NUR 257 - Test 1 Ch31-36

A. Encourage the client and family to be active partners in the management of the immunodeficiency.

. A home health nurse is caring for a client who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis? A. Encourage the client and family to be active partners in the management of the immunodeficiency. B. Encourage the client and family to manage the client's activity level and activities of daily living effectively. C. Make sure that the client and family understand the importance of monitoring fluid balance. D. Make sure that the client and family know how to adjust dosages of the medications used in treatment.

Partners Prevention of pregnancy Protection from STIs Practices Past history of STIs

5 P's for assessment of a patient with an STI

A. Wear a medical identification bracelet.

A 5-year-old client has been diagnosed with a severe food allergy. Which instruction should the nurse include when educating the parents about this client's allergy and care? A. Wear a medical identification bracelet. B. Know how to use the antihistamine pen. C. Know how to give injections of lidocaine. D. Avoid live attenuated vaccinations.

B. Carrying an epinephrine pen

A 5-year-old has been diagnosed with a severe walnut allergy after experiencing an anaphylactic reaction. Which topic is the nurse's priority when providing health education to the family? A. Beginning immunotherapy B. Carrying an epinephrine pen C. Maintaining the child's immunization status D. Avoiding all foods that have a high potential for allergies

C. An inflammation process

A 68-year-old client with a history of rheumatic disease has persistent swelling, no stiffness, and full range of motion to his left knee after an injury sustained several months ago. X-rays reveal no fracture of the extremity. Which factor is the most likely cause of the client's continued swelling? A. Degradation of cartilage B. Aging C. An inflammation process D. Reinjury not seen on x-ray results

B. Pain

A bone biopsy has just been completed on a client with suspected bone metastases. The nurse should prioritize assessments for which common complication of bone biopsy? A. Dehiscence at the biopsy site B. Pain C. Hematoma formation D. Infection

Fibromyalgia

A chronic disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping Cause: unknown

D. Effector stage

A client being treated for bacterial pneumonia initially experienced dyspnea and a high fever but now claims to be feeling better and is afebrile. The client is most likely in which stage of the immune response? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage

B. Colonization

A client has a concentration of S. aureus located on the skin. The client is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages? A. Infection B. Colonization C. Disease D. Bacteremia

D. Obtain a stool culture to identify possible pathogens.

A client has a diagnosis of AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate? A. Position the client in the high Fowler position whenever possible. B. Temporarily eliminate animal protein from the client's diet. C. Make sure the client eats at least two servings of raw fruit each day. D. Obtain a stool culture to identify possible pathogens.

A. Bone marrow suppression

A client has a diagnosis of rheumatoid arthritis, and the primary provider has now prescribed cyclophosphamide. The nurse's subsequent assessments should address which potential adverse effect? A. Bone marrow suppression B. Acute confusion C. Sedation D. Malignant hyperthermia

A. Increased eosinophils

A client has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the client will present with what alteration in laboratory values? A. Increased eosinophils B. Increased neutrophils C. Increased serum albumin D. Decreased blood glucose

ABC

A client has been brought to the emergency department after being found unresponsive, and anaphylaxis is suspected. The care team should attempt to assess for which potential causes of anaphylaxis? Select all that apply. A. Foods B. Medications C. Insect stings D. Autoimmunity E. Environmental pollutants

B. Phagocytic cells

A client has been brought to the emergency department by the parents after falling through the glass of a patio door, sustaining a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of which type of cell? A. Interferons B. Phagocytic cells C. Helper T cells D. Cytokines

ACE

A client has been diagnosed with Stevens-Johnson syndrome. Which factors are common triggers of this condition? Select all that apply. A. Tamoxifen and vemurafenib B. Exposure to cold objects, cold fluids, or cold air C. Allopurinol and nevirapine D. Wearing clothing washed in a detergent E. Radiation in combination with phenytoin

C. Arthrocentesis

A client has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate what diagnostic procedure? A. Arthrography B. Knee biopsy C. Arthrocentesis D. Electromyography

C. "The newer antihistamines are different than in years past, and cause less sedation."

A client has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young, I used to take antihistamines, but they always put me to sleep." How should the nurse best respond? A. "Newer antihistamines are combined with a stimulant that offsets drowsiness." B. "Most people find that they develop a tolerance to sedation after a few months." C. "The newer antihistamines are different than in years past, and cause less sedation." D. "Have you considered taking them at bedtime instead of in the morning?"

BCDE

A client has been transported to the emergency department after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply. A. Facilitate lung function testing. B. Assess breath sounds. C. Measure the client's oxygen saturation by oximeter. D. Monitor the client's respiratory pattern. E. Assess the client's respiratory rate.

B. Attachment

A client has come into contact with HIV. As a result, HIV glycoproteins have fused with the client's CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle? A. Integration B. Attachment C. Cleavage D. Budding

D. An HIV infection

A client has come into the free clinic asking to be tested for human immunodeficiency virus (HIV) infection. The client asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the acquired immunodeficiency syndrome (AIDS) virus are present in the blood, this indicates that the client has which of the following? A. Immunity to HIV B. An intact immune system C. An AIDS-related complication D. An HIV infection

D. Keep the hands well moisturized at all times

A client has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on the client's hands. What should the nurse teach the client to do? A. Wear powdered latex gloves when in public. B. Wash her hands with antibacterial soap every few hours. C. Maintain room temperature at 75 to 80°F (24° to 27°C) whenever possible. D. Keep the hands well moisturized at all times

D. Contact the primary provider immediately.

A client has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action? A. Arrange for a STAT assessment of the client's serum calcium levels. B. Perform active range of motion exercises. C. Assess the client's joint function symmetrically. D. Contact the primary provider immediately.

B. Infancy

A client has just been diagnosed with a primary immune deficiency disease (PIDD). The client has done some research online and believes this is an unlikely diagnosis due to the client's age. At which stage of life are people most commonly diagnosed with PIDD? A. Early childhood B. Infancy C. Adolescence D. Early adulthood

C. Identifying the offending agent, if possible

A client has presented with signs and symptoms that are consistent with contact dermatitis. Which aspect of care should the nurse prioritize when working with this client? A. Promoting adequate perfusion in affected regions B. Promoting safe use of topical antihistamines C. Identifying the offending agent, if possible D. Teaching the client to safely use an EpiPen

A. Type I

A client has sought care, stating that the client developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the client developed? A. Type I B. Type II C. Type III D. Type IV

A. Bone marrow suppression

A client has undergone treatment for urosepsis and received high doses of numerous antibiotics during the course of treatment. When planning the client's subsequent care, the nurse should be aware of which potential effect on the client's immune function? A. Bone marrow suppression B. Uncontrolled apoptosis C. Prostaglandin synthesis inhibition D. Immunosuppression

B. Droplet precautions

A client is admitted from the ED diagnosed with Neisseria meningitides. What type of isolation precautions should the nurse institute? A. Contact precautions B. Droplet precautions C. Airborne precautions D. Observation precautions

B. "This doesn't mean that you have an infection; it shows that the bacteria live on one of your skin surfaces."

A client is alarmed about testing positive for MRSA following culture testing during admission to the hospital. What should the nurse teach the client about this diagnostic finding? A. "There are promising treatments for MRSA, so this is no cause for serious concern." B. "This doesn't mean that you have an infection; it shows that the bacteria live on one of your skin surfaces." C. "The vast majority of clients in the hospital test positive for MRSA, but the infection doesn't normally cause serious symptoms." D. "This finding is only preliminary, and your doctor will likely order further testing."

