NU 225- Quiz #5

The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/ μL c. HIV-positive patient with a CD4+ count of 160/μL who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

D CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient will develop symptomatic HIV infection within 1 year." b. "The patient meets the criteria for a diagnosis of acute HIV infection." c. "The patient will be diagnosed with asymptomatic chronic HIV infection." d. "The patient has developed acquired immunodeficiency syndrome (AIDS)."

D Development of PCP meets the diagnostic criteria for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. CD4+ cell count trajectory b. HIV genotype and phenotype c. Patient's tolerance for potential medication side effects d. Patient's ability to follow a complex medication regimen

D Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patient's class schedule to help decide when the drugs should be taken.

D The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions are also useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule.

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.

D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (e.g., pneumonia, dementia, influenza) associated with HIV infection.

A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Take this medication on an empty stomach. b. Take this medication with a full glass of water. c. You may have vivid and bizarre dreams as a side effect. d. Continue to use contraception while taking this medication.

D To prevent harm, it is most critical to inform patients that efavirenz can cause fetal anomalies and should not be used in patients who may be or may become pregnant. The other information is also accurate, but it does not directly prevent harm. The medication should be taken on an empty stomach with water and patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams.

A child is being discharged home on a regimen of oral corticosteroids. What information is most important for the nurse to explain to the parents? A. Reduce the dosage as quickly as possible so dependence on the medication is avoided. B. Any new cuts should be washed with soap and water and then covered with a bandage. C. Increased appetite and energy are interpreted as a positive response to the medication. D. If the child becomes ill, notify the physician who ordered the medication immediately.

D. If the child becomes ill, notify the physician who ordered the medication immediately. If the child becomes ill, the physician who ordered the medication should be notified because of the increased stress. Supplemental glucocorticoids might be necessary during times of increased stress to prevent adrenal insufficiency. The dosage should be tapered to allow for a gradual return of adrenal function. Any new cuts should be washed with soap and water then covered with a bandage, but this is true for most children and is not specific to taking corticosteroids. Energy spurts do not indicate anything especially and increased appetite is common with this type of medication.

The nurse uses knowledge of the effects of stress on the immune system by encouraging patients to: a. sleep for 10 - 12 hours per day b. avoid exposure to upper respiratory tract infections c. receive regular immunizations when they are stressed d. use emotion - focused rather than problem - focused coping strategies

b. avoid exposure to upper respiratory tract infections

The nurse recognizes that a person who is subjected to chronic stress could be at higher risk for : a. osteoporosis b. colds and flus c. low blood pressure d. high serum cholesterol

b. colds and flus

Determination of whether an event is a stressor is based on a person's: a. tolerance b. perception c. adaption d. stubbornness

b. perception

An appropriate nursing intervention for a hospitalized patient who state she cannot cope with her illness is: a. controlling the environment to prevent sensory overload and promote sleep b. encouraging the patients family to offer emotional support by frequent visiting c. arranging for the patient to phone family and friends to maintain emotional bonds d. asking the patient to describe previous stressful situations and how she managed to resolve them

d. asking the patient to describe previous stressful situations and how she managed to resolve them

The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient? a. "You will need to be retested in 2 weeks." b. "You do not need to fear infecting others." c. "Since you don't have symptoms and you have had a negative test, you do not have HIV)." d. "We won't know for years if you will develop acquired immunodeficiency syndrome (AIDS)."

A HIV screening tests detect HIV-specific antibodies or antigens, but typically it takes a several week delay after initial infection before HIV can be detected on a screening test. Combination antibody and antigen tests (also known as fourth-generation tests) decrease the window period to within 3 weeks after infection. It is not known based on this information whether the patient is infected with HIV or can infect others.

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/μL and an undetectable viral load. What is the priority nursing intervention at this time? a. Encourage adequate nutrition, exercise, and sleep. b. Teach about the side effects of antiretroviral agents. c. Explain opportunistic infections and antibiotic prophylaxis. d. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

A The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. Maintaining healthy lifestyle behaviors is an important goal in this stage. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? a. Age c. Symptoms b. Lifestyle d. Sexual orientation

A The current Centers for Disease Control and Prevention policy is to offer routine testing for HIV to all individuals age 13 to 64 years. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing c. Rapid HIV antibody testing b. Enzyme immunoassay d. Immunofluorescence assay

A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.

An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching? a. Many drugs interact with antiretroviral medications. b. HIV infections progress more rapidly in older adults. c. Less frequent CD4+ level monitoring is needed in older adults. d. Hospice care is available for patients with terminal HIV infection.

A The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient beginning early ART is not a candidate for hospice. Progression of HIV is not affected by age although it may be affected by chronic disease.

The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a. Antibiotics may sometimes be prescribed to prevent infection. b. Continue taking antibiotics until all of the prescription is gone. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.

A, B, E All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded immediately because the number left will not be enough to treat a future infection. Hand washing is generally considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza.

A child who has measles and a compromised immune system needs to be watched for secondary infections or complications. Symptoms of which conditions should the nurse teach the parents to report immediately? Select all that apply. A. Bronchopneumonia B. Epiglottitis C. Laryngotracheobronchitis (croup) D. Otitis media E. Rheumatic fever F. Myocarditis

A, C, D, F Bronchopneumonia, otitis media and laryngotracheobronchitis (croup), and myocarditis can occur as complications of measles. Epiglottitis and rheumatic fever are not from measles.

The mother of a child with sickle cell disease calls the pediatrician's office because she thinks her son may have fifth disease. What information should the nurse give the mother? A. "Keep your child comfortable at home, but if you notice a major change in his activity level or behavior, call us immediately." B. "Use cool baths with oatmeal to decrease itching first thing in the morning and before going to bed at night." C. "Keep your child away from all of the other members of the household for the next three days." D. "Increase your son's intake of protein and fluids to help replace the liquid he is losing through his skin."

A. "Keep your child comfortable at home, but if you notice a major change in his activity level or behavior, call us immediately." Because the disease is mild, complications are not usually reported, especially in children. Patients with sickle cell disease or beta-thalassemia are at risk for anemia and aplastic crisis. A change in activity or energy could indicate anemia. Cool baths with oatmeal are not indicated for this illness. The child needs to be kept away from other family members for longer than 3 days. Increasing protein and fluids is not indicated for this child.

A child with recurrent infections, facial edema, hypertension, and delayed growth in height is seen in the pediatrician's office. Which question would be most important for the nurse to ask the mother? A. "What medications are being taken by your child?" B. "When did this current infection begin?" C. "Are your other children shorter than usual?" D. "Is your child having headaches?"

A. "What medications are being taken by your child?" Facial edema, hypertension, recurrent infections, and delayed growth in height are some of the clinical manifestations of excess steroid administered systemically. It would be important to know about when the infection began, but the child has a cluster of problems. It would be important to know if shortness in height runs in the family, but the child has a cluster of symptoms that can stem from systemic steroid use. Headaches can occur from hypertension, but the underlying problems, not the symptoms, need to be addressed.

Parents rush their 7-year-old child to a free-standing emergency clinic because of the child's having been stung by bees and is having rapid, labored breathing. What is the priority action by the nurse when the child gets into the examining room? A. Administer oxygen using a nasal cannula. B. Obtain a complete health history from the parents. C. Place a tourniquet distal to the area where the bee stings are. D. Get the code cart located down the hall in the locked treatment room.

A. Administer oxygen using a nasal cannula. Initially, the nurse maintains an adequate airway by administering oxygen and assisting with aerosol treatments and intubation as necessary. A brief, focused health history is indicated related to the insect bites. In the case of an insect sting or injected medication, a tourniquet applied to the affected extremity just proximal to the site might help confine the allergen. The nurse should stay with the patient. Someone else can get the code cart.

