Medsurge2 Week3

Which of the following is usually the most important consideration in decisions to initiate antiretroviral therapy?

CD4 counts *

A home care nurse is visiting a client with AIDS at home. During the visit, the nurse observes the caregiver providing care. Which of the following would alert the nurse to the need for additional teaching for the caregiver?

Caregiver cleans the client's anal area without wearing gloves

Which of the following would be consistent with the diagnosis of rheumatoid arthritis?

Cloudy synovial fluid

When caring for a client experiencing an acute gout attack, the nurse anticipates administering which medication?

Colchicine

Students are reviewing information about hypersensitivity disorders in preparation for class discussion the next day. The students demonstrate understanding of the material when they identify which of the following as a type IV hypersensitivity disorder?

Contact dermatitis

A patient is administered foscarnet to treat a case of CMV retinitis. Which of the following adverse effects should the nurse closely monitor in the patient?

Electrolyte imbalances

An elderly client is diagnosed with cancer. While reviewing -related changes in the immune system, the nurse identifies which of the following as having contributed to this client's condition?

Failure of lymphocytes to recognize mutant cells

The client with rheumatoid arthritis has a red blood cell count of 3.2 cells/cu mm. Which nursing diagnosis has the highest priority for the client?

Fatigue

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?

"Although AIDS is an immune deficiency, your child's condition is different from AIDS."

A client is prescribed didanosine (Videx) as part of his highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client?

"Be sure to take this drug about 1/2 hour before or 2 hours after you eat."

The nurse is obtaining a history from a patient with severe psoriasis. What question would be the most important to ask this patient to determine a genetic predisposition?

"Does anyone in your family have more than one autoimmune disease?"

The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective?

"I should avoid prolonged sun exposure."

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

"Monitor your body temperature."

There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency.

"Your immune system was most likely affected by an underlying disease process."

The nurse practitioner advises a patient with osteoarthritis that the initial analgesic of choice is acetaminophen, with a recommended dosage of __________ every 6 hours.

1,000 mg

A patient comes to the clinic with pruritus and nasal congestion after eating shrimp for lunch. The nurse is aware that the patient may be having an anaphylactic reaction to the shrimp. These symptoms typically occur within how many hours after exposure?

2 hours

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?

Administering ordered analgesics and monitoring their effects

Which of the following cell types are involved in humoral immunity?

B lymphocytes

A nurse comes to the employee health center for evaluation and is diagnosed with allergic contact dermatitis related to latex. Which of the following would the nurse most likely exhibit?

Blistering

A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which of the following reasons?

Exposure to foreign antigens may cause altered immune function.

The nurse is preparing to administer a medication that has an affinity for H1 receptors. Which medication would the nurse administer?

Diphenhydramine (Benadryl)

A nurse practitioner working in an allergy clinic is treating a patient who is allergic to ragweed. She advises the patient to expect an increase in symptoms during which of the following seasons?

Early fall

Which of the following clinical manifestations would the nurse expect to find in a client with osteoarthritis?

Early morning stiffness

Nursing students are reviewing various medications that can be used to treat allergic disorders. The students demonstrate understanding of the information when they identify which of the following as an intranasal corticosteroid?

Fluticasone

Which of the following is an early manifestation of HIV encephalopathy?

Headache

Which of the following indicates that a client with HIV has developed AIDS?

Herpes simplex ulcer persisting for 2 months

A nurse practitioner working in a dermatology clinic explained to a group of nursing students that the pathophysiology of an allergic response involves a chain of events that includes responses from lymphocytes, IgE, mast cells, and basophils. The nurse mentioned that the most important chemical mediator involved in the response is:

Histamine.

There are several types of reactions to latex. The nurse knows to be most concerned about laryngeal edema with the following reaction:

IgE-mediated hypersensitivity.

Which nursing diagnosis is least appropriate for the client with rheumatoid arthritis?

