy and let them know the client has several drug allergies. C) Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive. D) Give the client one medicine at a time and observe for allergic reactions.
C) Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.
A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have? A) Naturally acquired active immunity B) Artificially acquired active immunity C) Passive immunity transferred by the mother D) There is no immunity passed down from mother to child.
C) Passive immunity transferred by the mother
The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response? A) Ibuprofen (Advil) B) Angiotensin-converting enzyme inhibitors (ACE-I) C) Diuretics D) Corticosteroids
D) Corticosteroids
A client has dilated cardiomyopathy and has just found out he will be receiving a heart. What medication does the client understand that he will have to take for the duration of his life to help suppress the immune system to prevent rejection of the new heart? A) Infliximab (Remicade) B) Etanercept (Enbrel) C) Adalimumab (Humira) D) Cyclosporine (Sandimmune)
D) Cyclosporine (Sandimmune)
A client has discussed therapy for his HIV-positive status. What does the nurse understand is the goal of antiretroviral therapy? A) Reverse the HIV+ status to a negative status. B) Treat mycobacterium avium complex. C) Eliminate the risk of AIDS. D) Keep the CD4 cell count above 350/mm3 and viral load undetectable.
D) Keep the CD4 cell count above 350/mm3 and viral load undetectable.
You are the clinic nurse caring for a client with a suspected diagnosis of HIV. You are preparing to draw blood for a confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before testing a client for HIV? A) Advise the client to avoid excess fluid intake. B) Advise the client to abstain from having intercourse. C) Advise the client to take off any ornaments and metallic objects. D) Obtain a written consent from the client.
D) Obtain a written consent from the client.
What is the function of the thymus gland? A) Produces stem cells B) Programs B lymphocytes to become regulator or effector B cells C) Develops the lymphatic system D) Programs T lymphocytes to become regulator or effector T cells
D) Programs T lymphocytes to become regulator or effector T cells
A client injured the left eye while playing basketball when another player hit him in the eye with his elbow. The client complained that although the right eye was not affected, he is having difficulty now with the vision in that eye too. What does the nurse understand this phenomenon is known as? A) Cataracts B) Psychosomatic blindness C) Glaucoma D) Sympathetic uveitis
D) Sympathetic uveitis
The anatomy and physiology instructor is explaining a cell-mediated response to the pre- nursing students. What actions would the instructor explain occur in a cell-mediated response? A) Toxins of invading antigens are neutralized. B) The invading antigens link together (agglutination). C) The invading antigens precipitate. D) T-cell lymphocytes survey proteins in the body and attack the invading antigens.
D) T-cell lymphocytes survey proteins in the body and attack the invading antigens.
A client who is HIV/AIDS positive has orders for laboratory tests to be performed. What precautions should the nurse observe whenever there is a risk of exposure to the blood and body fluids of an infected client? A) Avoid any physical contact with the client. B) Avoid cleaning up spilled urine and feces. C) Wear barrier garments for as long as possible after leaving a client's room. D) Transport the specimens of body fluids in leak-proof containers.
D) Transport the specimens of body fluids in leak-proof containers.
A client is taking the immunosuppressant medication, azathioprine (Imuran), for the treatment of Crohn's disease. What statement made by the client demonstrates an understanding of the side effects of this medication? A) "I will notify the doctor if I have a fever or any other signs of infection." B) "I will drink at least 3 L of fluid per day." C) "I will notify the doctor if I am not having a bowel movement daily." D) "I will stop taking my medication if I notice any side effects and then notify the doctor."
A) "I will notify the doctor if I have a fever or any other signs of infection."
A 15-year-old client has been brought to the clinic by his mother and is suspected of having an immune system disorder. What tests would you expect to be ordered for this young client? A) Cerebral spinal fluids aspiration B) Sedimentary rate C) Complete blood count with differential D) Complete chemistry panel
C) Complete blood count with differential
A client has an allergic reaction to seafood with generalized edema and informs the nurse that he is unable to get his wedding ring off and it is too tight. The client was unable to remove it with soap and water. What action by the nurse can facilitate removal of the ring without damaging it? A) Administer a diuretic and wait for the swelling to go down. B) There is not another option other than to use a ring cutter to remove the ring. C) Use twine to wrap the finger and, when the tissue is compressed, pull the free end of the twine and remove the ring. D) Use a tongue blade to remove the ring.
C) Use twine to wrap the finger and, when the tissue is compressed, pull the free end of the twine and remove the ring.
A client is taking oral corticosteroids after having an exacerbation of asthma. What should the nurse be sure to include when instructing the client how to take the medication? A) The medication will cause weight loss. B) The medication will cause drowsiness so do not drive. C) Take the medication on an empty stomach to increase absorption. D) Take the medication in the morning with food.
D) Take the medication in the morning with food.
The client comes to the clinic to obtain the results from the test to determine if he is infected with HIV. The physician informs the client that he has a CD4 cell count of 300 cells/mm3 and a high viral load. What does the nurse anticipate the physician will discuss with the client? A) Retroviral therapy is not warranted at this time. B) The initiation of antibiotic therapy to prevent the development of an opportunistic infection C) The administration of an antifungal medication to prevent the development of an opportunistic fungal infection D) The initiation of antiretroviral therapy
D) The initiation of antiretroviral therapy
