MedSurg 3 3

Type III Immune Complex Reactions result from excess antigens causing immune complexes to form in the blood. Which of the following is an example of this? A. Rheumatoid arthritis B. Asthma C. Celluitis D. Shock

Answer- A Rationale: Most auto-immune disorders are Type III immune complex reactions.

Put the sequence of the inflammatory response in order. A. Phagocyte and antibacterial exudate destroy bacteria. B. Phagocytes migrate to the site of inflammation (Chemotaxis) C. Tissue damage causes a release of vasoactive and chemotactic factors that trigger an increase in blood flow and capillary permeability. D. Permeable capillaries allow an influx of fluid and cells.

Answer- C, D, B, A

Which of the following are ways that HIV may be transmitted? Select All That Apply. A. Sharing household utensils, towels, linens and toilets. B. Casual Contact. C. Parenterally. D. Via Mosquitos and Insects. E. Sexual Contact. F. Perinatal Contact.

Answer- C, E, F

An increase in immature neutrophils circulating in the blood in response to an infection is known as what? A. This is normal. B. Downward shift C. Shift to the right D. Shift to the left

Answer- D

The nurse provides discharge teaching to a client with acquired immunodeficiency syndrome (AIDS) and a low white blood cell (WBC) count. Which client statement indicates understanding of the content? Select all that apply. One, some, or all responses may be correct.

-"My roommate will take care of our cat's litter box." -"I will rinse my toothbrush in bleach once a week." -"Each time I get a new drink I will use a different cup." -"I will wash my hands thoroughly after shaking hands with anyone." -I will wash my armpits and peri-area twice daily if I can't shower." Rationale: When the client with AIDS has a low WBC, they should avoid changing the litter box. The client should rinse the toothbrush in bleach weekly and then rinse out the bleach with hot water. The client with a low WBC should not reuse cups and glasses. Hands should be washed with an antimicrobial soap before eating and drinking, after touching a pet, after using the toilet, and after shaking hands with anyone. If a client with AIDS cannot bathe daily with antimicrobial soap, they should ensure they wash their armpits, groin, genitals, and anal area twice daily with antimicrobial soap. Raw fruit and vegetables should be avoided, as should large gatherings of people who might be ill. The client with AIDS should take their temperature daily and also when they don't feel well. The client should avoid working with houseplants or in a garden.

The client is most at risk for developing the acute complications of

-Acute compartment syndrome -fat embolism syndrome -venous thromboembolism Rationale: Acute compartment syndrome, fat embolism syndrome, and venous thromboembolism are acute complications of a bone fracture. Acute compartment syndrome causes increased pressure within one or more compartments in the leg and may be called the ischemia-edema cycle. Fat embolism syndrome occurs when fat globules are released from the bone marrow into the blood stream, causing an embolism. Venous thromboembolism is a blood clot that is formed and then travels to a different area of the body, usually the lungs.

Which action would the nurse include in the plan of care for the client with SLE at this time? Select all that apply.

-Advise the client to have eyes checked at least every 6 months -Suggest the use of moist heat on joints -Teach the client to complete priority activities first -Inform the client to fold the children's clothes when sitting -Reassure client that she did not cause this disease -Monitor for depression Rationale: The client is taking hydroxychloroquine, a drug that can cause central vision loss and examinations are recommended every 6 months. Moist heat is the recommended treatment for joint pain in SLE (ice is only recommended when strains and sprains are present). Because of the fatigue that is present, priority activities are completed first when energy level is high, and folding clothes sitting down conserves energy. To decrease self-blame, clients need to know that an autoimmune disorder, like SLE, cannot be prevented. The client is prone to depression because of the stress that is placed on her marriage and work; with the addition of prednisone, depression may be intensified because of the fat redistribution (moon face, buffalo hump), acne, weight gain, thinning hair, increased facial and body hair, and possible stretch marks caused by long-term use of steroids. All of the changes listed can lead to body image issues, leading to depression.

The nurse quickly intervenes to address the client's change in status and notifies the surgeon. Which interventions would the nurse anticipate at this time? Select all that apply.

-Apply oxygen -Place on bedrest -Start intravenous (IV) fluids Rationale: The nurse would anticipate the following interventions: apply oxygen, place on bedrest, and start intravenous (IV) fluids. The client is experiencing a fat embolus. The client needs oxygen because the fat embolus has traveled to the lungs and the oxygen saturation level is low. The recommended treatment for a fat embolus is bedrest. Hydration (starting IV fluids) is also recommended treatment for a fat embolus.

Which factor would the nurse identify as increasing the risk of human immunodeficiency virus (HIV) transmission? Select all that apply. One, some, or all responses may be correct.

-Childbirth -Breast-feeding -Anal sex -Needle sharing -Oral sexual contact Rationale: HIV can be spread through childbirth and breast-feeding. Anal sex increases transmission because of exposure to mucous membranes to infected semen. Sharing needles can be a parenteral route for HIV transmission. Oral sexual contact with infected semen or vaginal secretions increases the risk of transmission. Having multiple sexual partners, not monogamy, increases the risk of HIV transmission. HIV cannot be transmitted through sharing plates and cups. Sharing toilet facilities does not transmit HIV.

