Practice Q's 4

The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is in antiretroviral therapy. The patient reports nausea, fever, severe diarrhea, and anorexia. Which prescribed medication does the nurse anticipate in order to relieve the anorexia and to stimulate the patient's appetite? 1) Dronabinol (Marinol) 2) Abacavir (Ziagen) 3) Ciprofloxacin (Cipro) 4) Zidovudine (Retrovir, AZT)

ANS: 1 Chapter page reference: 415 Feedback 1 Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase patient appetite and promote weight gain. 2 Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase. 3 Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent. 4 Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent.

The nurse is caring for a patient who is newly diagnosed with human immunodeficiency virus (HIV). The patient asks the nurse if there are ways to protect the patient's life partner from getting the HIV virus. After educating the patient, which statement indicates the need for further education? 1) "I know to use an oil-based lubricant to prevent spread of the disease to my partner." 2) "I can still kiss and hug my partner to show affection." 3) "I will not share my razor with my partner." 4) "I know I have to practice safer sex with my partner by using a latex condom."

ANS: 1 Chapter page reference: 416 Feedback 1 The nurse should educate the patient on methods that will decrease the risk of transmitting the HIV. The patient statement regarding the use of an oil-based lubricant requires further education. The patient should use only water-based lubricants, not oil-based, such as petroleum jelly, which can result in condom damage. 2 This patient statement indicates appropriate understanding of the information presented by the nurse. 3 This patient statement indicates appropriate understanding of the information presented by the nurse. 4 This patient statement indicates appropriate understanding of the information presented by the nurse.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is less than 200 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

ANS: 1 Chapter page reference: 417 Feedback 1 Toxoplasmosis is a complication that occurs when the patient's CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunodeficiency syndrome (AIDS). 2 Herpes zoster virus is a complication that occurs when the patient's CD4+ is between 500 and 350 cells/L. 3 Vaginal candidiasis is a complication that occurs when the patient's CD4+ count is greater than 500 cells/L. 4 Severe bacterial infection is a complication that occurs when the patient's CD4+ is 350 and 200 cells/L.

The nurse is providing care to a pediatric patient who is HIV-positive. The patient's mother is describing the child's current condition and activities to the nurse. Which parental statement indicates that the child may require further intervention? 1) "My child seems somewhat isolated and doesn't have any real friends." 2) "My child has a good appetite and eats regular meals." 3) "My child hasn't shown any sign of infection." 4) "My child attends school and doing well in class."

ANS: 1 Chapter page reference: 417-419 Feedback 1 This statement indicates that the patient is not adequately coping with the current situation and requires further assessment and/or intervention by the nurse. 2 Positive outcomes for an HIV patient would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school. 3 Positive outcomes for an HIV patient would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school. 4 Positive outcomes for an HIV patient would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.

The nurse determines that a patient's abdominal wound is in the proliferative phase of healing. What is occurring during this phase? Select all that apply. 1) Granulation 2) Angiogenesis 3) Epithelialization 4) Collagen synthesis 5) Reorganization of collagen

ANS: 1, 2, 3, 4 Chapter page reference: 1062 Feedback 1. As the capillary bed is laid down, the wound fills with granulation tissue and appears beefy red, shiny, and granular. 2. Endothelial cells are activated to initiate angiogenesis, which increases blood supply to the new tissue. 3. Keratinocytes help with epithelialization during this phase. 4. Macrophages synthesis collagen during this phase. 5. The reorganization of collagen occurs during the maturation phase.

The nurse instructs a group of community members on the difference between benign and malignant neoplasms. Which participant statements indicate that teaching has been effective? Select all that apply. 1) "Malignant tumors can grow back." 2) "Benign tumors stay in one area." 3) "Benign tumors grow slowly." 4) "Malignant tumors are easy to remove." 5) "Malignant tumors push other tissue out of the way."

ANS: 1, 2, 3, 4 Chapter page reference: 217 Feedback 1. This is correct. Malignant tumors are more difficult to remove. They invade neighboring tissue and can return once removed. 2. This is correct. Benign tumors are slow-growing and stay in one area. 3. This is correct. Benign tumors are slow-growing and stay in one area. 4. This is incorrect. Benign, not malignant, tumors are easy to remove. 5. This is incorrect. Benign, not malignant, tumors push other tissue out of the way.

The nurse is providing care to a pediatric patient who is diagnosed with DiGeorge's syndrome. Which data indicates a cardiovascular abnormality? Select all that apply. 1) Murmur 2) Cyanosis 3) Polycythemia 4) Failure to thrive 5) Cleft lip and palate

ANS: 1, 2, 3, 4 Chapter page reference: 371-375 Feedback 1. This is correct. A heart murmur indicates a cardiovascular abnormality. 2. This is correct. Cyanosis indicates a cardiovascular abnormality. 3. This is correct. Polycythemia indicates a cardiovascular abnormality. 4. This is correct. Failure to thrive indicates a cardiovascular abnormality. 5. This is incorrect. While cleft lip and palate often occurs with this syndrome, this data does not indicate a cardiovascular abnormality.

The nurse is providing discharge instructions to a patient being treated for cancer. For which symptoms should the patient be instructed to call for help at home? Select all that apply. 1) Desire to end life 2) Difficulty breathing 3) New onset of bleeding 4) Improved sense of well-being 5) Significant increase in vomiting

ANS: 1, 2, 3, 5 Chapter page reference: 239-245 Feedback 1. This is correct. The patient should be instructed to call for help with any difficulty breathing, significant increase in vomiting, a desire to end life, or a new onset of bleeding. 2. This is correct. The patient should be instructed to call for help with any difficulty breathing, significant increase in vomiting, a desire to end life, or a new onset of bleeding. 3. This is correct. The patient should be instructed to call for help with any difficulty breathing, significant increase in vomiting, a desire to end life, or a new onset of bleeding. 4. This is incorrect. An increased sense of well-being would be a desired effect of treatment for cancer. 5. This is correct. The patient should be instructed to call for help with any difficulty breathing, significant increase in vomiting, a desire to end life, or a new onset of bleeding.

The nurse is caring for a patient who is diagnosed with cancer. Which diagnostic tests may be helpful to assist with treatment options? Select all that apply. 1) MRI 2) Urinalysis 3) Stool analysis 4) Tumor markers 5) Physical assessment

ANS: 1, 2, 4 Chapter page reference: 229-231 Feedback 1. This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine treatment for cancer. 2. This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine treatment for cancer. 3. This is incorrect. A stool analysis is not a diagnostic test listed to determine treatment for cancer. 4. This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine treatment for cancer. 5. This is incorrect. A physical assessment may be useful to determine how a patient is responding to treatment, but it is not considered a diagnostic test.

The nurse is providing care to patient who is at an increased risk for infection due to poor dietary intake, a decreased white blood cell count, and diminished neutrophil activity. Which information in the patient's health history supports the current data? 1) Anorexia nervosa 2) Acute renal failure 3) Pulmonary disease 4) Cirrhosis of the liver

ANS: 1 Chapter page reference: 330-334 Feedback 1 Anorexia nervosa causes malnutrition causing a decreased white blood cell (WBC) count and diminished neutrophil activity leading to a risk for infection. 2 Acute renal failure leads to decreased neutrophil action and immunoglobulin activity causing an increased risk for infection. 3 Pulmonary disease leads to decrease neutrophil activity causing an increased risk for infection. 4 Cirrhosis of the liver is an example of hepatic disease. This leads to a decreased neutrophil count which increases the risk for infection.

The nurse is conducting a health history for a patient who is at risk for infection. Which question is appropriate when collecting data related to the patient's social history? 1) "Do you smoke cigarettes?" 2) "Are your immunizations current and up-to-date?" 3) "What type of reaction do you have with an allergy flair?" 4) "Did you have your spleen removed after your car accident?"

ANS: 1 Chapter page reference: 330-334 Feedback 1 This question is appropriate to assess the patient's social history. 2 This question is appropriate to assess the patient's immunization history. 3 This question is appropriate to assess the patient's current problem. 4 This question is appropriate to assess the patient's past medical or surgical history.

A nurse is caring for a patient with who is experiencing leukocytosis. When providing care to this patient, which action by the nurse is the most appropriate? 1) Assess for source of infection 2) Assess for bleeding and bruising 3) Place the patient in reverse isolation precautions 4) Instruct the patient on the use of an electric razor and soft toothbrush

ANS: 1 Chapter page reference: 330-334 Feedback 1 A patient with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm3), which is an indication of infection. The appropriate action by the nurse is to assess the patient for a source of the infection. 2 Instructing the patient on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a patient with decreased platelet levels, or thrombocytopenia. 3 Placing the patient in reverse isolation precautions would be appropriate for the patient with neutropenia, a decrease in the number of neutrophils. 4 Instructing the patient on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a patient with decreased platelet levels, or thrombocytopenia.

The nurse is providing care to a patient who experienced an allergic reaction. Which leukocyte does the nurse anticipate will be elevated? 1) Basophils 2) Monocytes 3) Eosinophils 4) Neutrophils

ANS: 1 Chapter page reference: 332-334 Feedback 1 An elevated basophil count indicates an allergic reaction. 2 Monocytes are produced for phagocytosis in order to ingest engulfed microorganisms. 3 An elevated eosinophil count indicates a parasitic infection. 4 An elevated neutrophil count indicates bacterial infection.

A nurse working in the emergency department (ED) is providing care for a group of patients. Which patient demonstrates a decline in immune response that typically occurs with the aging process? 1) An 88-year-old with pneumonia who has a temperature of 99.5°F. 2) A 56-year-old who has 8 mm induration at the site of a PPD skin test 72 hours earlier. 3) A 58-year-old who reports redness and itching due to a rash from contact with poison ivy. 4) A 70-year-old who has swelling and redness at the incision from an open appendectomy.

ANS: 1 Chapter page reference: 335-336 Feedback 1 The patient who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. 2 This patient is demonstrating an expected immune response as evidenced by redness, swelling, and induration. 3 This patient is demonstrating an expected immune response as evidenced by redness, swelling, and induration. 4 This patient is demonstrating an expected immune response as evidenced by redness, swelling, and induration.

