Unit 4 Test

The nurse is instructing the family on home care of a client with shingles. The family member asks whether their teenage children should stay in a different room. What is the best response by the nurse? "Yes, shingles is highly contagious." "Have they had chickenpox or the varicella vaccine?" "No, shingles is not contagious." "Because the client is in quite a bit of pain, it would probably be best."

"Have they had chickenpox or the varicella vaccine?"

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what? "One advantage of the TENS unit is it increases blood flow." "I could use the TENS unit if I feel pain somewhere else on my body." "I may need fewer pain medications with the TENS unit in place." "Wearing the TENS unit should not interfere with my daily activities."

"I could use the TENS unit if I feel pain somewhere else on my body."

A pregnant patient asks the nurse if it is all right for her take the varicella immunization for entrance into nursing school. What is the best response by the nurse? "If you will be working in the health care field, you must take the immunization." "It is not recommended that pregnant women take the live virus. You should wait until after your child is born." "It is not a live virus, so it should be fine." "You will have to delay entrance into the nursing program if they force you to take it."

"It is not recommended that pregnant women take the live virus. You should wait until after your child is born."

he acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? "Your wound will heal slowly as granulation tissue forms and fills the wound." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." "As soon as the infection clears, your surgeon will staple the wound closed."

"Your wound will heal slowly as granulation tissue forms and fills the wound."

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? 0300 1100 1500 1700

1700 It tends to be lowest from midnight to dawn and highest in the late afternoon to early evening

A sudden blow to the head results in pain that is transmitted by which type of fibers?

A delta

An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor? The client's size limits his activity level. Adipose tissue is poorly vascularized. Obesity is linked to impaired white blood cell function. The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound.

Adipose tissue is poorly vascularized.

What is an accurate guideline for removing soiled gloves after client care?

After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.

An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response? T cells directly attack the foreign pathogen. A circulating lymphocyte containing an antigenic message returns to the nearest lymph node. B lymphocytes produce antibodies that are specific to the pathogen. Granulocytes and macrophages engulf and destroy the invading agents.

B lymphocytes produce antibodies that are specific to the pathogen.

A client comes to the clinic and informs the nurse that he has a "painful area under his armpit." The nurse observes a 2-cm raised area that is erythremic and has a white substance inside of it. What does the nurse suspect the patient may be experiencing? A.A lesion B.An abscess C.A fluid-filled vesicle D.A cancerous tumor

B.An abscess

IgD IgE

Binds to antigens; promotes secretion of other immunoglobulins Promotes release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reactions

What are the two major processes involved in the inflammatory phase of wound healing?

Blood clotting is initiated and WBCs move into the wound.

A client comes to the clinic with complaints of fever, chills, and coughing and is found to be positive for influenza. The nurse is aware that the flu is transmitted from one infected person to another. What type of infection is this considered? A.Localized B.Generalized C.Community acquired D.Nosocomial

C.Community acquired

A client arrives at the emergency department complaining of severe diarrhea and vomiting that began after ingesting a hot dog at the ball park 6 hours ago. How does the nurse understand that the contaminated food was transmitted to the client? A.Droplet B.Airborne C.Vehicle D.Vector

C.Vehicle

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte. You Selected:

Cytotoxic T cell

An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated? Macrophages Helper T cells B cells Cytotoxic T cells

Cytotoxic T cells

The nurse is caring for an older adult client who develops a fever, rash over the trunk, and back and complains of feeling achy and very tired. What should the nurse suspect is occurring with this client? A.A roundworm infection B.Bacterial meningitis C.A urinary tract infection D.An autoimmune response

D.An autoimmune response

A client is admitted to an acute care facility with a diagnosis of appendicitis. Which laboratory results demonstrate the client's leukocytosis? A.Hemoglobin of 12 mg/dL B.Lymphocytes 1,500 C.Neutrophils of 3,150/mm3 D.White blood cell (WBC) count of 22,000 cells/mm3

D.White blood cell (WBC) count of 22,000 cells/mm3

Which of the following protective responses begin with the B lymphocytes?