Which finding would the nurse associate with chronic osteomyelitis? Select all that apply. One, some, or all responses may be correct.

-Elevated white blood count -Presence of avascular scar tissue - Elevated erythrocyte sedimentation rate Rationale: Characteristics of chronic osteomyelitis include an elevated white blood count, the presence of avascular scar tissue, and increased levels of erythrocyte sedimentation rate due to an infection. Decreased vitamin D levels are associated with osteoporosis, not osteomyelitis which is a bone infection. Characteristics of chronic osteomyelitis include warmth at the infection site (not cold) and constant bone pain not relieved by rest. A temperature that is significantly increased is associated with acute, not chronic, osteomyelitis. Reduced calcium is a causative factor and finding in those with osteoporosis.

A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) receives pentamidine for a protozoal infection. The nurse will monitor the client for which common side effect? Select all that apply. One, some, or all responses may be correct.

-Hypoglycemia -Decreased blood pressure -Oliguria -Sore throat -Fever Rationale: Hypoglycemia is a side effect of pentamidine. Decreased blood pressure and dysrhythmias are common side effects of this medication. Other common side effects include decreased urination, sore throat, and fever. Neutropenia, not leukocytosis, is associated with this medication. Electrolyte imbalances associated with pentamidine include hyperkalemia, not hypokalemia, and hypocalcemia, not hypercalcemia.

A client who has recently moved to the country attends the prenatal clinic at 30 weeks gestation for the first time. Although she states that she has had immunizations, she does not know which ones. Which immunization would the nurse recommend? Select the 3 correct immunizations.

-Influenza -Tetanus, Diphtheria, Pertussis (TDAP) -Hepatitis B Rationale: The influenza, TDAP, and Hepatitis B vaccines contain dead viruses and can be administered safely during pregnancy. The mumps, measles, and rubella (MMR), shingles, and varicella vaccines are all contraindicated because they contain live viruses, which are teratogenic.

The nurse discovers shrimp had been substituted for the pork in the egg roll, which led to the allergic response due to the client's allergy to shellfish. After 5 minutes, the nurse reassesses the client. Select the 4 assessment findings that would indicate the client was not progressing as expected and another epinephrine injection is needed.

-Oxygen saturation 85% -Development of stridor -Decreased level of consciousness -Cyanotic lips and fingers Rationale: The 4 assessment findings that would indicate the client was not progressing as expected and another epinephrine injection is needed include oxygen saturation 85%, development of stridor, decreased level of consciousness, and cyanotic lips and fingers. Oxygen saturation 85% is a decline from 88%, indicating another injection is needed. Stridor alerts the nurse that the respiratory tract is becoming more obstructed, indicating epinephrine is needed. Decreased level of consciousness is a decline in status, indicating hypoxia to the brain and another injection of epinephrine is required. Cyanotic lips and fingers indicate hypoxemia and hypoxia to the periphery and requires another injection of epinephrine.

Which nursing intervention would the nurse include in the plan of care for a client after a hip replacement? Select all that apply. One, some, or all responses may be correct.

-Place a pillow between the client's legs. -Require the client to use an elevated toilet seat. -Keep the client's hip in a neutral, straight position. -Use a fracture bedpan for urinary relief Rationale: Using a pillow between the legs provides comfort and helps keep the joint abducted. Use of an elevated toilet seat allows for easy movement and prevents hip dislodgement. Keeping the client's hip in a neutral, straight position prevents pain and discomfort and hip dislocation. For urinary relief a fracture bedpan should be used for post-surgical hip clients. A client that has had a hip replacement needs help while standing; therefore, the nurse should not have the client sit in an armless chair because the client may experience discomfort and difficulty when standing. Crossing the client's legs at the ankles and knees after a hip replacement may cause pain and venous stasis, promoting thrombus formation. The client's hip should not be flexed more than 45-60 degrees, and therefore should not sit in a low chair as this can cause dislocation of the hip joint. To prevent hip flexion the head of the bed should not be elevated beyond 45 degrees.

A primary health care provider schedules a bone scan for a client with osteoporosis. Which nursing action is beneficial for the client? Select all that apply. One, some, or all responses may be correct.

-Placing the client in the supine position -Informing a client that a mild sedative may be used -Instructing the client to push fluids after the test -Instructing the client to empty their bladder before the scan Rationale: A bone scan is done to assess osteomyelitis, osteoporosis, primary and metastatic malignant lesions of bone, and certain fractures. The client will be in the supine position for 1 hour during the bone scan. A mild sedative may be given to facilitate relaxation and cooperation during the test. The radionuclide will be excreted by urine and feces. The nurse should instruct the client to push fluids to facilitate urinary excretion. The nurse should instruct the client to empty the bladder before scanning. The client undergoing a computed tomography (CT), not bone, scan must be screened for a shellfish allergy to reduce the incidences of anaphylactic shock associated with the radiocontrast agent. Radio waves and a magnetic field are used during magnetic resonance imaging (MRI); therefore, the nurse should ensure that the client has no metal on the clothing before the procedure. The main risk of a myelogram is a spinal headache that usually resolves within 2 days of the procedure. A jelly-like substance is applied to the skin over the site in an ultrasound examination.