Which is the priority nursing action to decrease the risk for infection for a patient diagnosed with DiGeorge's syndrome? 1) Hand hygiene 2) Reverse isolation 3) Prokinetic agents 4) Droplet precautions

ANS: 1 Chapter page reference: 371-375 Feedback 1 Hand hygiene is the priority nursing action to decrease this patient's risk for infection. 2 Reverse isolation decreases the risk for infection for a patient who is neutropenic. 3 Prokinetic agents are administered to this patient for gastrointestinal symptoms. 4 Droplet precautions are implemented for a patient with a communicable disease.

Which is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia (XLA)? 1) Risk for infection 2) Decreased cardiac output 3) Anticipatory grieving 4) Fatigue

ANS: 1 Chapter page reference: 373 Feedback 1 The priority nursing diagnosis for a patient diagnosed with XLA is an increased risk for infection. 2 This is not the priority nursing diagnosis for this patient. 3 This is not the priority nursing diagnosis for this patient. 4 This is not the priority nursing diagnosis for this patient.

The nurse is providing care to a patient diagnosed with X-linked agammaglobulinemia (XLA). Which should the nurse include in the patient's plan of care? 1) Immunization with inactivated polio vaccine (IPV) 2) Administration of intravenous immunoglobulin every six months 3) Education regarding the use of high dose prophylactic antibiotics 4) Periodic magnetic resonance imagery (MRI) to monitor for respiratory complications

ANS: 1 Chapter page reference: 374-375 Feedback 1 Patients diagnosed with XLA should be immunized with IPV versus oral polio vaccine due to the risk of developing vaccine-acquired polio. 2 IVIG should be administered every three to four weeks, not every six months. 3 Education regarding low, not high, dose prophylactic antibiotics is required. 4 Periodic chest x-rays, not MRIs, to monitor for respiratory complications are included in the plan of care.

A nurse has been providing a young adult patient with a history of hypersensitivity reactions. The nurse is preparing instructions on the correct methods for using an EpiPen. Which patient statement indicates understanding of the proper technique? 1) "I make sure the EpiPen is always available." 2) "It's fine to leave the EpiPen out in the sun." 3) "No one else in my family knows how to use the EpiPen." 4) "I don't need a medical alert tag."

ANS: 1 Chapter page reference: 377-390 Feedback 1 The patient and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the patient studies, works, or plays. 2 Proper storage of the kit is important, avoiding exposure to sun or high temperature. 3 In addition to the patient, someone else should always know how to use the kit as well. 4 The patient should be encouraged to wear a medical alert bracelet or tag.

The nurse is caring for a patient in an allergy clinic. After completing the patient history, the nurse selects the nursing diagnosis of Risk for Shock. Which item in the patient's history supports the need for this nursing diagnosis? 1) A history of an anaphylactic reaction to shellfish. 2) A drug reaction to penicillin causing a rash. 3) A history of glomerulonephritis. 4) A history of dermatitis resulting from a response to changing laundry detergent.

ANS: 1 Chapter page reference: 377-390 Feedback 1 Type I hypersensitivities, such as anaphylactic reactions, occur immediately and may be life-threatening. Because the patient has a history of this type of reaction, Risk for Shock is an appropriate nursing diagnosis. 2 The other items would not necessitate the need for this nursing diagnosis. 3 The other items would not necessitate the need for this nursing diagnosis. 4 The other items would not necessitate the need for this nursing diagnosis.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient presents with a fever without other notable symptoms. Which is the most likely cause of this data? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

ANS: 1 Chapter page reference: 410 Feedback 1 A fever is caused by infection. 2 Weight loss is generally caused by worsening of the disease or disease progression. 3 Night sweats are caused by a mycobacterial infection. 4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.

The nurse is assessing a patient who is diagnosed with human immunodeficiency virus (HIV) who presents with a rash. Which assessment question is most appropriate? 1) "Are you taking Bactrim?" 2) "Have you recently used a new soap?" 3) "What have you eaten in the last few days?" 4) "Did you have unprotected sex within the last week?"

ANS: 1 Chapter page reference: 413 Feedback 1 A new onset rash for a patient diagnosed with HIV is often a delayed reaction to a prophylactic antibiotic, such as Bactrim. This question is the most appropriate. 2 While new soaps can cause a rash, this is not the most appropriate question for a patient diagnosed with HIV who presents with a rash. 3 While new soaps can cause a rash, this is not the most appropriate question for a patient diagnosed with HIV who presents with a rash. 4 Unprotected sex is unlikely to be the cause of a rash.

The nurse is discharging a pediatric patient who was recently diagnosed with acquired immunodeficiency syndrome (AIDS). When discussing appropriate health promotion activities for this child, which immunization is contraindicated? 1) Varicella vaccine 2) Haemophilus influenzae type B (HIB conjugate vaccine) 3) Hepatitis B vaccine (hep B) 4) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

ANS: 1 Chapter page reference: 415 Feedback 1 A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. 2 DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule. 3 DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule. 4 DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.

Which is the priority action for a nurse who is exposed to a needle-stick injury while providing patient care? 1) Washing the injury under running water 2) Squeezing the site to remove the patient's blood 3) Taking two or three drugs for 28 days 4) Consenting to a human immunodeficiency virus (HIV) test

ANS: 1 Chapter page reference: 415 Feedback 1 The priority nursing action in this situation is to wash the injury under running water. 2 The nurse should avoid squeezing the injury as this is likely to increase the risk for infection. 3 The nurse may be prescribed several drugs for 28 days; however, this is not the priority action. 4 The nurse is likely to consent to an HIV test; however, this is not the priority action.

The nurse accompanies the health-care provider into the patient's room and listens as the diagnosis of cancer is shared with the patient and family. Once the health-care provider leaves the room, the nurse notes that the patient and family are teary-eyed regarding the diagnosis. What is the nurse's most appropriate intervention at this time? 1) Provide emotional support in coping with the diagnosis. 2) Help the patient and family remain realistic about prognosis. 3) Provide teaching about the treatment options for this form of cancer. 4) Arrange for the patient to complete a medical power of attorney form.

ANS: 1 Chapter page reference: 239-245 Feedback 1 When a patient and family receive a new diagnosis of cancer, it tends to evoke many emotions, including fear, grief, and anger. The patient and family require emotional support at this time, and other actions can be initiated when they have time to learn to accept and cope with the diagnosis. 2 This is not an opportune time to teach, set goals, or make decisions regarding power of attorney. 3 This is not an opportune time to teach, set goals, or make decisions regarding power of attorney. 4 This is not an opportune time to teach, set goals, or make decisions regarding power of attorney.

The nurse is teaching a new mother the immune benefits of breastfeeding her newborn. Which immunoglobulin (Ig) should the nurse include as one that is passed from mother to newborn by breast milk? 1) IgA 2) IgD 3) IgE 4) IgG

ANS: 1 Chapter page reference: 321-330 Feedback 1 IgA is passed from mother to newborn in breast milk and provides immunity to the newborn. 2 IgD is not secreted in breast milk. 3 IgE is not secreted in breast milk. 4 IgG is passed through the placenta during pregnancy and provides the newborn with some immunity during the first few months of life.

Which nutritional deficiency often impacts a patient's ability to mount an immune response? 1) Proteins 2) Calcium 3) Potassium 4) Carbohydrates

ANS: 1 Chapter page reference: 321-330 Feedback 1 Nutritional status is a critical component of immunocompetence. Cellular immunity, phagocyte activity, and complement ability are greatly impacted by protein deficiencies. 2 A calcium deficiency is more likely to impact bone health. 3 A potassium deficiency is more likely to impact cardiovascular health. 4 A carbohydrate deficiency does not impact a patient's ability to mount an immune response.

A nurse is caring for a patient who is diagnosed with skin cancer. Which nursing interventions will reduce the growth of cancer cells and support normal cell function? Select all that apply. 1) Increasing calorie intake 2) Encouraging mobility and exercise 3) Encouraging increased rest and sleep 4) Assessing normal functioning of organ systems 5) Reducing oxygen supply to retard growth of cancer cells

ANS: 1, 3, 4 Chapter page reference: 239-245 Feedback 1. This is correct. Cancer cells grow faster than normal cells, so they use more nutrients for growth, resulting in wasting, which can only be counteracted by increasing the caloric intake of the patient. 2. This is incorrect. While patients should not be inactive, they should be taught to reduce activity to reduce weight loss and provide more energy to the healthy cells. 3. This is correct. Increased rest and sleep give the patient's body more energy to fight the cancer cells. 4. This is correct. Because cancer cells can grow in any area of the body, it is important for the nurse to assess normal functioning of all organ systems. 5. This is incorrect. Decreasing oxygen supply will retard cancer cell growth but it will also retard normal cell health.

The nurse is caring for a thin, older adult patient who is diagnosed with cancer and is receiving aggressive chemotherapy. The patient is experiencing severe side effects from the therapy and has lost 10 pounds in the past week. What should the nurse teach the patient to do? Select all that apply. 1) Keep a food diary and record intake. 2) Purchase fast foods and prepared foods. 3) Eat small frequent meals high in calories. 4) Drink liquid supplements to increase intake of nutrients. 5) Eat cold foods rather than hot foods, because they are better tolerated.

ANS: 1, 3, 4, 5 Chapter page reference: 239-245 Feedback 1. This is correct. The goal of nutritional teaching is to help the patient increase caloric and nutrient intake through the use of liquid supplements, small frequent meals, and a food diary that will help the nurse evaluate strengths and weaknesses of the current plan. 2. This is incorrect. Fast foods and prepared foods tend to be high in fat and sodium and are not the best choice because they do not contain adequate healthy nutrients. Instead, involving the family in preparing meals or in enrolling in Meals on Wheels may be better options for easy ways of obtaining meals. 3. This is correct. The goal of nutritional teaching is to help the patient increase caloric and nutrient intake through the use of liquid supplements, small frequent meals, and a food diary that will help the nurse evaluate strengths and weaknesses of the current plan. 4. This is correct. The goal of nutritional teaching is to help the patient increase caloric and nutrient intake through the use of liquid supplements, small frequent meals, and a food diary that will help the nurse evaluate strengths and weaknesses of the current plan. 5. This is correct. The patient receiving chemotherapy may tolerate cold foods better than hot foods.

