Adult Health 1 Exam 2 Concepts - Modules 3 and 4

The client has a diagnosis of lung cancer. To which areas does the nurse anticipate that this client's tumor may metastasize? Select all that apply. A. Brain B. Bone C. Lymph nodes D. Kidneys E. Liver (Chapter 23: Cancer Development)

A. B. C. E. Kidneys are not a typical site of metastasis.

The 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A. Elevated mononuclear leukocyte count B. Decreased leukocyte count C. Decreased neutrophil count D. Elevated erythrocyte sedimentation rate (Chapter 25: Care of Patients with Infection)

A. A. An abnormally large number of mononuclear leukocytes will confirm a diagnosis of mononucleosis. B. A decreased leukocyte count does not indicate mononucleosis. C. A decreased neutrophil count does not indicate mononucleosis. D. An elevated erythrocyte sedimentation rate does not indicate mononucleosis.

When caring for a client with cachexia, the nurse expects to note which symptom? A. Weight loss B. Anemia C. Bleeding tendencies D. Motor deficits (Chapter 24: Care of Patients with Cancer)

A. A. Cachexia results in extreme body wasting and malnutrition. Severe weight loss is expected. B. Anemia results from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. C. Bleeding tendencies result from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. D. Motor deficits result from spinal cord compression.

The client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates the need for further teaching by the nurse? A. "With this treatment, I probably cannot spread this virus to others." B. "This treatment does not kill the virus." C. "This medication prevents the virus from replicating in my body." D. "Research has shown the effectiveness of this therapy if I do not forget to take any doses." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

A. A. HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids; this statement indicates the need for further teaching. B. This is true. The medication inhibits viral replication. C. This is true. The medication inhibits viral replication. D. This is true. Remembering to take all doses of HAART is very important for preventing drug resistance.

While in the hospital, the client has developed methicillin-resistant infection in the foot. The client had undergone surgical débridement for gangrene. Which precaution is best for this client? A. The nurse dons a gown to prevent contact with the client or with client-contaminated items. B. Assign the client to a private room with a negative airflow. C. The nurse dons a mask when working within 3 feet of the client. D. Have the client wear a surgical mask when being transported out of the room. (Chapter 25: Care of Patients with Infection)

A. A. Health care providers should wear a gown when caring for a client with this infection. This is the best way to prevent the spread of infection. B. The client does not require respiratory isolation. C. Use of a mask is not the best way to prevent spread of this infection. D. The client does not need to wear a surgical mask when being transported out of the room because the infection is not airborne.

In discharging the client diagnosed with AIDS, which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? A. "Have you had sex with men or women or both?" B. "I hope you use condoms to protect your partners." C. "You must tell me all your partners' names, so I can let them know about possibly having AIDS." D. "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

A. A. A straightforward approach is nonjudgmental. B. "I hope you use" is a judgmental statement. C. Naming partners is voluntary. Also, assuming that more than one partner exists is judgmental. D. Asking for information in the name of the public health department is not straightforward, and the tone of this statement is judgmental.

The nurse is teaching the 47-year-old female client about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instructions? A. "My mother and grandmother had breast cancer, so I am at risk." B. "I get a mammography every 2 years since I turned 30." C. "A clinical breast examination is performed every month since I turned 40." D. "A CT scan will be done every year after I turn 50." (Chapter 23: Cancer Development)

A. A. A strong family history of breast cancer indicates a risk for breast cancer. B. Annual screening may be indicated for a strong family history. C. The client may perform a self-breast examination monthly; a clinical examination by a health care provider is indicated annually. D. An annual mammography is performed after age 40 or in younger clients with a strong family history.

When the nurse is counseling a 60-year-old African-American male client with all of these risk factors for lung cancer, teaching should focus most on which risk factor? A. Tobacco use B. Ethnicity C. Gender D. Increased age (Chapter 23: Cancer Development)

A. A. Although all of these are risk factors for lung cancer, the client's tobacco use is the only factor that he can change. B. Ethnicity is associated with lung cancer, but it is not modifiable. C. Gender is associated with lung cancer, but it is not modifiable. D. Increasing age is associated with lung cancer, but it is not modifiable.

Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is true? A. Antibiotics have been given to clients for conditions that do not require antibiotics. B. Microorganisms are more susceptible to antibiotics today than when they were given years ago. C. Additional precautions are taken, along with Standard Precautions, to prevent infection. D. Certain antibiotics are effective for specific infections only. (Chapter 25: Care of Patients with Infection)

A. A. Antibiotics have often been prescribed for conditions that do not require them, or have been given at higher doses or for longer periods of time than needed. As a result, a number of microorganisms have become resistant to certain antibiotics. B. Microorganisms are more resistant to certain antibiotics. C. Strictly adhered to Standard Precautions are adequate to prevent infection. D. Several microorganisms have become resistant to certain antibiotics.

Which information does the nurse include when teaching the client about antibiotic therapy for infection? A. Take all antibiotics as prescribed, unless side effects develop. B. Take antibiotics until symptoms subside, and then stop taking the drugs. C. Take antibiotics when symptoms of infection develop. D. Share antibiotics with family members who develop the same infection. (Chapter 25: Care of Patients with Infection)

A. A. Antibiotics should be taken as ordered. The provider must be contacted immediately if any side effects develop. B. Antibiotics must be taken until they are gone, even if the client feels better. C. Antibiotics are to be taken when prescribed, not when symptoms occur. D. Antibiotics should be taken only by the person for whom they are prescribed. They are not to be shared with anyone else.

When preparing the client for allergy testing, the nurse provides the client with which instruction? A. "Avoid taking your loratadine (Claritin) and triamcinolone (Azmacort) inhaler for 5 days before testing." B. "It is okay to use your fluticasone propionate (Flonase) nasal spray before testing." C. "Aspirin in a low dose is allowed to be taken before testing." D. "You can take antihistamine nasal sprays before testing." (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

A. A. Antihistamines and corticosteroid inhalers should be discontinued before skin testing to avoid suppressing an allergic response. B. Flonase is a steroid inhaler and should be discontinued for 5 days before testing. C. Allergists recommend that aspirin be withheld before testing. D. Nasal sprays that contain antihistamines are not permitted before testing.

Situation: A client recently diagnosed with HIV is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? A. Fluconazole (Diflucan) B. Trimethoprim/sulfamethoxazole (Bactrim) C. Rifampin (Rifadin) D. Acyclovir (Zovirax) (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

A. A. Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. B. Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. C. Rifampin (Rifadin) is used for treatment of tuberculosis. D. Acyclovir (Zovirax) is an antiviral agent.

Which statement accurately explains otitis media? A. The inflammatory response is triggered by the invasion of foreign proteins. B. Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders. C. It is caused by a left shift or increase in immature neutrophils. D. Many immune system cells released into the blood have specific effects. (Chapter 19: Inflammation and the Immune Response)

A. A. Inflammation is the process that occurs in response to invasion by organisms. In otitis media, it is a bacterium. B. These cell types are involved in inflammation; otitis media is an inflammation caused by infection. C. The less mature neutrophil forms should not be in the blood. The change in form is caused by infection, such as sepsis. D. Immune system cells take action when encountering a non-self or foreign protein to neutralize, destroy, or eliminate this foreign invader, but this does not cause inflammation.

The nurse is preparing the client for discharge on postoperative day 1after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client's discharge plan? A. "Please report any increased redness, swelling, warmth, pain, or lack of movement to your health care provider." B. "Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed." C. "A referral has been made to the American Cancer Society's Reach to Recovery program, and a volunteer will call you next week." D. "Avoid the prone and hunched-back positions, and ask your health care provider for any other needed activity restrictions." (Chapter 19: Inflammation and the Immune Response)

A. A. Instruction on increased signs and symptoms of inflammation could reveal signs of potential infection. B. Although this information should be included, it is not the most important instruction among the options listed. C. Referrals are important in helping with coping but are not the most important consideration when the client is being sent home on postoperative day 1. D. Positioning is important but is not the priority here.