The nurse plans to help a client get out of bed for the first time following a surgery on the right humerus. Which assessment would the nurse make before having the client sit on the side of the bed? Select all that apply. One, some, or all responses may be correct.

-Presence of safe footwear -Status of comfort and pain -Appearance of wound and skin -Presence of tubes or lines Rationale: Assessment of safe footwear before beginning the mobilization process will prevent the need for leaving the client to find footwear during the process. Pain and comfort must be assessed before beginning to move the client. The nurse will assess the appearance of the wound and skin prior to activities to ensure dressings are adequate and the activity will not cause local injury. Assessment of lines and tubes is important to assure that local injury or dislodgement of equipment will not result from the activity. The client will be encouraged to turn side-to-side, along with coughing and deep breathing at least hourly while in bed. Intake and output amounts are not relative to ensuring ambulatory safety. The client's walking gait cannot be observed until the client is out of bed.

Select the 3 findings that require immediate follow-up.

-Reports numbness and tingling in the right toes - pain 9/10 in the right leg -Right leg externally rotated Rationale: The findings that require immediate follow-up include: reports numbness and tingling in the right toes, reports pain 9/10 in the right leg, and right leg externally rotated. Numbness and tingling indicate nerve injury which requires immediate follow-up to prevent further damage. Pain at a 9/10 is severe and needs to be addressed. Right leg externally rotated indicates the leg is fractured.

Which neurovascular assessment would the nurse plan to perform immediately after a client has rotator cuff surgery? Select all that apply. One, some, or all responses may be correct.

-Skin color -Disproportionate pain -Presence of edema -Movement of the hand -Sensations in the extremity Rationale: Pale or dusky skin tone may indicate impaired circulation to the extremity. Pain that is disproportionate to the injury, especially with extension, may be a first sign of compartment syndrome. Edema may result from impaired circulation and may cause further impairment of circulation. The ability to move the area distal to surgery is indicative of adequate blood flow and integrity of nerves. Paresthesias may indicate lack of vascular or nerve integrity. Appropriate perception of sensations indicates functioning of nerves and is included in the neurovascular assessment. The quality of the pulse, not its rate, should be monitored. If it is weak and thready, it may indicate impaired circulation to the extremity. The level of orientation demonstrates neurological function. Post-surgical assessment of the respiratory system involves evaluation of the rate, pattern, and depth of breaths.

The nurse reviews the laboratory findings and new orders for the client who has systemic lupus erythematosus (SLE). Based upon the laboratory results and the new medication orders, the client is most at risk for

-infections -bleeding -fat redistribution Rationale: Based upon the laboratory results and the new medication orders, the client is most at risk for bleeding, infections, and fat redistribution. The platelets are low, indicating bleeding; the prednisone, hydroxychloroquine, and naproxen increase the risk of bleeding. The white blood cells are low, indicating susceptibility to infection; the prednisone also increases the risk for infection because of its antiinflammatory properties. Prednisone causes moon face and buffalo hump between shoulders due to its fat redistribution properties; the drug hydroxychloroquine has anticlotting effects, and the client has low platelets, which promotes bleeding.

The UAP reports that the client who just ambulated to the toilet, stubbed their toe and limped back to bed. When assessing the client you note redness, warmth and tenderness to palpation in the clients great toe, Which stage of inflammation would this bed categorized as? A. Stage 1 B. Stage 2 C. Stage 3 D. There is indication of an acute inflammatory response.

Answer- A Rationale: Redness, warmth and pain are all signs of inflammation. Stage 2 results in puss formations and exudate. Stage 3 results in new tissue formation and scar tissue.

SLE manifestations

A positive ANA, fever, cloudy urine, swollen joints, reddish rash over cheeks and nose, and fatigue even after a good night's sleep are consistent with SLE. A positive ANA indicates an autoimmune condition. Clients with SLE often have an intermittent fever due to the chronic systemic inflammation that is associated with a flare (exacerbation). Cloudy urine from the excess protein (causes urine to be foamy) occurs from the autoantibody attack on the kidneys, damaging the basement membrane. Swollen joints indicate the inflammation has affected the musculoskeletal system. A reddish rash over cheeks and nose is typical of the "butterfly" rash seen in SLE. Fatigue is a common finding in clients with SLE.

Which of the following is true regarding WBC? A. Eosinophils account for 15% of WBC B. Basophils account for 10% of WBC C. Tissue mast cells have binding sites for IgM D. Neutrophils account for for 55-70 % of normal WBC

Answer- D Rationale: Eosinophils account for 1-4%, Basophils account for 1% of WBC. Tissue mast cells have binding sites for IgE.

RA manifestations

A positive ANA, fever, swollen joints, and fatigue even after a good night's sleep are consistent with rheumatoid arthritis (RA). A positive ANA indicates an autoimmune condition. A persistent low-grade fever from the systemic effects of RA is typical. Swollen joints are hallmark assessments of RA; however, deformity occurs in RA. Fatigue is common due to the systemic inflammatory effects of RA. Cloudy urine is not generally associated with RA; RA is a disorder that affects primarily joints on both sides of the body. Skin lumps or redness is associated with RA, not a reddish rash over cheeks and nose.

What is a early clinical manifestation of RA?