The nurse is conducting a physical assessment for a patient with a compromised immune system. Which actions by the nurse are appropriate? Select all that apply. 1) Assessing general appearance 2) Recommending increased fluid intake 3) Checking joint range of motion (ROM), including that of the spine 4) Inspecting the mucous membranes of the nose and mouth for color and condition 5) Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness

ANS: 1, 3, 4, 5 Chapter page reference: 330-334 Feedback 1. This is correct. The techniques of inspection and palpation are especially important in assessing a patient's immune system: The nurse will assess the patient's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient's ROM, including that of the spine. 2. This is incorrect. While recommending that the patient increase fluid intake may be an appropriate intervention, this is not an action that is conducted during the physical assessment for this patient. 3. This is correct. The techniques of inspection and palpation are especially important in assessing a patient's immune system: The nurse will assess the patient's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient's ROM, including that of the spine. 4. This is correct. The techniques of inspection and palpation are especially important in assessing a patient's immune system: The nurse will assess the patient's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient's ROM, including that of the spine. 5. This is correct. The techniques of inspection and palpation are especially important in assessing a patient's immune system: The nurse will assess the patient's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient's ROM, including that of the spine.

The nurse is assessing a patient's immune system. Which findings increase the patient's risk for infection due to alterations in mechanical barriers? Select all that apply. 1) Dysphagia 2) Dry mouth 3) Nonintact skin 4) Urinary retention 5) Clogged tear duct

ANS: 1, 4 Chapter page reference: 321-330 Feedback 1. This is incorrect. Swallowing is a mechanical barrier to infection. Dysphagia, or impaired swallowing, increases the patient's risk for infection. 2. This is correct. Saliva is a biochemical, not mechanical, barrier to infection. A dry mouth increases the patient's risk for infection. 3. This is incorrect. Intact skin is a physical, not mechanical, barrier to infection. Nonintact skin increases the patient's risk for infection. 4. This is incorrect. Urination is a mechanical barrier to infection. Urinary retention increases the risk for bacterial growth and infection. 5. This is correct. Tears are a biochemical, not mechanical, barrier to infection. A clogged tear duct increases this patient's risk for infection.

A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee stings. Which clinical manifestations would necessitate the need to inject the child with epinephrine (EpiPen)? Select all that apply. 1) Skin that is cold and clammy to the touch 2) Skin that is warm and dry to the touch 3) The child is hyperactive and hyperverbal. 4) Complaints of thirst 5) Restlessness and confusion

ANS: 1, 4, 5 Chapter page reference: 383 Feedback 1. This is correct. General symptoms of shock that would necessitate an epinephrine injection include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. The skin may feel cold and clammy in shock. 2. This is incorrect. The skin will not be warm and dry to the touch. 3. This is incorrect. In shock, the patient will not be hyperactive or hyperverbal. 4. This is correct. Thirst is a common complaint in shock. 5. This is correct. General symptoms of shock that would necessitate an epinephrine injection include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. The skin may feel cold and clammy in shock.

A patient's leg wound is not healing as quickly as expected. What should the nurse do to determine the reason for the patient's poor healing? Select all that apply. 1) Obtain a referral for a dietician 2) Elevate the extremity on a pillow 3) Increase the frequency of dressing changes 4) Encourage increased independent movement 5) Obtain an order for prealbumin and albumin levels

ANS: 1, 5 Chapter page reference: 1069 Feedback 1. Nutritional status affects wound healing. A referral to a dietician may be needed. 2. Elevating the limb on a pillow will not enhance wound healing. 3. Increasing the frequency of dressing changes could damage fragile granulation tissue. 4. Increased activity will not necessarily improve wound healing, 5. Nutritional status affects wound healing. Prealbumin and albumin levels provide data about overall nutritional status.

The nurse is providing care to a patient who is suspected of having an immune deficiency. Which information in the patient's health history supports this suspected diagnosis? Select all that apply. 1) Persistent oral thrush 2) Tinea infection of the feet 3) One occurrence of pneumonia last year 4) Four or more infections in a one-year period 5) Two serious sinus infections in a one-year period

ANS: 1, 5 Chapter page reference: 370 Feedback 1. This is correct. Persistent oral thrush is an indication of immune deficiency. 2. This is incorrect. A tinea infection of the feet does not support suspected immune deficiency. 3. This is incorrect. Two, not one, occurrence of pneumonia within in one-year period indicates immune deficiency. 4. This is incorrect. Six, not four, or more infections in a one-year period supports the diagnosis of immune deficiency. 5. This is correct. Two or more serious sinus infections in a one-year period supports the diagnosis of immune deficiency.

Human immunodeficiency virus (HIV) infects and destroys CD4 cells. List the following events in the order in which they occur for a patient who is HIV-positive. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Virus invades helper T cell 2) Viral RNA converts with reverse transcriptase to viral DNA 3) Viral DNA integrates with host cell DNA. 4) Virus remains latent, or actively replicates 5) Virus sheds protein coat

ANS: 13452 Chapter page reference: 411 Feedback: The HIV virus gains entry into helper T cells, uses the cell DNA to replicate, interferes with normal function of the T cells, and destroys the normal cells.

A patient has a secondary closure surgical wound. What was most likely used to close this wound? 1) Tape 2) Grafts 3) Staples 4) Sutures

ANS: 2 Chapter page reference: 1068 Feedback 1 Tape is used to close a primary closure wound. 2 Grafts are used to close a secondary closure wound. 3 Staples are used to close a primary closure wound. 4 Sutures are used to close a primary closure wound.

The nurse is preparing a seminar that discusses the risk and incidence of cancer and culture. What information is considered culturally correct when teaching about the risk of developing cancer? 1) Hispanics have an increased risk of cervical, stomach, and liver cancer. 2) African-Americans are more likely to develop cancer than any other ethnic group. 3) The incidence and mortality rate of all type of cancers are lowest in the Caucasian population. 4) African-Americans are less likely to develop cancer than any other ethnic or racial group in the United States.

ANS: 2 Chapter page reference: 214-215 Feedback 1 There is no specific information about the Hispanic population. 2 African-American clients are more likely to develop cancer than any other ethnic group. 3 Mortality rates for cancer are the lowest in the Asian/Pacific Islander population. 4 African-Americans are more likely to develop cancer than any other ethnic or racial group in the United States.

The nurse is assisting the health-care provider with a bone marrow aspiration and biopsy on a patient who has leukemia. The patient also has thrombocytopenia. Upon completing of the test, which intervention is a priority for the nurse? 1) Make certain the patient understands the purpose of the test. 2) Hold pressure on the wound for approximately five minutes. 3) Label and refrigerate the specimen obtained by the physician. 4) Dispose of the equipment used, and clean the area properly.

ANS: 2 Chapter page reference: 231-239 Feedback 1 An explanation of the test is performed before the procedure is begun. 2 The most important task for the nurse is to prevent bleeding after the biopsy. Holding pressure on the wound for five minutes is effective. 3 Dealing with the specimen is accomplished by a third party or after the nurse stabilizes the patient. 4 Cleaning the area is completed after the patient is stable and the specimen is sent to the laboratory.

A patient has just been told that a colectomy and ileostomy are needed to treat a new diagnosis of colon cancer. Which nursing diagnosis should the nurse use to plan this patient's preoperative nursing care? 1) Knowledge Deficit 2) Anticipatory Grieving 3) Risk for Disuse Syndrome 4) Risk for Perioperative-Positioning Injury

ANS: 2 Chapter page reference: 239-245 Feedback 1 Now is not the time to begin instructions, because the patient will most likely be unable to learn or concentrate on what the nurse is teaching. 2 The patient and family will require support to deal with their emotional response to learning the patient has cancer and will undergo body image-changing surgery. 3 Disuse syndrome and injury from positioning may be factors after surgery. 4 Disuse syndrome and injury from positioning may be factors after surgery.

Which nursing action is appropriate when assessing a patient's tonsils during a physical examination? 1) Asking the patient to cough several times 2) Asking the patient to open the mouth and say "ah" 3) Palpating the soft tissue of the face near the patient's nose 4) Palpating the left upper quadrant of the patient's abdomen

ANS: 2 Chapter page reference: 330-334 Feedback 1 This action is not appropriate when assessing the patient's tonsils. 2 The tonsils are located between the palatine arches on either side of the pharynx; therefore, the nurse would ask the patient to open the mouth and say "ah" during the assessment process. 3 This action is appropriate when assessing the patient's sinuses, not the tonsils. 4 This action is appropriate when assessing the patient's spleen, not the tonsils.

The nurse is providing care to a patient who has an increased number of lymphocytes. Which explanation should the nurse provide to the patient regarding this abnormality? 1) "An elevated neutrophil count indicates your body is battling a parasitic infection." 2) "An elevated neutrophil count indicates your body is battling a bacterial infection." 3) "An elevated neutrophil count indicates your body is experiencing an allergic reaction." 4) "An elevated neutrophil count indicates your body is experiencing an adaptive immune response."

ANS: 2 Chapter page reference: 332-334 Feedback 1 An elevated eosinophil, not neutrophil, count indicates the body is battling a parasitic infection. 2 A bacterial infection is often indicated by an elevated neutrophil count. 3 An elevated basophil, not neutrophil, count indicates the body is experiencing an allergic reaction. 4 An elevated lymphocyte, not neutrophil, count indicates an adaptive immune response.

Which general manifestation should the nurse anticipate when providing care to a patient diagnosed with DiGeorge's syndrome? 1) Poor muscle tone 2) Failure to thrive 3) Shortness of breath 4) Delayed development

ANS: 2 Chapter page reference: 368-371 Feedback 1 Poor muscle tone is classified as an "other" manifestation of DiGeorge's syndrome. 2 Failure to thrive is a general manifestation of DiGeorge's syndrome. 3 Shortness of breath is a respiratory manifestation of DiGeorge's syndrome. 4 Delayed development is classified as an "other" manifestation of DiGeorge's syndrome.

