PCC II Final Material
One function of cell-mediated immunity is a. formation of antibodies. b. activation of the complement system. c. surveillance for malignant cell changes. d. opsonization of antigens to allow phagocytosis by neutrophils.
2C
A client was in an automobile accident and while there is the odor of alcohol on his breath, his speech is clear, and he is alert and answers questions posed to him. His blood alcohol level is determined to be 0.30 mg%. What conclusion can be drawn? A. The client has a high tolerance to alcohol. B. The client ate a high-fat meal before drinking. C. The client has a decreased tolerance to alcohol. D. The client's blood alcohol level is within legal limits.
A
A client who is dependent on alcohol tells the nurse, "Alcohol is no problem for me. I can quit anytime I want to." The nurse can assess this statement as indicating A. denial. B. projection. C. rationalization. D. reaction formation.
A
A desirable short-term goal for the nursing diagnosis Defensive coping related to biochemical changes as evidenced by aggressive verbal and physical behaviors would be A. making no attempts at self-harm within 12 hours of admission. B. sleeping soundly for 12 of the next 24 hours. C. willingly taking prescribed medication as offered by staff within 24 hours of admission. D. demonstrating psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission.
A
A diagnosis of AIDS is made when an HIV-infected patient has a. a CD4+ T cell count below 200/µL. b. a high level of HIV in the blood and saliva. c. lipodystrophy with metabolic abnormalities. d. oral hairy leukoplakia, an infection caused by Epstein-Barr virus.
A
A major principle the nurse should observe when communicating with a patient experiencing elated mood is to: a. Use a calm, firm approach. b. Give expanded explanations. c. Make use of abstract concepts. d. Encourage lightheartedness and joking.
A
A medication teaching plan for a patient receiving lithium should include: a. Periodic monitoring of renal and thyroid function. b. Dietary teaching to restrict daily sodium intake. c. The importance of blood draws to monitor serum potassium level. d. Discontinuing the drug if weight gain and fine hand tremors are noticed.
A
An acute phase nursing intervention aimed at reducing hyperactivity is redirecting the client to A. write in a diary. B. exercise in the gym. C. direct unit activities. D. orient a new client to the unit.
A
Nursing assessment of an alcohol-dependent client 6 to 12 hours after the last drink would most likely reveal the presence of A. tremors. B. seizures. C. blackouts. D. hallucinations.
A
Symptoms that would signal opioid withdrawal include A. lacrimation, rhinorrhea, dilated pupils, and muscle aches. B. illusions, disorientation, tachycardia, and tremors. C. fatigue, lethargy, sleepiness, and convulsions. D. synesthesia, depersonalization, and hallucinations.
A
The first-line drug used to treat mania is A. lithium carbonate (Lithium). B. carbamazepine (Tegretol). C. lamotrigine (Lamictal). D. clonazepam (Klonopin).
A
The most common cause of secondary immunodeficiencies is a. drugs. b. stress. c. malnutrition. d. human immunodeficiency virus.
A
The nurse is alerted to possible anaphylactic shock immediately after a patient has received intramuscular penicillin by the development of a. edema and itching at the injection site. b. sneezing and itching of the nose and eyes. c. a wheal-and-flare reaction at the injection site. d. chest tightness and production of thick sputum. (Lewis 224) Lewis, Sharon, Shannon Dirksen, Margaret Heitkemper, Linda Bucher. Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition. Mosby, 2014. VitalBook file. The citation provided is a guideline. Please check each citation for accuracy before use.
A
The nurse reminds the staff that standard precautions should be used when providing care for which type of patient? A. All patients regardless of diagnosis B. Pediatric and gerontologic patients C. Patients who are immunocompromised D. Patients with a history of infectious diseases
A
The only class of commonly abused drugs that has a specific antidote is the A. opiates. B. hallucinogens. C. amphetamines. D. benzodiazepines.
A
The priority nursing diagnosis for a hyperactive manic client during the acute phase is A. risk for injury. B. ineffective role performance. C. risk for other-directed violence. D. impaired verbal communication.
A
The provision of optimal care for patients withdrawing from substances of abuse is facilitated by the nurse's understanding that severe morbidity and mortality are often associated with withdrawal from: a. Alcohol and CNS depressants. b. CNS stimulants and hallucinogens. c. Narcotic antagonists and caffeine. d. Opiates and inhalants.
A
The reason newborns are protected for the first 6 months of life from bacterial infections is because of the maternal transmission of a. IgG. b. IgA. c. IgM. d. IgE.
A
The treatment team meets to discuss Cody's plan of care. Which of the following factors will be priorities when planning interventions? A. Readiness to change and support system B. Current college performance C. Financial ability D. Availability of immediate family to come to meetings
A
To plan care for a manic client the nurse must consider that lithium cannot be started until A. the physical examination and laboratory tests are analyzed. B. the initial doses of antipsychotic medication have brought behavior under control. C. seclusion has proven ineffective as a means of controlling assaultive behavior. D. electroconvulsive therapy can be scheduled to coincide with lithium administration.
A
Transmission of HIV from an infected individual to another most commonly occurs as a result of a. unprotected anal or vaginal sexual intercourse. b. low levels of virus in the blood and high levels of CD4+ T cells. c. transmission from mother to infant during labor and delivery and breastfeeding. d. sharing of drug-using equipment, including needles, syringes, pipes, and straws.
A
What action should the nurse take on learning that a manic client's serum lithium level is 1.8 mEq/L? A. Withhold medication and notify the physician. B. Continue to administer medication as ordered. C. Advise the client to limit fluids for 12 hours. D. Advise the client to curtail salt intake for 24 hours.
A
When a client reports that lithium causes an upset stomach, the nurse suggests taking the medication: A. with meals B. with an antacid C. 30 minutes before meals D. 2 hours after meals
A
Which assessment data would be most consistent with a severe opiate overdose? A. Blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min B. Blood pressure, 120/80 mm Hg; pulse, 84 beats/min; respirations, 20 breaths/min C. Blood pressure, 140/90 mm Hg; pulse, 76 beats/min; respirations, 24 breaths/min D. Blood pressure, 180/100 mm Hg; pulse, 72 beats/min; respirations, 28 breaths/min
A
Which behavior would be most characteristic of a client during a manic episode? A. Going rapidly from one activity to another B. Taking frequent rest periods and naps during the day C. Being unwilling to leave home to see other people D. Watching others intently and talking little
A
Which side effects of lithium can be expected at therapeutic levels? A. Fine hand tremor and polyuria B. Nausea and thirst C. Coarse hand tremor and gastrointestinal upset D. Ataxia and hypotension
A
Which strategy can the nurse teach the patient to eliminate the risk of HIV transmission? a. Using sterile equipment to inject drugs b. Cleaning equipment used to inject drugs c. Taking zidovudine (AZT, ZDV, Retrovir) during pregnancy d. Using latex or polyurethane barriers to cover genitalia during sexual contact for accuracy before use.
A
The nurse has developed a plan for a client with a severe sleep pattern disturbance to spend 20 minutes in the gym exercising each afternoon. Which intervention should be scheduled for upon returning to the unit? A. Rest B. Group therapy C. A protein-based snack D. Unstructured private time
A A depressed client usually has little energy. After even a short exercise period, the client may feel exhausted and need rest.