Anorexia

Discuss three ways to treat and/or manage Type 1 hypersensitivity.

Answer- 1. Immunotherapy- desensitizing or allergy shots where a dilute solutions of a known allergen is injected into patient. 2. Avoidance 3. Education to patient and family

A client who has been hiking in the woods comes to the ED with urticaria. After administering an antihistamine as prescribed, what teaching does the nurse provide? A. Avoid outdoor activity. B. Use a sauna to relieve pain. C. Apply tea bags to the lesions. D. Consume 1 to 2 alcoholic beverages.

Answer- A Rationale: Management of urticaria (hives) focuses on removing the triggering substance and relieving symptoms. The client should stay indoors at this time, as something in the woods likely triggered the reaction. Because the skin reaction is caused by histamine release, topical and/or oral antihistamines such as diphenhydramine (Benadryl) are helpful. Teach the client to avoid overexertion, alcohol consumption, and warm environments such as warm or hot showers, which contribute to blood vessel dilation and make the symptoms worse. Nothing further needs to be applied to the lesions at this time.

The nurse has educated a client with a shellfish allergy about angioedema. Which client statement requires further nursing teaching? A. "Shrimp is OK to eat because it is not a shellfish." B. "I keep an epinephrine injector in my backpack." C. "Angioedema includes swelling of eyes, lips, and tongue." D. "When I see a new provider, I will disclose my shellfish allergy."

Answer- A Rationale: Shrimp is a shellfish, and should not be consumed by clients with shellfish allergies. This statement therefore requires further teaching by the nurse. The client should carry an epinephrine injector at all times. Symptoms of angioedema include swelling of eyes, lips, and tongue. clients should report all allergies to health care providers.

A client has been admitted to the ED with bilateral eyelid swelling and subsequent difficulty seeing. What is the priority nursing assessment? A. Airway B. Nasal cavity C. Visual disturbance D. Drugs taken consistently

Answer- A Rationale: The client likely has angioedema that has caused the swelling. This can progress very quickly to affect the airway. Interventions focus on stopping the reaction and ensuring an adequate airway. While swelling can invade the nasal cavity, the priority is on securing and maintaining the airway. The visual disturbance will likely return when eyelid swelling is decreased. Knowing the drugs the client consistently takes can be determined after the airway is secured.

The client with newly diagnosed HIV is preparing for discharge, which of the following statements made by the client indicates a need for further teaching? A. I should only seek help dealing with this diagnosis if I have suicidal ideations. B. I should continue to learn more about my condition and what symptoms to report. C. I may need homecare management for my condition. D. I should keep a list of resources and follow-up care.

Answer- A Rationale: The client should begin dealing with psychosocial effects of the disease immediately.

Rheumatoid arthritis is characterized by tissue destruction, fibrotic changes, and scarring. Which of the following are early signs of the disease? A. Joint inflammation B. General weakness C. Fatigue D. Joint deformity E. Subcutaneous nodules

Answer- A, B, C Rationale: Joint deformity and subcutaneous nodules are late signs.

Allergens are contracted via which of the following routes? Select All That Apply. A. Inhaled (plant pollens, fungal spores, animal dander, house dust, grass, ragweed) B. Ingested (foods, food additives, drugs) C. Injected (insect or other venom, drugs, biologic substances such as contrast dyes) D. Skin or mucous membrane contacted (latex, pollens, foods, environmental proteins)

Answer- A, B, C, D

What cluster of symptoms would the assess for in a patient with suspected HIV? Select All That Apply. A. Opportunistic infections. B. Malignancies. C. Endocrine complications. D. Cardiovascular complications.

Answer- A, B, C, D

A client has been admitted to the medical-surgical floor with multiple problems. Which assessment finding does the nurse identify that is consistent with AIDS? Select all that apply. A. Persistent pain B. Persistent diarrhea C. Kaposi's sarcoma D. Wasting syndrome E. Esophageal candidiasis

Answer- A, B, C, D, E Rationale: All assessment findings are consistent with AIDS.

Which of the following interventions would be appropriate for health promotion and maintenance? Select All That Apply. A. Avoid known allergens B. Wear medical alert bracelet C. Notify health care personnel about specific allergies D. Carry anaphylaxis kit or epinephrine injector E. Health records should prominently display list of specific allergens F. Implement precautionary measures if drug or agent must be used despite history of allergic reaction

Answer- A, B, C, D, E, F

What treatment does the nurse anticipate will be ordered by the provider? (Select all that apply.) A. Oxygen B. IV fluids C. Epinephrine D. Acetaminophen E. Diphenhydramine

Answer- A, B, C, E Rationale: If the reaction is severe, the provider may order the first-line drug epinephrine for the client. Antihistamines such as diphenhydramine are second-line drugs and are usually given for angioedema and urticaria. Acetaminophen is not indicated. IV fluids are usually started when a reaction is suspected, and the provider may order oxygen to address the client's shortness of breath.

Which of the following regarding WBC with differential is accurate? A. Lymphocyte account for 20-40 % B. Segmented neutrophils account for 40-60% C. Band neutrophils account for 5% D. Reticulocytes account for 1% E. Basophils account for 1%

Answer- A, B, C, E Rationale: Reticulocytes are not included in a WBC with diff.