Imbalanced nutrition: greater than body requirements

A client comes to the emergency department complaining of difficulty breathing. He states, "It feels like my throat is closing up. We were out to dinner and then I started feeling strange after we ate our shrimp cocktail." The client is leaning forward with a respiratory rate of 36 breaths per minute. His skin is pale. The nurse suspects anaphylaxis. Which nursing diagnosis would be the priority?

Ineffective airway clearance related to bronchospasm and laryngeal edema

A patient is receiving gold sodium thiomalate (Myochrysine) for the treatment of RA. What does the nurse understand about the action of this compound?

Inhibits T- and B-cell activity

Which of the following aid in diagnosing the risk of anaphylaxis?

Intradermal testing

A patient with osteoarthritis is taking up to 4 grams of acetaminophen daily. The nurse knows to obtain periodic:

Liver enzyme results.

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?

Lymphocyte

An arthrocentesis is done to remove synovial fluid from a joint. Synovial fluid from an inflamed joint is characteristically:

Milky, cloudy, and dark yellow.

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan

Monitor your body temperature

A patient is suspected of having myositis. The nurse prepares the patient for what procedure that will confirm the diagnosis?

Muscle biopsy

which of the following are usually the first choice in the treatment of RA

NSAIDS *

A 6-year-old experienced an allergic reaction to shellfish. The nurse practitioner gave the mother a booklet that includes teaching points about food allergies. The nurse reminded the mother to be vigilant for mild systemic reactions such as:

Nasal congestion and sneezing.

a client asks the nurse what the difference between OA and RA

OA is non inflammatory and RA is inflammatory swollen joints *

Which of the following is the leading cause of disability and pain in the elderly?

Osteoarthritis

Which type of contact dermatitis requires light exposure in addition to allergen contact?

Photoallergic

A patient had unprotected sex with an HIV-infected person and arrives in the clinic requesting HIV testing. Results determine a negative HIV antibody test and an increased viral load. What stage does the nurse determine the patient is in?

Primary infection

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells.

hyperglycemia, what insulin would you give

Regular and IV fluids to rehydrate

Nursing assessment for tinnitus, gastric intolerance, and bleeding is important for patient who take which class of medications for a rheumatic disease?

Salicylates

A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines?

Sedation

Nutritional education for patients with RA includes recommending the increase of isoflavones (anti-inflammatory properties) in the diet by eating:

Soybeans.

What organ is considered lymphoid tissue?

Spleen

What education should the nurse provide to the patient taking long-term corticosteroids?

The patient should not stop taking the medication abruptly and should be weaned off of the medication. *

Which of the following is an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage?

Tophi

A client is scheduled to begin immunotherapy. The nurse would explain that the client will receive injections initially at which interval

Weekly

The majority of patient with primary immunodeficiency are in which age group?

Younger than 20

A nurse practitioner is managing the care of a patient who has gout. Choose the medication that she would prescribe as the drug of choice to prevent tophi formation and promote tophi regression.

Zyloprim

a nurse is impleminting appropriate infection control precautions for a client who is positive for HIV the nurse demonstrates a need for review when they identify a mode of transmission is

urine *

A nurse is assessing a client with possible osteoarthritis. The most significant risk factor for primary osteoarthritis is:

age.

most common secondary immunodeficiency disorder

aids *

the nurse is educating a patient with allergy rhinitis about how the condition is induced

airborne pollins or mold *

which of the following would a nurse prioritize as the most important action to prevent anaphylaxis

avoid that shit *

Which type of hypersensitivity reaction involves immune complexes formed when antigens bind to antibodies?

type III

As part of the assessment process for a patient suspected of having gout, the nurse evaluated his serum uric acid levels. Select the value that is considered above the saturation point for crystal formation.

d. 6.8 mg/dL

pt hospitalized case of severe gout, gross swelling if large toe and pain rated at 10/10 with a dx of gout what should labs reveal

hyperuricemia *

osteoarthritis is known as a disease that

is the most common and frequently disabling of joint disorders *

a client presents at the clinic with an allergy disorder the client asks the nurse what an allergy disorder is

it is a hyper immune response to something in the environment that is usually harmless *

gout

metatarsophalangeal *

which of the following is the most common cause for a patient to seek medical attention for arthritis

pain *

which intervention is the is the single most important action for the patient to take to prevent anaphylaxis

prevention *

The lower the patient's viral load,

the longer the survival time.