A depressed, socially withdrawn client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can best begin to attack this cognitive distortion by A. suggesting, "Let's look at what you just said, that you can 'never do anything right.'" B. querying, "Tell me what things you think you are not able to do correctly." C. asking, "Is this part of the reason you think no one likes you?" D. saying, "That is the most unrealistic thing I have ever heard."
A Cognitive distortions can be refuted by examining them, but to examine them the nurse must gain the client's willingness to participate.
A 34-year-old female patient who has systemic lupus erythematosus is receiving plasmapheresis to treat an acute attack. What symptoms will the nurse monitor to determine if the patient develops complications related to the procedure? A. Hypotension, paresthesias, and dizziness B. Polyuria, decreased reflexes, and lethargy C. Intense thirst, flushed skin, and weight gain D. Abdominal cramping, diarrhea, and leg weakness
A Common complications associated with plasmapheresis are hypotension and citrate toxicity. Citrate is used as an anticoagulant and may cause hypocalcemia, which may manifest as headache, paresthesias, and dizziness. Polyuria, decreased reflexes, and lethargy are symptoms of hypercalcemia. Abdominal cramping, diarrhea, and leg weakness indicate hyperkalemia. Intense thirst, flushed skin, and weight gain indicate hypernatremia with normal or increased extracellular fluid volume.
The nurse is caring for a patient experiencing an immune response. She assesses the patient for development of a hyperimmune response because cytotoxic T cells A. May kill healthy cells along with foreign antigens. B. Are the most prevalent type of T lymphocyte. C. Can suppress the immune response. D. Diminish dendritic cell function.
A Cytotoxic T lymphocytes can kill healthy tissue along with antigens. Suppressor T cells help to keep cytotoxic T cells in check. Helper T cells are the most prevalent type of T lymphocyte, not cytotoxic cells. Cytotoxic T lymphocytes do not suppress the immune response but are a factor in optimal immune functioning. Suppressor T lymphocytes help to suppress the function of cytotoxic cells. Dendritic cell function enhances cytotoxic T lymphocyte functioning.
When the nurse remarks to a depressed client, "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to A. wait quietly for the client to reply. B. prompt the client if the reply is slow. C. repeat the question if the client does not answer promptly. D. review the client's medical record to support the client's response.
A Depressed clients think slowly and take long periods to formulate answers and respond. The nurse must be prepared to wait for a reply
When teaching a patient infected with HIV regarding transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? A. "I will need to isolate any tissues I use so as not to infect my family." B. "I will notify all of my sexual partners so they can get tested for HIV." C. "Unprotected sexual contact is the most common mode of transmission." D. "I do not need to worry about spreading this virus to others by sweating at the gym."
A HIV is not spread casually. The virus cannot be transmitted through hugging, dry kissing, shaking hands, sharing eating utensils, using toilet seats, or attending school with an HIV-infected person. It is not transmitted through tears, saliva, urine, emesis, sputum, feces, or sweat.
A 62-year-old patient has acquired immunodeficiency syndrome (AIDS), and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study result? A. The patient has the virus present and can transmit the infection to others. B. The patient is not able to transmit the virus to others through sexual contact. C. The patient will be prescribed lower doses of antiretroviral medications for 2 months. D. The syndrome has been cured, and the patient will be able to discontinue all medications.
A In human immunodeficiency virus (HIV) infections, viral loads are reported as 1real numbers of copies/μL or as undetectable. "Undetectable" indicates that the viral load is lower than the test is able to report. "Undetectable" does not mean that the virus has been eliminated from the body or that the individual can no longer transmit HIV to others.
Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? A. Onset of action is from 1 to 6 weeks. B. They tend to be more effective for men. C. Recent memory impairment is commonly observed. D. They often cause the client to have diurnal variation.
A People are accustomed to fast results from medication: thirty minutes for aspirin, 24 hours for antibiotics. Information is necessary to prevent discouragement and maintain compliance.
The nurse is teaching a patient with a new diagnosis of systemic lupus erythematosus (SLE) about her disease. The nurse recognizes that the patient understands the information when she states A. "I need to avoid getting infections because they will increase the immune response in my body, which can make my SLE worse." B. "I need to be sure to take all the available immunizations to keep me from getting sick." C. "Because of my SLE, my immune system is already diminished, so I need to avoid people with the flu." D. "As long as I take all my prescribed medications, I won't have to make any lifestyle changes as a result of my SLE."
A SLE is a hyperimmunity problem. Pathogens trigger the immune response in the body, which can exacerbate the SLE. Immunizations trigger the immune response in the body to help create antibodies. In patients with autoimmune diseases such as SLE, immunizations can exacerbate the disease. SLE is not the result of immunosuppression. Lifestyle changes are required with most chronic illnesses such as SLE. Patients cannot depend on medications alone.
A patient admitted to an acute care floor has rubor of an area of injury on the left lower extremity. The nurse understands that this redness is caused by A. Vasodilation. B. Extravasation. C. Neutrophils. D. Exudate.
A The inflammatory process results in rubor, or redness, of an area of insult. The body responds to injury by increasing the blood flow to an area through vasodilation. This allows increased oxygen and more nutrients and appropriate white blood cells to reach the area, isolating the area and beginning the immune response. Extravasation is the movement of fluid from its confined space into the surrounding tissue. Neutrophils are one of the most common types of white blood cells. Exudate is the fluid filled with proteins and white blood cells that moves out of the vascular spaces through extravasation.
The HIV-infected patient is taught health promotion activities including good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? A. Delaying disease progression B. Preventing disease transmission C. Helping to cure the HIV infection D. Enabling an increase in self-care activities
A These health promotion activities along with mental health counseling, support groups, and a therapeutic relationship with health care providers will promote a healthy immune system, which may delay disease progression. These measures will not cure HIV infection, prevent disease transmission, or increase self-care activities.
On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response increases with age? A. Autoimmune response B. Cell-mediated immunity C. Hypersensitivity response D. Humoral immune response
A With aging, autoantibodies increase, which lead to autoimmune diseases (e.g., systemic lupus erythematosus, acute glomerulonephritis, rheumatoid arthritis, hypothyroidism). Cell-mediated immunity decreases with decreased thymic output of T cells and decreased activation of both T and B cells. There is a decreased or absent delayed hypersensitivity reaction. Immunoglobulin levels decrease and lead to a suppressed humoral immune response in older adults.
A healthy 65-year-old man who lives at home is at the clinic requesting a "flu shot." When assessing the patient, what other vaccinations should the nurse ask the patient about receiving (select all that apply)? A. Shingles B. Pneumonia C. Meningococcal D. Haemophilus influenzae type b (Hib) E. Measles, mumps, and rubella (MMR)
A, B The patient should receive the shingles (heres zoster) vaccine, Pneumovax, and influenza. The other options do not apply to this patient. Meningococcal vaccination is recommended for adults at risk (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies). Adults born before 1957 are generally considered immune to measles and mumps. Haemophilus influenzae type b (Hib) vaccination is only considered for adults with selected conditions (e.g., sickle cell disease, leukemia, HIV infection or for those who have anatomic or functional asplenia) if they have not been previously vaccinated.