Which of the following are true regarding immunity in the older adult? Select All That Apply. A. Nutrition status, environmental conditions, drug, disease, and age change immunity B. Microbiome changes; overgrowth of more pathogenic organisms occurs C. Higher T-cell function D. B-lymphocytes take longer to become sensitized and begin to make antibodies to new antigen exposures E. Circulating autoantibodies decreases

Answer- A, B, D Rationale: There is a lower T cell function. Circulating autoantibodies increases.

A client with AIDS is having difficulty maintaining body weight. Which intervention will the nurse provide? Select all that apply. A. Ensure regular mouth care. B. Provide three large meals daily. C. Encourage low fat food choices. D. Provide foods that are high in calories. E. Encourage drinking at least 1 L of fluid per day. F. Collaborate with the registered dietician nutritionist.

Answer- A, C, D, F Rationale: Clients should be drinking at least 2 to 3 L of fluids per day. Collaboration with the dietician is important to include high calorie, high protein foods. Avoid dietary fat, because fat intolerance often occurs as a result of the disease and as a side effect of some antiretroviral drugs. Provide small, frequent meals as they are often better tolerated than large meals. Mouth care can improve appetite.

Upon removing a dressing from a wound, the nurse notices a strong odor. What is the appropriate nursing action? A. action is necessary at this time. B. Notify the health care provider of a possible wound infection. C. Clean the wound and reassess for presence of infection. D. Culture the wound and anticipate an order for antibiotics.

Answer- C Rationale: Wound fluid and debris often interact with the dressing and may result in an odor when the dressing is removed. Gently clean the wound and reassess. Signs of infection are most frequently stalled wound healing, presence of purulent exudate, increased wound size or depth, fever, elevated WBC count, and increased pain. Cultures are not usually obtained.

Which of the following descriptions would fall into HIV Stage 2? Select All That Apply. A. Patient develops a first positive HIV test result within 6 months after a negative HIV test result. CD4+ T-cell counts are usually in the normal range, and no AIDS-defining condition is present. B. Patient has a confirmed HIV infection, but no information regarding CD4+ T-cell counts, CD4+ T-cell percentages, and AIDS-defining illnesses is available. C. Patient has a CD4+ T-cell count of less than 200 cells/mm3 (0.2 X 109/L) or a percentage of less than 14%. Any patient, regardless of CD4+ T-cell counts or percentages who has an AIDS-defining illness. AIDS diagnosis. D. Patient has a CD4+ T-cell count of greater than 500 cells/mm3 (0.5 X 109/L) or a percentage of 29% or greater. No AIDS-defining illnesses are present. E.Patient has a CD4+ T-cell count between 200 and 499 cells/mm3 (0.2 to 0.499 X 109/L) or a percentage between 14% and 28%. No AIDS-defining illnesses are present.

Answer- A, D, and E Rationale: B is an unknown stage and C is HIV Stage 3.

A client comes to the ED with mild shortness of breath and a runny nose. The triage nurse notes that the client's lips and eyes are somewhat swollen. What action will the nurse take at this time?

Answer- An accurate and detailed history is important; the nurse will begin collecting this information as long as the client is not in imminent danger, although the client will likely be triaged back to the environment of care right away, given the risk of this condition progressing quickly. The client should be asked to describe the onset and duration of problems related to possible allergen exposure. Ask about work, school, and home environments and possible exposures through food, hobbies, leisure, or sports activities. The client should also be asked about the presence of allergies among close relatives because of the tendency for type I allergies to be inherited

A patient presents with a red, macular, facial rash ("butterfly") to sun-exposed areas, and chronic lesions and inflammation to mucous membranes. What does the nurse suspect pending ANA, hematologic, and neuro assessments? A. Psoriasis B. SLE C. Eczema D. Rheumatoid Arthritis

Answer- B

Which of the following is not a factor in analyzing cues for the patient with HIV? A. Pain. B. Fashion sense C. Cognitive decline. D. Diarrhea. E. Psychosocial distress

Answer- B

When caring for four clients, which client does the nurse identify at highest risk for infection? A. 20-year-old with stomach pain B. 31-year-old with chronic kidney disease C. 44-year-old using a 10-day steroid taper D. 62-year-old with history of prostate hyperplasia

Answer- B Rationale: The client's immune status plays a large role in determining risk for infection. Congenital abnormalities, acquired health problems (for example, kidney injury, steroid dependence, cancer, AIDS) and advancing age can increase a client's risk of developing immunologic deficiencies. Chronic physical and psychological stress can also depress the immune system, making the client more susceptible to infection.

A client reports having unprotected intercourse and is concerned about exposure to HIV. The nurse will assess whether the client has which initial symptom? A. Lymphocytopenia B. Flu-like symptoms C. Opportunistic infection D. Reduced numbers of CD4+ T-cells

Answer- B Rationale: When a person is infected with HIV, the first manifestations are flu-like symptoms including fever, night sweats, chills, headache, and muscle aches. As time passes, CD4+ T-cells are infected and taken out of service. This cell count drops to below-normal levels, and those that remain may not function normally. Lymphocytopenia (decreased lymphocyte counts) occurs as a result. Also, as the CD4+ T-cell level drops, the client is at risk for bacterial, fungal, and viral infections, as well as some opportunistic cancers.