A mother calls the pediatrician's office and states that her 4-year-old son looks like "someone slapped his cheeks" and he's running a fever. What would the nurse suspect the child has based on the mother's description? A. Fifth disease B. Rubella C. Scarlet fever D. Roseola infantum

A. Fifth disease Fifth disease is a relatively mild systemic disease. Typically the child may appear well but has an intense, fiery red, edematous rash on the cheeks, which gives a "slapped cheek" appearance or a history of a rash that "comes and goes." Before the appearance of the rash, many children are asymptomatic or have nonspecific symptoms such as headache runny nose, malaise, and mild fever. Rubella often has the following signs and symptoms: Older children may report profuse nasal drainage, diarrhea, malaise, sore throat, headache, low-grade fever, polyarthritis, eye pain, aches, chills, anorexia, and nausea. Scarlet fever is known for the "strawberry tongue" and a fine red papular rash in the axillae, groin, and neck, which feels like sandpaper to the touch. Roseola infantum causes a sudden high fever (103 to 106° F [39.4 to 41.1° C]), malaise, and irritability, a mild cough, runny nose, abdominal pain, headache, vomiting, and diarrhea, and then several days later when the fever subsides a rash appears. The rash consists of rose-pink maculopapules or macules that blanch with pressure.

The nurse recognizes that a patient with newly diagnosed breast cancer is using an emotion focused coping process when she a. joins a support group for women with breast cancer b. considers the pros and cons of the various treatment options c. delays treatment until her family can take a weekend trip together d. tells the nurse that she has a good prognosis because the tumor is small

A. Joins a support group for women with breast cancer

An adolescent female with systemic lupus erythematosus (SLE) is trying to learn how to live with her illness. What teaching by the nurse is priority? A. Use protection against the sun whenever she is outside, regardless of the season. B. Maintain a high-protein diet to maintain healthy skin integrity and muscle fibers. C. Plan her schedule so she gets at least 10 hours of solid, deep sleep each night. D. Keep a diary so she can document her thoughts and feelings as she adjusts.

A. Use protection against the sun whenever she is outside, regardless of the season. Using protection against the sun whenever she is outside, regardless of the season, is a must to avoid triggers that cause exacerbations. A high-protein diet is usually contraindicated, because it places stress on the kidneys because protein molecules are large. Sleep and rest are important with prevention of fatigue, rather than a specific number of hours' being asleep as the priority. Keeping a diary so she can document her thoughts and feelings as she adjusts is important, but the physiologic needs must be addressed before the psychological ones.

which of the following examples reflects the relationship among the mind-body-spirit?

ALL OF THEM a. A 75-year-old man who enjoys doing crossword puzzles everyday b. A 25-year-old man who has been successfully treated for testicular cancer c. A 55-year-old man who is impotent because of his prostate cancer surgery d. A 34-year-old woman who is angry because of her recent diagnosis of breast cancer e. A 65-year-old woman struggling with rehabilitation after having hip replacement surgery

1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Provide 100% oxygen using a nonrebreather mask.

ANS: A, E, C, B, D The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last. DIF: Cognitive Level: Analyze (analysis) REF: 201 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

It is important for the parents of a child who has had a severe allergic reaction to either peanuts or tree nuts to talk to their health care provider about whether the child should have medication available at school in case of an unanticipated exposure to nuts. Epinephrine is now available and easy to use in a device known as the ____________.

ANS: EpiPen The EpiPen is an auto-inject that can be given through the child's clothing. After the injection is given, the pen should be held in place for 10 seconds so that all medication can be delivered.

_________________________ is a chronic, multisystem, autoimmune disease characterized by inflammation of the connective tissue.

ANS: Systemic lupus erythematosus SLE SLE varies in severity and is marked by remission and exacerbations. Although the etiology is unknown, genetic, hormonal, environmental, and immune response factors are likely to be responsible.

It is late winter when a 7-year-old child reports to the school nurse with fever, headache, myalgia, and glandular swelling. After assessment the nurse's preliminary diagnosis includes the viral infection most commonly known as ________.

ANS: mumps The classic indication of mumps is parotid glandular swelling, although a number of children will have no such swelling. This is often accompanied by fever. The parents should be notified and provided with educational information regarding care of the child with the mumps.

The nurse observes a red butterfly-shaped rash that spreads across the child's cheeks and nose. This assessment finding is characteristic of which condition? a. Systemic lupus erythematosus (SLE) b. Rheumatic fever c. Kawasaki disease d. Anaphylactic reaction

ANS: A Feedback A A red, flat or raised malar "butterfly" rash over the cheeks and bridge of the nose is a clinical manifestation of SLE. B A major manifestation of rheumatic fever is erythema marginatum, which appears as red skin lesions spread peripherally over the trunk. C An erythematous rash, induration of the hands and feet, and erythema of the palms and soles are manifestations of Kawasaki disease. D Initial symptoms of anaphylaxis include severe itching and rapid development of erythema.

Which statement made by an adolescent girl indicates an understanding about the prevention of sexually transmitted diseases (STDs)? a. "I know the only way to prevent STDs is to not be sexually active." b. "I practice safe sex because I wash myself right after sex." c. "I won't get any kind of STD because I take the pill." d. "I only have sex if my boyfriend wears a condom."

ANS: A Feedback A Abstinence is the only foolproof way to prevent an STD. B STDs are transmitted through body fluids (semen, vaginal fluids, blood). Perineal hygiene will not prevent an STD. C Oral contraceptives do not protect women from contracting STDs. D A condom can reduce but not eliminate an individual's chance of acquiring an STD.

The nurse is planning care for an adolescent with AIDS. The priority nursing goal is to a. Prevent infection. b. Prevent secondary cancers. c. Restore immunologic defenses. d. Identify source of infection.

ANS: A Feedback A As a result of the immunocompromise that is associated with HIV infection, the prevention of infection is paramount. Although certain precautions are justified in limiting exposure to infection, these must be balanced with the concern for the child's normal developmental needs. B Preventing secondary cancers is not currently possible. C Current drug therapy is affecting the disease progression; although not a cure, these drugs can suppress viral replication preventing further deterioration. D Case finding is not a priority nursing goal.

Which statement is true regarding how infants acquire immunity? a. The infant acquires humoral and cell-mediated immunity in response to infections and immunizations. b. The infant acquires maternal antibodies that ensure immunity up to 12 months age. c. Active immunity is acquired from the mother and lasts 6 to 7 months. d. Passive immunity develops in response to immunizations.

ANS: A Feedback A Infants acquire long-term active immunity from exposure to antigens and vaccines. Immunity is acquired actively and passively. B The term infant's passive immunity is acquired from the mother and begins to dissipate during the first 6 to 8 months of life. C Passive immunity is acquired from the mother. D Active immunity develops in response to immunizations.

Which suggestion is appropriate to teach a mother who has a preschool child who refuses to take the medications for HIV infection? a. Mix medications with chocolate syrup or follow with chocolate candy. b. Mix the medications with milk or an essential food. c. Skip the dose of medication if the child protests too much. d. Mix the medication in a syringe, hold the child down firmly, and administer the medication.

ANS: A Feedback A Liquid forms of HIV medications may be foul tasting or have a gritty texture. Chocolate will help to make these foods more palatable and is liked by most children. B Medications should be mixed with nonessential foods. C Doses of medication should never be skipped. D Fighting with the child or using force should be avoided. A nonessential food that will make the taste of the medication more palatable for the child should be the correct action. The administration of medications for the child with HIV becomes part of the family's everyday routine for years.

What is the primary nursing concern for a hospitalized child with HIV infection? a. Maintaining growth and development b. Eating foods that the family brings to the child c. Consideration of parental limitations and weaknesses d. Resting for 2 to 3 hours twice a day

ANS: A Feedback A Maintaining growth and development is a major concern for the child with HIV infection. Frequent monitoring for failure to thrive, neurologic deterioration, or developmental delay is important for HIV-infected infants and children. B Nutrition, which contributes to a child's growth, is a nursing concern; however, it is not necessary for family members to bring food to the child. C Although an assessment of parental strengths and weaknesses is important, it will be imperative for health care providers to focus on the parental strengths, not weaknesses. This is not as important as the frequent assessment of the child's growth and development. D Rest is a nursing concern, but it is not as high a priority as maintaining growth and development. Rest periods twice a day for 2 to 3 hours may not be appropriate.