During HIV infection a. the virus replicates mainly in B-cells before spreading to CD4+ T cells. b. infection of monocytes may occur, but antibodies quickly destroy these cells. c. the immune system is impaired predominantly by the eventual widespread destruction of CD4+ T cells. d. a long period of dormancy develops during which HIV cannot be found in the blood and there is little viral replication. e. opportunistic diseases occur more often when the CD4+ T cell count is high and the viral load is low.
A, B, C
Select all the organs from the following list that are part of the immune system. (Select all that apply): A. Adenoids. B. Appendix. C. Bone marrow. D. Gallbladder. E. Liver. F. Thyroid gland.
A, B, C
When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply)? A. Grapes B. Oranges C. Bananas D. Potatoes E. Tomatoes
A, C, D, E Because some proteins in rubber are similar to food proteins, some foods may cause an allergic reaction in people who are allergic to latex. The most common of these foods are bananas, avocados, chestnuts, kiwi fruit, tomatoes, water chestnuts, guava, hazelnuts, potatoes, peaches, grapes, and apricots.
A patient has been admitted with major depressive disorder. What typical signs and symptoms would the nurse expect to assess? (Select all that apply): A. Poor eye contact. B. Increased fever. C. Appetite changes. D. Increased white blood cell count. E. Slowed speech.
A, C, E Typical signs of depression include sleep disturbance; poor eye contact; loss of interest in events; guilt; decreased energy, speech, and concentration; appetite changes; and slowed motor movements. Increased fever and white blood cell count are indicative of infection, not depression.
Which of the following describe the symptoms of the manic phase of bipolar disorder? (select all that apply): A. Excessive energy B. Fatigue and increased sleep C. Low self-esteem D. Pressured speech E. Purposeless movement F. Racing thoughts G. Withdrawal from environment H. Distractibility
A, D, E, F, H All these options describe mania. The other options more aptly describe the opposite of what happens in mania.
A bipolar client whose continuing phase treatment consists of lithium therapy and cognitive-behavioral therapy may become noncompliant with medication. Which factor would be of least concern to the nurse developing a psychoeducation plan to foster compliance? A. The side-effects are unpleasant. B. The voices tell the client to stop taking it. C. The client prefers to feel "high" and energetic. D. The client feels well and denies the possibility of recurrence.
B
A client brought to the emergency department after phenylcyclohexylpiperidine (PCP) ingestion is both verbally and physically abusive, and the staff is having difficulty keeping him and themselves safe. The nursing intervention that would be most therapeutic is A. taking him to the gym on the psychiatric unit. B. obtaining an order for seclusion and close observation. C. assigning a psychiatric technician to "talk him down." D. administering naltrexone as needed per hospital protocol.
B
A client prescribed a monamine oxidase inhibitor (MOA) has a pass to go out to lunch. Given a choice of the following entrees, the client can safely eat A. avocado salad plate. B. fruit and cottage cheese plate. C. kielbasa and sauerkraut. D. liver and onion sandwich.
B
A desired outcome for the maintenance phase of treatment for a manic client would be that the client will A. exhibit optimistic, energetic, playful behavior. B. adhere to follow-up medical appointments. C. take medication more than 50% of the time. D. use alcohol to moderate occasional mood "highs."
B
A female patient tells the nurse that she would like to begin taking St. John's wort for depression. What teaching should the nurse provide? a. "St. John's wort should be taken several hours after your other antidepressant." b. "St. John's wort has generally been shown to be effective in treating depression." c. "This supplement is safe to take if you are pregnant." d. "St. John's wort is regulated by the FDA, so you can be assured of its safety."
B
A hospital has seen a recent increase in the incidence of hospital care-associated infections (HAIs). Which measure should be prioritized in the response to this trend? A. Use of gloves during patient contact B. Frequent and thorough hand washing C. Prophylactic, broad-spectrum antibiotics D. Fitting and appropriate use of N95 masks
B
A new psychiatric technician mentions to the nurse, "Depression seems to be a disease of old people. All the depressed clients on the unit are older than 60 years." The reply by the nurse that clarifies the prevalence of this disease is A. "That is a good observation. Depression does mostly strike people older than 50 years." B. "Depression is seen in people of all ages, from childhood to old age." C. "Depression is most often seen among the middle adult age group." D. "The age of onset for most depressive episodes is given as 18 years."
B
A person who covertly supports the substance-abusing behavior of another is called a(n) A. patsy. B. enabler. C. participant. D. minimizer.
B
An outcome for a manic client during the acute phase that would indicate that the treatment plan was successful would be that the client A. reports racing thoughts. B. is free of injury. C. is highly distractible. D. ignores food and fluid.
B
Antiretroviral drugs are used to a. cure acute HIV infection. b. decrease viral RNA levels. c. treat opportunistic diseases. d. decrease pain and symptoms in terminal disease.
B
Cocaine exerts which of the following effects on a client? A. Stimulation after 15 to 20 minutes B. Stimulation and anesthetic effects C. Immediate imbalance of emotions D. Paranoia
B
Cody is a 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months. He is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for Cody's treatment plan while in the hospital? A. Cody will return to a predrug level of functioning within 1 week. B. Cody will be medically stabilized while in the hospital. C. Cody will state within 3 days that he will totally abstain from drugs and alcohol. D. Cody will take a leave of absence from college to alleviate stress.
B
Erik is a 26-year-old patient who abuses heroin. He states to you, "I've been using more heroin lately. I told my provider about it and she said I need more and more heroin to feel the effect I want." You know this describes: A. intoxication. B. tolerance. C. withdrawal. D. addiction.
B
For assessment purposes, the nurse should identify the body system most at risk for decompensation during a severe manic episode as: a. Renal b. Cardiac c. Endocrine d. Pulmonary
B
In assessing the joints of a patient with osteoarthritis, the nurse understands that Heberden's nodes a. are often red, swollen, and tender. b. indicate osteophyte formation at the DIP joints. c. are the result of pannus formation at the PIP joints. d. occur from deterioration of cartilage by proteolytic enzymes.
B
Nadia has been diagnosed with bipolar disorder. Which is an outcome for Nadia in the continuation of treatment phase of bipolar disorder? a. Patient will avoid involvement in self-help groups. b. Patient will adhere to medication regimen. c. Patient will demonstrate euphoric mood. d. Patient will maintain normal weight.
B
Sasha has been having angry outbursts with staff and peers on the unit. You are talking with Sasha on her third day of admission. You ask whether she is having any thoughts of suicide. Sasha becomes angry and defensive, shouting, "I'm sick of you people! Are you ever do is ask me the same question over and over. Get out of here!" Your response is based on the knowledge that: A. Sasha is getting better because she is able to be assertive. B. Sasha may be at high risk for self-harm. C. Sasha is probably experiencing transference. D. Sasha may be angry at someone else and projecting that anger to staff.
B
The major reason for hospitalization for depressed patients is: A. inability to go to work. B. suicidal ideation. C. loss of appetite. D. psychomotor agitation.
B
The nurse can expect a client demonstrating typical manic behavior to be attired in clothing that is A. dark colored and modest. B. colorful and outlandish. C. compulsively neat and clean. D. ill-fitted and ragged.