Which of the following is the first barrier method that can be controlled by the woman?

Female condom

A patient is on ART for the treatment of HIV. What does the nurse know would be an adequate CD4 count to determine the effectiveness of treatment for a patient per year?

50 mm3 to 150 mm3

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?

Bone marrow transplantation

An elderly client is diagnosed with a respiratory infection. While reviewing age-related changes in the immune system, the nurse identifies which of the following as having contributed to this client's infection?

Impaired ciliary action from exposure to environmental toxins

A patient in the clinic states, "My boyfriend told me he went to the clinic and was treated for gonorrhea." While testing for the sexually transmitted infection (STI), what else should be done for this patient?

Inform the patient that it would be beneficial to test for HIV.

After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which of the following?

Jabs the autoinjector into the outer thigh at a 90-degree angle *

Which of the following are chemical mediators that initiate and mediate the inflammatory response?

Leukotrienes

A client with acquired immunodeficiency syndrome is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?

Listen and show interest as the client expresses feelings.

Which of the following immunity types becomes active as a result of the infection of a specific microorganism? Choose the correct option.

Naturally acquired active immunity

Which type of immunity becomes active as a result of the infection of a specific microorganism?

Naturally acquired active immunity

A 16-year-old client suspected of having HIV/AIDS asks the nurse what causes AIDS. What should the nurse say?

The human immunodeficiency virus

The nurse is preparing to administer the recommended dose of intravenous gamma-globulin for a 60-kg male patient. How many grams will the nurse administer?

30 g

Diagnosis of Kaposi's sarcoma (KS) is made by which of the following?

Biopsy

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.

Cytotoxic T cell

Which of the following is a age-related change associated with the immune system?

Decreased antibody production

Which of the following is associated with impaired immunity in the aging patient?

Decreased renal function

When assessing the skin of a client with allergic contact dermatitis, the nurse would most likley expect to find irritation at which area?

Dorsal aspect of the hand

HIV is harbored within which type of cell?

Lymphocyte

Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as containing the genetic viral material?

Ribonucleic acid (RNA)

Which of the following statements accurately reflects current stem cell research?

The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.

A female patient who is 38 years of age has begun to suffer from rheumatoid arthritis. She is also being assessed for disorders of the immune system. She works as an aide at a facility that cares for children infected with AIDS. Which of the following is the most important factor related to the patient's assessment?

Use of other drugs

The nurse practitioner treating a patient with allergic rhinitis decides pharmacologic therapy would be helpful. Which of the following is she most likely to prescribe?

Allegra

A 17-year-old client is a student in an HIV education course you offer at the local high school. During the class, he seems very concerned about HIV transmission via body fluids. You explain that while the virus may be present in several body fluids, transmission happens via which body fluids? Choose all correct options.

Breast milk Vaginal secretions

A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find?

Hypokalemia

The nurse practitioner explains to the patient scheduled for the RAST that the test will measure allergen-specific __________.

Ig E

When the body is in contact with an allergen, this lymphocyte, located in the respiratory and intestinal mucosa, triggers the release of histamine. Choose that lymphocyte.

Ig E

Radioallergosorbent testing (RAST) measures which of the following immunoglobulins?

IgE

A patient is suspected to have an immunodeficiency disorder. The physician orders a nitroblue tetrazolium reductase (NTR) test to diagnose this patient. What does the nurse suspect that this disorder is related to?