Humoral

What immunoglobulin is present in small amounts and is thought to be related to allergic responses?

IgE

Why is acute pain said to be protective in nature?

It warns an individual of tissue damage or disease.

A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact her bone marrow is unable to produce a sufficient amount of what? Lymphocytes Cytoblasts Antibodies Capillaries

Lymphocytes

A client has a sore throat, fever, and malaise. The physician diagnosed a strep infection of the throat and ordered a gluteal injection of penicillin. Which intervention should the nurse perform after administering the injection? Make the client wait in the office at least 30 minutes before leaving. Advise the client to avoid fluid intake for at least 30 minutes. Advice the client to avoid food intake for at least 30 minutes. Instruct the client to lie down for at least four hours before leaving.

Make the client wait in the office at least 30 minutes before leaving.

IgG IgA IgM

Neutralizes bacterial toxins; accelerates phagocytosis Interferes with entry of pathogens through exposed structures or pathways Agglutinates (clusters) antigens and lyses (dissolves) cell walls

An older adult has developed a sacral pressure ulcer. What should the nurse assess in order to ensure adequate wound healing and prevent poor outcomes for this client? Select all that apply.

Nutritional status Caloric intake Quality of food ingested

The nurse is assessing an older adult patient just admitted to the hospital. Why is it important that the nurse carefully assess pain in the older adult patient? Older people are expected to experience chronic pain. Older people have a decreased pain threshold. Older people experience reduced sensory perception. Older people have increased sensory perception.

Older people experience reduced sensory perception.

Which of the following occurs when the antigen-antibody molecule is coated with a sticky substance what also facilitates phagocytosis?

Opsonization

The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply.

Pain with redness and swelling Localized heat Purulent or malodorous drainage

A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of what?

Phagocytic cells

phagocytes

Phagocytosis is the process of engulfing and digesting bacteria and foreign material

The nurse directs the unlicensed assistive personnel (UAP) to help a partially blind older adult client with meals. Which information is appropriate for the nurse to provide the UAP to facilitate the client's comfort and safety during mealtime? Select all that apply. Place client in upright position at a 45- to 90-degree angle in the bed or chair Provide verbal cues regarding location of food on plate Cut food into small pieces Ensure that the temperature of food is safe Place a pillow behind the neck for support

Place client in upright position at a 45- to 90-degree angle in the bed or chair Provide verbal cues regarding location of food on plate Cut food into small pieces Ensure that the temperature of food is safe

Which strategy(ies) does the nurse use to maintain proper body mechanics and prevent self-injury? Select all that apply. Place feet shoulder width apart when lifting an object Plant feet firmly on the floor when supporting the client during dangling Bend at the waist when lifting an object Lock elbows when grasping onto objects Hold objects an arm's length away when lifting and carrying them

Place feet shoulder width apart when lifting an object Plant feet firmly on the floor when supporting the client during dangling

The client is postoperative for a right total-knee arthroplasty, and medications include lidocaine 5% (Lidoderm). Past history includes a left mastectomy and herpes zoster following treatment with chemotherapy. The best nursing action is to: Question the use of lidocaine 5%. Apply the patch to the right thigh. Remove the patch after 12 hours. Withhold opioids during lidocaine use.

Remove the patch after 12 hours.

The nurse, as a member of the patient's health care team, obtains pain assessment information to identify goals for pain management. Select the most important factor that the nurse would use for goal setting: Severity of the pain as judged by the patient Anticipated harmful effects of the pain experience Anticipated duration of the pain Medical interventions for pain management

Severity of the pain as judged by the patient

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

Stem cell transplantation

A patient with a recent diagnosis of HIV infection has expressed to the nurse that he is motivated to learn as much about his disease as possible. The patient has heard and read about the role of the different T cells, but is unclear of their roles in the immune response. Which of the following roles of T cells should the nurse identify? Select all that apply. Stimulating the immune system Secreting cytokines Directly attacking antigens Activating other T cells Producing antibodies

Stimulating the immune system Secreting cytokines Directly attacking antigens Activating other T cells

Conduction EX Convection EX

The body transfer heat to ice pack causing ice to melt Oscillitaing fan is blowing cool air across surface to warm body

The nurse is assessing a client's risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity? The client takes a beta blocker for the treatment of hypertension. The client is under significant psychosocial stress. The client had a pulmonary embolism 18 months ago. The client has a family history of breast cancer.