What is the most common mode of transmission of human immunodeficiency virus (HIV) in the pediatric population? a. Perinatal transmission b. Sexual abuse c. Blood transfusions d. Poor handwashing

ANS: A Feedback A Perinatal transmission accounts for the highest percentage (91%) of HIV infections in children. Infected women can transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breastfeeding. B Cases of HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV infections. C Although in the past some children became infected with HIV through blood transfusions, improved laboratory screening has significantly reduced the probability of contracting HIV from blood products. D Poor handwashing is not an etiology of HIV infection.

Which intervention is appropriate for a hospitalized child who has crops of lesions on the trunk that appear as a macular rash and vesicles? a. Place the child in strict isolation; airborne and contact precautions. b. Continue to practice Standard Precautions. c. Pregnant women should avoid contact with the child. d. Screen visitors for immunity to measles.

ANS: A Feedback A The child's skin lesions are characteristic of varicella. Varicella is transmitted through direct contact, droplets, and airborne particles. In the hospital setting, children with varicella should be placed in strict isolation, and on Contact and Airborne Precautions. The purpose is to prevent transmission of microorganisms by inhalation of small-particle droplet nuclei and to protect other patients and health care providers from acquiring this disease. B The child's skin lesions are characteristic of varicella. Additional measures must be instituted to protect other patients and staff who may be susceptible to the disease. C Certain viral illnesses such as rubella and fifth disease are known to affect the fetus if the woman contracts the disease during pregnancy. This child appears to have varicella. Pregnancy is not a contraindication to caring for a child with varicella. D The child appears to have varicella. Screening visitors for immunity to measles is irrelevant. It is important to screen visitors for immunity to varicella.

A nurse in a well-child clinic is teaching parents about their child's immune system. Which statement by the nurse is correct? a. The immune system distinguishes and actively protects the body's own cells from foreign substances. b. The immune system is fully developed by 1 year of age. c. The immune system protects the child against communicable diseases in the first 6 years of life. d. The immune system responds to an offending agent by producing antigens.

ANS: A Feedback A The immune system responds to foreign substances, or antigens, by producing antibodies and storing information. Intact skin, mucous membranes, and processes such as coughing, sneezing, and tearing help maintain internal homeostasis. B Children up to age 6 or 7 years have limited antibodies against common bacteria. The immunoglobulins reach adult levels at different ages. C Immunization is the basis from which the immune system activates protection against some communicable diseases. D Antibodies are produced by the immune system against invading agents, or antigens.

The nurse teaches a patient who is experiencing stress at work how to use imagery as a relaxation technique. Which statement by the nurse would be most appropriate? a. "Think of a place where you feel peaceful and comfortable." b. "Place the stress in your life in an image that you can destroy." c. "Bring what you hear and sense in your present work environment into your image." d. "If your work environment is stressful, continue visualizing to overcome the distress."

ANS: A Imagery is the use of one's mind to generate images that have a calming effect on the body. When using imagery for relaxation, the patient should visualize a comfortable and peaceful place. The goal is to offer a relaxing retreat from the actual work environment. Imagery can also be used to specifically target a disease, problem, or stressor.

3. A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE c. Basophils b. IgA d. Neutrophils

ANS: A Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis. DIF: Cognitive Level: Apply (application) REF: 194 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

An adult patient who is hospitalized following a motorcycle accident when a car ran a red light tells the nurse, "I didn't sleep last night because I worried about missing work at my new job and losing my insurance coverage." Which nursing diagnosis is appropriate to include in the plan of care? a. Anxiety b. Defensive coping c. Ineffective denial d. Risk prone health behavior

ANS: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient data do not support defensive coping, ineffective denial, or risk prone health behavior as problems for this patient.

13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.

ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity. DIF: Cognitive Level: Application (apply) REF: 210 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

4. An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals

ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection. DIF: Cognitive Level: Apply (application) REF: 196 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A preschooler is diagnosed with helminthes. The child's mother is very upset and wants to know how her child could have contracted this illness. After obtaining a detailed history, the nurse identifies all possible transmission modes. Select all modes that apply. a. Playing in the backyard sandbox b. Not washing hands before eating c. Placing hands in the mouth and nail biting d. Skin-to-skin contact with other children e. Scratches from a neighborhood cat

ANS: A, B, C Feedback Correct Common helminthes include roundworm, pinworm, tapeworm, and hookworm. Children are frequently infected as the result of frequent hand-mouth activity (unwashed hands, nail biting, not washing hands after using the toilet) and the likelihood of fecal contamination from sandboxes (especially if dogs and cats deposit fecal material in them). Other causes include not adequately washing fruits and vegetables before eating them and drinking contaminated water. Incorrect Skin-to-skin contact with other children and scratches from a cat are not transmission modes for helminthes.

The mother of an HIV-positive infant who is 2 months old questions the nurse about which childhood immunizations her child will be able to receive. Which immunizations should an HIV-positive child be able to receive according to the American Academy of Pediatrics recommendation for immunizing infants who are HIV positive? Select all that apply. a. Hepatitis B b. DTaP c. MMR d. IPV e. HIB

ANS: A, B, D, E Feedback Correct Routine immunizations are appropriate. Incorrect The MMR vaccination is not given at 2 months of age. If it were indicated, CD4+ counts are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the child's CD4+counts. Only IPV should be used for HIV-infected children.

Which home care instructions should the nurse provide to the parents of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. a. Give supplemental vitamins as prescribed. b. Yearly influenza vaccination should be avoided. c. Administer trimethoprim-sulfamethoxazole (Bactrim) as prescribed. d. Notify the physician if the child develops a cough or congestion. e. Missed doses of antiretroviral medication do not need to be recorded.

ANS: A, C, D Feedback Correct The parents should be taught that supplemental vitamins will be prescribed to aid in nutritional status. Bactrim is administered to prevent the opportunistic infection of Pneumocystis pneumonia. The physician should be notified if the child with AIDS develops a cough and congestion. Incorrect The yearly influenza vaccination is recommended and any missed doses of antiretroviral medication need to be recorded and reported.

The nurse should provide which information to parents about the prevention of parasitic infections? Select all that apply. a. Perform good handwashing. b. Diaper a child when swimming. c. Avoid cleaning the bathroom facilities with bleach. d. Shoes should be worn outside. e. Fruits and vegetables should be washed before eating.

ANS: A, D, E Feedback Correct Children are more commonly infected with parasites than adults, primarily as a result of frequent hand-to-mouth activity and the likelihood of fecal contamination. Good handwashing can prevent the transmission. Shoes should be worn when outside to prevent transmission, and fruits and vegetables should be washed before eating. Incorrect The child should not swim in a pool that allows diapered children. The bathroom facilities should be cleaned with bleach to decrease the chance of transmission.

A young child with HIV is receiving several antiretroviral drugs. The purpose of these drugs is to a. Cure the disease. b. Delay disease progression. c. Prevent the spread of disease. d. Treat Pneumocystis carinii pneumonia.

ANS: B Feedback A At this time, cure is not possible. B Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune system, and delay disease progression. C These drugs do not prevent the spread of the disease. D Pneumocystis carinii prophylaxis is accomplished with antibiotics.

What should be included in health teaching to prevent Lyme disease? a. Complete the immunization series in early infancy. b. Wear long sleeves and pants tucked into socks while in wooded areas. c. Give low-dose antibiotics to the child before exposure. d. Restrict activities that might lead to exposure for the child.

ANS: B Feedback A Currently there is no vaccine available for Lyme disease. The Lyme disease vaccine had been approved for persons ages 15 to 70 years; however, was withdrawn from the market in 1992. B Wearing long sleeves and pants, and tucking the pants into socks keeps ticks on the clothing and prevents them from hiding on the body. C Antibiotics are used to treat, not prevent, Lyme disease. D Children should be allowed to maintain normal growth and development with activities such as hiking.