The nurse asks the client about a history of any allergies. The client, who reports coming straight from work as a nursing assistant, admits to a peanut allergy, but denies eating today. Which laboratory test does the nurse anticipate the provider will order? (Select all that apply.) A. Electrolytes B. Immunoglobulin E C. CBC with differential D. Liver function tests (LFT) E. Kidney function tests (KFT)

Answer- B, C Rationale: With the CBC with differential (diff), look for increased eosinophils, which may be as high as 12% (normal = 1%). Some clients may also have a higher than normal total WBC count. Normal IgE levels are about 39 IU/mL (<100 IU/mL). This level is greatly increased with allergies.

In Type I Hypersensitivity (Also called rapid hypersensitivity, or atopic allergy) is the most common type, results from the increased production of the immunoglobulin E (IgE) antibody class. Which of the following would not be considered a condition associated with Type 1 Hypersensitivity? A. Angioedema B. Anaphylaxis C. Dependent pitting edema D. Allergic asthma

Answer- C Rationale: Dependent pitting edema is generally caused by peripheral vascular issues.

Upon receiving a new IV medication, a client becomes short of breath with itching and hives. What is the priority nursing action? A. Assess vital signs B. Review the client's allergies C. Stop the intravenous infusion D. Administer diphenhydramine as ordered

Answer- C Rationale: If an IV drug is suspected to be causing the anaphylaxis, stop the drug immediately but do not remove the venous access because restarting an IV is difficult when the client is severely hypotensive. Other actions can be done after the new medication infusion is stopped.

Which client does the nurse identify whose immune function is most efficient? A. 12 month old infant B. 18 year old adolescent C. 32 year old adult D. 49 year old adult

Answer- C Rationale: Immune function is most efficient when people are in their 20s and 30s and slowly declines with increasing age. The immune system is developing and changing during infancy and teen years.

Which of the following would the nurse not to expect on the care plan for the patient with HIV? A. Potential for poor gas exchange. B. Potential for impaired skin integrity. C. Potential for increased immunity. D. Potential for infection.

Answer- C Rationale: Patients with HIV have impaired immunity.

A patient with lymphoma receiving monoclonal antibody therapy presents to the ED, with an serum potassium of 6 and a calcium of 12, What does the nurse predict is the diagnosis of this patient? A. SVC syndrome B. HIT C. Tumor Lysis Syndrome D. Gout

Answer- C Rationale: The key information is that TLS is common in lymphoma patients with monoclonal antibody therapy, pertinent lab results are high potassium and calcium.

Which of following statements about the effects of HIV is false? A. When HIV enters a CD4+ T-cell, the host cell stops being an active immune system cell and becomes a virus factory . B. Gradually, CD4+ T-cell count falls, viral numbers (viral load) rises. C. Immune system weakens. D. Everyone with HIV has AIDS.

Answer- D Rationale: Everyone with Stage HIV- III has AIDS, Not everyone with HIV has AIDS

A 40-year-old client with polycystic kidney disease is to receive a kidney transplant. When the nurse begins to administer 2 units of leukocyte-poor packed red blood cells to treat a low hemoglobin, the client asks why this has been prescribed. What is the appropriate nursing response? A. "It causes fewer blood reactions for pre-transplant patients." B. "It is less likely to causes hemolysis, or destruction of the blood cells, after transfusion." C. "All pre-transplant patients receive leukocyte-poor blood because it is absorbed better by the body." D. "It will decrease the risk of obtaining white blood cells from the donor that could make it harder for your transplanted kidney to function."

Answer- D Rationale: Human leukocyte antigens (HLAs) are found on the surface of all body cells and serve as a "cellular fingerprint" recognizing self and non-self cells. When the HLAs of the immune system encounter a cell that is foreign, the immune system cell then takes action to neutralize, destroy, or eliminate this foreign invader. Transfusion of blood that contains leukocytes increases the number of HLAs introduced to the body. Evidence shows that leukocytes present in cellular blood products are the main component involved in the occurrence of HLA immunization, and several studies show that leukocyte-poor blood products are less able to induce it. HLA immunization through blood transfusion will make it harder to find an acceptable kidney transplant match for the patient (for example, HLA match for kidney transplant).

A patient receiving ACE Inhibitors develops lip swelling, firm swelling of face, tongue, and neck. The patient also had difficulty speaking and swallowing, which are all symptoms f angioedema, What should the nurse do immediately to stop the reaction? A. Apply O2 via NC B. Flush the IV line C. Put in an NG tube D. Stop the medication

Answer- D Rationale: In order to stop the reaction, you must stop the medication. Nasal an oral swelling are present in angioedema, so applying O2 via NC may not be effective and you should consider preserving the airway with a trach or intubation, the first intervention however is to stop the medication.

Five minutes later, the client with the peanut allergy continues to experience some shortness of breath, and reports tongue swelling and anxiety. What is the priority nursing intervention? A. Assess lung sounds B. Provide reassurance C. Notify the health care provider D. Contact the Rapid Response Team

Answer- D Rationale: The client has tongue swelling, indicating angioedema. She is still short of breath and may have abnormal breath sounds such as crackles and wheezes. Respiratory failure due to swelling of the tongue and larynx may soon follow. Emergency respiratory management is critical during an anaphylactic reaction because severity increases with time. This is the time to call the Rapid Response Team so they will be on the way; all other actions can immediately follow their notification.