The client is under significant psychosocial stress.

When assessing a client's vital signs, a nursing student has explained to the client each of their next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce their intention to assess the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information? The client may alter the rate of respirations if the client is aware that his breaths are being counted. The nurse likely assessed the client's respiratory rate simultaneous when counting the heart rate. Temperature, pulse, and blood pressure are more volatile than respiratory rate. Tachypnea is an expected finding among hospitalized individuals.

The client may alter the rate of respirations if the client is aware that his breaths are being counted.

The nurse is caring for a victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurse's aide (NA) tells the nurse that she is concerned because the client's resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 37.3°C (99.1°F) axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as the nurse assesses this client's physiologic status? The client's understanding of pain physiology The client's serum glucose level The client's white blood cell count The client's rating of her pain

The client's rating of her pain

neutrophils (microphages)

The first phagocytes to leave the blood vessels in response to infection or cell damage cell mediator

A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this?

The interactions that occur between T cells and B cells

The nurse talks with a client who states, "My primary care provider wants me to try a TENS unit for my pain. How can electricity decrease my pain?" Which response is most appropriate?

The mild electrical impulses block the pain signal before it can reach the brain."

Nursing students are reviewing information about infectious diseases and events associated with infection. Students demonstrate understanding of the information when they identify the incubation period as which of the following?

Time between exposure and onset of symptoms

A nurse is explaining the phases of pain to a client. Place the sequence of the phases in order, from first to last.

Transduction Transmission Perception Modulation

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client?

Wait for 15 to 20 minutes before measuring the oral temperature

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

Weak pulse

It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor?

a harsh, inspiratory sound that may be compared to crowing

Immunoglobulins (also known as antibodies) promote the destruction of invading cells in various ways, using different mechanisms. Which mechanism is used by immunoglobulins to destroy pathogenic antigens? All options are correct. neutralization agglutination precipitation

all options are correct

The nurse understands that which statement is true about tolerance and addiction?

although clients may need increasing levels of opioids, they are not addicted.

Which client would be the most appropriate candidate to move by using a powered stand-assist device? a comatose client who is being taken for x-rays an alert client after knee-replacement surgery who is being assisted to ambulate an obese client who has Alzheimer disease and is being escorted to the shower room a car accident victim with fractures in both legs who is being moved to another room

an alert client after knee-replacement surgery who is being assisted to ambulate

The nurse would recognize which client as being particularly susceptible to impaired wound healing? an obese woman with a history of type 1 diabetes a client whose breast reconstruction surgery required numerous incisions a man with a sedentary lifestyle and a long history of cigarette smoking A client who is NPO (nothing by mouth) following bowel surgery

an obese woman with a history of type 1 diabetes

During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is:

analgesics.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature?

apply timid water

A client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues? applying tape to the side of the blisters using paper tape on the blisters applying the dressing with a binder applying skin barrier to protect the skin

applying the dressing with a binder

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? assessing for the use of antihypertensives assessing the client for claustrophobia assessing the wound for active bleeding assessing the client's mental status

assessing the wound for active bleeding

Cytotoxic T cells Suppressor T cells

bind to invading cells, destroy the targeted invader by altering their cellular membrane and intracellular environment, and stimulate the release of chemicals called lymphokines limit or turn off the immune response in the absence of continued antigenic stimulation.