What is the primary nursing concern for a child having an anaphylactic reaction? a. Identifying the offending allergen b. Ineffective breathing pattern c. Increased cardiac output d. Positioning to facilitate comfort

ANS: B Feedback A Determining the cause of an anaphylactic reaction is important to implement the appropriate treatment, but the primary concern is the airway. B Laryngospasms resulting in ineffective breathing patterns is a life-threatening manifestation of anaphylaxis. The primary action is to assess airway patency, respiratory rate and effort, level of consciousness, oxygen saturation, and urine output. C During anaphylaxis, the cardiac output is decreased. D During the acute period of anaphylaxis, the nurse's primary concern is the child's breathing. Positioning for comfort is not a primary concern during a crisis.

How should the nurse respond to a parent who asks, "How can I protect my baby from whooping cough?" a. "Don't worry; your baby will have maternal immunity to pertussis that will last until they are approximately 18 months old." b. "Make sure your child gets the pertussis vaccine." c. "See the doctor when the baby gets a respiratory infection." d. "Have your pediatrician prescribe erythromycin."

ANS: B Feedback A Infants do not receive maternal immunity to pertussis and are susceptible to pertussis. Pertussis is highly contagious and is associated with a high infant mortality rate. B Primary prevention of pertussis can be accomplished through administration of the pertussis vaccine. C Prompt evaluation by the primary care provider for respiratory illness will not prevent pertussis. D Erythromycin is used to treat pertussis. It will not prevent the disease.

Which STD should the nurse suspect when an adolescent girl comes to the clinic because she has a vaginal discharge that is white with a fishy smell? a. Human papillomavirus b. Bacterial vaginosis c. Trichomonas d. Chlamydia

ANS: B Feedback A Manifestations of the human papillomavirus are anogenital warts that begin as small papules and grow into clustered lesions. B Bacterial vaginosis is characterized by a profuse, white, malodorous (fishy smelling) vaginal discharge that sticks to the vaginal walls. C Infections with Trichomonas are frequently asymptomatic. Symptoms in females may include dysuria, vaginal itching, burning, and a frothy, yellowish-green, foul-smelling discharge. D Many people with chlamydial infection have few or no symptoms. Urethritis with dysuria, urinary frequency, or mucopurulent discharge may indicate chlamydial infection.

A nurse is conducting a health education class for a group of school-age children. Which statement made by the nurse is correct about the body's first line of defense against infection in the innate immune system? a. Nutritional status b. Skin integrity c. Immunization status d. Proper hygiene practices

ANS: B Feedback A Nutritional status is an indicator of overall health, but it is not the first line of defense in the innate immune system. B The first lines of defense in the innate immune system are the skin and intact mucous membranes. C Immunizations provide artificial immunity or resistance to harmful diseases. D Practicing good hygiene may reduce susceptibility to disease, but it is not a component of the innate immune system.

The Center for Disease Control (CDC, 2009) recommendation for immunizing infants who are HIV positive is a. Follow the routine immunization schedule. b. Routine immunizations are administered; assess CD4+ counts before administering the MMR and varicella vaccinations. c. Do not give immunizations because of the infant's altered immune status. d. Eliminate the pertussis vaccination because of the risk of convulsions.

ANS: B Feedback A Routine immunizations are appropriate; however, CD4+ cell counts should be assessed before administering the MMR and varicella vaccines to establish adequate immune system function. B Routine immunizations are appropriate. CD4+ cells are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the child's CD4+ counts. Only inactivated polio virus (IPV) should be used for HIV-infected children. C Immunizations are given to infants who are HIV positive. D The pertussis vaccination is not eliminated for an infant who is HIV positive.

What is the best response to a parent of a 2-month-old infant who asks when the infant should first receive the measles vaccine? a. "Your baby can get the measles vaccine now." b. "The first dose is given any time after the first birthday." c. "She should be vaccinated between 4 and 6 years of age." d. "This vaccine is administered when the child is 11 years old."

ANS: B Feedback A Some immunizations are initiated at 2 months of age, but not the measles vaccine. B The first measles, mumps, rubella (MMR) vaccine is recommended routinely at 1 year of age. C The second dose of MMR is recommended at 4 to 6 years of age. D Children should receive their second MMR dose no later than 11 to 12 years of age.

What should the nurse expect to observe in the prodromal phase of rubeola? a. Macular rash on the face b. Koplik spots c. Petechiae on the soft palate d. Crops of vesicles on the trunk

ANS: B Feedback A The macular rash with rubeola appears after the prodromal stage. B Koplik spots appear approximately 2 days before the appearance of a rash. C Petechiae on the soft palate occur with rubella. D Crops of vesicles on the trunk are characteristic of varicella.

17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list

ANS: B Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing. DIF: Cognitive Level: Apply (application) REF: 208 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse knows that this is a painful procedure and wants to provide music to help the patient relax. Which action is best for the nurse to take? a. Use music composed by Mozart. b. Ask the patient about music preferences. c. Select music that has 60 to 80 beats/minute. d. Encourage the patient to use music without words.

ANS: B Although music with 60 to 80 beats/minute, music without words, and music composed by Mozart are frequently recommended to reduce stress, each patient responds individually to music and personal preferences are important

21. Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first? a. Apply antiinflammatory cream. b. Place a tourniquet above the site. c. Administer subcutaneous epinephrine. d. Reschedule the patient's other allergen tests.

ANS: B Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. The other actions may occur, but the tourniquet application slows the allergen progress into the patient's system, allowing treatment of the anaphylactic response. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. Other testing may be delayed and rescheduled after development of anaphylaxis. DIF: Cognitive Level: Analysis (analyze) REF: 201 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find a different way to earn extra money." b. "I will take oral antihistamines before going to work." c. "I will get a prescription for epinephrine and learn to self-inject it." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

ANS: B Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem. DIF: Cognitive Level: Apply (application) REF: 197 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

1. The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders

ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity. DIF: Cognitive Level: Apply (application) REF: 196 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

2. Which example should the nurse use to explain an infant's "passive immunity" to a new mother? a.Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases

ANS: B Colostrum in breast milk provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a person's bone marrow after high-dose chemotherapy. DIF: Cognitive Level: Apply (application) REF: 192 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "I need to be monitored closely for development of malignant tumors." b. "After a couple of years I will be able to stop taking the cyclosporine." c. "If I develop acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."

ANS: B Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics. DIF: Cognitive Level: Apply (application) REF: 209 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

19. A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first? a. Monitor the patient's edema. b. Administer a dose of epinephrine. c. Provide a prescription for oral antihistamines d. Ask the patient about the use of new skin products.

ANS: B Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. The nurse should not wait and assess for development of additional edema. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Exposure to skin products does not address the immediate concern of a possible anaphylactic reaction. DIF: Cognitive Level: Analyze (analysis) REF: 202 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who is sneezing after subcutaneous immunotherapy c. Patient who has graft-versus-host disease and severe diarrhea d. Patient with multiple chemical sensitivities who has muscle stiffness

ANS: B Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 203 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

11. Which statement by a patient would alert the nurse to a risk for decreased immune function? a. "I had a chest x-ray 6 months ago." b. "I had my spleen removed after a car accident." c. "I take one baby aspirin every day to prevent stroke." d. "I usually eat eggs or meat for at least two meals a day."

ANS: B Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function. DIF: Cognitive Level: Apply (application) REF: 206 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient who is taking antiretroviral medication to control human immunodeficiency virus (HIV) infection tells the nurse about feeling mild depression and anxiety. Which additional information about the patient is most important to communicate to the health care provider? a. The patient's blood pressure is 152/88 mm Hg. b. The patient uses over-the-counter St. John's wort. c. The patient recently experienced the death of a close friend. d. The patient expresses anxiety about whether the drugs are effective.

ANS: B St. John's wort interferes with metabolism of medications that use the cytochrome P450 enzyme system, including many HIV medications. The health care provider will need to check for toxicity caused by the drug interactions. Teaching is needed about drug interactions. The other information will also be reported but does not have immediate serious implications for the patient's health

14. A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? a. Corticosteroids c. Hepatitis B vaccine b. Gamma globulin d. Fresh frozen plasma

ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient. DIF: Cognitive Level: Apply (application) REF: 192 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

8. The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? a. Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. b. Document the patient's history and teach about clinical manifestations of a type I latex allergy. c. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.