Which should the nurse plan to monitor when providing care to a patient who is diagnosed with DiGeorge's syndrome? 1) Sodium 2) Calcium 3) Potassium 4) Magnesium

ANS: 2 Chapter page reference: 371-375 Feedback 1 Sodium is not an electrolyte the nurse should plan to monitor when providing care to this patient. 2 A patient with DiGeorge's syndrome often has hypoparathyroidism resulting in a decreased serum calcium level; therefore, the nurse would plan to monitor the patient's calcium. 3 Potassium is not an electrolyte the nurse should plan to monitor when providing care to this patient. 4 Magnesium is not anticipated to be affected by this diagnosis.

The nurse is providing care to a patient with autoimmune hepatitis. Which medication should the nurse prepare to teach this patient about based on the diagnosis? 1) Epinephrine 2) Azathioprine 3) Cyclosporine 4) Mycophenolate mofetil

ANS: 2 Chapter page reference: 377-390 Feedback 1 Epinephrine is not used in the treatment of automimmune hepatitis. 2 Azathioprine is used to treat autoimmune hepatitis and rheumatoid arthritis. 3 Cyclosporine is used to treat psoriasis, rheumatoid arthritis, multiple sclerosis, myasthenia gravis, scleroderma, and is used to prevent organ transplant rejection. 4 Mycophenolate mofetil is used to treat scleroderma, lupus, and to prevent organ transplant rejection.

The nurse suspects that the patient is experiencing a reaction to a specific antigen. Which laboratory result supports the conclusion made by the nurse? 1) Indirect Coombs' showing no agglutination 2) Patch test with a 1-inch area of erythema 3) 2% eosinophils in the WBC count 4) Rh antigen with negative results

ANS: 2 Chapter page reference: 377-390 Feedback 1 Indirect Coombs' test detects the presence of circulating antibodies against RBCs. No agglutination is considered a normal finding. 2 An area of erythema after a patch test indicates a positive response to a specific antigen. 3 An eosinophil count of 2% is within the normal range. 4 An Rh antigen with a negative result indicates that the patient does not carry the antigen and is not an indicator of a reaction to a specific antigen.

A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching would the nurse provide to improve this patient's comfort? 1) Keep doors and windows open on high-allergen days to circulate air. 2) Maintain a clean, dust-free environment. 3) Take antihistamine and leukotriene medication as ordered 4) Stop taking oral corticosteroids immediately once symptoms disappear.

ANS: 2 Chapter page reference: 377-390 Feedback 1 The nurse should instruct the patient to keep doors and windows closed on high-allergen days and to remain indoors if possible. 2 A patient with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should also include teaching on maintaining a clean, dust-free environment. 3 Medication instruction should include instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. 4 The patient should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 500 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

ANS: 2 Chapter page reference: 409 Feedback 1 This is not a stage for the classification of HIV. 2 Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L. 3 Stage 2 is documented for a patient with a CD4+ count of 200-499 cells/L. 4 Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has lost 15% of body weight since the last appointment. Which reason should the nurse include in a teaching session for this patient regarding this occurrence? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

ANS: 2 Chapter page reference: 410 Feedback 1 A fever is caused by infection. 2 Weight loss is generally caused by worsening of the disease or disease progression. 3 Night sweats are caused by a mycobacterial infection. 4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.

The nurse notes that a patient has several lacerations over the coccyx area. What finding most likely caused these lesions? 1) Heat 2) Pressure 3) Shearing 4) Moisture

ANS: 3 Chapter page reference: 1060 Feedback 1 Heat does not cause a laceration. 2 Pressure could cause an ulcer. 3 A laceration is a break in the skin caused by high shearing forces that exert a diagonal force on the skin causing damage. 4 Moisture would cause maceration.

A patient is prescribed phototherapy as treatment for psoriasis. Which patient statement indicates that teaching about this treatment has been effective? 1) "I should expect my skin to feel painful from the treatments." 2) "I should expect my skin to become red from the treatments." 3) "I should not have a treatment if my skin gets red or is blistered." 4) "I should expect occasional blisters and drainage from the treatments."

ANS: 3 Chapter page reference: 1060 Feedback 1 Phototherapy should be held if the skin becomes painful. 2 Phototherapy should be held if the skin becomes reddened. 3 Phototherapy should be held if the skin becomes red or blistered. 4 Phototherapy should be held if the skin develops blisters with drainage.

A patient with a pressure ulcer is prescribed a zinc supplement. What should the nurse explain to the patient about this supplement? 1) It helps strengthen capillaries. 2) It helps with immune function. 3) It is needed for protein synthesis. 4) It aids with red blood cell formation.

ANS: 3 Chapter page reference: 1079 Feedback 1 Ascorbic acid (vitamin C) strengthens capillaries. 2 Ascorbic acid (vitamin C) improves immune function. 3 Zinc helps with collagen formation and protein synthesis. 4 Copper helps with red blood cell formation.

A nurse is caring for a patient with cancer. The nurse teaches the patient about which potentially undesirable cellular alterations that can occur during the cell cycle? 1) Dysphagia 2) Adaptation 3) Hyperplasia 4) Differentiation

ANS: 3 Chapter page reference: 215-217 Feedback 1 Dysphagia and adaptation are not a part of the cell cycle. 2 Dysphagia and adaptation are not a part of the cell cycle. 3 Potentially undesirable cellular alterations that can occur during the cell cycle include hyperplasia and anaplasia. Hyperplasia is an increase in the number or density of normal cells. 4 Differentiation is a normal process occurring over many cell cycles that allows cells to specialize in certain tasks.

The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse? 1) "The doctor prefers this test." 2) "Why are you concerned about this test?" 3) "It is more specific in diagnosing your condition." 4) "To rule out the possibility that your problems are caused by pneumonia."

ANS: 3 Chapter page reference: 229-231 Feedback 1 Health-care provider preference is not a factor for why the CT was ordered. 2 The patient's question is valid and should not be minimized by asking why the patient is having concerns about the test. 3 Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors in the lung parenchyma and pleura. 4 A chest x-ray can be used to diagnose pneumonia.

A patient with anemia caused by chemotherapy is prescribed synthetic erythropoietin. When teaching the patient about the therapeutic effect of this treatment, which is appropriate for the nurse to include? 1) Increase in platelets 2) Decrease in lymph fluid 3) Increase in red blood cells 4) Decrease in white blood cells

ANS: 3 Chapter page reference: 231-239 Feedback 1 Erythropoietin will not stimulate or decrease the production of platelets, white blood cells, or lymph fluid. 2 Erythropoietin will not stimulate or decrease the production of platelets, white blood cells, or lymph fluid. 3 Erythropoietin is a hormone produced in the body to stimulate production of red blood cells; synthetic forms are available for administration to cancer patients or others with significantly low red blood cell counts. 4 Erythropoietin will not stimulate or decrease the production of platelets, white blood cells, or lymph fluid.

The nurse is caring for a patient with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this patient? 1) Restrict fluid intake 2) Replace hand hygiene with gloves 3) Restrict visitors with communicable illnesses. 4) Insert an indwelling urinary catheter to prevent skin breakdown

ANS: 3 Chapter page reference: 231-239 Feedback 1 Fluid intake should be encouraged. 2 Gloves may be appropriate but should never replace hand hygiene. 3 In the neutropenic patient, visitors with communicable infections should be restricted. 4 Invasive procedures such as indwelling catheters should be avoided.

A patient with terminal colon cancer is refusing all food and fluids. The patient has a living will that states no artificial nutrition is to be provided; however, the family is asking for a gastrostomy tube. What should the nurse do? 1) Take the case to the hospital's ethics committee. 2) Honor the family's wishes and have them sign a consent form. 3) Honor the patient's refusal and help the family come to terms with the situation. 4) Talk to the physician so he or she can move forward with the family's wishes.

ANS: 3 Chapter page reference: 239-245 Feedback 1 An ethics committee is usually considered when there is an ethical dilemma and more input is needed to make a decision. In this case, the patient has made a decision and it should be honored. 2 Patients, not their families, should make decisions about their own health care and treatment. 3 A nurse is morally obligated to withhold food and fluids if it is determined to be more harmful to administer them than to withhold them. The nurse must also honor competent patients' refusal of food and fluids. This position is supported by the ANA's Code of Ethics for Nurses, through the nurse's role as a patient advocate and through the moral principle of autonomy. 4 The physician may or may not be involved, but would not disregard the patient's refusal.

A patient being treated with chemotherapy for cancer complains of fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia. Which diagnosis should the nurse use as the priority when planning this patient's care? 1) Powerlessness 2) Ineffective Coping 3) Activity Intolerance 4) Imbalanced Nutrition, Less than Body Requirements

ANS: 3 Chapter page reference: 239-245 Feedback 1 Powerlessness is the lack of control over current situations, but this is not the patient's current problem. Her needs/symptoms are physical, and according to Maslow's theory must be met prior to emotional needs. Although the patient might be having coping issues, the physical symptoms are her greatest complaints; therefore, coping is not the top priority in planning her care. Again, physiological needs must be met prior to self-actualization needs. 2 Powerlessness is the lack of control over current situations, but this is not the patient's current problem. Her needs/symptoms are physical, and according to Maslow's theory must be met prior to emotional needs. Although the patient might be having coping issues, the physical symptoms are her greatest complaints; therefore, coping is not the top priority in planning her care. Again, physiological needs must be met prior to self-actualization needs. 3 The symptoms (fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia) are caused by aplastic anemia from bone marrow suppression, which is a side effect of the chemotherapy drugs. Decreased red blood cells cause less oxygen to be delivered to body tissues, resulting in tissue hypoxia. Tachycardia is a compensation mechanism to speed up the delivery of oxygen that is available in the fewer number of cells that are present. Tissue hypoxia will result in muscle fatigue, and the symptoms that are related to aplastic anemia will decrease endurance and ability to perform activities. 4 Nutrition is not the cause of the symptoms, which are related to tissue hypoxia.

