MS final (exam 2)

The nurse is on a mission trip to a third-world country to provide nursing care to a large group of clients. A client asks the nurse to look at his leg which is grossly edematous compared to the other extremity, What does the nurse understand is the most common cause of this disorder known as elephantiasis?

A parasitic worm

A client was found to have low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply

Abnormal erythrocyte production blood loss Destruction of normally formed red blood cells

A client who had sexual contact with a partner who is HIV positive recently developed flulike symptoms such as a low-grade fever, headache, and muscle pain. What does the nurse suspect the client is experiencing?

Acute retroviral syndrome

A client had a left radical mastectomy with an axillary node dissection 6 months ago and is having a large amount of edema in the left arm down to the fingers. What should the nurse inform the client, is the reason for the edema?

An accumulation of lymphatic fluid that results from impaired lymph circulation.

The nurse is caring for a client who is undergoing bone marrow aspiration to determine the blood cell formation status. What nursing intervention should the nurse provide to the client during the test?

support the client and monitor the status

A client tells the nurse. "You know I have AIDS. I still cannot afford to tell my employer because they will probably cancel my health insurance, then what would I do?" What is the best response by the nurse?

"An employer cannot cancel you currently active health insurance on the basis of AIDS"

A client requires a blood transfusion for anemia and tells the nurse. "I don't want a transfusion because I don't want to get AIDS." Which is the best response from the nurse to the client?

"The blood is screened, and your risk is one in two million."

The nurse reinforces education for a client who is diagnosed with coagulopathy. Which client statement indicated a correct understanding of the definition of this disorder?

"my diagnosis means that I am missing or lacking components needed to control bleeding"

A client with early-stage rheumatoid arthritis asks the nurse what to do to help ease the symptoms of the disease. What would be the best response by the nurse?

"the doctor could prescribe anti-inflammatory drugs."

A client is considering beginning sexual relations and wants to know the best way to be protected form a sexually transmitted infection and HIV. What is the best response by the nurse?

"using a latex condom and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV"

The nurse is inspecting the tonsils of a client who complains of a sore throat due to size and appearance. What is the appropriate documentation for observation of tonsils that touch the uvula?

3

A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client. What priority information should be included?

Be alert for signs and symptoms of infection and report them immediately to the physician.

A nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate?

Candidiasis

A client diagnosed with polycythemia vera has come into the clinic because they have developed a night time cough, fatigue, and shortness of breath. From these clinical manifestations, what complication would the nurse suspect in this client?

Congestive heart failure

The nurse is obtaining medication history information from a client with Crohn's disease. What medication would the nurse include when asking what medications the client has taken for suppression of the inflammatory and immune response?

Corticosteroids

A client presents to the clinic with reports of itching and hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?

Diphenhydramine

The nurse is caring for a client with chronic fatigue syndrome. what is a realistic nursing intervention when taking care of a client with this diagnosis?

Educate the client about the disease process.

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?

Epoetin alfa (Epogen)

A client with a diagnosis of pernicious anemia come to the clinic complaining of numbness and tingling in his arms and legs. What do these symptoms indicate?

Neurologic involvement

A client is admitted to the emergency department with significant blood loss. The physician prescribes 2 units of packed red blood cells to be transferred immediately. Which blood groups would be compatible with his O Rh-positive blood groups?

O Rh positive or O Rh negative

A client with multiple myeloma is complaining of sever pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?

Obtain the pain medication and delay the bath and position change until the medication reaches its peak.

The client is receiving chemotherapy for a diagnosis of lymphosarcoma. The client experiences nausea. What measures should the nurse suggest to help the client reduce the feeling of nausea?

Offer clear liquids such as carbonated beverages, water, and ice pops.

A laboring mother asks the nurse if the baby will have immunity to some illness when born. what type of immunity does the nurse understand that the newborn will have?

Passive immunity transferred by the mother.

The nurse observes that a client who had an arterial blood gas performed 30 minutes ago is still oozing blood from the puncture site. The pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability of the blood to clot?

Platelets

A client with non-Hodgkin's lymphoma is receiving chemotherapy for treatment. The client is complaining of nausea during the treatment. To maintain fluid intake what type of food or fluid could the nurse offer the client?

Popsicle

The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?

Progressive tissue damage without any verifiable etiology.

The nurse administers an injection to a client with AIDS. When finished the nurse attempts to recap the needle and sustains a needle-stick to the finger what is the priority action by the nurse?

Report the incident to the supervisor

The nurse is administering a skin test to detect exposure to TB. How would the nurse determine if the client was exposed to TB?

The injection area swells if the client has developed antibodies against the antigen.

The nurse is observing the skin of a client who is taking medications that depress the hematopoietic system and notices multiple areas of ecchymosis on the arms; bleeding for a prolonged period after an IV was started; and reports of black tarry stool. What does the nurse understand may be a side effect of this medication that the client displays?

Thrombocytopenia

The nurse is inspecting the tonsils for a client with a fever and sore throat. The nurse observes purulent exudate on the surface of the tonsils. What does this finding indicate to the nurse?

Tonsilitis

The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion?

Urine output of 15mL/hour

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform what?

Western blot test for confirmation of diagnosis

The nurse will be assisting the physician with a bone marrow aspiration. Where should the nurse cleanse, clip hair, and drape the skin prior to the procedure?

over the posterior superior iliac crest

The nurse has several clients scheduled for annual wellness examinations throughout the day. For which client should the nurse prepare the shingles vaccine?

A 65-year-old client who had chicken pox at the age of 12

A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?

Artificially acquired active immunity

The nurse is preparing to start an IV for a client who is combative. What precautionary measure should the nurse take in order to avoid a needle-stick?

Ask for assistance

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?

Bank autologous blood

A client who is diagnosed with multiple myeloma experiences decreased production of RBCs. Which prescribed medication should the nurse prepare to administer to increase the production of erythrocytes?

Erythropoietin

A client with lupus has had anti-neoplastic drugs prescribed. Why would the physician prescribe these medications for an autoimmune disease?

For their immunosuppressant effects.

A teenaged client with hemophilia sustains a leg laceration after falling off a skateboard and is brought to the emergency department. The laceration is bleeding even with direct pressure to the site. What does the nurse anticipate will be prescribed for administration to control bleeding?

Fresh frozen plasma

A nurse is providing care to a cancer client. Which protein in plasma functions primarily as an immunologic agents?

Gamma globulins

When obtaining vital signs form a client who has reduced erythrocyte production and a hemoglobin level of 8.2 g/dL what result would be indicative of these lab studies?

Heart rate of 120 beats/minute

A client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?

How to apply an elastic sleeve or stocking.

A client with Hodgkin's disease has bilateral lymph nodes that are affected with extension through the spleen as well as affecting the bone marrow. What stage of the disease does the nurse recognize the client is in?

IV

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?

IgE

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?

Monitor the client for reactions.

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

Natural killer cells

Why would it be important for the nurse to question the client about sexual practices, history of a subtance use disorder, and lifestyle during the interview process?

To determine if the client has practices that are at risk factors for acquired immunodeficiency syndrome (aids)

The nurse is sending a client to be fitted for a compression garment for the treatment of lymphedema after having a mastectomy and node dissection. What does the nurse inform the client the garment will do to decrease the edema? select all that apply

Increase local tissue pressure decreases stretching of the skin helps muscles to propel lymphatic drainage prevents tissue refilling with an excess volume of lymph

The nurse has four clients that come to the clinic for healthcare. Which client has the highest risk factor for HIV infection?

a 26-year-old inmate who received tattoos in prison.