ANS: B The patient's allergy history and occupation indicate a risk of developing a latex allergy. The patient should be taught about symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Using latex gloves increases the chance of developing latex sensitivity. Oil-based creams will increase the exposure to latex from latex gloves. DIF: Cognitive Level: Apply (application) REF: 203 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A hospitalized patient with diabetes tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up. This is so frustrating." Which response by the nurse is most appropriate? a. "It is probably just coincidental that your blood glucose is higher when you are ill." b. "Stressors such as illness cause the release of hormones that increase blood glucose." c. "Increased blood glucose occurs because the liver is not able to metabolize glucose as well during stressful times." d. "Your diet is different here in the hospital than at home and that is the most likely cause of the increased glucose level."

ANS: B The release of cortisol, epinephrine, and norepinephrine increase blood glucose levels. The increase in blood glucose is not coincidental. The liver does not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose

A hospitalized child has developed a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse plans which interventions when caring for this child? Select all that apply. a. Airborne isolation b. Administration of vancomycin (Vancocin) c. Contact isolation d. Administration of mupirocin (Bactroban) ointment to the nares e. Administration of cefotaxime (Cefotetan)

ANS: B, C, D Feedback Correct Vancomycin is used to treat MRSA along with mupirocin ointment to the nares. The patient is placed in contact isolation to prevent spread of the infection to other patients. Incorrect The infection is not transmitted by the airborne route so only contact isolation is required. This infection is resistant to cephalosporins.

A patient who is hospitalized with a pelvic fracture after a motor vehicle accident just received news that the driver of the car died from multiple injuries. What actions should the nurse take based on knowledge of the physiologic stress reactions that may occur in this patient (select all that apply)? a. Assess for bradycardia. b. Ask about epigastric pain. c. Observe for decreased appetite. d. Check for elevated blood glucose levels. e. Monitor for a decrease in respiratory rate.

ANS: B, C, D The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and increase blood glucose levels. In addition, stress causes an increase in respiratory and heart rates

What is the drug of choice the nurse should administer in the acute treatment of anaphylaxis? a. Diphenhydramine b. Histamine inhibitor (cimetidine) c. Epinephrine d. Albuterol

ANS: C Feedback A Although diphenhydramine may be indicated, epinephrine is the first drug of choice in the immediate treatment of anaphylaxis. B Although a histamine inhibitor such as cimetidine may be indicated, epinephrine is the first drug of choice in immediate treatment of anaphylaxis. C Epinephrine is the first drug of choice in immediate treatment of anaphylaxis. Treatment must be initiated immediately because it may only be a matter of minutes before shock occurs. D Albuterol is not usually indicated for treatment of anaphylaxis.

Which statement by a mother about antiretroviral agents for the management for her 5-year-old child with acquired immunodeficiency syndrome (AIDS) indicates that she has a good understanding? a. "When my child's pain increases, I double the recommended dosage of antiretroviral medication." b. "Addiction is a risk, so I only use the medication as ordered." c. "Doses of the antiretroviral medication are selected on the basis of my child's age and growth." d. "By the time my child is an adolescent she will not need her antiretroviral medications any longer."

ANS: C Feedback A Antiretroviral medications are not administered for pain relief. Doubling the recommended dosage of any medication is not appropriate without an order from the physician. B Addiction is not a realistic concern with antiretroviral medications. C Doses of antiretroviral medication to treat HIV infection for infants and children are based on individualized age and growth considerations. D Antiretroviral medications are still needed during adolescence. Doses for adolescents are based on pubertal status by Tanner staging.

Children receiving long-term systemic corticosteroid therapy are most at risk for a. Hypotension b. Dilation of blood vessels in the cheeks c. Growth delays d. Decreased appetite and weight loss

ANS: C Feedback A Hypertension is a clinical manifestation of long-term systemic steroid administration. B Dilation of blood vessels in the cheeks is associated with an excess of topically administered steroids. C Growth delay is associated with long-term steroid use. D Increased appetite and weight gain are clinical manifestations of excess systemic corticosteroid therapy.

Which intervention is appropriate for a child receiving high doses of steroids? a. Limit activity and receive home schooling. b. Decrease the amount of potassium in the diet. c. Substitute a killed virus vaccine for live virus vaccines. d. Monitor for seizure activity.

ANS: C Feedback A Limiting activity and home schooling are not routine for a child receiving high doses of steroids. B The child receiving steroids is at risk for hypokalemia and needs potassium in the diet. C The child on high doses of steroids should not receive live virus vaccines because of immunosuppression. D Children on steroids are not typically at risk for seizures.

The mother of an infant with multiple anomalies tells the nurse that she had a viral infection in the beginning of her pregnancy. Which viral infection is associated with fetal anomalies? a. Measles b. Roseola c. Rubella d. Herpes simplex virus (HSV)

ANS: C Feedback A Measles is not associated with congenital defects. B Most cases of roseola occur in children 6 to 18 months old. C The rubella virus can cross the placenta and infect the fetus, causing fetal anomalies. D HSV can be transmitted to the newborn infant during vaginal delivery, causing multisystem disease. It is not transmitted transplacentally to the fetus during gestation.

What should the nurse include in a teaching plan for the mother of a toddler who will be taking prednisone for several months? a. The medication should be taken between meals. b. The medication needs to be discontinued because of the risks associated with long-term usage. c. The medication should not be stopped abruptly. d. The medication may lower blood glucose, so the mother needs to observe for signs of hypoglycemia.

ANS: C Feedback A Prednisone should be taken with food to minimize or prevent gastrointestinal bleeding. B Although there are adverse effects from long-term steroid use, the medication must not be discontinued without consulting a physician. Acute adrenal insufficiency can occur if the medication is withdrawn abruptly. The dosage needs to be tapered. C The dosage must be tapered before the drug is discontinued to allow the gradual return of function in the pituitary-adrenal axis. D The medication puts the child at risk for hyperglycemia.

Which statement indicates that a father understands the treatment for his child who has scarlet fever? a. "I can stop the medicine when my child feels better." b. "I will apply antibiotic cream to her rash twice a day." c. "I will give the penicillin for the full 10 days." d. "My child can go back to school when she has been on the antibiotic for a week."

ANS: C Feedback A The bacteria will not be eradicated if a partial course of antibiotics is given. B Treatment of scarlet fever does not include topical antibiotic cream. C It is necessary to give the entire course of antibiotic for 10 to 14 days. Penicillin is the preferred treatment for any streptococcal infection. D The child is no longer contagious after 24 hours of antibiotic therapy and can return to daycare or school.

What is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+ T cells? a. Wiskott-Aldrich syndrome b. Idiopathic thrombocytopenic purpura c. Acquired immunodeficiency syndrome (AIDS) d. Severe combined immunodeficiency disease

ANS: C Feedback A Wiskott-Aldrich syndrome is not a viral illness. B Idiopathic thrombocytopenic purpura is not a viral illness. C Acquired immune deficiency is caused by the human immunodeficiency virus (HIV), which primarily attacks the CD4+ T cells. D Severe combined immunodeficiency disease is not a viral illness.

6. Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."

ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes. DIF: Cognitive Level: Apply (application) REF: 200 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Obtain the patient's blood pressure and heart rate. b. Question the patient about any clear nasal discharge. c. Observe for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.

ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions. DIF: Cognitive Level: Apply (application) REF: 199 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

7. The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a. Schedule an additional dose the following week. b. Administer the scheduled dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction. DIF: Cognitive Level: Apply (application) REF: 203 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the medication at this time? a. The patient restricts salt to 2 grams per day. b. The patient eats green leafy vegetables daily. c. The patient drinks grapefruit juice every day. d. The patient drinks 3 to 4 quarts of fluid each day.

ANS: C Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function. DIF: Cognitive Level: Apply (application) REF: 209 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

9. What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? a. Plasmapheresis eliminates eosinophils and basophils from blood. b. Plasmapheresis decreases the damage to organs from T lymphocytes. c. Plasmapheresis removes antibody-antigen complexes from circulation. d. Plasmapheresis prevents foreign antibodies from damaging various body tissues.