The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A. A client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B. A client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C. A client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D. A client with xerostomia associated with laryngeal cancer who needs oral care before breakfast (Chapter 24: Care of Patients with Cancer)

A. A. Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune suppressed people; the nurse should see this client first. B. The client can be assessed later; he is not currently nauseated. C. This client is not in distress and can be assessed later. D. The client with dry mouth can be assessed later, or the nurse can delegate mouth care to unlicensed assistant personnel.

The nurse manager in a long-term care facility is developing a plan for primary and secondary prevention of colorectal cancer. Which tasks associated with the screening plan will be delegated to nursing assistants within the facility? A. Testing of stool specimens for occult blood B. Teaching about the importance of dietary fiber C. Referring clients for colonoscopy procedures D. Giving vitamin and mineral supplements (Chapter 23: Cancer Development)

A. A. Testing of stool specimens for occult blood is done according to a standardized protocol and can be delegated to nursing assistants. B. Client education is within the scope of practice of the professional nurse, not of the LPN or nursing assistant. C. Referral for further care is best performed by the professional nurse. D. Administration of medications is beyond the nursing assistant scope of practice and should be done by licensed nursing personnel.

Situation: The client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? A. Epinephrine (Adrenalin) B. Fexofenadine (Allegra) C. Cromolyn sodium (Nasalcrom) D. Zileuton (Zyflo) (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

A. A. The client is experiencing an anaphylactic reaction, and epinephrine is a first-line sympathomimetic used to treat anaphylaxis. B. Fexofenadine (Allegra) is a nonsedating antihistamine and is not a first-line drug to treat anaphylaxis. C. Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug; it is used to prevent symptoms of allergic rhinitis but is not useful during an acute episode. D. Zileuton (Zyflo) is a leukotriene antagonist; it is used to prevent symptoms of allergic rhinitis but is not useful during an acute episode.

The client recently admitted to the hospital is to receive an antibiotic intravenously for the first time for a urinary tract infection. Before checking the five R's prior to administration, what is the nurse's first action? A. Review the clinical records and ask the client about any known allergies. B. Check with the pharmacy for any known allergies for this client. C. Check the client's identification band for any allergies. D. Ask the nurse who previously cared for the client about any known allergies. (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

A. A. The clinical record should have all known hypersensitivities listed for the client. Also, ask the client about any known allergies. B. The pharmacy is not responsible for obtaining from the client information on all known allergies. C. This is also part of the five R's process at the bedside before the medication is given. D. Asking the previous nurse is not an appropriate safety measure before medication administration.

Which member of the health care team demonstrates reducing the risk for infection for the client with acquired immune deficiency syndrome (AIDS)? A. The dietary worker hands the disposable meal trays to the LPN assigned to the client. B. The social worker encourages the client to verbalize about stressors at home. C. Housekeeping thoroughly cleans and disinfects the hallways near the client's room. D. The health care provider orders vital signs including temperature every 8 hours. (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

A. A. This limits the number of health care personnel entering the room. B. Verbalizing stressors does not reduce the risk for infection. C. Cleaning of bathrooms, not hallways, at least once daily by housekeeping reduces infection. D. Vital signs, including temperature, should be taken every 4 hours to detect potential infection but does not reduce the risk for infection.

Which information must the organ transplant nurse emphasize before each client is discharged? A. Taking immune suppressant medications increases your risk for cancer and the need for screenings. B. You are at increased risk for cancer when you reach 60 years of age. C. Immunosuppressant medications will decrease your risk for developing cancers. D. After 6 months, you may stop immune suppressant medications, and your risk for cancer will be the same as that of the general population. (Chapter 23: Cancer Development)

A. A. Use of immune suppressant medications to prevent organ rejection increases the risk for cancer. B. Advanced age is a risk factor for all people, not just for organ transplant recipients. C. Although a small risk for disease transmission is present, 70% of clients with acquired immune deficiency syndrome (AIDS) may develop cancer. D. Immune suppressant medications must be taken for the life of the organ; the risk for developing cancer remains.