D. Depressing antibody response

A client is being treated for cancer, and the nurse has identified the nursing diagnosis of Risk for Infection Due to Protein Losses. Protein losses inhibit immune response in which way? A. Causing apoptosis of cytokines B. Increasing interferon production C. Causing CD4+ cells to mutate D. Depressing antibody response

D. Determining whether the immune response will be the production of antibodies or a cell-mediated response

A client is fighting an active infection. What function will cytokines perform in this immune response? A. Determining whether a cell is foreign B. Determining if lymphokines will be activated C. Determining whether the T cells will remain in the nodes and retain a memory of the antigen D. Determining whether the immune response will be the production of antibodies or a cell-mediated response

B. The client is infected with HIV but lacks HIV-specific antibodies.

A client is in the primary infection stage of human immunodeficiency virus (HIV). Which statement regarding this client's current health status is most accurate? A. The client's HIV antibodies are successfully, but temporarily, killing the virus. B. The client is infected with HIV but lacks HIV-specific antibodies. C. The client's risk for opportunistic infections is at its peak. D. The client may or may not develop long-standing HIV infection.

B. Montelukast

A client is learning about a new diagnosis of asthma with the asthma nurse. What medication will best prevent the onset of acute asthma exacerbations? A. Diphenhydramine B. Montelukast C. Albuterol sulfate D. Epinephrine

B. Cytotoxic (type II)

A client is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the client begins to exhibit signs and symptoms of a transfusion reaction. The client is suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed type (type IV)

C. The response stage

A client is responding to a microbial invasion and the client's differentiated lymphocytes have begun to function in either a humoral or a cellular capacity. During what stage of the immune response does this occur? A. The recognition stage B. The effector stage C. The response stage D. The proliferation stage

B. Empty bladder

A client is scheduled for a bone scan to rule out osteosarcoma of the pelvic bones. Which client status would be most important for the nurse to verify before the client's scan? A. Completion of the bowel cleansing regimen B. Empty bladder C. No allergy to penicillins D. Fast for at least 8 hours

D. Cancel and reschedule the skin test when the client stops taking the corticosteroid.

A client is scheduled for a skin test. The client informs the nurse that the client used a corticosteroid earlier today to alleviate allergy symptoms. Which nursing intervention should the nurse implement? A. Note the corticosteroid use in the electronic health record and continue with the test. B. Modify the skin test to check for grass, mold, or dust allergies only. C. Administer sodium valproate to reverse the effects of corticosteroid usage. D. Cancel and reschedule the skin test when the client stops taking the corticosteroid.

D. Low serum calcium and low phosphorus level

A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results are most suggestive of this diagnosis? A. High chloride, calcium, and magnesium levels B. High parathyroid and calcitonin levels C. Low serum calcium and magnesium levels D. Low serum calcium and low phosphorus level

A. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B. "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." C. "OA originates with an infection. RA is a result of your body's cells attacking one another." D. "OA is associated with impaired immune function; RA is a consequence of physical damage."

C. Eggs and wheat

A client is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. Which food items would the nurse inform the client are common allergens? A. Citrus fruits and rice B. Root vegetables and tomatoes C. Eggs and wheat D. Hard cheeses and vegetable oils

B. Delayed hypersensitivity skin test

A client is undergoing testing to determine the overall function of the client's immune system. Which test will best identify the functioning of the client's cellular immune system? A. Immunoglobulin testing B. Delayed hypersensitivity skin test C. Specific antibody response D. Total serum globulin assessment

AE

A client is vigilant in self-care but is frustrated by a recent history of upper respiratory infections and influenza. Which aspects of the client's lifestyle may have a negative effect on immune response? Select all that apply. A. Exercises at the gym twice a day B. Does not consume any red meat C. Takes over-the-counter daily vitamins D. Sleeps approximately seven hours daily E. Works as a medical researcher

A. "I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in."

A client on airborne precautions asks the nurse to leave the door open. What is the nurse's best reply? A. "I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in." B. "I'll keep the door open for you, but please try to avoid moving around the room too much." C. "I can open your door if you wear this mask." D. "I can open your door, but I'll have to come back and close it in a few minutes."

D. Standard and airborne precautions

A client on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? A. Standard precautions only B. Droplet precautions C. Standard and contact precautions D. Standard and airborne precautions

D. Dupuytren disease

A client presents at the clinic with a report of morning numbness, cramping, and stiffness in the fourth and fifth fingers of the right hand. What disease process should the nurse suspect? A. Tendonitis B. A ganglion C. Carpal tunnel syndrome D. Dupuytren disease

D. Mild systemic reaction

A client received a bee sting on the lip approximately 2 hours ago and has arrived at an urgent/walk-in clinic for treatment because the swelling is now accompanied by nasal congestion. On assessment, the client reports pruritus and a sensation of warmth at the site. Which degree of anaphylaxis is the client experiencing? A. No systemic reaction B. Moderate systemic reaction C. Severe systemic reaction D. Mild systemic reaction

A. A primary immune deficiency

A client requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this client most likely has which type of immune disorder? A. A primary immune deficiency B. A gammopathy C. An autoimmune disorder D. A rheumatic disorder

A. Carpel tunnel syndrome

A client tells the nurse that they haves pain and numbness in the thumb, first finger, and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the client has what health problem? A. Carpel tunnel syndrome B. Tendonitis C. Impingement syndrome D. Dupuytren contracture

C. Follow-up testing will be promptly performed to confirm the result.

A client underwent an antibody test for human immunodeficiency virus (HIV) as part of a screening process and has just been told that the results were positive. Which anticipatory guidance regarding the next step should the nurse provide to the client? A. The client will be started on fluoxetine in 1 month. B. Antiretroviral therapy will begin within 3 months. C. Follow-up testing will be promptly performed to confirm the result. D. The client will be monitored for signs and symptoms of HIV to determine the need for treatment

B. Refer the client to a primary care provider to have the medication changed.

A client was prescribed an oral antibiotic for the treatment of sinusitis. The client has now stopped, reporting the development of a rash shortly after taking the first dose of the drug. Which response by the nurse would be most appropriate? A. Encourage the client to continue with the medication while monitoring the skin condition closely. B. Refer the client to a primary care provider to have the medication changed. C. Arrange for the client to go to the nearest emergency department. D. Encourage the client to take an over-the-counter antihistamine with each dose of the antibiotic.