A patient receiving radiation therapy as treatment for colorectal cancer is experiencing nausea and vomiting. What should the nurse encourage the patient to do? 1) Use a commercial mouthwash before eating a meal. 2) Eat spicy or well-seasoned foods instead of bland foods. 3) Delay the intake of a meal until three to four hours after treatment. 4) Avoid all food and liquid until nausea and vomiting stop.

ANS: 3 Chapter page reference: 239-245 Feedback 1 Using a mouthwash and eating spicy foods are not recommended interventions for nausea and vomiting. 2 Using a mouthwash and eating spicy foods are not recommended interventions for nausea and vomiting. 3 Nausea and vomiting are not uncommon in a client receiving radiation, and the patient may benefit from delaying meals for a few hours after treatment, allowing the primary effects to subside somewhat. 4 Avoiding all food and liquid could put the patient at risk for dehydration.

Which type of immunoglobulin (Ig) is produced during an allergic reaction? 1) IgA 2) IgD 3) IgE 4) IgM

ANS: 3 Chapter page reference: 321-330 Feedback 1 IgA is not produced during an allergic reaction. 2 IgD is not produced during an allergic reaction. 3 IgE is produced during an allergic reaction. 4 IgM is not produced during an allergic reaction.

The nurse is conducting a health history for a patient who is at risk for infection. Which question is appropriate when collecting data related to the current problem? 1) "Do you smoke cigarettes?" 2) "Are your immunizations current and up-to-date?" 3) "What type of reaction do you have with an allergy flair?" 4) "Did you have your spleen removed after your car accident?"

ANS: 3 Chapter page reference: 330-334 Feedback 1 This question is appropriate to assess the patient's social history. 2 This question is appropriate to assess the patient's immunization history. 3 This question is appropriate to assess the patient's current problem. 4 This question is appropriate to assess the patient's past medical or surgical history.

Which respiratory manifestation should the nurse anticipate when providing care to a patient diagnosed with DiGeorge's syndrome? 1) Poor muscle tone 2) Failure to thrive 3) Shortness of breath 4) Delayed development

ANS: 3 Chapter page reference: 368-371 Feedback 1 Poor muscle tone is classified as an "other" manifestation of DiGeorge's syndrome. 2 Failure to thrive is a general manifestation of DiGeorge's syndrome. 3 Shortness of breath is a respiratory manifestation of DiGeorge's syndrome. 4 Delayed development is classified as an "other" manifestation of DiGeorge's syndrome.

Which should the nurse include in the plan of care for a patient diagnosed with DiGeorge's syndrome to treat gastrointestinal reflux disorder (GERD)? 1) Hand hygiene 2) Reverse isolation 3) Prokinetic agents 4) Droplet precautions

ANS: 3 Chapter page reference: 371-375 Feedback 1 Hand hygiene is the priority nursing action to decrease this patient's risk for infection. This is not appropriate to treat GERD. 2 Reverse isolation decreases the risk for infection for a patient who is neutropenic. 3 Prokinetic agents are administered to treat GERD for this patient. 4 Droplet precautions are implemented for a patient with a communicable disease.

Which respiratory data should the nurse anticipate when assessing a patient diagnosed with X-linked agammaglobulinemia (XLA)? 1) Wheezes 2) Rhonchi 3) Tachypnea 4) Eupnea

ANS: 3 Chapter page reference: 374 Feedback 1 Wheezing is not anticipated for this patient. 2 Rhonchi is not anticipated for this patient. 3 Tachypnea, or increased respiratory rate, is anticipated for this patient. 4 Absent or decreased breath sounds, not eupnea, is anticipated for this patient.

The nurse is assessing a patient who is receiving intravenous (IV) antibiotics. Which item in the patient's health history increases the risk for experiencing a hypersensitivity reaction? 1) 26 years of age 2) Caucasian race 3) Previous antibiotic therapy 4) Concurrent chronic illness

ANS: 3 Chapter page reference: 377-390 Feedback 1 Age, sex, concurrent illnesses, and previous reactions to related substances have been identified as having a role in risk for hypersensitivity; however, these pose a lower risk than previous exposure. 2 Age, sex, concurrent illnesses, and previous reactions to related substances have been identified as having a role in risk for hypersensitivity; however, these pose a lower risk than previous exposure. 3 Anyone can have a hypersensitivity reaction. However, risk generally increases with previous exposure, because antigens must be formed with the first exposure before hypersensitivity is likely to occur. 4 Age, sex, concurrent illnesses, and previous reactions to related substances have been identified as having a role in risk for hypersensitivity; however, these pose a lower risk than previous exposure.

A pediatric patient with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen. Which statement is appropriate for the nurse to include in the discharge instructions for this patient and family? 1) "This medication does not come prefilled and must be measured." 2) "Keep the medication in the car at all times." 3) "Frequently check the expiration date of the medication." 4) "Keep the medication in one location that is easy to remember."

ANS: 3 Chapter page reference: 377-390 Feedback 1 An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The EpiPen comes prefilled to ensure a quick delivery when necessary. 2 The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. 3 The expiration date should be checked frequently to ensure accurate strength. 4 The patient should have multiple EpiPens and they should be kept in multiple areas, not one location.

The nurse is providing care to a patient with psoriasis. Which medication should the nurse prepare to teach this patient about based on the diagnosis? 1) Epinephrine 2) Azathioprine 3) Cyclosporine 4) Mycophenolate mofetil

ANS: 3 Chapter page reference: 377-390 Feedback 1 Epinephrine is not used in the treatment of psoriasis. 2 Azathioprine is used to treat autoimmune hepatitis and rheumatoid arthritis. 3 Cyclosporine is used to treat psoriasis, rheumatoid arthritis, multiple sclerosis, myasthenia gravis, scleroderma, and is used to prevent organ transplant rejection. 4 Mycophenolate mofetil is used to treat scleroderma, lupus, and to prevent organ transplant rejection.

The nurse is caring for a patient with a history of latex allergies. The patient develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which is the priority intervention for this patient? 1) Teach the patient regarding using a kit that contains treatment for allergic reactions. 2) Administer diphenhydramine (Benadryl) by mouth every four hours per the health-care provider's orders. 3) Administer epinephrine 1:1,000 by subcutaneous injection per the health-care provider's orders. 4) Collect a detailed history from the patient regarding the history of latex allergies.

ANS: 3 Chapter page reference: 377-390 Feedback 1 Patients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit. 2 Diphenhydramine is often given as well but by injection, not by mouth. 3 For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. 4 The nurse does not have time to collect a detailed history, because of the severity of the patient's signs and symptoms.

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 300 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

ANS: 3 Chapter page reference: 409 Feedback 1 This is not a stage for the classification of HIV. 2 Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L. 3 Stage 2 is documented for a patient with a CD4+ count of 200-499 cells/L. 4 Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.

Which immunization should the nurse encourage for a patient who is diagnosed with Stage 2 human immunodeficiency virus? 1) Measles, mumps, and rubella (MMR) vaccine 2) Oral polio vaccine (OPV) 3) Influenza vaccine 4) Varicella vaccine

ANS: 3 Chapter page reference: 415 Feedback 1 This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV. 2 This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV. 3 The influenza vaccine is not a live virus vaccine and is recommended annually, early in the flu season, for patients with HIV. 4 This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is greater than 500 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

ANS: 3 Chapter page reference: 417 Feedback 1 Toxoplasmosis is a complication that occurs when the patient's CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunodeficiency syndrome (AIDS). 2 Herpes zoster virus is a complication that occurs when the patient's CD4+ is between 500 and 350 cells/L. 3 Vaginal candidiasis is a complication that occurs when the patient's CD4+ count is greater than 500 cells/L. 4 Severe bacterial infection is a complication that occurs when the patient's CD4+ is 350 and 200 cells/L.

The nurse notes that a patient's wound is weeping and edematous. In which phase of healing is this wound? 1) Maturation 2) Hemostasis 3) Proliferative 4) Inflammatory

ANS: 4 Chapter page reference: 1062 Feedback 1 In the maturation phase there is less fluid within the wound and collagen fibers reorganize. 2 In the hemostasis phase of healing platelets and clotting factors are activated. 3 In the proliferative phase of healing granulation tissue forms and the wound contracts. 4 In the inflammatory phase of healing fluid escapes into the wound and causes edema.

A patient has a blood-filled blister surrounded by tissue that is painful, mushy, and warm to the touch. How should the nurse classify this skin presentation? 1) Stage III ulcer 2) Stage IV ulcer 3) Unstageable 4) Suspected tissue injury

ANS: 4 Chapter page reference: 1074 Feedback 1 A stage III pressure ulcer has full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. 2 A stage IV pressure ulcer has full thickness loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. It often includes undermining and tunneling. 3 An unstageable wound has full thickness tissue loss where the base of the ulcer is covered in slough or eschar in the wound bed. 4 A suspected deep tissue injury is a purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.

A patient being treated for cancer has a tumor designation of Stage IV, T4, N3, M1. What does this staging indicate to the nurse? 1) The tumor is small in size. 2) There is one single tumor to treat. 3) The tumor will respond to chemotherapy. 4) The tumor has metastasized with lymph node involvement.

ANS: 4 Chapter page reference: 217 Feedback 1 T refers to the depth of invasion. A 4 indicates a large, not small, tumor. 2 There is no way to determine the number of tumors based on this designation. 3 The staging system is not used to determine tumor response to chemotherapy. 4 Stage IV indicates metastasis. N refers to the absence or presence and extent of lymph node involvement. A 3 indicates a significant number of lymph nodes are involved.

A patient is receiving chemotherapy for the treatment of leukemia. While providing care for this patient, which clinical manifestations would indicate tumor lysis syndrome? 1) Thrombocytopenia 2) Respiratory distress 3) Upper-extremity edema 4) Altered levels of consciousness

ANS: 4 Chapter page reference: 217-226 Feedback 1 Thrombocytopenia occurs with a hematological emergency. 2 Space-occupying lesions can cause respiratory distress and upper-extremity edema. 3 Space-occupying lesions can cause respiratory distress and upper-extremity edema. 4 Tumor lysis causes a metabolic emergency. Because of electrolyte imbalance, the signs can be oliguria and altered levels of consciousness.