The nurse explains to the client that which risk factor most likely contributed to his primary liver carcinoma? A. Infection with hepatitis B virus B. Consuming a diet high in animal fat C. Exposure to radon D. Familial polyposis (Chapter 23: Cancer Development)

A. A. Hepatitis B and C are risk factors for primary liver cancer. B. Consuming a diet high in animal fat may predispose to colon or breast cancer. C. Exposure to radon is a risk factor for lung cancer. D. Familial polyposis is a risk factor for colorectal cancer.

The nurse includes which of the following in teaching regarding the warning signs of cancer? Select all that apply. A. Persistent constipation B. Scab present for 6 months C. Curdlike vaginal discharge D. Axillary swelling E. Headache (Chapter 23: Cancer Development)

A. B. D. Curdlike discharge represents yeast infection.

Which interventions will the home health nurse teach to family members to reduce confusion in the client diagnosed with AIDS dementia? Select all that apply. A. Change the decorations in the home according to the season. B. Put the bed close to the window. C. Write out detailed instructions, and have the client read them over before performing a task. D. Ask the client what time he or she prefers to shower or bathe. E. Mark off the days of the calendar, leaving open the current date. (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

A. B. D. E. Directions should be short and simple and uncomplicated.

A client is prescribed prednisone for treatment of a type I reaction. The nurse plans to monitor the client for which adverse effects? Select all that apply. A. Fluid retention B. Gastric distress C. Hypotension D. Infection E. Osteoporosis (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

A. B. D. E. Hypertension is an adverse effect of prednisone.

A client is admitted with a catheter-associated methicillin-resistant Staphylococcus aureus (MRSA) infection. Which personal protective equipment is appropriate when providing client care? Select all that apply. A. Mask B. Gloves C. Shoe covers D. Goggles E. Gown (Chapter 25: Care of Patients with Infection)

A. B. E. A nurse caring for a client with MRSA must don gloves and a gown in all cases. Based on the procedures and the chance for airborne droplets and/or splattering, the nurse may find it necessary to wear a mask and goggles. Personal protective equipment (PPE) must be worn when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., skin of a client incontinent of stool or urine) could occur. Shoe covers are generally not required when caring for a client with MRSA. Reference: p. 443, Safe and Effective Care Environment

When caring for a client with suspected syndrome of inappropriate antidiuretic hormone secretions (SIADH), the nurse reviews the medical record to uncover which signs and symptoms consistent with this syndrome? Diagnostics: Na: 115 K: 4.2 Creatinine: 0.8 Assessment: Neuro: Episodes of confusion Cardiac: Pulse 88 and regular Musculoskeletal: Weakness, tremors Medications: Ondansetron (Zofran) Cyclophosphamide (Cytoxan) A. Hyponatremia B. Mental status changes C. Azotemia D. Bradycardia E. Weakness (Chapter 24: Care of Patients with Cancer)

A. B. E. Azotemia refers to buildup of nitrogenous waste products in the blood, typically from renal damage.

The nurse is aware that which factors are possible transmission routes for HIV? Select all that apply. A. Breast-feeding B. Anal intercourse C. Mosquito bites D. Toileting facilities E. Oral sex (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

A. B. E. HIV is not spread by mosquito bites or by other insects.

The registered nurse is teaching a nursing student about the importance of observing for bone marrow suppression during chemotherapy. Select the person who displays bone marrow suppression. A. Client with hemoglobin of 7.4 and hematocrit of 21.8 B. Client with diarrhea and potassium level of 2.9 mEq/L C. Client with 250,000 platelets D. Client with 5000 white blood cells/mm3 (Chapter 24: Care of Patients with Cancer)

A. Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia; this client has anemia demonstrated by low hemoglobin and hematocrit.