B. Proliferation

A client was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response? A. Effector B. Proliferation C. Response D. Recognition

B. Proliferation stage

A client was scratched by an old tool and developed a virulent staphylococcus infection. During the immune response, circulating lymphocytes containing the antigenic message returned to the nearest lymph node. During what stage of the immune response did this occur? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage

B. Impaired skin integrity related to Kaposi sarcoma

A client who has acquired immunodeficiency syndrome (AIDS) has been admitted for the treatment of Kaposi sarcoma. Which nursing diagnosis should the nurse associate with this complication of AIDS? A. Risk for disuse syndrome related to Kaposi sarcoma B. Impaired skin integrity related to Kaposi sarcoma C. Diarrhea related to Kaposi sarcoma D. Impaired swallowing related to Kaposi sarcoma

A. Administer antidiarrheal medications on a scheduled basis, as prescribed.

A client with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea? A. Administer antidiarrheal medications on a scheduled basis, as prescribed. B. Encourage the client to eat three balanced meals and a snack at bedtime. C. Increase the client's oral fluid intake. D. Encourage the client to increase his or her activity level.

B. Importance of personal hygiene

A client with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? A. Appropriate use of prophylactic antibiotics B. Importance of personal hygiene C. Signs and symptoms of wasting syndrome D. Strategies for adjusting antiretroviral dosages

A. Protective isolation

A client with Wiskott-Aldrich syndrome (WAS) is admitted to the medical unit. The nurse caring for the client should prioritize which intervention? A. Protective isolation B. Fresh-frozen plasma (FFP) administration C. Chest physiotherapy D. Nutritional supplementation

C. Assess the client for signs and symptoms of infection.

A client with a diagnosis of primary immunodeficiency disease informs the nurse that the client has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the client's vital signs are within reference ranges, what action should the nurse take? A. Administer a nebulized bronchodilator. B. Perform oral suctioning. C. Assess the client for signs and symptoms of infection. D. Teach the client deep breathing and coughing exercises.

B. Ineffective individual coping with chronicity of condition

A client with a documented history of allergies presents to the clinic. The client reports being frustrated by chronic nasal congestion, anosmia (inability to smell), and inability to concentrate. The nurse should identify which nursing diagnosis? A. Deficient knowledge of self-care practices related to allergies B. Ineffective individual coping with chronicity of condition C. Acute confusion related to cognitive effects of allergic rhinitis D. Disturbed body image related to sequelae of allergic rhinitis

D. IgE

A client with a family history of allergies has experienced an allergic response based on a genetic predisposition. This atopic response is usually mediated by which immunoglobulin (Ig)? A. IgA B. IgM C. IgG D. IgE

A. Immunosuppression

A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which complication of therapy? A. Immunosuppression B. Agranulocytosis C. Anemia D. Thrombocytopenia

C. "Many clients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks."

A client with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond? A. "Complementary therapies generally have not been approved, so clients are usually discouraged from using them." B. "Researchers have not looked at the benefits of alternative therapy for clients with HIV, so we suggest that you stay away from these therapies until there is solid research data available." C. "Many clients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks." D. "You'll need to meet with your doctor to choose between an alternative approach to treatment and a medical approach."

A. "You seem like you're feeling angry. Is that something that we could talk about?"

A client with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on a medical unit. The nurse observes that the client expresses anger and irritation when the call bell isn't answered immediately. Which response would be the most appropriate? A. "You seem like you're feeling angry. Is that something that we could talk about?" B. "Try to remember that stress can make your symptoms worse." C. "Would you like to talk about the problem with the nursing supervisor?" D. "I can see you're angry. I'll come back when you've calmed down."

C. Cellular

A client with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. Which immune response predominates in this situation? A. Humoral B. Nonspecific C. Cellular D. Antibody

C. Complement system

A client with hepatitis B has been admitted to the medical intensive care unit with sepsis. Which immunity function was most likely compromised? A. Lymphatic system B. Passive immunity C. Complement system D. Monoclonal antibodies

A. "I can only imagine how you feel. Would you like to talk about it?"

A client with multiple food and environmental allergies expresses frustration and anger over having to be so watchful all the time and wonders if it is really worth it. Which response by the nurse would be best? A. "I can only imagine how you feel. Would you like to talk about it?" B. "Let's find a quiet spot, and I'll teach you a few coping strategies." C. "That's the same way that most clients who have a chronic illness feel." D. "Do you think that maybe you could be managing things more efficiently?"

B. Restrict consumption of foods high in purines.

A client with rheumatoid arthritis comes to the clinic reporting pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize? A. Take OTC calcium supplements consistently. B. Restrict consumption of foods high in purines. C. Ensure fluid intake of at least 4 L per day. D. Restrict weight-bearing on right foot.

B. The client will remain in the clinic to be monitored for 30 minutes following the injection.

A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment? A. The client will be given a low dose of epinephrine before the treatment. B. The client will remain in the clinic to be monitored for 30 minutes following the injection. C. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months. D. The allergen will be given by the peripheral intravenous (IV) route

C. "I'll make sure to monitor my body temperature on a regular basis."

A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement? A. "I'll make sure I get enough exposure to sunlight to keep up my vitamin D levels." B. "I'll try to be as physically active as possible between flare-ups." C. "I'll make sure to monitor my body temperature on a regular basis." D. "I'll stop taking my steroids when I get relief from my symptoms."

D. Take this medication without regard to meals.

A client's current antiretroviral regimen includes enfuvirtide (T-20). What dietary counseling will the nurse provide based on the client's medication regimen? A. Avoid high-fat meals while taking this medication. B. Limit fluid intake to 2 L/day. C. Limit sodium intake to 2 g/day. D. Take this medication without regard to meals.

C. Cytotoxic T cells

A client's current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by which cells? A. Suppressor T cells B. Memory T cells C. Cytotoxic T cells D. Complement T cells

A. Rheumatoid arthritis (RA)

A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with which health problem? A. Rheumatoid arthritis (RA) B. Systemic lupus erythematosus (SLE) C. Osteoporosis D. Polymyositis

A. Herpes simplex

A client's exposure to which microorganism is most likely to trigger a cellular response? A. Herpes simplex B. Staphylococcus aureus C. Pseudomonas aeruginosa D. Beta-hemolytic Streptococcus

D. Asthma

A client's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this client consequently faces an increased risk of which health problem? A. Bronchitis B. Systemic lupus erythematosus (SLE) C. Rheumatoid arthritis (RA) D. Asthma

D. Neutrophils

A client's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at this client's site of inflammation? A. Eosinophils B. Red blood cells C. Lymphocytes D. Neutrophils

C. Gastric secretions

A client's natural immunity is enhanced by processes that are inherent in the physical and chemical barriers of the body. What is a chemical barrier that enhances natural immunity? A. Cell cytoplasm B. Interstitial fluid C. Gastric secretions D. Cerebrospinal fluid

C. Viral set point

A client's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the client's immune response. This is known as what physiologic state? A. Static stage B. Latent stage C. Viral set point D. Window period