A client who engages in sex with men and women asks the nurse about ways to prevent HIV transmission. Which method will the nurse teach? Select all that apply. A. Begin antiviral drug therapy B. Take an HIV home screening test C. Engage only in vaginal intercourse D. Use condoms during sexual activity E. Discuss PrEP with a health care provider

Answer- D, E Rationale: Clients who wish to prevent HIV transmission should use condoms during sexual activity to reduce risk of exposure. Clients who are HIV-negative but at high risk for exposure to HIV should be taught to discuss PrEPwith a health care provider. Beginning antiviral drug therapy is reserved for clients who have tested HIV positive. Taking an HIV home screening test may reveal the client's HIV status, but this does not prevent transmission. Engaging only in vaginal intercourse does not assure that HIV will not be transmitted.

Which is not one of the hematological changes associated with aging? A. Decrease in blood volume with lower levels of plasma proteins. B. Bone marrow produces fewer blood cells C. Total RBC, WBC counts are lower. D. Lymphocytes are more reactive to antigens and gain immune function. E. Hemoglobin levels fall after middle-age.

Answer- D. Rationale: Lymphocytes are less reactive to antigens and lose immune function.

What is the best intervention to prevent transmission of HIV?

Answer- Standard precautions and good hand hygiene.

Based on the client's history of new onset of shortness of breath and edema of the eyes and lips, what does the nurse suspect is the problem? What questions are appropriate to ask this client?

Answer- The nurse anticipates that the client may be having an anaphylactic reaction. The client stated a peanut allergy. These have been linked to contact with latex. Because the client had been working prior to presenting to the ED, the nurse should inquire about use of latex gloves at work. Anaphylaxis is the most dramatic and life-threatening example of type I hypersensitivity reaction; it occurs rapidly and systemically.

The client is very weak and reports anorexia, painful swallowing, severe diarrhea, and occasional vomiting. The nurse delegates mouth care to assistive personnel (AP). What instructions will the nurse provide to the AP?

Answer- The nurse will instruct the AP to offer the client rinses with sodium bicarbonate and normal saline every 2 hours, to use a soft toothbrush, to remind the client to drink plenty of fluids, and to report back, particularly if the client has any abnormal appearances in the mouth, or mouth pain.

When the body makes antibodies directed against self cells that have some form of foreign protein attached to them, what is this known as? A. Hypersensitivity type 3 B. Acute Kidney Injury C. Type 2 Cytotoxic Reactions D. Infection

Answer- Type 2 Cytotoxic Reactions Rationale: This happens when patients receive the wrong type of blood transfusions.

What are the five cardinal signs of inflammation?

Answer- Warmth, Redness, Swelling, Pain and Decreased function.

Which assessment finding alerts the nurse to determine that inflammation has progressed to the cellular level? A. Pus B. Warmth C. Redness D. Swelling

Answer-A Rationale: Responses at the tissue level cause the five cardinal symptoms of inflammation: warmth, redness, swelling, pain, and decreased function. Stage II is the cellular exudate part of the response. In this stage, neutrophilia (an increased number of circulating neutrophils) occurs. Exudate in the form of pus occurs, containing dead WBCs, necrotic tissue, and fluids that escape from damaged cells.

After a week, the client is being prepared for discharge to home, where the client lives with a spouse and 2 children. What teaching will the nurse provide to the family?

Answer: When the client is discharged, one of the most important things for him or her to remember is Standard Precautions and good handwashing.When at home, the client and family should have a good understanding that body fluids—including feces, vomitus, urine, blood, or any other body fluid—should be cleaned away with soap and water, and the area disinfected with a 1:10 bleach solution for at least 5 minutes. If bed linens or clothes become soiled, they should be washed in hot water with one cup of bleach added per load of laundry. Dispose of needles and other "sharps" in a labeled puncture-proof container to avoid needle stick injuries.

What is an X ray study of a joint after contrast medium has been injected to enhance visualization

Arthrogram

What is the term for a diagnostic or surgical procedure in which a fiber optic tube is inserted into a joint for direct visualization?

Arthroscopy

A patient w/ a recent femoral fracture has fatty globules in urine, what is the first action?

Assess respiratory status

What is the clinical term for inflammation of bursae?

Bursitis

What topical cream is used for local analgesic for RA and OA?

Capsaicin

Another term for polymyositis which occurs with a purplish skin rash is?

Dermatomyositis

What is a sign of lipodystrophy?

Emaciated legs

What is a short term effect of prednisone?

Emotional changes

Naproxen, colchincine and indomethacin are prescribed for ?

Gout

What virus causes Kaposi's sarcoma

HHV8 (Human Herpes Virus 8)

What is a s/sx of Sjogren's Syndrome?

Hip pain and burning eyes

A patch test with a 1" area of erythema indicates what?

Hypersensitivity reaction

What antibody is seen during a hypersensitivity reaction?

IgE

What does the lab ESR test for?

Inflammation

What is a s/sx of compartment syndrome?