A patient is scheduled to undergo a prostate biopsy. The patient asks the nurse what is expected immediately following the procedure. Which response by the nurse is the most appropriate? 1) 'Your sexual partners will need to be notified." 2) "You will need to avoid strenuous activity for 24 hours." 3) "You will not have any restrictions following the biopsy." 4) "You will likely experience discomfort for 24-48 hours after the procedure."

ANS: 4 Chapter page reference: 229-231 Feedback 1 There is no need to notify sexual partners following the procedure. 2 Strenuous activity is avoided only for about four hours. 3 The patient must restrict activity for only a short period after the procedure. 4 The patient may experience discomfort for one to two days after the procedure.

The nurse is caring for a patient who had a bone marrow transplant for the treatment of leukemia several weeks ago. The patient requires protective isolation. Which statement by the patient's family indicates understanding of this type of isolation? 1) "It will be important to restrict all visitors." 2) "We will encourage oral hygiene twice a day." 3) "You will have to administer all medications by IM injection." 4) "We will encourage meticulous hand washing among all visitors."

ANS: 4 Chapter page reference: 231-239 Feedback 1 Restrict only visitors with colds, flu, or infection. 2 Oral hygiene should be encouraged after every meal. 3 Medications by injection should be avoided. 4 A patient on protective isolation will be at an increased risk for infection. It will be important to encourage meticulous hand washing among all people who come in contact with the patient.

The nurse is providing care to a patient with a compromised immune system. Which independent nursing intervention is appropriate for the nurse to include in the patient's plan of care? 1) Recommending gene transfer therapy 2) Administering corticosteroids, per order 3) Prescribing prophylactic antibiotic therapy 4) Educating on the importance of a nutritious diet

ANS: 4 Chapter page reference: 320-321 Feedback 1 It is outside the scope of nursing practice to prescribe medication and to recommend therapies. The nurse can administer antibiotics and educate the patient on gene transfer therapy, if prescribed by the health-care provider. 2 Administering corticosteroids, per order, is a collaborative intervention. 3 It is outside the scope of nursing practice to prescribe medication and to recommend therapies. The nurse can administer antibiotics and educate the patient on gene transfer therapy, if prescribed by the health-care provider. 4 While these may be appropriate treatments for a patient who is experiencing a compromised immune system, the only independent nursing intervention is educating the patient on the importance of a nutritious diet.

The nurse is providing care to a patient who had the spleen removed after a car accident. Which type of infection is this patient at an increased risk for experiencing? 1) Viral 2) Fungal 3) Parasitic 4) Bacterial

ANS: 4 Chapter page reference: 321-330 Feedback 1 A splenectomy does not increase the risk for viral infection. 2 A splenectomy does not increase the risk for fungal infection. 3 A splenectomy does not increase the risk for parasitic infection. 4 The impact of a splenectomy is a loss of recognition and encapsulation of bacteria; therefore, this patient is at an increased risk for bacterial infection.

Which physiological barriers protect the patient's body against microorganisms? 1) A surgical incision 2) Occasional smoking 3) Alcoholic beverages 4) Adequate urinary output

ANS: 4 Chapter page reference: 321-330 Feedback 1 A surgical incision can both allow microorganisms to enter the body. 2 The consumption of alcoholic beverages has been known to increase the risk for infection. 3 Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. 4 A physiological barrier protecting patients against microorganism is adequate urinary output. The act of voiding flushes organisms that might try to enter the body through the urinary meatus.

The nurse is teaching a group of patients about first-line defense against infection. Which patient statement indicates the need for further education? 1) "The skin is a first-line defense against infection." 2) "A sneeze is a mechanical first-line defense against infection." 3) "My saliva is a biochemical first-line defense against infection." 4) "A cut with pus is a mechanical first-line defense against infection."

ANS: 4 Chapter page reference: 321-330 Feedback 1 This statement indicates correct understanding of first-line defenses against infection. 2 This statement indicates correct understanding of first-line defenses against infection. 3 This statement indicates correct understanding of first-line defenses against infection. 4 Pus or exudate indicates cellular infiltration which is a second line of defense against infection. This second line of defense is an inflammatory response to acute cellular injury.

The nurse is providing care to a patient who has a decreased neutrophil count and elevated hepatic enzymes. Which data in the patient's health history supports this laboratory data indicating an increased risk for infection? 1) Anorexia nervosa 2) Acute renal failure 3) Pulmonary disease 4) Cirrhosis of the liver

ANS: 4 Chapter page reference: 330-334 Feedback 1 Anorexia nervosa causes malnutrition causing a decreased white blood cell (WBC) count and diminished neutrophil activity leading to a risk for infection. 2 Acute renal failure leads to decreased neutrophil action and immunoglobulin activity causing an increased risk for infection. 3 Pulmonary disease leads to decrease neutrophil activity causing an increased risk for infection. 4 Cirrhosis of the liver is an example of hepatic disease. This leads to a decreased neutrophil count which increases the risk for infection.

The nurse is conducting a health history for a patient who is at risk for infection. Which question is appropriate when collecting data related to the patient's past medical history? 1) "Do you smoke cigarettes?" 2) "Are your immunizations current and up-to-date?" 3) "What type of reaction do you have with an allergy flair?" 4) "Did you have your spleen removed after your car accident?"

ANS: 4 Chapter page reference: 330-334 Feedback 1 This question is appropriate to assess the patient's social history. 2 This question is appropriate to assess the patient's immunization history. 3 This question is appropriate to assess the patient's current problem. 4 This question is appropriate to assess the patient's past medical or surgical history.

Which question should the nurse to ask during a health history with an adolescent patient, accompanied by a parent, to determine immune status? 1) "Is your child sexually active?" 2) "Is your child planning to go to college?" 3) "Does your child smoke tobacco products?" 4) "Are your child's immunizations up-to-date?"

ANS: 4 Chapter page reference: 330-334 Feedback 1 While sexual activity places the adolescent at risk for sexual transmitted infections, this is not the most appropriate question for the nurse to ask to determine immune status. 2 This question is not applicable to the adolescent's immune status. 3 While smoking can increase the risk for infection, this is not an appropriate question for the nurse to ask an adolescent patient when a parent is in the room. 4 Inquiring about the child's immunization status is appropriate during the health history interview to determine immune status.

The nurse is providing care for a patient diagnosed with agammaglobulinemia. Which is the anticipated treatment for this patient? 1) Oral diphenhydramine 2) Topical corticosteroids 3) Subcutaneous epinephrine 4) Intravenous immunoglobulin (IVIG)

ANS: 4 Chapter page reference: 373 Feedback 1 Diphenhydramine is not the anticipated pharmacological treatment for this patient. 2 Corticosteroids are not the anticipated pharmacological treatment for this patient. 3 Epinephrine is not the anticipated pharmacological treatment for this patient. 4 IVIG is the anticipated pharmacological treatment for this patient.

Which immune disorder should the nurse include in the plan of care for a patient who is receiving chemotherapeutic agents in the treatment of cancer? 1) B-cell deficiency 2) T-cell deficiency 3) Excessive immune response 4) Secondary immune deficiency

ANS: 4 Chapter page reference: 375-377 Difficulty: Easy Feedback 1 Chemotherapy does not cause B-cell deficiency. 2 Chemotherapy does not cause T-cell deficiency. 3 Chemotherapy does not cause an excessive immune response. 4 Chemotherapy often results in a secondary immune deficiency.

The nurse is preparing to assess a patient when one of the patient's family members begins showing symptoms of a latex sensitivity. Which action by the nurse is the most appropriate? 1) Ask the family member to leave the unit 2) Transfer the patient to a department that does not use latex products 3) Wait until Monday to report the problem to the supervisor of the unit 4) Obtain latex-free products for the patient's room

ANS: 4 Chapter page reference: 377-390 Feedback 1 Asking the family member to leave would be a violation of the patient's rights. 2 Transferring the patient to a department that does not use latex products is not realistic because the family member might experience exposure on another unit. (No hospital unit can be latex-free.) 3 Waiting until Monday does not solve the problem. 4 When symptoms of sensitivity to latex occur on exposure, latex-free products should be supplied.

The nurse is caring for a patient who is experiencing anaphylactic shock following the administration of a medication. Which position is the most appropriate for the nurse to place the patient based on this data? 1) Trendelenburg position 2) Flat, with legs slightly elevated 3) Supine position 4) High Fowler position

ANS: 4 Chapter page reference: 377-390 Feedback 1 The Trendelenburg position elevates the foot of the bed and is no longer recommended for the treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. 2 Lying flat is not recommended. 3 A person in a supine position may not be able to maintain an open airway. 4 Placing the patient in Fowler or high Fowler position allows optimal lung expansion and ease of breathing.

The nurse is admitting a pediatric patient to the hospital with a ventroperitoneal (VP) shunt malfunction. The patient's family speaks very little English. The interpreter has arrived and the nurse is obtaining a health history from the parents and learns that the patient received the shunt at birth after a menigocele repair. Based on this data, which product should be avoided when providing care to this patient? 1) Synthetic rubber gloves 2) Polyethylene gloves 3) Nonpowdered nitrile gloves 4) Latex gloves

ANS: 4 Chapter page reference: 377-390 Feedback 1 This product is appropriate for this patient. 2 This product is appropriate for this patient. 3 This product is appropriate for this patient. 4 Patients with a history of meningocele typically experience severe latex allergies. It is important for the nurse, and other health-care providers, to use latex alternative products on this patient.

Which is the priority nursing action to decrease the risk of a transfusion reaction? 1) Assessing the patient's vital signs per policy 2) Documenting the procedure in the medical record 3) Verifying the patient's identity using two identifiers 4) Checking the bag to ensure it is the correct blood type

ANS: 4 Chapter page reference: 377-390 Feedback 1 While assessing the patient's vital signs per policy is important, this is not the priority nursing action to decrease the risk of a transfusion reaction. 2 While documenting the procedure in the medical record is important, this is not the priority nursing action to decrease the risk of a transfusion reaction. 3 While verifying the patient's identity using two identifiers is important, this is not the priority nursing action to decrease the risk of a transfusion reaction. 4 The priority nursing action to decrease the risk of a transfusion reaction is to ensure the bag contains the correct blood type for the patient.