C. Cell-mediated immune function

A client's recent diagnostic testing included a total lymphocyte count. The results of this test will allow the care team to gauge what aspect of the client's immunity? A. Humoral immune function B. Antigen recognition C. Cell-mediated immune function D. Antibody production

A. Human immunodeficiency virus (HIV) encephalopathy

A clinic nurse is caring for a client admitted with acquired immunodeficiency syndrome (AIDS). The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of which complication? A. Human immunodeficiency virus (HIV) encephalopathy B. B-cell lymphoma C. Kaposi sarcoma D. Wasting syndrome

D. Fatigue related to pain

A clinic nurse is caring for a client newly diagnosed with fibromyalgia. When developing a care plan for this client, which nursing diagnosis should the nurse prioritize? A. Impaired urinary elimination related to neuropathy B. Altered nutrition related to impaired absorption C. Disturbed sleep pattern related to central nervous system stimulation D. Fatigue related to pain

C. Increased uric acid levels

A clinic nurse is caring for a client with suspected gout. While describing the pathophysiology of gout to the client, what should the nurse explain? A. Autoimmune processes in the joints B. Chronic metabolic acidosis C. Increased uric acid levels D. Unstable serum calcium levels

D. Functional status

A community health nurse is performing a visit to the home of a client who has a history of rheumatoid arthritis (RA). On which aspect of the client's health should the nurse focus most closely during the visit? A. Understanding of rheumatoid arthritis B. Risk for cardiopulmonary complications C. Social support system D. Functional status

ABE

A female client who is HIV negative arrives for a gynecologist appointment and reports that her husband, who is HIV positive, no longer wants to wear a latex condom. Which alternative treatments would the nurse recommend to reduce the likelihood of HIV transmission? Select all that apply. A. Dental dam B. Polyurethane female condom C. Microbicidal vaginal suppository D. Non-latex male condoms E. Pre-exposure prophylaxis

A. Antibodies

A gardener sustained a deep laceration while working and requires sutures. The date of the client's last tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus immunization, which will allow for the release of which type of substance? A. Antibodies B. Antigens C. Cytokines D. Phagocytes

C. Impaired ciliary action

A gerontologic nurse is caring for a 78-year-old client who has a diagnosis of pneumonia. Which age-related change increases older adults' susceptibility to respiratory infections? A. Atrophy of the thymus B. Bronchial stenosis C. Impaired ciliary action D. Decreased diaphragmatic muscle tone

ACE

A health care provider is taking post-exposure prophylaxis (PEP) medications for exposure to a client with human immunodeficiency virus (HIV). Which topics will the health care provider need to understand regarding PEP administration prior to beginning this regimen? Select all that apply. A. Potential drug toxicities B. Needed dietary changes C. Potential drug interactions D. Sleep pattern disturbances E. Adherence requirements

C. Anaphylaxis due to a latex allergy

A junior nursing student is having an observation day in the operating room. Early in the day, the student reports eye swelling and dyspnea to the OR nurse. What should the nurse suspect? A. Cytotoxic reaction due to contact with the powder in the gloves B. Immune complex reaction due to contact with anesthetic gases C. Anaphylaxis due to a latex allergy D. Delayed reaction due to exposure to cleaning products

B. Wear a condom every time the client has intercourse.

A male client with gonorrhea asks the nurse how they can reduce the risk of contracting another sexually transmitted infection (STI). The client is not in a monogamous relationship. The nurse should instruct the client to do what action? A. Ask all potential sexual partners if they have an STI. B. Wear a condom every time the client has intercourse. C. Consider intercourse to be risk-free if the partner has no visible discharge, lesions, or rashes. D. Aim to limit the number of sexual partners to fewer than five over their lifetime.

A. Frequent handwashing reduces transmission of pathogens from one client to another

A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice? A. Frequent handwashing reduces transmission of pathogens from one client to another. B. Wearing gloves is known to be an adequate substitute for handwashing. C. Bar soap is preferable to liquid soap. D. Waterless products should be avoided in situations where running water is unavailable.

D. Nonspecific immunity

A neonate exhibited some preliminary signs of infection, but the infant's condition resolved spontaneously prior to discharge home from the hospital. This infant's recovery was most likely due to which type of immunity? A. Cytokine immunity B. Specific immunity C. Active acquired immunity D. Nonspecific immunity

B. Keeping appointments for desensitization procedures

A nurse at an allergy clinic is providing education for a client starting immunotherapy for the treatment of allergies. Which education should the nurse prioritize? A. Scheduling appointments for the same time each month B. Keeping appointments for desensitization procedures C. Avoiding antihistamines for the duration of treatment D. Keeping a diary of reactions to the immunotherapy

C. So that early signs of impending infection can be detected and treated

A nurse caring for a client who has an immunosuppressive disorder knows that continual monitoring of the client is critical. What is the primary rationale behind the need for continual monitoring? A. So that the client's functional needs can be met immediately B. So that medications can be given as prescribed and signs of adverse reactions noted C. So that early signs of impending infection can be detected and treated D. So that the nurse's documentation can be thorough and accurate

D. Diabetes

A nurse educator is developing a care plan concerning a risk of infection related to vascular insufficiency. Which disease and/or injury would most likely align with this nursing care plan? A. Transient ischemic attack (TIA) B. Major burns C. Chronic obstructive pulmonary disease (COPD) D. Diabetes

D. Humoral

A nurse has admitted a client who has been diagnosed with urosepsis. Which immune response predominates in sepsis? A. Mitigated B. Nonspecific C. Cellular D. Humoral

A. "The faster the onset of symptoms, the more severe the reaction."

A nurse has asked the nurse educator if there is any way to predict the severity of a client's anaphylactic reaction. Which response by the nurse educator would be best? A. "The faster the onset of symptoms, the more severe the reaction." B. "The reaction will be about one-third more severe than the client's last reaction to the same antigen." C. "There is no way to gauge the severity of a client's anaphylaxis, even if it has occurred repeatedly in the past." D. "The reaction will generally be slightly less severe than the last reaction to the same antigen."

B. Passive acquired immunity

A nurse has given an 8-year-old client the scheduled vaccination for rubella. This vaccination will cause the client to develop which expected and desired condition? A. Natural immunity B. Passive acquired immunity C. Cellular immunity D. Mild hypersensitivity

C. Spina bifida

A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a client's plan of care. The presence of which chronic health problem would most likely prompt this diagnosis? A. Herpes simplex B. Human immunodeficiency virus (HIV) C. Spina bifida D. Hypogammaglobulinemia

B. The client's body mass index is 34 (obese).

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor? A. The client has a 30 pack-year smoking history. B. The client's body mass index is 34 (obese). C. The client has primary hypertension. D. The client is 58 years old

B. Tachypnea and restlessness

A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? A. Oral temperature of 37.2°C (99°F) B. Tachypnea and restlessness C. Frequent loose stools D. Weight loss of 0.45 kg (1 lb) since yesterday

A. Perianal region and oral mucosa

A nurse is assessing the skin integrity of a client who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? A. Perianal region and oral mucosa B. Sacral region and lower abdomen C. Scalp and skin over the scapulae D. Axillae and upper thorax

B. Weak pulse

A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration? A. Labile BP B. Weak pulse C. Fever D. Diaphoresis

C. "AIDS isn't transmitted by casual contact."

A nurse is caring for a client hospitalized with AIDS. A friend comes to visit the client and privately asks the nurse about the risk of contracting HIV when visiting the client. What is the nurse's best response? A. "Do you think that you might already have HIV?" B. "Your immune system is likely very healthy." C. "AIDS isn't transmitted by casual contact." D. "You can't normally contract AIDS in a hospital setting."