B
The nurse is reviewing orders given for a patient with depression. Which order should the nurse question? a. A low starting dose of a tricyclic antidepressant b. An SSRI given initially with an MAOI c. Electroconvulsive therapy to treat suicidal thoughts d. Elavil to address the patient's agitation
B
What statement about the comorbidity of depression is accurate? A. Depression most often exists in an individual as a single entity. B. Depression is commonly seen in individuals with medical disorders. C. Substance abuse and depression are seldom seen as comorbid disorders. D. Depression may coexist with other disorders but is rarely seen with schizophrenia
B
When a hyperactive manic client expresses the intent to strike another client, the initial nursing intervention would be to A. question the client's motive. B. set verbal limits. C. initiate physical confrontation. D. prepare the client for seclusion.
B
Which symptom related to communication is likely to be present in a patient experiencing mania? a. Mutism b. Verbosity c. Poverty of ideas d. Confabulation
B
You are caring for Mick, a 32-year-old patient with chemical addiction who will soon be preparing for discharge. A principle of counseling interventions that should be observed when caring for a patient with chemical addiction is to: a. Praise the patient for compliant behavior. b. Communicate that relapses are always possible. c. Confirm that the patient's recovery is considered complete after discharge. d. Encourage Mick to resume his former friendships to regain a sense of normalcy.
B
Which nursing diagnosis would be least useful for a depressed client who shows psychomotor retardation? A. Constipation B. Death anxiety C. Activity intolerance D. Self-care deficit: bathing/hygiene
B A client with psychomotor retardation has vegetative signs of depression and is often constipated, too tired to engage in activities, and lacks the energy to attend to personal hygiene. Depressed clients usually do not have death anxiety. They are more likely to welcome the idea of dying
A patient presents to the clinic with observable edema and erythema of the left forearm. On palpation, the nurse finds the area very warm and tender. The nurse understands that the patient is experiencing A. An allergic reaction. B. A complement cascade. C. IgE reactions. D. Clonal diversity.
B A complement cascade is responsible for the dilation of blood vessels and leaking of fluid from the vascular system to the area of insult, resulting in the swelling and redness associated with an inflammatory response. An allergic reaction can cause edema and erythema, but the question does not provide enough information to determine the specific cause of the swelling and redness. IgE is a specific immunoglobulin associated with signs and symptoms of allergic rhinitis. Clonal diversity refers to the maturation process of cells.
A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? A. Anxiety. B. Seasonal affective disorder. C. Medication side effects. D. Antisocial personality.
B Decreased exposure to sunlight in winter months can reduce the production of serotonin in the brain, leading to a type of depression termed seasonal affective disorder; this tends to resolve with the longer days and increased exposure to sun of spring and summer. There are not enough data to identify anxiety or signs linked to medication, which also tend to not resolve with seasons. Antisocial traits include isolation but also include behaviors of manipulation and lack of remorse in interpersonal relationships.
The nurse is caring for a patient newly diagnosed with HIV. The patient asks what would determine the actual development of AIDS. The nurse's response is based on the knowledge that what is a diagnostic criterion for AIDS? A. Presence of HIV antibodies B. CD4+ T cell count below 200/µL C. Presence of oral hairy leukoplakia D. White blood cell count below 5000/µL
B Diagnostic criteria for AIDS include a CD4+ T cell count below 200/µL and/or the development of specified opportunistic infections, cancers, wasting syndrome, or dementia. The other options may be found in patients with HIV disease but do not define the advancement of HIV infection to AIDS.
A 66-year-old man with type 2 diabetes mellitus and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask? A. "Did you have any hypoglycemic reactions?" B. "Have you noticed any bruising or bleeding?" C. "Have you had any dizzy spells when standing up?" D. "Do you have any numbness or tingling in your feet?"
B Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both glucosamine and chondroitin may increase the risk of bleeding. Anticoagulant therapy is indicated for patients with atrial fibrillation to reduce the risk of a thromboembolism and a stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose levels, and hyperglycemia may occur. Peripheral neuropathy symptoms that can develop with prolonged hyperglycemia include numbness and tingling in the feet.
When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which statement? A. "I should take the Naprosyn as prescribed to help control the pain." B. "I should try to stay standing all day to keep my joints from becoming stiff." C. "I can use a cane if I find it helpful in relieving the pressure on my back and hip." D. "A warm shower in the morning will help relieve the stiffness I have when I get up."
B It is important to maintain a balance between rest and activity to prevent overstressing the joints with OA. Naproxen (Naprosyn) may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.
Which of the following is true of the relationship between bipolar disorder and suicide? A. Patients need to be monitored only in the depressed phase because this is when suicides occur. B. Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide. C. Patients with bipolar disorder are not considered high risk for suicide. D. As long as patients with bipolar disorder adhere to their medication regimen, there is little risk for suicide
B Mortality rates for bipolar disorder are severe because 25% to 60% of individuals with bipolar disorder will make a suicide attempt at least once in their lifetime, and nearly 20% of all deaths among this population are from suicide. Suicides occur in both the depressed and the manic phase. Bipolar patients are always considered high risk for suicide because of impulsivity while in the manic phase and hopelessness when in the depressed phase. Although staying on medications may decrease risk, there is no evidence to suggest that only patients who stop medications commit suicide
A nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient uses which description of the condition? A. Joint destruction caused by an autoimmune process B. Degeneration of articular cartilage in synovial joints C. Overproduction of synovial fluid resulting in joint destruction D. Breakdown of tissue in non-weight-bearing joints by enzymes
B OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.
The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which finding should the nurse expect to be present on examination of the patient's knees? A. Ulnar drift B. Pain with joint movement C. Reddened, swollen affected joints D. Stiffness that increases with movement
B OA is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis (RA) not osteoarthritis. Not all joints are reddened or swollen. Only Heberden's and Bouchard's nodes may be. Stiffness decreases with movement.
The nurse was accidently stuck with a needle used on an HIV-positive patient. After reporting this, what care should this nurse first receive? A. Personal protective equipment B. Combination antiretroviral therapy C. Counseling to report blood exposures D. A negative evaluation by the manager
B Postexposure prophylaxis with combination antiretroviral therapy can significantly decrease the risk of infection. Personal protective equipment should be available although it may not have stopped this needle stick. The needle stick has been reported. The negative evaluation may or may not be needed but would not occur first.
A 20-year-old man is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? A. Warm, moist heat and massage B. Rest, ice, compression, and elevation C. Antipyretic and antibiotic drug therapy D. Active movement and exercise to prevent stiffness
B Rest, ice, compression, and elevation (RICE) is a key concept in treating soft tissue injuries and related inflammation. Heat may be applied 24 to 48 hours after the injury.
The nurse is completing an admission assessment of a new patient to the unit. The nurse notes a long, thin, fading scar on the patient's abdomen in the right lower quadrant. The nurse knows that scar tissue results from A. Optimal functioning of the inflammatory process after an injury. B. Fibrous tissue replacing damaged tissue when injury is extensive. C. The development of chronic inflammation. D. A surgical incision.
B Scar tissue, or fibrous repair of damaged tissue, occurs when an area is damaged too extensively for the body to replace damaged tissue with identically functioning tissue after removal of injurious agents and pathogens. Optimal functioning of the inflammatory process will result in regeneration of tissue that functions identically to the damaged and replaced tissue. Chronic inflammation can result in fibrous, or scar, tissue, but that scar tissue production is continuous as the inflammation continues. Fibrous tissue production can result from many different kinds of injuries, not just surgical wounds.
Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? A. "You will need to get rid of your pets." B. "You should sleep in an air-conditioned room." C. "You would do best to stay indoors during the winter months." D. "You will need to dust your house with a dry feather duster twice a week."
B Seasonal allergic rhinitis is most commonly caused by pollens from trees, weeds, and grasses. Airborne allergies can be controlled by sleeping in an air-conditioned room, daily damp dusting, covering the mattress and pillows with hypoallergenic covers, and wearing a mask outdoors.
A patient who is at a health clinic with complaints of a sore throat is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing? A. Primary prevention. B. Secondary prevention. C. Tertiary prevention. D. Modified prevention.
B Secondary prevention is aimed at early detection of problems, in this case, the identification of depression for early intervention. Primary prevention for mood disorders focuses on stress reduction and societal issues such as reducing poverty and racism. Tertiary prevention aims to reduce disability from a diagnosed condition; for mood disorders, this includes prevention of relapse and protection from harm. Modified prevention is not a recognized level of prevention, although prevention interventions may need to be adapted to meet specific individual situations.
An statement that would show acceptance of a depressed, mute client would be A. "I will be spending time with you each day to try to improve your mood." B. "I would like to sit with you for 15 minutes now and again this afternoon." C. "Each day we will spend time together to talk about things that are bothering you." D. "It is important for you to share your thoughts with someone who can help you evaluate your thinking."
B Spending time with the client without making demands is a good way to show acceptance.
The nursing diagnosis Imbalanced nutrition: less than body requirements has been identified for a client diagnosed with severe depression. The most reliable evaluation of outcomes will be based on the client's A. energy level. B. weekly weights. C. observed eating patterns. D. statement of appetite.
B The client's body weight is the most reliable and objective evaluation of success in treating this nursing diagnosis.
A 25-year-old male patient has been diagnosed with HIV. The patient does not want to take more than one antiretroviral drug. What reasons can the nurse tell the patient about for taking more than one drug? A. Together they will cure HIV. B. Viral replication will be inhibited. C. They will decrease CD4+ T cell counts. D. It will prevent interaction with other drugs.
B The major advantage of using several classes of antiretroviral drugs is that viral replication can be inhibited in several ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance that is a major problem with monotherapy. Combination therapy also delays disease progression and decreases HIV symptoms and opportunistic diseases. HIV cannot be cured. CD4+ T cell counts increase with therapy. There are dangerous interactions with many antiretroviral drugs and other commonly used drugs.
The patient has inflammation and is complaining of malaise, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? A. Local response B. Systemic response C. Infectious response D. Acute inflammatory response
B The systemic response to inflammation includes the manifestations of a shift to the left in the WBC count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in 2 to 3 weeks and usually leaves no residual damage.
Which statement about metabolic side effects of ART is true (select all that apply)? a. These are annoying symptoms that are ultimately harmless. b. ART-related body changes include central fat accumulation and peripheral wasting. c. Lipid abnormalities include increases in triglycerides and decreases in high-density cholesterol. d. Insulin resistance and hyperlipidemia can be treated with drugs to control glucose and cholesterol. e. Compared to uninfected people, insulin resistance and hyperlipidemia are more difficult to treat in HIV-infected patients
B, C, D
The patient is admitted to the ED with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing measures will help identify the need for further assessment of the cause of this patient's manifestations (select all that apply)? A. Assessment of lung sounds B. Assessment of sexual behavior C. Assessment of living conditions D. Assessment of drug and syringe use E. Assessment of exposure to an ill person
B, D With these symptoms, assessing this patient's sexual behavior and possible exposure to shared drug equipment will identify if further assessment for the HIV virus should be made or the manifestations are from some other illness (e.g., lung sounds and living conditions may indicate further testing for TB).
A manic client tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." The best approach for the nurse to use would be A. "What an offensive thing to suggest!" B. "I don't have sex with clients." C. "It's time to work on your art project." D. "Let's walk down to the seclusion room."
C
A teaching need is revealed when a client taking disulfiram (Antabuse) states, A. "I usually treat heartburn with antacids." B. "I take ibuprofen or acetaminophen for headache." C. "Most over-the-counter cough syrups are safe for me to use." D. "I have had to give up using aftershave lotion."
C
An appropriate long-term goal/outcome for a recovering substance abuser would be that the client will A. discuss the addiction with significant others. B. state an intention to stop using illegal substances. C. abstain from the use of mood-altering substances. D. substitute a less addicting drug for the present drug.
C
Beck's cognitive theory suggests that the etiology of depression is related to A. sleep abnormalities. B. serotonin circuit dysfunction. C. negative processing of information. D. a belief that one has no control over outcomes.
C
During HIV infection a. the virus replicates mainly in B-cells before spreading to CD4+ T cells. b. infection of monocytes may occur, but antibodies quickly destroy these cells. c. the immune system is impaired predominantly by the eventual widespread destruction of CD4+ T cells. d. a long period of dormancy develops during which HIV cannot be found in the blood and there is little viral replication.
C
In helping an addicted individual plan for ongoing treatment, which intervention is the first priority for a safe recovery? A. Ongoing support from at least two family members must be secured. B. The client needs to be employed. C. The client must strive to maintain abstinence. D. A regular schedule of appointments with a primary care provider must be set up
C
In teaching a patient with Sjögren's syndrome about drug therapy for this disorder, the nurse includes instruction on use of which drug? a. Pregabalin (Lyrica) b. Etanercept (Enbrel) c. Cyclosporine (Restasis) d. Cyclobenzaprine (Flexeril)
C
Opportunistic diseases in HIV infection a. are usually benign. b. are generally slow to develop and progress. c. occur in the presence of immunosuppression. d. are curable with appropriate drug interventions.
C
Sasha is a 38-year-old patient admitted with major depression. Which of the following statements Sasha makes alerts you to a common accompaniment to depression? A. "I still pray and read my Bible every day." B. "My mother wants to move in with me, but I want to independent." C. "I still feel bad about my sister dying of cancer. I should have done more for her!" D. "I've heard others say that depression is a sign of weakness."
C
Screening for HIV infection generally involves a. laboratory analysis of blood to detect HIV antigen. b. electrophoretic analysis for HIV antigen in plasma. c. laboratory analysis of blood to detect HIV antibodies. d. analysis of lymph tissues for the presence of HIV RNA.
C
The most helpful message to transmit about relapse to the recovering alcoholic client is that lapses A. are an indicator of treatment failure. B. are caused by physiological changes. C. result from lack of good situational support. D. can be learning situations to prolong sobriety.
C
The nurse is planning care for a patient with depression who will be discharged to home soon. What aspect of teaching should be the priority on the nurse's discharge plan of care? a. Pharmacological teaching b. Safety risk c. Awareness of symptoms that increase depression d. The need for interpersonal contact
C
The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment? A. It will gather platelets for use later when needed. B. It will cause anemia because it removes whole blood and RBCs are damaged. C. It will remove the IgG autoantibodies and antigen complexes from the plasma. D. It will remove the peripheral stem cells in order to cure the autoimmune disease.
C
Tyler is a 31-year-old patient admitted with acute mania. He tells the staff and the other patients that he is on a secret mission given to him by the President of the United States to monitor citizens for terrorist activity. He states, "I am the only one he trusts, because I am the best!" For documentation purposes you know that this behavior is referred to as: A. unpredictability. B. rapid cycling. C. grandiosity. D. flight of ideas.