ANS: C Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE. DIF: Cognitive Level: Understand (comprehension) REF: 205 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

24. A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor crossmatching are positive d. Panel of reactive antibodies (PRA) percentage is low

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation because a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable. DIF: Cognitive Level: Apply (application) REF: 208 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer. She is usually well organized and calm but the nurse who is giving her preoperative instructions observes that she is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Focus teaching on preventing postoperative complications. c. Try to calm patient and reinforce and repeat teaching about the surgery. d. Encourage the patient to have bladder repair at the same time as the hysterectomy.

ANS: C Since behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. It is also important to try to calm the patient by listening to her concerns and fears. Psychiatric referral will not necessarily be needed for her, but that can better be evaluated after surgery. Focusing on postoperative care does not address the need for preoperative instruction such as the procedure, NPO instructions before surgery, date and time of surgery, medications to be taken and/or discontinued before surgery, etc. The issue of incontinence is not immediately relevant in the discussion of preoperative teaching for her hysterectomy.

A middle-aged male patient with usually well-controlled hypertension and diabetes visits the clinic. Today he has a blood pressure of 174/94 and a blood glucose level of 190 mg/dL. What additional patient information may indicate that an intervention by the nurse is needed? a. The patient indicates that he usually does blood glucose monitoring several times each day. b. The patient states that he usually takes his prescribed antihypertensive medications on a daily basis. c. The patient reports that he and his wife are getting divorced and are in a custody battle over their 12-year-old son. d. The patient states that the results are related to his family history because both of his parents have high blood pressure and diabetes.

ANS: C The increase in blood pressure and glucose levels possibly suggests that stress caused by his divorce and custody battle may be adversely affecting his health. The nurse should assess this further and develop an appropriate plan to assist the patient in decreasing his stress. Although he has been very compliant with his treatment plan in the past, the nurse should assess whether the stress in his life is interfering with his management of his health problems. The family history will not necessarily explain why he has had changes in his blood pressure and glucose levels

20. A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action? a. Provide high-flow oxygen. c. Assess the patient's airway. b. Administer antihistamines. d. Remove the stinger from the site.

ANS: C The initial action with any patient with difficulty breathing is to assess and maintain the airway. The patient's symptoms of anxiety and difficulty breathing may have other causes than anaphylaxis, so additional assessment is warranted. The other actions are part of the emergency management protocol for anaphylaxis, but the priority is airway assessment and maintenance. DIF: Cognitive Level: Analysis (analyze) REF: 202 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who suffers from frequent migraines tells the nurse, "My life feels chaotic and out of my control. I will not be able to manage if anything else happens." Which response should the nurse make initially? a. "Regular exercise may get your mind off the pain." b. "Guided imagery can be helpful in regaining control." c. "Tell me more about how your life has been recently." d. "Your previous coping strategies can be very helpful to you now."

ANS: C The nurse's initial strategy should be further assessment of the stressors in the patient's life. Exercise, guided imagery, or understanding how to use coping strategies that worked in the past may be of assistance to the patient, but more assessment is needed before the nurse can determine this

18. The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

ANS: C There is no increased exposure to infection from a patient who had an anaphylactic reaction. Treatment for a patient with acute rejection includes administration of additional immunosuppressants and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. DIF: Cognitive Level: Apply (application) REF: 201 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

Which organs and tissues control the two types of specific immune functions? a. The spleen and mucous membranes b. Upper and lower intestinal lymphoid tissue c. The skin and lymph nodes d. The thymus and bone marrow

ANS: D Feedback A Both the spleen and mucous membranes are secondary organs of the immune system that act as filters to remove debris and antigens and foster contact with T lymphocytes. B Gut-associated lymphoid tissue is a secondary organ of the immune system. This tissue filters antigens entering the gastrointestinal tract. C The skin and lymph nodes are secondary organs of the immune system. D The thymus controls cell-mediated immunity (cells that mature into T lymphocytes). The bone marrow controls humoral immunity (stem cells for B lymphocytes).

A child taking oral corticosteroids for asthma is exposed to varicella. The child has not had the varicella vaccine and has never had the disease. What intervention should be taken to prevent varicella from developing? a. No intervention is needed unless varicella develops. b. Administer the varicella vaccine as soon as possible. c. The child should begin a course of oral antibiotics. d. The child should be prescribed acyclovir.

ANS: D Feedback A Children taking oral corticosteroids are immunosuppressed and are at high risk for serious complications. Intervention must be taken to prevent the disease when exposure occurs. B The varicella vaccine is a live virus vaccine and is contraindicated for an immunosuppressed child. C An antibiotic is not effective in treating varicella zoster, which is a virus. D For children receiving short-term corticosteroid treatment, acyclovir is often used in the treatment plan.

Which statement made by a parent indicates incorrect information about intervention for a child's fever? a. "I should keep her covered lightly when she has a fever." b. "I'll give her plenty of liquids to keep her hydrated." c. "I can give her acetaminophen for a fever." d. "I'll look for over-the-counter preparations that contain aspirin."

ANS: D Feedback A Dressing the child in light clothing and using lightweight covers will help reduce fever and promote the child's comfort. B Adequate hydration will help maintain a normal body temperature. C Acetaminophen or ibuprofen should be used as directed for fever control. D Aspirin products are avoided because of the possibility of development of Reye's syndrome. The parent should check labels on all over-the-counter products to be sure they do not contain aspirin.

What discharge information should the nurse give to the parents of a male adolescent who has been diagnosed with the Epstein-Barr virus? a. It is particularly important to protect the adolescent's head during physical activities. b. The teen will feel like himself and be back to his usual routines in a week. c. The treatment of the Epstein-Barr virus is prolonged bed rest, usually lasting several months. d. Fatigue may persist, and the adolescent may need to increase school activities gradually.

ANS: D Feedback A During the acute and recovery phases, activity restrictions, which include no contact sports or roughhousing, are implemented to protect the child's enlarged spleen from rupture. B The recovery process from infectious mononucleosis is a slow and gradual one. C Bed rest is indicated during the acute stage of the illness, usually lasting 2 to 4 weeks. D The recovery period is often lengthy and fatigue may continue, necessitating a gradual return to school activities.

What should be included in the care for a neonate who was diagnosed with pertussis? a. Monitoring hemoglobin level b. Hearing test before discharge c. Serial platelet counts d. Treatment of all close contacts with a prophylactic antibiotic

ANS: D Feedback A Pertussis does not affect the hemoglobin level. B A complication of pertussis is not hearing impairment. C Pertussis does not affect platelets. D Erythromycin, azithromycin, or clarithromycin is given to all close contacts for the child diagnosed with pertussis.

A parent asks the nurse how she will know whether her child has fifth disease. The nurse should advise the parent to be alert for which manifestation? a. Bull's-eye rash at the site of a tick bite b. Lesions in various stages of development on the trunk c. Maculopapular rash on the trunk that lasts for 2 days d. Bright red rash on the cheeks that looks like slapped cheeks

ANS: D Feedback A The bull's-eye rash at the site of a tick bite is a manifestation of Lyme disease. B Varicella is manifested as lesions in various stages of development—macule, papule, then vesicle, first appearing on the trunk and scalp. C Roseola manifests as a maculopapular rash on the trunk that can last for hours or up to 2 days. D Fifth disease manifests with an intense, fiery red, edematous rash on the cheeks, which gives a "slapped cheek" appearance.

A nurse is teaching parents about the importance of immunizations for infants because of immaturity of the immune system. The parents demonstrate that they understand the teaching if they make which statement? a. "The spleen reaches full size by 1 year of age." b. "IgM, IgE, and IgD levels are high at birth." c. "IgG levels in the newborn infant are low at birth." d. "Absolute lymphocyte counts reach a peak during the first year."

ANS: D Feedback A The spleen reaches its full size during adulthood. B IgM, IgE, and IgD are normally in low concentration at birth. IgM, IgE, IgA, and IgD do not cross the placenta. C The term newborn infant receives an adult level of IgG as a result of transplacental transfer from the mother. D Absolute lymphocyte counts reach a peak during the first year.