D. Modify the environment to reduce the severity of allergic symptoms.

A nurse is caring for a client who has allergic rhinitis. What intervention would be most likely to help the client meet the goal of improved breathing pattern? A. Teach the client to take deep breaths and cough frequently. B. Use antihistamines daily throughout the year. C. Teach the client to seek medical attention at the first sign of an allergic reaction. D. Modify the environment to reduce the severity of allergic symptoms.

D. Ensuring that there are no metal objects on or in the client

A nurse is caring for a client who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure? A. Assessing the client for signs and symptoms of active infection B. Ensuring that the client can remain immobile for up to 3 hours C. Assessing the client for a history of nut allergies D. Ensuring that there are no metal objects on or in the client

C. Antigenic determinant

A nurse is caring for a client who has had a severe antigen-antibody reaction. Which portion of the antigen is involved in binding with the antibody? A. Antibody agglutination B. Antigenic message C. Antigenic determinant D. Antibody response

B. Thigh

A nurse is caring for a client who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse explains that the client should self-administer epinephrine at which site? A. Forearm B. Thigh C. Deltoid muscle D. Abdomen

BD

A nurse is caring for a client who is suspected of having giant cell arteritis (GCA). Which laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply. A. Erythrocyte count B. Erythrocyte sedimentation rate C. Creatinine clearance D. C-reactive protein E. D-dimer

C. An elevated serum alkaline phosphatase level and a normal serum calcium level

A nurse is caring for a client with Paget disease and is reviewing the client's most recent laboratory values. Which of the following values are most characteristic of Paget disease? A. An elevated level of parathyroid hormone and low calcitonin levels B. A low serum alkaline phosphatase level and a low serum calcium level C. An elevated serum alkaline phosphatase level and a normal serum calcium level D. An elevated calcitonin level and low levels of parathyroid hormone

A. Avoid lifting more than one-third of body weight without assistance.

A nurse is caring for an adult client diagnosed with a back strain. What health education should the nurse provide to this client? A. Avoid lifting more than one-third of body weight without assistance. B. Focus on using back muscles efficiently when lifting heavy objects. C. Lift objects while holding the object a safe distance from the body. D. Tighten the abdominal muscles and lock the knees when lifting an object.

A. Stress on the weakened bone must be avoided.

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client? A. Stress on the weakened bone must be avoided. B. Increased heart rate enhances perfusion and bone healing. C. Bed rest results in improved outcomes in clients with osteomyelitis. D. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.

ABDE

A nurse is completing the nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. A. Serum albumin level B. Weight history C. White blood cell count D. Body mass index E. Blood urea nitrogen (BUN) level

C. Limiting intake of alcohol

A nurse is educating a client with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? A. Ensuring adequate rest B. Limiting exposure to sunlight C. Limiting intake of alcohol D. Smoking cessation

B. The interactions that occur between T cells and B cells

A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this? A. The movement of B cells in and out of lymph nodes B. The interactions that occur between T cells and B cells C. The differentiation between different types of T cells D. The universal role of the complement system

B. Apoptosis

A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process? A. The cellular immune response B. Apoptosis C. Phagocytosis D. Opsonization

ADE

A nurse is implementing the care plan of diarrhea related to enteric pathogens of human immunodeficiency virus infections. Which interventions are needed to reach the goal of resuming usual bowel habits? Select all that apply. A. Administer antimicrobials. B. Restrict fluid to 1500 mL/50.7 fl oz daily. C. Implement a BRAT diet. D. Administer antitussives. E. Establish normal bowel pattern.

B. Diarrhea

A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis? A) Acute Abdominal Pain B) Diarrhea C) Bowel Incontinence D) Constipation

ABCE

A nurse is performing the admission assessment of a client who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. A. Current medication regimen B. Identification of client's support system C. Immune system function D. Genetic risk factors for HIV E. History of sexual practices

C. Joint stiffness lasting longer than 1 hour, especially in the morning

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A. Cool joints with decreased range of motion B. Signs of systemic infection C. Joint stiffness lasting longer than 1 hour, especially in the morning D. Visible atrophy of the knee and shoulder joint

B. Erythematous rash

A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). Which skin manifestation would the nurse expect to observe on inspection? A. Petechiae B. Erythematous rash C. Jaundice D. Skin sloughing

B. Proliferation stage

A nurse is planning a client's care and is relating it to normal immune response. During which stage of the immune response do sensitized lymphocytes stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage

C. Women

A nurse is planning the assessment of a client who is exhibiting signs and symptoms of an autoimmune disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is known to be higher among which group? A. Young adults B. Native Americans/First Nations C. Women D. People of Hispanic descent

A. Ineffective role performance related to pain

A nurse is planning the care of a client who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. Which nursing diagnosis is most likely to apply to this client's care needs? A. Ineffective role performance related to pain B. Risk for impaired skin integrity related to myalgia C. Risk for infection related to tissue alterations D. Unilateral neglect related to neuropathic pain

D. Thorough and consistent hand hygiene

A nurse is planning the care of a client who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this client? A. Administration of IVIG B. Antibiotic administration C. Appropriate use of gloves and goggles D. Thorough and consistent hand hygiene

A. Ineffective airway clearance

A nurse is planning the care of a client with acquired immunodeficiency syndrome (AIDS) who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this client? A. Ineffective airway clearance B. Impaired oral mucous membranes C. Imbalanced nutrition: Less than body requirements D. Activity intolerance

A. Ensuring adequate exposure to sunlight

A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis? A. Ensuring adequate exposure to sunlight B. Eating a low-purine diet C. Performing cardiovascular exercise while avoiding weight-bearing exercises D. Taking thyroid supplements as prescribed

D. Emergency equipment should be readily available

A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? A. The client must not have received an immunization within 7 days. B. The nurse should administer albuterol 30 to 45 minutes prior to the test. C. Prophylactic epinephrine should be given before the test. D. Emergency equipment should be readily available

AB

A nurse is preparing a presentation for a local high school health class about STIs. When discussing the most commonly reported STIs, which infection would the nurse most likely include? Select all that apply. A. chlamydia B. gonorrhea C. human papillomavirus infection D. herpes simplex 2 virus infection E. syphilis

C. Avoid recapping the needle before disposing of it.

A nurse is preparing to administer a client's scheduled dose of subcutaneous heparin. To reduce the risk of needlestick injury, the nurse should perform which action with used needles? A. For multiple injections, insert the needle into the bed. B. Recap the needle immediately before leaving the room. C. Avoid recapping the needle before disposing of it. D. Wear gloves when administering the injection.