C
When intervening with a patient who is intoxicated from alcohol, it is useful to first: a. Let the patient sober up. b. Decide immediately on care goals. c. Ask what drugs other than alcohol the patient has recently used. d. Gain adherence by sharing your personal drinking habits with the patient.
C
Which of the drugs used by a polysubstance abuser is most likely to be responsible for withdrawal symptoms requiring both medical intervention and nursing support? A. Opiates B. Marijuana C. Barbiturates D. Hallucinogens
C
Which of the following is true regarding substance addiction and medical comorbidity? A. Most substance abusers do not have medical comorbidities. B. There has been little research done regarding substance addiction disorders and medical comorbidity. C. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. D. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.
C
Which room placement would be best for a client experiencing a manic episode? A. A shared room with a client with dementia B. A single room near the unit activities area C. A single room near the nurses' station D. A shared room away from the unit entrance
C
Select the nursing diagnosis least likely to be chosen after analysis of data pertinent to a client with post-partum depression. A. Impaired parenting B. Ineffective role performance C. Health-seeking behaviors D. Risk for impaired parent/infant/child attachment
C A client with severe depression of any etiology will not have the mental or physical energy to engage in health-seeking behaviors. Further, her negative view of self and the world would preclude such thinking.
The nurse is providing care for a patient who has been living with HIV for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? A. A new onset of polycythemia B. Presence of mononucleosis-like symptoms C. A sharp decrease in the patient's CD4+ count D. A sudden increase in the patient's WBC count
C A decrease in CD4+ count signals an exacerbation of the severity of HIV. Polycythemia is not characteristic of the course of HIV. A patient's WBC count is very unlikely to suddenly increase, with decreases being typical. Mononucleosis-like symptoms such as malaise, headache, and fatigue are typical of early HIV infection and seroconversion.
A nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which activity pattern? A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise C. Regular exercise program of walking D. Frequent rest periods with minimal exercise
C A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in the patient with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.
A 21-year-old student had taken amoxicillin once as a child for an ear infection. She is given an injection of Penicillin V and develops a systemic anaphylactic reaction. What manifestations would be seen first? A. Dyspnea B. Dilated pupils C. Itching and edema D. Wheal-and-flare reaction
C A systemic anaphylactic reaction starts with edema and itching at the site of exposure to the antigen. Shock can rapidly develop with rapid, weak pulse; hypotension; dilated pupils; dyspnea, and possible cyanosis. The wheal-and-flare reaction occurs with a localized anaphylactic reaction such as a mosquito bite
The nurse is reviewing the erythrocyte sedimentation rate (ESR) for one of her patients. An elevated ESR A. Determines specific causes of inflammation. B. Identifies the location of inflammation within the body. C. Confirms the nonspecific presence of inflammation. D. Indicates a diagnosis of systemic lupus.
C An elevated ESR is indicative of the presence of inflammation in the body. Proteins produced during the inflammatory process adhere to red blood cells, causing them to be heavier and settle out of blood samples at a faster rate than normal. The ESR does not identify specific causes of inflammation and does not determine a specific location of inflammation. The ESR is a nonspecific indicator of inflammation.
When the clinician mentions that a client has anhedonia, the nurse can expect that the client A. has poor retention of recent events. B. experienced a weight loss from anorexia. C. obtains no pleasure from previously enjoyed activities. D. has difficulty with tasks requiring fine motor skills.
C Anhedonia is the term for the lack of ability to experience pleasure.
The nurse is monitoring the effectiveness of antiretroviral therapy (ART) for a 56-year-old man with acquired immunodeficiency syndrome (AIDS). What laboratory study result indicates the medications have been effective? A. Increased viral load B. Decreased neutrophil count C. Increased CD4+ T cell count D. Decreased white blood cell count
C Antiretroviral therapy is effective if there are decreased viral loads and increased CD4+ T cell counts.
A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? A. Frequent examination of the character and quantity of exudate B. Monitoring for signs and symptoms of local or systemic infections C. Assessment of the patient's circulation distal to the location of the dressing D. Assessment of the range of motion of the ankle and the patient's activity tolerance
C Any compression dressing requires vigilant assessment of the circulation distal to the dressing site, since tissue and nerve damage is a significant risk. This supersedes the importance of assessing the patient's mobility. Exudate and infection would not normally accompany a soft tissue injury such as a sprain.
The nurse is caring for a patient who has osteoarthritis (OA) of the knees. The nurse teaches the patient that the most beneficial measure to protect the joints is to do what? A. Use a wheelchair to avoid walking as much as possible. B. Sit in chairs that cause the hips to be lower than the knees. C. Eat a well-balanced diet to maintain a healthy body weight. D. Use a walker for ambulation to relieve the pressure on the hips.
C Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The chairs that would be best for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for OA of the knees.
A person who has numerous hypomanic and dysthymic episodes can be assessed as demonstrating characteristics of A. bipolar II disorder. B. bipolar I disorder. C. cyclothymia. D. seasonal affective disorder.
C Cyclothymia refers to mood swings involving hypomania and dysthymia of 2 years' duration. The mood swings are not severe enough to prompt hospitalization
Assessment of the thought processes of a client diagnosed with depression is most likely to reveal A. good memory and concentration. B. delusions of persecution. C. self-deprecatory ideation. D. sexual preoccupation.
C Depressed clients never feel good about themselves. They have a negative, self-deprecating view of the world.
A 19-year-old male being tested for multiple allergies develops localized redness and swelling in reaction to a patch skin test. Which intervention by the nurse would have the highest priority? A. Notify the primary care provider B. Apply a topical antiinflammatory cream C. Remove the patch and extract from the skin D. Administer oral diphenhydramine (Benadryl)
C If a severe reaction to a patch skin test occurs, the nurse should immediately remove the patch and the extract from the skin. Next the nurse should apply a topical antiinflammatory cream to the site. A subcutaneous injection of epinephrine may also be necessary but would need a health care provider's order.
A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can identify this cognitive distortion as an example of A. self-blame. B. catatonia. C. learned helplessness. D. discounting positive attributes.
C Learned helplessness results in depression when the client feels no control over the outcome of a situation.
A pregnant woman who was tested and diagnosed with HIV infection is very upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? A. "The baby will probably be infected with HIV." B. "Only an abortion will keep your baby from having HIV." C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." D. "The duration and frequency of contact with the organism will determine if the baby gets HIV infection."
C On average, 25% of infants born to women with untreated HIV will be born with HIV. The risk of transmission is reduced to less than 2% if the infected pregnant woman is treated with antiretroviral therapy. Duration and frequency of contact with the HIV organism is one variable that influences whether transmission of HIV occurs. Volume, virulence, and concentration of the organism as well as host immune status are variables related to transmission via blood, semen, vaginal secretions, or breast milk
It is likely that a client diagnosed with seasonal affective disorder will begin to experience fewer symptoms in the A. fall. B. winter. C. spring. D. summer.
C Seasonal affective disorder occurs during the months when sunlight diminishes. Clients may begin to feel effects in the late fall and will be affected throughout the winter. They improve during the spring and feel well during the summer.