Which action is initiated when a child has been scratched by a rabid animal? a. No intervention unless the child becomes symptomatic b. Administration of immune globulin around the wound c. Administration of rabies vaccine on days 3, 7, 14, and 28 d. Administration of both immune globulin and vaccine as soon as possible after exposure

ANS: D Feedback A Transmission of rabies can occur from bites with contaminated saliva, scratches from the claws of infected animals, airborne transmission in bat-infested caves, or in a laboratory setting. Rabies is fatal if no intervention is taken to prevent the disease. B Human rabies immune globulin is infiltrated locally around the wound and the other half of the dose is given intramuscularly. This is only part of the treatment after rabies exposure. C The rabies vaccine is given within 48 hours of exposure and again on days 3, 7, 14, and 28. D Human rabies immune globulin and the first dose of the rabies vaccine are given after exposure.

25. A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's symptoms did not improve in 2 months. d. There is a 2-cm wheal at the site of the allergen injection.

ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months. DIF: Cognitive Level: Analyze (analysis) REF: 203 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

An overweight female patient who had enjoyed active outdoor activities is stressed because she is limited in what she can do because she has osteoarthritis in her hips. Which action by the nurse will best assist the patient to cope with this situation? a. Ask the patient what activities she misses the most. b. Have the patient practice frequent relaxation breathing. c. Teach the patient to use imagery to decrease pain and decrease stress. d. Encourage the patient to think about how weight loss might improve symptoms.

ANS: D For problems that can be changed or controlled, problem-focused coping strategies, such as encouraging the patient to lose weight, are most helpful. The other strategies also may assist the patient in coping with her problem, but they will not be as helpful as a problem-focused strategy.

22. A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer a skin test by the cutaneous scratch method.

ANS: D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching. DIF: Cognitive Level: Apply (application) REF: 200 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

10. The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? a. Shortness of breath c. Transfusion reaction b. High blood pressure d. Extremity numbness

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis. DIF: Cognitive Level: Apply (application) REF: 205 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient is extremely anxious about having a biopsy on a femoral lymph node in the groin area. Which relaxation technique would be best for the nurse to use at this time? a. Meditation b. Yoga stretching c. Guided imagery d. Relaxation breathing

ANS: D Relaxation breathing is an easy relaxation technique to teach and use. The patient should remain still during the biopsy and not move or stretch any of his extremities. Meditation and guided imagery require more time to practice and learn

An adult patient arrived in the emergency department (ED) with minor facial lacerations after a motor vehicle accident and has an initial blood pressure (BP) of 182/94. Which action by the nurse is most appropriate? a. Start an IV line to administer antihypertensive medications. b. Discuss the need for hospital admission to control blood pressure. c. Treat the abrasions and discuss the risks associated with hypertension. d. Recheck the blood pressure after the patient is stabilized and has received treatment.

ANS: D When a patient experiences an acute stressor, the blood pressure increases. The nurse should plan to recheck the BP after the patient has stabilized and received treatment. This will provide a more accurate indication of the patient's usual blood pressure. Elevated blood pressure that occurs in response to acute stress does not increase the risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.

Clostridium difficile (C-difficile) is a gram-positive anaerobic bacteria known to cause diarrhea, abdominal cramps, and fever. The CDC has reported that children are at minimal risks as this infection affects primarily the elderly or patients who are immunocompromised. Is this statement true or false?

ANS: F In 2005, the CDC reported an increase in the number of cases of Clostridium difficile in children who were previously thought to be at minimal risk. Children ages 1 to 4 are primarily affected.

Human cytomegalovirus (CMV) infection is a common cause of congenital infection and is the leading cause of hearing loss and intellectual disability in the United States. The neonate may be infected during the prenatal, perinatal, or postnatal period. Only infections acquired in utero cause permanent infection. Is this statement true or false

ANS: T Approximately one third of women with primary CMV infection transmit the virus to the fetus. The prevalence is one in 150 live births. Only 10% of infected newborns go on to manifest symptoms. These include jaundice, lethargy, seizures, petechiae, respiratory distress, enlarged liver, and microcephaly.

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient how to dispose of tissues with respiratory secretions. b. Stock the patient's room with the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.

B A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because it is an early stage of HIV infection, the infant will not contract HIV. d. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).

B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Explain to the patient that this is an expected finding. c. Request that an antibiotic be prescribed for the patient. d. Advise the patient that this indicates influenza infection.

B Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu. Ice will not decrease the swelling in persistent generalized lymphadenopathy

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)? a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection

B, C Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.

The nurse is teaching a mother about the use of oral corticosteroids to her 8-year-old child. Instruction by the nurse is correct if which information is given? Select all that apply. A. Administer the medication on an empty stomach to promote absorption. B. Give the medication with milk or food to prevent stomach upset. C. Postpone the administration of live virus vaccines until the oral corticosteroids are no longer being taken. D. Give live virus vaccines when the dose of oral corticosteroids is being reduced. E. Keep the child away from anyone with colds and coughs.

B, C, E Corticosteroids should be given with milk or food to prevent stomach upset. Live virus vaccines should not be given while a child is receiving corticosteroids. Corticosteroids mask infection and decrease the child's resistance to infection so they need to be kept away from sick or potentially sick individuals. Corticosteroids should be given with milk or food to prevent stomach upset. Live virus vaccines should not be given while a child is receiving corticosteroids

The camp nurse is telling a group of campers and their counselors how to avoid insect and tick bites. What information should the nurse include? Select all that apply. A. Dark, long-sleeved shirts should be worn. B. A hat is helpful when in wooded and grassy areas. C. Try to stay on paths rather than walking through dense areas. D. Apply insect repellent lightly on the hands. E. Ticks should be scraped off the skin. F. Shirts should be tucked into the pants.

B, C, F A hat is very helpful to protect the head from insects getting in the hair when in wooded and grassy areas. Trying to stay on paths rather than walking through dense areas is true. Shirts should be tucked into the pants to prevent insects and ticks getting to the skin. Light, long sleeved shirts should be worn because of being able to see insects and ticks. Insect repellent should not be applied on the hands because the hands often touch the eyes and mouth. Ticks should be removed with tweezers. The tick should be removed as close to the skin as possible using steady upward pressure. Ensure that all mouthparts are removed from the skin.

A child is experiencing intestinal cramping, diarrhea, and mucosal lesions. Which allergens would the nurse suspect are triggering these responses? Select all that apply. A. Pears B. Strawberries C. Apples D. Pollen E. Wheat F. Grass

B, E Foods that trigger an allergic reaction include milk, wheat, eggs, strawberries, tomatoes, oranges, chocolate, nuts, and shellfish. Wheat is a common trigger for allergic reactions. Apples do not generally trigger allergic reactions. Pollen is an environmental allergen and would not cause the symptoms listed. It would cause sneezing; red, itchy nose, eyes, pharynx, and palate; edematous nasal passages; tongue clicking; runny or congested nose; mouth breathing; chronic cough; dark circles under eyes; nose wrinkling; and pale, boggy nasal mucous membranes. Grass would cause the same reaction as pollen does. Pears do not generally trigger allergic reactions.

The mother of a 2-year-old with recurrent and resistant respiratory tract infections and chronic diarrhea and who is below the 50th percentile on the growth chart calls the pediatrician's office because her child is now pulling at her ears. In addition to the possibility of an ear infection, what might the nurse suspect the child is also experiencing? A. An oncology problem B. An immunology problem C. Some type of nut-related allergy D. An inner emotional conflict

B. An immunology problem Repeated or persistent respiratory tract infection, repeated or persistent otitis media or sinusitis, poor response to appropriate therapy, chronic diarrhea and failure to thrive can indicate an immunologic disorder. Nut-related allergies exhibit themselves in respiratory and cutaneous signs such as wheezing, swelling, and redness. There is no data that refers to any emotional issues. There is no data to say that an oncology problem exists.