Intense pain, numbness, absent pulse

What should a patient avoid eating with gout?

Liver

What is a side effect of Etanercept?

Lower blood cell counts

The tension test is used to diagnosis which autoimmune disorder?

MG

A patient develops hemolytic anemia after receiving a medication. Which action is appropriate?

No further doses of medication

What medication is used for acid reflux in Scleroderma?

Omeprazole

Indicate which findings the nurse would monitor to indicate osteomyelitis, wound infection, or hemorrhagic shock. Each row must have at least 1, but may have more than 1, response option selected.

Osteomyelitis -Erythema and heat around affected area -Increased pulse -Chills -Bone pain -Increased temperature Wound Infection -Erythema and heat around affected area -Increased pulse -Chills -Increased temperature Hemorrhagic Shock -Decreased blood pressure -Increased pulse Rationale: Findings for osteomyelitis (infection in the bone) include erythema and heat around affected area, increased pulse, chills, bone pain, and increased temperature. Inflammation results in the erythema and heat around the affected area. An increase in temperature causes an increase in pulse and chills. Bone pain is a common complaint in clients with osteomyelitis. The temperature is generally higher than 101°F (38.3°C). Osteomyelitis may cause an increase in blood pressure or the blood pressure may not be affected. Findings for a wound infection include erythema and heat around affected area, increased pulse, chills, and increased temperature. Inflammation results in the erythema and heat around affected area. An increase in temperature causes an increase in pulse and chills. In wound infection, the blood pressure may increase or stay the same and bone pain is not common. Hemorrhagic shock is decreased blood pressure and a lack of perfusion from excessive blood loss. This loss causes a decreased blood pressure (hypotension) and increased pulse (due to compensation for the hypotension). Shock causes cool, clammy skin, not erythema and heat. Chills are not typical of shock. Bone pain is not common in shock. The temperature may decrease, especially in the skin, but may be within the normal, expected range for the client.

Systemic lupus causes what blood result?

Pancytopenia

Which of the following is a tx for Guillain Barre syndrome ?

Plasmapheresis (STEROID TX DOES NOT WORK)

Which allergy test can be used if a skin test is unable to be used on a pt?

RAST

1300: Client is an 18-year-old male who arrived in the emergency department (ED) via rescue with complaints of chest pain, and "heart racing." Client was involved in a motorcycle accident 2 days prior and sustained multiple fractures in the left leg. He was treated in the emergency room with a bone reduction and immobilization with a temporary cast placed on his left lower leg. Client was instructed to follow up with the orthopedic surgeon next week, but due to the chest pain he came into the ED for treatment. No significant medical history noted. Vital signs are temperature 98.6°F (37°C), heart rate of 128 beats per minute (bpm), respiratory rate of 28 breaths per minute, blood pressure of 100/54 mmHg, and pulse oximetry reading of 89%.

Rationale: Fat embolism syndrome (FES) is a serious complication that can occur after a bone fracture. It occurs when fat globules enter the circulatory system following a fracture. The symptoms include chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and hypoxemia. A diagnostic test for FES is a chest X-ray revealing pulmonary infiltrates. Treatment includes supplemental oxygen to treat the hypoxemia, bedrest, and intravenous (IV) fluids. The nurse should monitor the client's mental status and oxygen level related to the hypoxemia. Atelectasis is a respiratory complication with decreased breath sounds The client would be encouraged to increase oral fluids. The client may need steroid therapy, not an order for aspirin. Intubation equipment should be placed at the client's bedside, not suction and tracheostomy equipment. .

What is megestrol used for?

Stimulate patient's appetite

A patient has a facial rash on both cheeks and the bridge of the nose. Which autoimmune disorder presents with this?

Systemic Lupus

The nurse determines the client is experiencing a complication from:

The nurse suspects the client is most likely experiencing anaphylaxis The nurse would first administer the epi-pen , followed by applying oxygen Rationale: The nurse suspects the client is experiencing anaphylaxis. The client has a food allergy of shellfish. The nurse would first administer the epi-pen, followed by applying oxygen. The client is exhibiting signs of anaphylaxis 20 minutes after eating an egg roll; the signs include wheezing, facial swelling, swollen lips, pruritus, tachypnea, tachycardia, decreased blood pressure, and decreased oxygen saturations. The nurse would first administer the epi-pen to keep the airway open and decrease the effects of anaphylactic shock. Most deaths are a result of delayed administration of epinephrine. The nurse would then apply oxygen to combat the hypoxia and hypoxemia. The client does not have asthma or have a history of asthma. Even though the client has wheezing this is from the allergic response, not asthma.

What should be reported immediately to surgeon after a total hip replacement- post op day 1?

Unequal extremity lengths

What lab value is elevated in gout?

Uric Acid

What teaching point would the nurse include for a patient with RA?

Use large joints rather than small joints

What would be included in teaching for Sjorgen's syndrome?

Use tepid water and have humidifiers

A patient is in Buck's traction. What is the correct teaching?

Weights never touch floor

What confirms HIV after the ELISA test?

Western Blot Analysis

What are the symptoms of ototoxicity?

ataxia, tinnitus, and hearing loss

Myasthenia gravis includes which assessments?

blurred vision