The patient with diabetes mellitus has been ill for some time with a severe lung infection needing corticosteroids and antibiotics. The patient does not feel like eating. The nurse understands that this patient is likely to develop A. major histoincompatibility. B. primary immunodeficiency. C. secondary immunodeficiency. D. acute hypersensitivity reaction.
C Secondary immunodeficiency is most commonly caused by immunosuppressive drugs, such as corticosteroids. It can also be caused by diabetes mellitus, severe infection, malnutrition, and chronic stress, all of which are present in this patient. The other options are not possible for this patient.
A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? A. "I will call your care provider. Perhaps you need a different medication." B. "Don't worry. We can try taking it at a different time of day to help it work better." C. "It usually takes a few weeks for you to notice improvement from this medication." D. "Your life is much better now. You will feel better soon."
C Seeing a response to antidepressants takes 3 to 6 weeks. No change in medication is indicated at this point of treatment, because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that his or her life is better does not acknowledge the patient's feelings.
A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse? A. "The person may have sleep more, have trouble completing hygiene needs, and have a poor appetite." B. "The person may have sudden spikes in blood pressure and crave foods that are sweet or salty." C. "The person may have excess energy, talk a lot, feel restless, and spend too much money." D. "The person may experience decreased energy and interest in activities beginning in the winter months."
C Signs that a person is cycling into a manic phase include sleeping and eating less and having increased energy and racing thoughts, increased impulsivity, and increased spending behaviors. Blood pressure may increase related to increased activity, but increased blood pressure and food cravings alone are not indicative of mania. Increased sleep and poor appetite and hygiene are indicative of depression. Decreased energy in winter seasons is indicative of seasonal affective disorder related to decreased sunlight.
The nurse determines that the patient may be suffering from an acute bacterial infection based upon which laboratory test result? A. Increased platelet count B. Increased blood urea nitrogen C. Increased number of band neutrophils D. Increased number of segmented myelocytes
C The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.
A depressed client is noted to pace most of the time, pull at her clothes, and wring her hands. These behaviors are consistent with A. senile dementia. B. hypertensive crisis. C. psychomotor agitation. D. central serotonin syndrome.
C These behaviors describe the psychomotor agitation sometimes seen in clients with the agitated type of depression.
A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, what is the nurse's priority action? A. Monitor the patient's fluid balance. B. Assess the patient's need for analgesia. C. Monitor for signs and symptoms of an adverse reaction. D. Assess the patient for changes in level of consciousness.
C When administering immunotherapy, it is imperative to closely monitor the patient for any signs of an adverse reaction. The high risk and significant consequence of an adverse reaction supersede the need to assess the patient's fluid balance. Pain and changes in level of consciousness are not likely events when administering immunotherapy.
The woman is afraid she may get HIV from her bisexual husband. What should the nurse include when teaching her about preexposure prophylaxis (select all that apply)? A. Take fluconazole (Diflucan). B. Take amphotericin B (Fungizone). C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband.
C, D, E Using male or female condoms, having monthly HIV testing for the patient and her husband, and the woman taking emtricitabine and tenofovir regularly has shown to decrease the infection of heterosexual women having sex with a partner who participates in high-risk behavior. Fluconazole and amphotericin B are taken for Candida albicans, Coccidioides immitis, and Cryptococcosus neoformans, which are all opportunistic diseases associate with HIV infection.
A bipolar client tells the nurse, "I have the finest tenor voice in the world. The three tenors who do all those TV concerts are going to retire because they can't compete with me." The nurse would make the assessment that the client is displaying A. flight of ideas. B. distractibility. C. limit testing. D. grandiosity.
D
A client has been using cocaine intranasally for 4 years. When brought to the hospital in an unconscious state, nursing measures should include A. induction of vomiting. B. administration of ammonium chloride. C. monitoring of opiate withdrawal symptoms. D. observation for hyperpyrexia and seizures.
D
A nurse is educating a patient about the causes of depression. Which statement lets the nurse know the patient understands the neurobiological theory of depression? a. "My depression is made worse because my marriage is stressful." b. "Sometimes I believe that I can't help myself. That's why I get so depressed." c. "I'm depressed because my parents were depressed." d. "If I take these medications as prescribed, I should start to think clearly and feel energized."
D
A patient comes to a clinic with a chief complaint of, "My left arm is red and swollen. It hurts badly enough that I couldn't go to work today." The physician orders computer-assisted tomography (CT) scanning of the left upper extremity. The nurse knows the patient understands the reason for the procedure when he states A. "I need to have this done because my arm is broken." B. "The doctor wants me to have this so that the pain will stop." C. "This will tell you what I did to my elbow because I really don't know what happened." D. "This test will help to better determine where the injury actually is and how severe it is."
D
A syndrome that occurs after stopping the long-term use of a drug is called A. amnesia. B. tolerance. C. enabling. D. withdrawal.
D
As you evaluate a patient's progress, which treatment outcome would indicate a poor general prognosis for long-term recovery from substance abuse? a. Patient demonstrates improved self-esteem. b. Patient demonstrates enhanced coping abilities. c. Patient demonstrates improved relationships with others. d. Patient demonstrates positive expectations for ongoing drug use.
D
Benzodiazepines are useful for treating alcohol withdrawal because they A. block cortisol secretion. B. increase dopamine release. C. decrease serotonin availability. D. exert a calming effect.
D
Cody is preparing for discharge. He tells you, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? A. "It helps your mood so that you don't feel the need to do drugs." B. "It will keep you from experiencing flashbacks." C. "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." D. "It helps prevent relapse by reducing drug cravings."
D
In a type I hypersensitivity reaction the primary immunologic disorder appears to be a. binding of IgG to an antigen on a cell surface. b. deposit of antigen-antibody complexes in small vessels. c. release of cytokines used to interact with specific antigens. d. release of chemical mediators from IgE-bound mast cells and basophils.
D
Sasha's roommate Kate was admitted with major depression and suicidal ideation with a plan to overdose. Kate is preparing for discharge and asks you, "Why did Dr. Travis give me a prescription for only 7 days of amitriptyline?" Your response is based on the knowledge that: A. amitriptyline (Elavil) is very expensive, so the patient may have to buy fewer at a time. B. Dr. Travis is going to see how Kate responds to the first week of medication to evaluate its effectiveness. C. Dr. Travis wants to see whether any minor side effects occur within the first week of administration. D. amitriptyline (Elavil) is lethal in overdose.
D
Ten days after receiving a bone marrow transplant, a patient develops a skin rash on his palms and soles, jaundice, and diarrhea. What is the most likely etiology of these clinical manifestations? A. The patient is experiencing a type I allergic reaction. B. An atopic reaction is causing the patient's symptoms. C. The patient is experiencing rejection of the bone marrow. D. Cells in the transplanted bone marrow are attacking the host tissue.
D
The nurse is caring for a patient who exhibits disorganized thinking and delusions. The patient repeatedly states, "I hear voices of aliens trying to contact me." The nurse should recognize this presentation as which type of major depressive disorder (major depression)? a. Seasonal Affective Disorder b. Dysthymic Disorder c. Premenstrual Dysphoric disorder d. Psychotic
D
The term tolerance, as it relates to substance abuse, refers to A. the use of a substance beyond acceptable societal norms. B. the additive effects achieved by taking two drugs with similar actions. C. the signs and symptoms that occur when an addictive substance is withheld. D. the need to take larger amounts of a substance to achieve the same effects.