Phagocytic cells

The inflammatory response needs to be balanced so that what is helpful does not become harmful if mediators are secreted in excess. Which of the following are the primary mediators in an inflammatory response?

T cells and cytokines

T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do?

T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person.

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?

T-cell lymphocytes survey proteins in the body and attack the invading antigens.

A client reports an allergy to morphine sulfate, which represents an example of a hypersensitivity reaction. Which of the following statements correctly describes the process of hypersensitivity?

The body produces inappropriate or exaggerated responses to specific antigens.

The nurse is teaching a client who has been diagnosed with Hashimoto's thyroiditis. Which of the following statements correctly describes the process of autoimmunity?

The normal protective immune response attacks the body, damaging tissues.

Which of the following statements reflects the treatment of HIV infection?

Treatment of HIV infection for an individual patient is based on the clinical condition of the patient, CD4 T cell count level, and HIV RNA (viral load).

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching

"I can eat whatever I want as long as it's low in fat."

After teaching a client with immunodeficiency about ways to prevent infection, the nurse determines that teaching was successful when the client states which of the following?

"I should avoid being around other people who have an infection."

The nurse receives a phone call at the clinic from the family of a patient with AIDS. They state that the patient started "acting funny" after complaining of headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?

"The patient may have cryptococcal meningitis and will need to be evaluated by the physician."

The nurse is discussing sexual activity with a patient recently diagnosed with HIV. The patient states, "As long as I have sex with another person who is already infected, I will be okay." What is the best response by the nurse?

"You should avoid having unprotected sex with a person who is HIV positive because you can increase the severity of the infection in both you and your partner."

Which of the following medications are usually withheld for 48 to 96 hours before skin testing? Select all that apply.

-Corticosteroids -Antihistamines -Over-the-counter (OTC) allergy medications

A 38-year old female client has begun to suffer from rheumatoid arthritis. She is also being assessed for disorders of the immune system. She works as an aide at a facility which cares for children infected with AIDS. Which of the following factors will hold the greatest implications during the client's assessment? Choose all that apply.

-Her work environment -Her history of immunizations and allergies -Her use of other drugs

A nurse practitioner who works in an inner-city health clinic would recommend HIV testing to the patient who is most likely to have a diagnosis of HIV. Which of the following is most likely to have this diagnosis?

African American gay man

Immunoglobulins (also known as antibodies) promote the destruction of invading cells in various ways, using different mechanisms. Which of the following mechanisms is used by immunoglobulins to destroy pathogenic antigens?

All options are correct

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following?

Antibodies to HIV are not present in his blood.

A patient undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The patient becomes anxious because the area begins to swell. Which of the following may be used to decrease anxiety in this patient?

Assure the patient that this is a normal reaction

Which of the following assessment should be completed if suspecting immune dysfunction in the neurosensory system?

Ataxia

A patient with common variable immunodeficiency (CVID) is extremely fatigued and not feeling well. What lab test does the nurse anticipate the patient will have to detect a common development related to the disease?

B12 level

When a patient has an allergic reaction, chemical mediators in the body produce a response. Which of the following is a primary mediator that is preformed and ready for an immediate response?

Basophils

A client with a history of allergic rhinitis comes to the clinic for an evaluation. The client is prescribed triamcinolone. Which of the following would the nurse include when teaching the client about this drug?

Be aware that some nasal burning and itching may occur.

While taking the health history of a newly admitted client, the nurse reviews general lifestyle behaviors. Which of the following would have a positive effect on the immune system?

Biofeedback, relaxation, and hypnosis

A patient is being treated in the intensive care unit for sepsis related to ventilator-associated pneumonia. The patient is on large doses of three different antibiotics. What severe outcome should the nurse monitor for in the lab studies?

Bone marrow suppression

The nurse practitioner who is monitoring the patient's progression of HIV is aware that the most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is:

Chronic diarrhea.

Activation of a natural immunity response is enhanced by physical and chemical barriers. Which of the following is a physical barrier, which the nurse knows can be altered by illness, nutrition, or lifestyle?