A nurse is caring for a pediatric patient who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the patient is experiencing a type I hypersensitivity reaction? 1) Erythema 2) Fever 3) Joint pain 4) Hypotension

ANS: 4 Chapter page reference: 378-385 Feedback 1 Erythema and fever are associated with type IV hypersensitivity reactions. 2 Fever and joint pain are associated with a type III hypersensitivity reactions. 3 Fever and joint pain are associated with a type III hypersensitivity reactions. 4 Clinical manifestations associated with a type I hypersensitivity reaction include hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria.

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of less than 200 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

ANS: 4 Chapter page reference: 409 Feedback 1 This is not a stage for the classification of HIV. 2 Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L. 3 Stage 2 is documented for a patient with a CD4+ count of 200-499 cells/L. 4 Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.

A nurse is performing an admission assessment on a patient with symptoms that indicate human immunodeficiency virus (HIV). Which question from the nurse addresses a major risk factor for contracting HIV? 1) "Has your partner been experiencing these symptoms?" 2) "When was your first sexual experience?" 3) "Have you had any fever, diarrhea, or chills over the last 48 hours?" 4) "Have you ever experimented with intravenous drugs?"

ANS: 4 Chapter page reference: 409-410 Feedback 1 Assessing recent symptoms, and asking if the patient's partner is experiencing the same symptoms, does not assess the patient's risk factors for HIV transmission. 2 The patient's first sexual experience is not applicable to the patient's current risk for HIV. 3 Assessing recent symptoms, and asking if the patient's partner is experiencing the same symptoms, does not assess the patient's risk factors for HIV transmission. 4 One risk factor for contracting HIV is the use of intravenous recreational drugs. This question is appropriate to determine the patient's risk for HIV.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has shortness of breath when walking, but no problems breathing at rest. Which is the most likely cause for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

ANS: 4 Chapter page reference: 411 Feedback 1 A fever is caused by infection. 2 Weight loss is generally caused by worsening of the disease or disease progression. 3 Night sweats are caused by a mycobacterial infection. 4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.

Which patient should the nurse offer the opportunity for human immunodeficiency virus (HIV) testing during an annual physical examination? 1) A 66-year-old male patient 2) A 75-year-old female patient 3) An 8-year-old school-age child 4) An 18-year-old young adult patient

ANS: 4 Chapter page reference: 416 Feedback 1 This patient is not within the suggested age range for HIV testing during an annual physical examination. 2 This patient is not within the suggested age range for HIV testing during an annual physical examination. 3 This patient is not within the suggested age range for HIV testing during an annual physical examination. 4 The nurse offers HIV testing to all patients between the ages of 15 years and 65 years of age.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 250 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

ANS: 4 Chapter page reference: 417 Feedback 1 Toxoplasmosis is a complication that occurs when the patient's CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunodeficiency syndrome (AIDS). 2 Herpes zoster virus is a complication that occurs when the patient's CD4+ is between 500 and 350 cells/L. 3 Vaginal candidiasis is a complication that occurs when the patient's CD4+ count is greater than 500 cells/L. 4 Severe bacterial infection is a complication that occurs when the patient's CD4+ is 350 and 200 cells/L.

Place the progression of human immunodeficiency virus (HIV) in sequential order. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) AIDS 2) Death 3) Seroconversion 4) Viral transmission 5) Acute viral infection 6) Asymptomatic chronic infection

ANS: 435612 Chapter page reference: 411 Feedback: The progression of HIV is as follows: first, viral transmission occurs; second, seroconversion occurs; next, the patient has symptoms of an acute viral infection; fourth, the patient has an asymptomatic chronic infection; fifth, the patient becomes symptomatic and is diagnosed with AIDS; lastly, the patient

Which scenario should the nurse provide as one in which active immunity is acquired when educating a group within the community? 1) Having measles as a child 2) Receiving an injection of gamma globulin 3) Becoming ill with tetanus and receiving tetanus toxoid 4) Receiving a rabies shot after being bitten by a rabid dog

ANS: 1 321-330 Feedback 1 When the patient has the disease, the body stimulates the process of acquired active immunity. 2 Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity. 3 Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity. 4 Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.

A patient with a sacral stage III pressure ulcer has an elevated temperature. What diagnostic test would help determine if this patient is developing osteomyelitis? 1) CT scan 2) Bone biopsy 3) Venous Doppler 4) Serum electrolytes

ANS: 1 Chapter page reference: 1082 Feedback 1 If osteomyelitis is suspected, evaluation with a CT scan is recommended. 2 A bone biopsy is not recommended to diagnose osteomyelitis. 3 A venous Doppler is not used to diagnose osteomyelitis. 4 Serum electrolytes are not used to diagnose osteomyelitis.

The nurse has completed a seminar teaching a group in the community about ways to reduce cancer risks. The nurse returns a month later to evaluate the effectiveness of the seminar. Which statements made by members of the group indicate retention and application of the material presented by the nurse to reduce the risk of developing cancer? 1) "I stopped using tanning booths." 2) "I have reduced my intake of fiber." 3) "I have increased the amount of lean red meat in my diet." 4) "I began drinking two glasses of red wine a day with dinner."

ANS: 1 Chapter page reference: 226-229 Feedback 1 Use of tanning booths increases the risk of skin cancer, so discontinuing use would indicate understanding. 2 Increased fiber intake reduces the risk of colon cancer. 3 Increasing the amount of lean red meat and drinking two glasses of red wine daily are not actions that reduce cancer risk. 4 Increasing the amount of lean red meat and drinking two glasses of red wine daily are not actions that reduce cancer risk.

The nurse is teaching a patient scheduled for a colonoscopy on pre- and postprocedure care. Which statement by the patient indicates the need for further teaching? 1) "It might be quite painful." 2) "The procedure will only take about one hour." 3) "The physician might take tissue samples for further analysis." 4) "I will likely have medications that will make me drowsy during the test."

ANS: 1 Chapter page reference: 229-231 Feedback 1 The colonoscopy is not a painful examination. 2 It usually takes about an hour. 3 Tissue samples are often taken during colonoscopies. 4 The client will be given conscious sedation, which causes drowsiness.

The nurse is caring for a patient with leukemia. Which treatment should the nurse expect to be prescribed? 1) Chemotherapy 2) IV fluid therapy 3) Diuretic therapy 4) Electrolyte replacement therapy

ANS: 1 Chapter page reference: 231-239 Feedback 1 The patient with an alteration in cell growth has cancer and will most likely be treated with chemotherapy and antibiotics. 2 Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat cancer, although they may be used if complications develop. 3 Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat cancer, although they may be used if complications develop. 4 Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat cancer, although they may be used if complications develop.

A nurse is caring for a patient with leukemia who is neutropenic. Which intervention will the nurse implement to ensure this patient's safety? 1) Place patient in reverse isolation 2) Place patient in standard precaution isolation 3) Administer a prophylactic gram-negative antibiotic 4) Administer neutrophil colony-stimulating factor (N-CSF) as ordered

ANS: 1 Chapter page reference: 231-239 Feedback 1 A patient who is neutropenic has a decrease in the level of white blood cells (WBCs) and is susceptible to infection and/or disease. To ensure the safety of the patient with neutropenia, the nurse will place the patient in reverse isolation. 2 Standard precautions should be used for all patients and this does not ensure safety of the neutropenic patient. 3 Administer a broad-spectrum antibiotic as ordered. 4 Administer granulocyte colony-stimulating factor (G-CSF) as ordered.

During a treatment meeting on an oncology unit, the nurse learns that a patient is scheduled for chemotherapy before surgery. What are the purposes for this patient to receive chemotherapy at this specific time? 1) Shrink the tumor 2) Improve wound healing 3) Eradicate all cancer cells 4) Allow the immune system to kill cancer cells

ANS: 1 Chapter page reference: 231-239 1 Chemotherapy before surgery is used to shrink the tumor. 2 Chemotherapy is not used to improve wound healing. 3 It is impossible to eradicate all cancer cells with chemotherapy. 4 The use of chemotherapy before surgery will not allow the immune system to kill the cancer cells.

During an assessment, the nurse notes that a patient receiving radiation treatments for breast cancer has excoriated skin. What is the priority nursing diagnosis? 1) Risk for Infection 2) Activity Intolerance 3) Excess Fluid Volume 4) Ineffective Breathing Pattern

ANS: 1 Chapter page reference: 239-245 Feedback 1 Radiation causes skin excoriation. With the excoriation, the patient is at risk for infection due to skin breakdown. 2 Depending on the assessment, the patient may or may not have activity intolerance. 3 The patient who receives radiation is more at risk for fluid volume deficit. 4 There is no evidence of respiratory difficulties in this patient.

A nurse is planning care for a patient with leukemia. The nurse chooses "Risk for Bleeding" as the nursing diagnosis. Which interventions support this nursing diagnosis? 1) Educate patient in use of soft toothbrush for oral care 2) Use non-electric razor when providing grooming for patient 3) Apply pressure to arterial puncture sites for 5 minutes 4) Encourage patient to breathe deeply and huff cough frequently

ANS: 1 Chapter page reference: 239-245 Feedback 1 The patient at risk for bleeding has specific interventions to which the nurse should adhere. The nurse should educate the patient in the use of a soft toothbrush. 2 An electric razor is preferred when providing grooming for a patient who is at risk for bleeding. 3 The nurse should also limit the use of parenteral injections and apply 15-20 minutes of pressure to any arterial puncture sites. 4 The nurse should discourage the patient to forcefully cough to prevent further bleeding.

The nurse is caring for an adolescent Asian patient with a strong family history of breast cancer. What should the nurse teach the patient regarding cancer prevention? 1) Perform monthly breast self-examination. 2) Teach the side effects of cancer treatment. 3) Talk to family members who have the disease. 4) Discuss cancer fears with the health-care provider.