Radiation EX Evaporation EX

body gives off heat waves from uncovered surfaces body fluid periscipation vaporized from skin

A client has undergone treatment for urosepsis and received high doses of numerous antibiotics during the course of treatment. When planning the client's subsequent care, the nurse should be aware of what potential effect on the client's immune function?

bone marrow suppresion

A client with an injured right leg is to be taken to the diagnostic unit of the health care facility. The nurse is required to transfer the client from the bed into a wheelchair. Which should the nurse do when transferring the client? lower the bed to the supine position before helping the client out of bed. bend knees and back when preparing to raise the client to standing position brace the knees against the outsides of the client's knees to assist the client to stand assist the client to a standing position from the right side of the bed

brace the knees against the outsides of the client's knees to assist the client to stand

Nurses must understand and practice proper body mechanics and often need to teach clients the use of proper body mechanics for safe walking and movement. The nurse is teaching a client to lift an object by bending at the knees and hips and keeping the back straight. When the client follows this advice, which principle of body mechanics is being followed to maintain balance? center of gravity line of gravity base of support gravital plane

center of gravity

The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic, isometric, and isokinetic exercises into the class. Which activity is an isometric exercise? sitting in a chair with a low weight on the ankle and lifting the knee to the seat level of the chair walking single file at a rate of 3 miles (5 km)/hour around a racetrack two times contracting the gluteal muscles while holding a simple yoga pose carrying an air-filled ball while wading through the water across the width of a pool

contracting the gluteal muscles while holding a simple yoga pose

A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply. covering the wound with a gauze moistened with normal saline reinserting the protruding structures and applying a pressure dressing placing the client in the low Fowler position using sterile technique packing the wound with iodoform gauze

covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position using sterile technique

A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? Select all that apply. cutaneous somatic neuropathic acute chronic

cutaneous acute

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

cutaneous stimulation

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

Which of the following is a age-related change associated with the immune system?

decreased antibody production

Monocytes/Macrophages

ecause they are large, are present in tissues such as the lungs, liver, lymph nodes, spleen, and peritoneum

A client is admitted to the unit following an amputation of the left leg below the knee. The team is creating a plan of care for this client. Which intervention should the nurse question the team about? encouraging ROM at least every 8 hours elevating the stump to prevent pressure injuries involving physical therapy in the plan of care teaching the client to use a trapeze for transfers

elevating the stump to prevent pressure injuries

A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected? full-thickness skin loss skin pallor blister formation eschar formation

full-thickness skin loss

A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which of the following complications of therapy?

immunosuppression

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

immunosuppression

A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to:

infection because the spleen removes bacteria from the blood.

The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication? interferons interleukins tumor necrosis factor colony-stimulating factor

interferons

A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:

laceration

Which immunity type becomes active as a result of infection by a specific microorganism?

naturally acquired active immunity

A client's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at this client's site of inflammation?

neutrophils

A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand? Eosinophils Neutrophils B cells Monocytes

neutrophils pg.506

A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of what?

phagocytic cells

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? proliferation phase hemostasis inflammatory phase maturation phase

proliferation

A nurse is admitting a client who exhibits signs and symptoms of a nutritional deficit. Inadequate intake of what nutrient increases a client's susceptibility to infection?

proteins

The nurse is caring for a woman with a labial carbuncle. Which intervention will most likely be included in the plan of care?

soaking in a warm bath for drainage

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as:

somatic pain

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound?

stage II

A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing? primary intention secondary intention tertiary intention quadratic intention

tertiary intention

The nurse is providing care to a team of clients. Which clients are at risk for injury to the skin? Select all that apply. the client who has a body mass index (BMI) of 34 the client who is emaciated from self-induced vomiting and food deprivation the client who has a temperature of 104°F (40°C) and is perspiring the ambulatory client who is recovering from an endoscopic procedure for abdominal pain the client who is experiencing an allergic reaction and is scratching the skin

the client who has a body mass index (BMI) of 34 the client who is emaciated from self-induced vomiting and food deprivation the client who has a temperature of 104°F (40°C) and is perspiring the client who is experiencing an allergic reaction and is scratching the skin

The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger helps in cellular repair in small doses yet destroys healthy tissue in excessive doses?

tumor necrosis factor pg554

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the:

upper left quadrant of abdomen

A client has recently been diagnosed with rheumatoid arthritis, and is also receiving further testing for disorders of the immune system. The client works as an aide at a facility caring for children infected with AIDS. Which factors will hold significant implications during the client's assessment? Select all that apply.

work environment history of immunizations and allergies use of other drugs