D. The use of corticosteroids increases the risk of osteoporosis.

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate? A. High levels of vitamin D can cause osteoporosis. B. A nonmodifiable risk factor for osteoporosis is a person's level of activity. C. Secondary osteoporosis occurs in women after menopause. D. The use of corticosteroids increases the risk of osteoporosis.

ABCD

A nurse is providing care for a client who has a recent diagnosis of Paget disease. When planning this client's nursing care, what should interventions address? Select all that apply. A. Impaired physical mobility B. Acute pain C. Disturbed auditory sensory perception D. Risk for injury E. Risk for unstable blood glucose

B. Systemic lupus erythematosus (SLE)

A nurse is providing care for a client who has a rheumatic disorder. The nurse's focused assessment includes the client's mood, behavior, level of consciousness, and neurologic status. Which diagnosis is most likely for this client? A. Osteoarthritis (OA) B. Systemic lupus erythematosus (SLE) C. Rheumatoid arthritis (RA) D. Gout

C. Maintenance of adequate levels of activated vitamin D

A nurse is providing care for a client who has osteomalacia. What major goal should guide the choice of medical and nursing interventions? A. Maintenance of skin integrity B. Prevention of bone metastasis C. Maintenance of adequate levels of activated vitamin D D. Maintenance of adequate parathyroid hormone function

D. Subcortical neurodegenerative disease

A nurse is providing ongoing care for a client who is positive for human immunodeficiency virus (HIV), and assessment reveals a client with a newly delayed and shortened speech pattern. The client, who previously had no neurological or motor deficits, has forgotten that they are in the hospital and has trouble getting out of bed. Which problem is the client most likely experiencing related to these signs and symptoms? A. Cryptococcal meningitis B. Cytomegalovirus retinitis C. Peripheral neuropathy D. Subcortical neurodegenerative disease

C. An antineoplastic

A nurse is reviewing a client's medication administration record in an effort to identify drugs that may contribute to the client's recent immunosuppression. What drug is most likely to have this effect? A. An antibiotic B. A nonsteroidal anti-inflammatory drug (NSAID) C. An antineoplastic D. An antiretroviral

D. Antibodies are made by B lymphocytes in response to a specific antigen.

A nurse is reviewing the immune system before planning an immunocompromised client's care. How should the nurse characterize the humoral immune response? A. Specialized cells recognize and ingest cells that are recognized as foreign. B. T lymphocytes are assisted by cytokines to fight infection. C. Lymphocytes are stimulated to become cells that attack microbes directly D. Antibodies are made by B lymphocytes in response to a specific antigen.

C. Calcitonin

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? A. Estrogen B. Parathyroid hormone (PTH) C. Calcitonin D. Progesterone

A. Evaluating the effects of the musculoskeletal disorder on the client's function

A nurse is taking a health history on a client with musculoskeletal dysfunction. What should the nurse prioritize during this phase of the assessment? A. Evaluating the effects of the musculoskeletal disorder on the client's function B. Evaluating the client's adherence to the existing treatment regimen C. Evaluating the presence of genetic risk factors for further musculoskeletal disorders D. Evaluating the client's active and passive range of motio

DE

A nurse is teaching an educational class to a group of older adults at a community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. A. Vitamin B12 B. Potassium C. Calcitonin D. Calcium E. Vitamin D

B. 200 cells/mm3 of blood

A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold? A. 75 cells/mm3 of blood B. 200 cells/mm3 of blood C. 325 cells/mm3 of blood D. 450 cells/mm3 of blood

B. A client who is at 30 weeks' gestation

A nurse knows of several clients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which client? A. A client who has previously been treated for tuberculosis B. A client who is at 30 weeks' gestation C. A client who is on estrogen-replacement therapy D. A client with a severe allergy to eggs

C. Computed tomography with contrast solution

A nurse should prioritize and closely monitor a client for a potentially severe anaphylactic reaction after the client has received which medical intervention? A. Measles-mumps-rubella vaccine B. Rapid administration of intravenous fluids C. Computed tomography with contrast solution D. Nebulized bronchodilator

C. Small frame and female sex

A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What of the following risk factors should the educator describe? A. Recurrent infections and prolonged use of NSAIDs B. High alcohol intake and low body mass index C. Small frame and female sex D. Male sex, diabetes, and high protein intake

A. Contact

A nursing home resident has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents? A. Contact B. Droplet C. Airborne D. Positive pressure isolation

C. Hematopoietic stem cell transplantation (HSCT)

A pediatric nurse is working with an interdisciplinary team and parents to care for a 6-month-old client who has recently been diagnosed with severe combined immune deficiency (SCID). Which treatment is likely of most benefit to this client's type of primary immune deficiency disease (PIDD)? A. Combined radiotherapy and chemotherapy B. Antibiotic therapy C. Hematopoietic stem cell transplantation (HSCT) D. Treatment with colony-stimulating factors (CSFs)

B. Arthritis

A public health nurse is organizing a campaign that will address the leading cause of musculoskeletal-related disability. The nurse should focus on what health problem? A. Osteoporosis B. Arthritis C. Hip fractures D. Lower back pain

C. Older adults with compromised health status

A public health nurse promoting the annual influenza vaccination is focusing health promotion efforts on the populations most vulnerable to death from influenza. The nurse should focus on which of the following groups? A. Preschool-aged children B. Adults with diabetes and/or kidney disease C. Older adults with compromised health status D. Infants under the age of 12 months

A. Assess for signs and symptoms of anaphylaxis.

A school nurse is caring for a 10-year-old who appears to be having an allergic response. Which intervention should be the initial action of the school nurse? A. Assess for signs and symptoms of anaphylaxis. B. Assess for erythema and urticaria. C. Administer an over-the-counter (OTC) antihistamine. D. Administer epinephrine.

B. Washing hands immediately after removing gloves

A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions? A. Wearing a mask and gown when starting an IV line B. Washing hands immediately after removing gloves C. Recapping all needles promptly after use to prevent needlestick injuries D. Double-gloving when working with a client who has a bloodborne illness

A. Removing the cat from the family's home

After the completion of testing, a 7-year-old client's allergies have been attributed to the family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote which action? A. Removing the cat from the family's home B. Administering over-the-counter antihistamines to the client regularly C. Keeping the cat restricted from the client's bedroom D. Maximizing airflow in the house

D. "Your baby could contract HIV before, during, or after delivery."

An 18-year-old client who is pregnant has tested positive for human immunodeficiency virus (HIV) and asks the nurse if her baby is going to be born with HIV. Which response by the nurse is the best? A. "Your baby has a one in four chance of being born with HIV." B. "Your health care provider is likely the best one to answer that question." C. "If the baby is HIV-positive, we can't do anything until after the birth, so try not to worry." D. "Your baby could contract HIV before, during, or after delivery."