D
What is the ethical obligation of the nurse who sees a peer divert a narcotic, compared with the ethical obligation when the nurse observes a peer who is under the influence of alcohol? A. The nurse should immediately report the peer who is diverting narcotics and should defer reporting the alcohol-using nurse until a second incident takes place. B. Neither should be reported until the nurse has collected factual evidence. C. No report should be made until suspicions are confirmed by a second staff member. D. Supervisory staff should be informed as soon as possible in both cases.
D
What is the most appropriate nursing intervention to help an HIV-infected patient adhere to a treatment regimen? a. "Set up" a drug pillbox for the patient every week. b. Give the patient a video and a brochure to view and read at home. c. Tell the patient that the side effects of the drugs are bad but that they go away after a while. d. Assess the patient's routines and find adherence cues that fit into the patient's life circumstances.
D
When a client experiences four or more mood episodes in a 12-month period, the client is said to be A. dyssynchronous. B. incongruent. C. cyclothymic. D. rapid cycling.
D
When the wife of a manic client asks about genetic transmission of bipolar disorder, the nurse's answer should be predicated on the knowledge that A. no research exists to suggest genetic transmission. B. much depends on the socioeconomic class of the individuals. C. highly creative people tend toward development of the disorder. D. the rate of bipolar disorder is higher in relatives of people with bipolar disorder.
D
You are caring for Leah, a 26-year-old patient who has been abusing CNS stimulants. Which statement provides a basis for planning care for a patient who abuses CNS stimulants? a. Symptoms of intoxication include dilation of the pupils, dryness of the oronasal cavity, and excessive motor activity. b. Medical management focuses on removing the drugs from the body. c. Withdrawal is simple and rarely complicated. d. Postwithdrawal symptoms include fatigue and depression.
D
The nurse is teaching a 24-year-old female patient who has a latex allergy about preventing and treating allergic reactions. Which statement, if made by the patient, indicates a need for further teaching? A. "My dentist should be told about my latex allergy." B. "I should avoid foods such as bananas, avocados, and kiwi." C. "I will use vinyl gloves for activities such as housekeeping." D. "Because my reactions are not severe, I will not need an EpiPen."
D An individual with latex allergies should carry an injectable epinephrine pen. The proteins in latex are similar to the proteins in certain foods and may cause an allergic reaction in people who are allergic to latex. Foods to avoid include banana, avocado, chestnut, kiwi, tomato, water chestnuts, guava, hazelnuts, potatoes, peaches, grapes, and apricots. Vinyl gloves are not latex and are safe to use. Individuals with latex allergies need to share this information with all health care providers and wear a medical alert bracelet.
Tyler is being discharged home to his family. Which of the following is important teaching to include for the patient and the family to recognize possible signs of impending mania? A. Increased appetite B. Decreased social interaction C. Increased attention to bodily functions D. Decreased sleep
D Changes in sleep patterns are especially important because they usually precede mania. Even a single night of unexplainable sleep loss can be taken as an early warning of impending mania. The other options do not indicate impending mania.
A 52-year-old female patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? A. Cough, diarrhea, headaches, blurred vision, muscle fatigue B. Night sweats, fatigue, fever, and persistent generalized lymphadenopathy C. Oropharyngeal candidiasis or thrush, vaginal candidal infection, or oral or genital herpes D. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea
D Clinical manifestations of an acute infection with HIV include flu-like symptoms between 2 to 4 weeks after exposure. Early chronic HIV infection clinical manifestations are either asymptomatic or include fatigue, headache, low-grade fever, night sweats, and persistent generalized lympadenopathy. Intermediate chronic HIV infection clinical manifestations include candidal infections, shingles, oral or genital herpes, bacterial infections, Kaposi sarcoma, or oral hairy leukoplakia. Late chronic HIV infection or acquired immunodeficiency syndrome (AIDS) includes opportunistic diseases (infections and cancer).
Dysthymia cannot be diagnosed unless it has existed for A. at least 3 months. B. at least 6 months. C. at least 1 year. D. at least 2 years.
D Dysthymia is a chronic condition that by definition has to have existed for longer than 2 years.
The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action? A. Administer IV diphenhydramine (Benadryl). B. Administer nitroprusside as soon as possible. C. Anticipate tracheostomy with laryngeal edema. D. Place the patient recumbent and elevate the legs.
D In this emergency situation, the ABCs (airway, breathing, circulation) are being followed. For hypotension the patient should be placed in a recumbent position with the legs elevated, epinephrine will continue to be administered every 2-5 minutes, and fluids will be administered with vasopressors. Diphenhydramine is an antihistamine used to treat allergy symptoms. Anticipating a tracheostomy may occur with ongoing patient monitoring. Nitroprusside is a vasodilator and would not be used now.
The nurse is caring for a patient with a diagnosis of multiple sclerosis (MS). The nurse needs to be aware that the patient has A. Primary immunodeficiency. B. Secondary immunodeficiency. C. Optimal immune response. D. Exaggerated immune response.
D MS is an autoimmune disease, which is a form of exaggerated immune response. MS is not a problem of immunodeficiency, nor is it an optimal immune response.
A client who has been assessed by the nurse as moderately depressed is given a prescription for daily doses of a selective serotonin reuptake inhibitor. The client mentions that she will take the medication along with the St. John's wort she uses daily. The nurse should A. agree that taking the drugs at the same time will help her remember them daily. B. caution the client to drink several glasses of water daily. C. suggest that the client also use a sun lamp daily. D. explain the high possibility of an adverse reaction.
D Serotonin malignant syndrome is a possibility if St. John's wort is taken with other antidepressants.
The nurse is providing postoperative care for a 30-year-old female patient after an appendectomy. The patient has tested positive for human immunodeficiency virus (HIV). What type of precautions should the nurse observe to prevent the transmission of this disease? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions
D Standard precautions are indicated for prevention of transmission of HIV to the health care worker. HIV is not transmitted by casual contact or respiratory droplets. HIV may be transmitted through sexual intercourse with an infected partner, exposure to HIV-infected blood or blood products, and perinatal transmission during pregnancy, at delivery, or though breastfeeding.
Which of the following patients is at higher risk for inflammatory reactions? A. 2-year-old girl with a healthy diet. B. 38-year-old man who is obese. C. 54-year-old woman in menopause. D. 79-year-old man with diabetes.
D The 79-year-old man is at highest risk for inflammatory reactions among these patients for two reasons, his age and having diabetes. The risk would be high during the first year of life, but this 2-year-old girl has gotten beyond this risk period and she also has the positive factor of a healthy diet. The 38-year-old man is not in a high-risk category because of age but is because of obesity. Although a 54-year-old woman is getting older, being in menopause does not increase the risk for inflammatory reactions.
A depressed client tells the nurse he is in the "acute phase" of his treatment for depression. The nurse recognizes that the client has been in treatment A. for more than 4 months. B. that is directed toward relapse prevention. C. that focuses on prevention of future depression. D. to reduce depressive symptoms.
D The acute phase of depression therapy (6-12 weeks) is directed toward the reduction of symptoms and restoration of psychosocial and work function and may require some hospitalization.