A child with a depressed immune system due to chemotherapy for cancer has been admitted to the pediatric unit because of possible measles. What would the nurse expect to assess if the child is in the prodrome period of the disease? A. Confusion, chorea, and conjunctivitis B. Coryza, cough, and conjunctivitis C. Coordination problems, clubbing, and contractures D. Croup, congestion, and crying

B. Coryza, cough, and conjunctivitis Typically, children have a prodrome period with fever that rises gradually and the "three Cs" ([coryza or profuse runny nose], cough, and conjunctivitis) that lasts between 1 and 4 days. There are no coordination problems, clubbing of the digits, or contractures. Croup is a collection of problems and is not seen with measles. Crying is very vague, but there is some congestion. Confusion doesn't occur unless the fever is very high. There are no uncoordinated movements, but conjunctivitis is present.

The nurse is working with a teenager with systemic lupus erythematosus (SLE). What therapeutic management would the nurse expect to include during patient and family education? A. Foods that are high protein and low sodium B. Oral corticosteroids to control inflammation C. Gold salts to suppress the inflammatory process D. An exercise regimen to build up muscle strength and endurance

B. Oral corticosteroids to control inflammation Corticosteroids to control inflammation is the current primary mode of therapy. Gold salts are slow-acting anti-rheumatic agents used for those who do not respond to nonsteroidal anti-inflammatory drugs. Exercise should be done in moderation. A balanced diet without exceeding caloric expenditures is recommended.

A school-age child is recovering from infectious mononucleosis. What information should the nurse give the mother about activities when he returns to school? A. The child should eat away from the other children in the lunchroom. B. Participation in his physical education class should be limited to non-contact sports. C. Allow the child to rest until he returns to school without worrying about homework. D. He will be able to return to school full-time when he has his medical release.

B. Participation in his physical education class should be limited to non-contact sports. Participation in his physical education class should be limited to non-contact sports and quiet activities to protect the child's enlarged spleen from rupture. Allowing the child to postpone homework until he returns to school could put the child behind and cause additional stress. He might need to return to school part-time when he has his medical release. There is no reason he needs to eat away from the other children in the lunchroom. However, he should not share any of his lunch or anything saliva has touched.

The nurse is explaining the time interval between early manifestations of disease and the overt clinical syndrome to a parent calling about her sick child. Which word would the nurse use? A. The incubation period B. The prodromal period C. The desquamation period D. The period of communicability

B. The prodromal period The definition of prodromal period is the interval between early manifestations of the disease and the appearance of overt clinical symptoms. The "desquamation period" refers to the shedding of skin. The period of communicability is the time when the child is infectious. The incubation period is the time from exposure to appearance of first symptom.

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.

C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.

A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient how to reduce risky behaviors. b. Inform the patient about the available treatments. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to identify individuals who had intimate contact with the patient.

C After an initial positive antibody test result, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about the HIV status of other individuals.

The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient complains of feeling "constantly tired." b. The patient can't explain the effects of indinavir (Crixivan). c. The patient reports missing some doses of zidovudine (AZT). d. The patient reports having no side effects from the medications.

C Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Fatigue is a common side effect of ART. The nurse should discuss medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of AZT.

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time? a. Nystatin tablet b. Oral acyclovir (Zovirax) c. Oral saquinavir (Invirase) d. Aerosolized pentamidine (NebuPent)

C It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? a. "Thinking about dying will not improve the course of AIDS." b. "Do you think that taking an antidepressant might be helpful?" c. "Can you tell me more about the thoughts that you are having?" d. "It is important to focus on the good things about your life now."

C More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" or suggesting an antidepressant discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient.

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Clean drug injection equipment before each use." b. "Ask those who share equipment to be tested for HIV." c. "Consider participating in a needle-exchange program." d. "Avoid sexual intercourse when using injectable drugs."

C Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Needle stick injury with a suture needle during a surgery b. Splash into the eyes while emptying a bedpan containing stool c. Needle stick with a needle and syringe used for a venipuncture d. Contamination of open skin lesions with patient vaginal secretions

C Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions

C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose rapid HIV-antibody test is positive b. Patient whose latest CD4+ count has dropped to 250/μL c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs

C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.

A mother calls the pediatrician's office to find out how to provide comfort for her son who is itching from chickenpox. Information from the nurse is correct if which information is shared with the mother? A. "Encourage frequent warm baths." B. "Give acetaminophen (Tylenol)." C. "Give diphenhydramine (Benadryl)." D. "Apply a thick coat of Caladryl lotion over open lesions."

C. "Give diphenhydramine (Benadryl)." Antipruritic medicines such as diphenhydramine (Benadryl) are useful for severe itching, which interferes with sleep and may contribute to secondary infection. Caladryl lotion (contains Benadryl) should be applied sparingly over open lesions to minimize absorption. Cool baths are recommended for relief of itching. Acetaminophen (Tylenol) has no anti-itching effects.

The office nurse is taking a history on a child's illness from the parents. The nurse notes that the parents treated their 7-year-old child appropriately for a fever when they report that they provided what care? A. Gave baby aspirin (ASA) B. Bathed the child in cold water C. Gave fluids at frequent intervals D. Gave alternating dosages of acetaminophen (Tylenol) and ibuprofen (Motrin)

C. Gave fluids at frequent intervals Providing fluids at frequent intervals helps to meet the body's need for fluids during a febrile illness. Alternating acetaminophen (Tylenol) and ibuprofen (Motrin) might result in an overdose and has no real benefit. Aspirin is associated with Reye's syndrome and should not be given to children with a fever. The cold bath will chill the child and cause shivering, which is a response that will increase the body temperature.

The nurse is using Standard Precautions while caring for her patients. Nursing care is correct if which procedures are used to promote infection control? A. Gloves are worn any time a patient is touched. B. Needles are capped immediately after use and disposed of in a special container. C. Gloves are worn to change diapers when there are loose or explosive stools. D. Masks are used only when caring for patients with airborne infections.

C. Gloves are worn to change diapers when there are loose or explosive stools. Changing a diaper with loose or explosive stools has the greatest risk for exposure to body substances. Masks are a component of Transmission-Based Precautions and not Standard Precautions. Gloves are not indicated unless there is potential for contact with body substances. Used needles should never be capped. They should be immediately disposed of in a rigid puncture-proof container.

The nurse would expect which findings in a patient as a result of the physiologic effect of stress on the reticular formation? a. an episode of diarrhea while awaiting painful dressing changes b. refusal to communicate with nurses while awaiting a cardiac catheterization c. inability to sleep the night before beginning to self administer insulin injections d. increased blood pressure, decreased urine output and hyperglycemia after a car accident

C. Inability to sleep the night before beginning to self administer insulin injections

The school nurse is discussing prevention of human immunodeficiency virus (HIV) transmission with adolescents in a health class. What information is appropriate to include? A. The virus is easily transmitted. B. The virus is only transmitted through blood. C. Intravenous drug users should not share needles. D. Condoms should be used for homosexual sex.

C. Intravenous drug users should not share needles. HIV is spread through blood and body fluids. Intravenous needles that have been used should not be shared. They may be contaminated with the virus. Condoms should be used for both heterosexual and homosexual sex. The virus is not transmitted unless blood or body fluids directly contact non-intact skin or mucous membrane. If those conditions exist, then transmission is indeed "easy." Body fluids may also transmit the virus.

A 9-year-old child with a known peanut allergy has an allergic reaction right after eating potato chips with his classmates served from a large bowl during a party. After the child has been cared for, what action is most important for the nurse to initiate? A. A further investigation of the potato chips B. Asking if the child is allergic to potatoes C. Washing the serving bowl with soap and hot water D. Asking the child if this reaction happens often

C. Washing the serving bowl with soap and hot water For children with allergies to peanuts or other nuts, an anaphylactic reaction can occur with exposure to nut oils, surfaces contaminated with nuts, shell fragments, or cooking and serving utensils used previously for nut products. The bowl needs to be washed well. This would be helpful, but if the bowl still contains nut residue, the child would be in danger when consuming anything from this bowl. More than likely the potato chips had nothing to do with the child's allergic reaction. At this age the child should know if there is an allergy to potatoes.

During a stressful circumstance that is uncontrollable, which type of coping strategy is the most effective? a. avoidance b. coping flexibility c. emotion focused coping d. problem focused coping

C. emotion focused coping