A. Osteomyelitis

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem? A. Osteomyelitis B. Osteoporosis C. Osteomalacia D. Septic arthritis

C. Maintain cleanliness in the home, but recognize that the home does not need to be sterile.

An immunosuppressed client is receiving chemotherapy treatment at home. What infection-control measure should the nurse recommend to the family? A. Family members should avoid receiving vaccinations until the client has recovered from his or her illness. B. Wipe down hard surfaces with a dilute bleach solution once per day. C. Maintain cleanliness in the home, but recognize that the home does not need to be sterile. D. Avoid physical contact with the client unless absolutely necessary.

A. Agglutination

An infection control nurse is presenting an in-service reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining? A. Agglutination B. Cellular immune response C. Humoral response D. Phagocytic immune response

A. Centers for Disease Control and Prevention (CDC)

An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization? A. Centers for Disease Control and Prevention (CDC) B. American Medical Association (AMA) C. Environmental Protection Agency (EPA) D. American Nurses Association (ANA)

A. Anaphylactic (type 1)

An office worker eats a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger, and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed-type (type IV)

HIV-associated neurocognitive disorder (HAND)

Complication of HIV/AIDS that manifests as: difficulties with attention, concentration, and memory; loss of motivation; irritability; depression; and slowed movements. also known as HIV encephalopathy

C. Bridge natural and acquired immunity.

Diagnostic testing has revealed a deficiency in the function of a client's complement system. This client is likely to have an impaired ability to do what action? A. Protect the body against viral infection. B. Mark the parameters of the immune response. C. Bridge natural and acquired immunity. D. Collect immune complexes during inflammation

Low Purine

Diet limitations for a person with gout

Anti-inflammatory diet

Diet recommended for those with back pain. Consists of Kale, broccoli and spinach

ECBAD

During a code blue, a nurse sustained a needlestick injury from a client whose human immunodeficiency virus (HIV) status was unknown. The nursing supervisor is notified, an incident report is generated, and a post-HIV exposure prophylaxis checklist is started for this nurse. In which order would the checklist be implemented? A. Administer post-exposure prophylaxis (PEP) medication. B. Advise exposed health care providers to use precautions. C. Get counseling at the time of exposure. D. Undergo early reevaluation after exposure. E. Determine the HIV status of the client.

A. acquired immunity.

During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses: A. acquired immunity. B. natural immunity. C. phagocytic immunity. D. humoral immunity.

Stage 0

Early HIV infection; inferred from laboratory testing

Passive Immunity

Examples include: •transfer of antibodies from mother to infant through breast feeding; receiving immune globulin through injections

A. Use caution when shaving the client.

Family members are caring for a client with HIV in the client's home. What should the nurse encourage family members to do to reduce the risk of infection transmission? A. Use caution when shaving the client. B. Use separate dishes for the client and family members. C. Use separate bed linens for the client. D. Disinfect the client's bedclothes regularly.

CT Scan

Fastest scan that requires no intervention prior.

Immune System

Functions to remove foreign antigens such as viruses and bacteria to maintain homeostasis.

Airborne precautions

Hospitalized patient should be in a negative pressure room with the door closed; health care providers should wear an N-95 respirator (mask) at all times when in the room ex: TB, COVID19, varicella

blood body fluids not through casual contact

How is HIV trasmitted?

IgE antibodies

Hypersensitive reaction to an allergen initiated by immunologic mechanisms that is usually mediated by _________________

Immunocompromised

If a person has had their spleen removed, they are considered to be ____________________________.

Active Immunity

Immunologic defenses developed by person's own body Lasts many years; may last a lifetime

Airway

Issue you need to worry about with urticaria.

Epinephrine

Medication used for anaphylactic reactions

Biphosphonates

Medications for osteoporosis/paget's disease

Antiobiotics (penicillin)

Most common cause of anaphylaxis

MRSA (methicillin-resistant Staphylococcus aureus)

Most common cause of osteomyelitis

Osteoarthritis

Most common form of joint disease Characterized by noninflammatory degenerative disorder of the joints

Needles/Drug Use

Most common way HIV is spread?

Breastfeeding

Mother's with newborns should refrain from _______________________ if that have HIV.

Unknown stage

No information on CD4+ T-lymphocyte count or percentage

A. Efavirenz

On admission to a medical unit, a client with human immunodeficiency virus (HIV) tests positive for benzodiazepine. The client denies using this medication. Which medication is likely causing a false-positive result? A. Efavirenz B. Doravirine C. Nevirapine D. Etravirine

72 hours

Post-exposure Prophylaxis of HIV must begin within ______ of exposure, before the virus has time to make too many copies of itself in your body.

Standard Precautions

Precautions used for all patients to prevent heath care associated infections

Stage 1

Primary/acute •Period from infection with HIV to the development of HIV-specific antibodies •Dramatic drops in CD4+ T-cell counts normally 500 to 1500 cells/mm3 of blood

Circulation

Priority assessment for hand/foot surgeries.

4

Rebound attack can occur ___ hours after initial anaphylactic shock?

Human Immune Deficiency Virus (HIV)

Remains a public health issue Early detection and ongoing treatments are important aspects of care Treatments include: Anti-virals, Antiretroviral drugs

HIV

Respiratory manifestations of this condition include: •Shortness of breath, dyspnea, cough, chest pain

MRI

Scan that is only available during normal working hours. It requires nurse to ensure patient has no metal.

allergic rhinitis

Seasonal allergies

A. Male-to-male sexual contact

Since the emergence of the human immunodeficiency virus (HIV), there have been significant changes in epidemiologic trends. At present, members of which group are most affected by new cases of HIV? A. Male-to-male sexual contact B. Heterosexual contact C. Male-to-male sexual contact with injection drug use D. People 25 to 29 years of age

compartment syndrome

Swelling and pain unrelieved by medication after a lower extremity surgery can be indicative of ______________

Bone Marrow

T cells and B cells

Passive Immunity

Temporary immunity Results from transfer of a source outside of the body that has developed immunity through previous disease or immunization

Tinel Sign

Test used to determine if a person has carpal tunnel syndrome.

B. Contraction of bronchial smooth muscle

The nurse in an allergy clinic is educating a new client about the pathology of the client's health problem. What response should the nurse describe as a possible consequence of histamine release? A. Constriction of small venules B. Contraction of bronchial smooth muscle C. Dilation of large blood vessels D. Decreased secretions from gastric and mucosal cells

D. Hold the condom during withdrawal so it doesn't come off.

The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, which instruction should the nurse give the attendees? A. Apply the condom prior to erection. B. A condom may be reused with the same partner if ejaculation has not occurred. C. Use skin lotion as a lubricant if alternatives are unavailable. D. Hold the condom during withdrawal so it doesn't come off.