Cilia of the respiratory tract

A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority?

Disturbed body image related to loss of fat in the face and arms

A client suspected of having HIV has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?

ELISA

A 38-year-old female patient has begun to suffer from rheumatoid arthritis. She is also being assessed for disorders of the immune system. She works as an aide at a facility that cares for children infected with AIDS. Which of the following is the most important factor related to the patient's assessment?

Her use of other drugs

Which of the following body substances causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?

Histamine

Which of the following protective responses begin with the B lymphocytes?

Humoral

The body has several mechanisms to fight disease, one of which is sending chemical messengers. Specifically, the messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?

Interferons

The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?

Lymphoid tissues

The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents?

Macrophages

Histamine release in anaphylaxis causes which of the following?

Nasal congestion

A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?

Naturally acquired active immunity

Which type of cells destroys antigens already coated with antibody?

Null

A client with AIDS is exhibiting shortness of breath, cough, and fever. The nurse most likely would suspect infection with which of the following

Pneumocystis jiroveci *

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements?

Primary immunodeficiencies develop early in life after protection from maternal antibodies

A client is diagnosed with multiple site cancers and has received whole-body irradiation. The nurse is concerned about a compromised immune system in this client for which of the following reasons?

Radiation destroys lymphocytes.

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

Risk for injury

The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following?

Serum, which depletes the body's store of immunoglobulins

A patient arrives at the clinic and informs the nurse that she has a very sore throat as well as a fever. A rapid strep test returns a positive result and the patient is given a prescription for an antibiotic. How did the streptococcal organism gain access to the patient to cause this infection?

Through the mucous membranes of the throat

A client has undergone a kidney transplant. The nurse is concerned about a compromised immune system in this client for which of the following reasons?

Use of anti-rejection drugs

A patient tells the nurse, "I can't believe I have ineffective immune function and am getting sick again. I exercise rigorously and compete regularly." What is the best response by the nurse?

"Rigorous exercise can cause negative effects on immune response."

An older adult has developed a sacral pressure ulcer. What should the nurse assess in order to ensure adequate wound healing and prevent poor outcomes for this patient? (Select all that apply.)

-Nutritional status -Caloric intake -Quality of food ingested

A 45-year-old waitress with a history of IV drug use also is HIV-positive. She has been following her antiretroviral medication regimen faithfully and is doing well. She's attending college to get a social work degree and is focused on a bright future. In her regular CD counts, what factor will indicate she has progressed from HIV to AIDS?

CD count < 200/mm

A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:

Lymphocytes migrate to areas of the lymph node

You are caring for a client who has a diagnosis of HIV. Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications?

Side effects of drug therapy

An older adult widowed woman informs the nurse that she notices vaginal dryness now that she has become sexually active again. She is not using barrier protection because it makes the dryness worse. What education should the nurse provide to the patient?

Vaginal dryness is common in postmenopausal women, and there are creams that can be used, but she should use a latex condom.

A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test?

Western blot assay

While monitoring the patient's eosinophil level, the nurse suspects a definite allergic disorder when seeing an eosinophil value of what percentage of the total leukocyte count?

15% to 40%

The nurse is preparing to infuse gamma-globulin intravenously (IV). When administering this drug, the nurse knows the speed of the infusion should not exceed what rate?

3 mL/min

In the immune response cycle, lymphocytes interfere with disease by picking up specific antigens from organisms to alter their function during which stage of an immune response?

Proliferation

In the interest of public health, the CDC has developed HIV Transmission Prevention strategies. The strategies address the routes that HIV can be transmitted and steps that can be taken to reduce or eliminate transmission. Which categories of risk are addressed by these strategies? Choose all correct options.

Sexual activity Illegal drugs

A 15-year-old client has been brought to the clinic by their mother and is suspected of having an immune system disorder. What tests would you expect to be ordered for this young client?

Complete blood count with differential