ANS: 1 Chapter page reference: 226-229 Feedback 1 In families with a disease, the nurse should inform patients about breast self-examination. 2 Teaching the side effects of cancer treatment would be appropriate if the patient was diagnosed with breast cancer. 3 Talking to family members who have the disease will not help with early detection or prevention. 4 The patient can discuss cancer fears with the nurse; however, this action will not help prevent the development of the disease.

A home health nurse is conducting home visits for several patients who are diagnosed with acquired immunodeficiency syndrome (AIDS). Which patient would the nurse see first? 1) A patient who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count 2) A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath 3) A patient with wasting syndrome who needs modifications and education regarding dietary changes 4) A patient who is receiving IV antibiotics daily for toxoplasmosis

ANS: 2 Chapter page reference: 417 Feedback 1 The home health nurse should see the patient with PCP because of the complaint of shortness of breath with the new onset of fever. All of the patients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this patient first to obtain vital signs and perform a respiratory assessment. 2 This patient needs to be seen by the nurse; however, based on the ABCs (airway, breathing, and circulation) this patient is not the priority. 3 This patient needs to be seen by the nurse; however, based on the ABCs (airway, breathing, and circulation) this patient is not the priority. 4 This patient needs to be seen by the nurse; however, based on the ABCs (airway, breathing, and circulation) this patient is not the priority.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 480 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

ANS: 2 Chapter page reference: 417 Feedback 1 Toxoplasmosis is a complication that occurs when the patient's CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunodeficiency syndrome (AIDS). 2 Herpes zoster virus is a complication that occurs when the patient's CD4+ is between 500 and 350 cells/L. 3 Vaginal candidiasis is a complication that occurs when the patient's CD4+ count is greater than 500 cells/L. 4 Severe bacterial infection is a complication that occurs when the patient's CD4+ is 350 and 200 cells/L.

The nurse instructs a group of community members about ways to reduce the development of cancer. Which participant statements indicate that teaching has been effective? Select all that apply. 1) "I need to cut down on my smoking." 2) "I need to get my home tested for radon." 3) "I need to keep my children away from smokers." 4) 'Sunscreen should be applied before spending time outdoors." 5) "I should eat at least two servings of fruits or vegetables each day."

ANS: 2, 3, 4 Chapter page reference: 226-229 Feedback 1. This is incorrect. All smoking should be discouraged. 2. This is correct. The home should be tested for radon, which is a known cancer-causing substance. 3. This is correct. Children should be protected from exposure to tobacco smoke. 4. This is correct. Sunscreen should be used by those who spend time outside regularly for work or recreation. 5. This is incorrect. Efforts to reduce the development of cancer include eating five servings of fruits and vegetables each day.

The nurse is reviewing the laboratory values of a patient who is newly diagnosed with acquired immunodeficiency syndrome (AIDS). Which values should be reported to the patient's health-care provider? Select all that apply. 1) CD4 cell count 1,100/mm3 2) T4 cell count 150 3) CD4 lymphocytes 12% 4) Viral load 11,500 copies/mL 5) WBC 6,500

ANS: 2, 3, 4 Chapter page reference: 417-419 Feedback 1. This is incorrect. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range. 2. This is correct. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range. 3. This is correct. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range. 4. This is correct. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range. 5. This is incorrect. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range.

The nurse is preparing to perform a health assessment on an adult patient who has a family history of cancer. Which questions should the nurse ask the patient to assess for the early warning signs of cancer? Select all that apply. 1) "Have you noticed a change in your appetite?" 2) "Have you noticed any cuts that have not healed?" 3) "Have you had any changes in bowel or bladder habits?" 4) "Have you experienced any problems swallowing?" 5) "Do you have a cough that is not associated with seasonal allergies?'

ANS: 2, 3, 4, 5 Chapter page reference: 217-266 Feedback 1. This is incorrect. Changes in appetite or cough that is associated with seasonal allergies are not associated with the early warning signs of cancer. 2. This is correct. Nurses should assess all patients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness. 3. This is correct. Nurses should assess all patients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness. 4. This is correct. Nurses should assess all patients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness. 5. This is correct. Nurses should assess all patients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness.

Which locations should the nurse include when discussing the storage and production of lymphocytes during an education session for novice nurses? Select all that apply. 1) Liver 2) Spleen 3) Thymus 4) Lymph nodes 5) Bone marrow

ANS: 2, 3, 4, 5 Chapter page reference: 321-330 Feedback 1. This is incorrect. The liver does not store or produce lymphocytes. 2. This is correct. Lymphocytes are found in the spleen. 3. This is correct. Lymphocytes are found in the thymus. 4. This is correct. Lymphocytes are found in the lymph nodes. 5. This is incorrect. Lymphocytes are found in the bone marrow.

A patient receives the yellow fever vaccine before traveling to the Amazon Basin and asks the nurse how the vaccine provides protection. Which responses by the nurse is the most appropriate? Select all that apply. 1) "The body's immune system eats away at the protective sheath that covers the nerves." 2) "A response from yellow fever-specific T cells is activated. B cells secrete yellow fever antibodies." 3) "In the lymph nodes, part of the lymphoid system, the macrophages present yellow fever antigens to T cells and B cells." 4) "The initial weak infection is eliminated and the patient is left with a supply of memory T and B cells for future protection against yellow fever." 5) "Human macrophages engulf the weakened vaccine virus as if it is dangerous and antigens stimulate the immune system to attack it."

ANS: 2, 3, 4, 5 Chapter page reference: 321-330 Feedback 1. This is incorrect. The immune system damaging the myelin is the autoimmune response that occurs with multiple sclerosis (MS). 2. This is correct. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. 3. This is correct. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. 4. This is correct. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present. 5. This is correct. Macrophages ingest antigens and signal helper T cells that antigens are present.

The nurse is planning care for a pediatric patient diagnosed with human immunodeficiency virus (HIV). The nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric patient. Based on this nursing diagnosis, which actions by the nurse are appropriate? Select all that apply. 1) Administering tuberculosis skin tests every six months 2) Teaching proper food-handling techniques to the family 3) Instructing on the importance of consuming ample fresh fruits and vegetables 4) Assessing the health status of all visitors 5) Monitoring hand-washing techniques used by the family

ANS: 2, 4, 5 Chapter page reference: 417-419 Feedback 1. This is incorrect. Tuberculosis skin tests should be administered annually, not every six months. 2. This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. 3. This is incorrect. Fresh fruits and vegetables are not recommended for a patient with a depressed immune system. 4. This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. 5. This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection.

The nurse is assessing a patient's immune system. Which findings increase the patient's risk for infection due to alterations in biochemical barriers? Select all that apply. 1) Dysphagia 2) Dry mouth 3) Nonintact skin 4) Urinary retention 5) Clogged tear duct

ANS: 2, 5 Chapter page reference: 321-330 Feedback 1. This is incorrect. Swallowing is a mechanical, not biochemical, barrier to infection. 2. This is correct. Saliva is a biochemical barrier to infection. A dry mouth increases the patient's risk for infection. 3. This is incorrect. Intact skin is a physical, not biochemical, barrier to infection. 4. This is incorrect. Urination is a mechanical, not biochemical, barrier to infection. 5. This is correct. Tears are a biochemical barrier to infection. A clogged tear duct increases this patient's risk for infection.

A nurse is developing a plan of care for a patient diagnosed with human immunodeficiency virus (HIV). The patient states, "I don't plan on giving up sex just because I am HIV positive." Based on this data, which is the priority nursing diagnosis for this patient? 1) Risk for Infection 2) Death Anxiety 3) Deficient Knowledge 4) Social Isolation

ANS: 3 Chapter page reference: 417 Feedback 1 While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, "I don't plan on giving up sex just because I am HIV positive." The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners. 2 While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, "I don't plan on giving up sex just because I am HIV positive." The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners. 3 While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, "I don't plan on giving up sex just because I am HIV positive." The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners. 4 While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, "I don't plan on giving up sex just because I am HIV positive." The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners.

A nurse working in an intensive care unit (ICU) is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement when providing direct care? 1) Droplet 2) Reverse 3) Standard 4) Contact

ANS: 3 Chapter page reference: 418 Feedback 1 Droplet precautions are not necessary as HIV is not transmitted via the route. 2 Reverse precautions are needed for a patient who is experiencing neutropenia. 3 Health-care workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the health-care professionals treat all patients alike, eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids. 4 Contact precautions are not necessary as HIV does not require additional precautions aside from standard precautions.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). Which patient statement indicates the need for further education regarding HIV management? 1) "I will eat small, frequent meals." 2) "I will use condoms for every sexual encounter." 3) "I will take my medications when others can see me, even if that means taking them late." 4) "I will ask my spouse to clean the cat litter to decrease my risk for developing toxoplasmosis."

ANS: 3 Chapter page reference: 419 Feedback 1 This patient statement indicates correct understanding regarding HIV management. 2 This patient statement indicates correct understanding regarding HIV management. 3 Adherence is essential in managing the progression of the disease. Taking medications as ordered and at the same time each day (plan administration times around activities of daily living) helps maintain therapeutic drug levels and decreases the risk of viral resistance developing. 4 This patient statement indicates correct understanding regarding HIV management.

Which laboratory test should the nurse anticipate for a patient who reports chronic inflammation? 1) Varicella titer 2) Type and crossmatch 3) Erythrocyte sedimentation rate (ESR) 4) Complete blood count (CBC), with differential

ANS: 3 Chapter page reference: 332-334 Feedback 1 A varicella titer is anticipated for a patient who is uncertain of his or her chicken pox status. 2 A type and crossmatch is anticipated for a patient who has lost blood and requires a transfusion. 3 An ESR screens for the presence of the inflammatory process. 4 A CBC, with differential measures total leukocytes with a breakdown of leukocyte types and percentage present.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient reports night sweats. Which is the most likely reason for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

ANS: 3 Chapter page reference: 410 Feedback 1 A fever is caused by infection. 2 Weight loss is generally caused by worsening of the disease or disease progression. 3 Night sweats are caused by a mycobacterial infection. 4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.