ADE

The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. A. Using appropriate personal protective equipment B. Placing clients in negative pressure isolation rooms C. Placing clients in positive pressure isolation rooms D. Using safe injection practices E. Performing hand hygiene

D. Palpation of the client's lymph nodes

The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment? A. Percussion of the client's abdomen B. Palpation of the client's liver C. Auscultation of the client's apical heart rate D. Palpation of the client's lymph nodes

D. Improved coping with lifestyle modifications

The nurse is creating a care plan for a client suffering from allergic rhinitis. What outcome should the nurse identify? A. Appropriate use of prophylactic antibiotics B. Safe injection of corticosteroids C. Improved skin integrity D. Improved coping with lifestyle modifications

A. Risk for disturbed body image related to skin lesions

The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan? A. Risk for disturbed body image related to skin lesions B. Risk for disuse syndrome related to dermatitis C. Risk for ineffective role performance related to dermatitis D. Risk for self-care deficit related to skin lesions

D. Risk for impaired gas exchange related to airway obstruction

The nurse is providing care for a client who has a diagnosis of hereditary angioedema. When planning this client's care, what nursing diagnosis should be prioritized? A. Risk for infection related to skin sloughing B. Risk for acute pain related to loss of skin integrity C. Risk for impaired skin integrity related to cutaneous lesions D. Risk for impaired gas exchange related to airway obstruction

A. A client with an anaphylactic reaction after a bee sting

The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. Which client would have this type of reaction? A. A client with an anaphylactic reaction after a bee sting B. A client with a skin reaction resulting from adhesive tape C. A client with a diagnosis of myasthenia gravis D. A client with rheumatoid arthritis

A. Stem cell transplantation

The nurse is providing care for a client who has multiple sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment? A. Stem cell transplantation B. Serial immunizations C. Immunosuppression D. Genetic engineering

D. "Many children outgrow their food allergies in a few years if they avoid the offending foods."

The nurse is providing health education to the parents of a 3-year-old who has been diagnosed with food allergies. Which statement should the nurse make when teaching this family about the child's health problem? A. "Food allergies are a lifelong condition, but most families adjust well to the necessary lifestyle changes." B. "Consistent use of over-the-counter antihistamines can often help a child overcome food allergies." C. "Make sure that you carry a steroid inhaler with you at all times, especially when you eat in restaurants." D. "Many children outgrow their food allergies in a few years if they avoid the offending foods."

B. Spleen

The nurse should recognize a client's risk for impaired immune function if the client has undergone surgical removal of which of the following? A. Thyroid gland B. Spleen C. Kidney D. Pancreas

Carpal Tunnel Syndrome

This condition manifests as: numbness, weakness, and pain in your hand and wrist, and the fingers may become swollen and useless.

palliative care

Treatment for metastatic bone tumors.

Allergic reactions

Treatment includes: - Oxygen as needed - Epinephrine as needed - Histamines - Corticosteroids

C-reactive protein and ESR

Two lab results that when elevated are indicative of an infection.

anaphylactic

Type I hypersensitivity Most severe Urticaria

cytotoxic

Type II hypersensitivity Antibody-mediated immune reaction in which antibodies (IgG or IgM) are directed against cellular or extracellular matrix antigens, resulting in cellular destruction, functional loss, or damage to tissues. Ex: Penicillin, myasthenia gravis, thrombocytopenia

Delayed

Type IV hypersensitivity •A common immune response that occurs through direct action of sensitized T cells when stimulated by contact with antigen. It is referred to as a delayed response in that it will usually require 12-24 hours at a minimum for signs of inflammation to occur locally. •Example: contact dermatitis (eg, poison ivy rash), tuberculin skin test reactions

Gout

Type of inflammatory arthritis that causes pain and swelling in your joints

B. To decrease risk of transmission to vulnerable clients

What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis? A. To decrease nurses' susceptibility to health care-associated infections B. To decrease risk of transmission to vulnerable clients C. To eventually eradicate the influenza virus in the United States D. To prevent the emergence of drug-resistant strains of the influenza virus

High protein

Which diet should be recommended to someone that is immunocompromised?

B. An older adult client with an infected pressure ulcer in the sacral area

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A. A middle-aged adult who takes ibuprofen daily for rheumatoid arthritis B. An older adult client with an infected pressure ulcer in the sacral area C. A 17-year-old football player who had orthopedic surgery 6 weeks prior D. An infant diagnosed with jaundice

D. A client with severe allergies to grass and tree pollen

Which of the following individuals would be the most appropriate candidate for immunotherapy? A. A client who had an anaphylactic reaction to an insect sting B. A child with allergies to eggs and dairy C. A client who has had a positive tuberculin skin test D. A client with severe allergies to grass and tree pollen

D. HIV encephalopathy

Which of the following is a clinical syndrome that is characterized by a progressive decline in cognitive, behavioral, and motor functions as a direct result of HIV infection? A. Cryptococcal meningitis B. Neuropathy C. Progressive multifocal leukoencephalopathy D. HIV encephalopathy

Top to bottom

With external fixators, pin care should include cleaning each pin from __________________ .

Skin integrity

Would Kaposi's Sarcoma be a skin integrity issue or an airway issue?

LGBT

Youth most at risk for HIV infection due to embarassment?

Paget's disease

a bone disease of unknown cause characterized by the excessive breakdown of bone tissue, followed by abnormal bone formation

Allergen

a substance that causes an allergic reaction

Hypersensitivity

abnormal heightened reaction to a stimulus of any kind

Lupus

autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. characterized by a butterfly rash

Kaposi's sarcoma

cancer cells are found in the skin or mucous membranes that line the gastrointestinal (GI) tract, from mouth to anus, including the stomach and intestines.

Colonization

describes microorganisms present without host inference or interaction

infection

indicates host interaction with the organism

Osteomyelitis

infection of the bone

B lymphocytes

mature in bone marrow

T lymphocytes

mature in thymus where they also differentiate into cells with various functions.

Natural Immunity

nonspecific response to any foreign invader Includes: white blood cell action, inflammatory response and physical barriers Ex: COVID-19

acquired immunity

specific against a foreign antigen -result of prior exposure to an antigen -active or passive -ex: chicken pox

Lymphoid Tissue

spleen and lymph nodes

Immunity

the body's specific protective response to foreign agent or organism; resistance to a disease, specifically infectious disease.

Hives

urticaria is the medical term for

Allergy

•An inappropriate, often harmful response of the immune system to normally harmless substances

Stage 3

•CD4+count drops below 200 cells/mm3 of blood •Considered to have AIDS for surveillance purposes

Stage 2

•Occurs when T-lymphocyte cells are between 200 and 499 cells/mm3

contact precautions

•Use for organisms spread by skin-to-skin contact, such as antibiotic-resistant organisms or Clostridium difficile •Use of barriers to prevent transmission

Droplet precautions

•Used for organisms transmitted by close contact with respiratory or pharyngeal secretions: influenza, meningococcus •Wear a face mask but door may remain open; transmission is limited to close contact

Bone Scan

•small amount of radioactive material is injected into a vein and travels through the blood. The radioactive material collects in the bones and is detected by a scanner Patient needs to empty bladder prior to procedure, to remove the unabsorbed tracer from the patient's body