The nurse is assessing a client with suspected serum sickness. Which symptoms will be consistent with serum sickness? Select all that apply. A. Arthralgia B. Blurred vision C. Lymphadenopathy D. Malaise E. Ptosis (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

A. C. D. Blurred vision is not a symptom of serum sickness.

Which signs or symptoms should the nurse report immediately because they indicate thrombocytopenia secondary to cancer chemotherapy? Select all that apply. A. Bruises B. Fever C. Petechiae D. Epistaxis E. Pallor (Chapter 24: Care of Patients with Cancer)

A. C. D. Fever is a sign of infection secondary to neutropenia.

Which potential side effects should be included in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? A. Fatigue B. Changes in color of hair C. Change in taste D. Changes in skin of the neck E. Difficulty swallowing (Chapter 24: Care of Patients with Cancer)

A. C. D. E. Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair.

The nurse has received in report that the client receiving chemotherapy has severe neutropenia. Which of the following does the nurse plan to implement? Select all that apply. A. Assess for fever. B. Observe for bleeding. C. Administer pegfilgrastim (Neulasta). D. Do not permit fresh flowers or plants in the room. E. Do not allow his 16-year-old son to visit. F. Teach the client to omit raw fruits and vegetables from his diet. (Chapter 24: Care of Patients with Cancer)

A. C. D. F. Thrombocytopenia, or low platelet levels, cause bleeding, not low neutrophils (a type of white blood cell [WBC]).

The nurse presents a seminar on HIV testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention (CDC) regarding HIV testing? Select all that apply. A. "I am 78 years old, and I was treated and cured of syphilis many years ago." B. "In 1986, I received a transfusion of platelets." C. "Seven years ago, I was released from a penitentiary." D. "I used to smoke marijuana 30 years ago, but I have not done any drugs since that time." E. "At 68, I am going to get married for the fourth time." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

A. C. E. HIV testing is recommended for clients who received a blood transfusion between 1978 and 1985.

Which finding in the client with HIV disease who is receiving antiretroviral therapy indicates to the nurse that the treatment is effective? A. CD4+ cells 700/mm3 B. CD4+ cells 200/mm3 C. CD8+ cells 700/mm3 D. CD8+ cells 200/mm3 (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

A. The HIV selectively infects and causes the destruction of the CD4 cells (T-helper cells). The normal CD4+ cell number is 600 to 1500/mm3. An increase in this population of cells in a client with HIV disease above 500 indicates the medication regimen is effective in suppressing viral replication. Reference: p. 369, Health Promotion and Maintenance

Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A. Potential for lack of understanding related to side effects of chemotherapy B. Risk for Injury related to sensory and motor deficits C. Potential for ineffective coping strategies related to loss of motor control D. Altered sexual function related to erectile dysfunction (Chapter 24: Care of Patients with Cancer)

B. A. Although this information may be helpful, the priority is the client's safety because of lack of sensation or innervation. B. The highest priority is safety. C. The nurse should address the client's coping, after providing for safety. D. Erectile dysfunction may be a manifestation of peripheral neuropathy, but the priority is the client's safety.

Which statement about handwashing, in accordance with recommendations by the Centers for Disease Control and Prevention (CDC), is true? A. If gloves are worn between treatments for clients sharing a room, handwashing is not necessary until the nurse has finished assessing the second client. B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. C. Handwashing does not need to be done after resetting a client's IV pump. D. If the hands are not visibly soiled, washing the hands is not necessary. (Chapter 25: Care of Patients with Infection)

B. A. Hands must be washed between all client contacts, and gloves must be changed. B. Microorganisms that can be transmitted to another client can be found on intact skin. Handwashing must be done between all contacts with each client. C. Handwashing must be done after contact with all clients or their equipment. D. Handwashing must be done when any contact with the client occurs, even when hands are not visibly soiled.

The nurse is assigned to care for four clients. Which client will the nurse assess first? A. An HIV-positive client with Kaposi's sarcoma who is described increased swelling to the right arm sarcoma lesion B. A client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature C. A client who has been admitted to receive a monthly dose of immune serum globulin to treat Bruton's agammaglobulinemia D. A client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. A. Information regarding this client indicates that the physiologic status is relatively stable. B. The temperature elevation indicates that infection may be occurring in this client, who is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated. C. Information regarding this client indicates that the physiologic status is relatively stable. D. Information regarding this client indicates that the physiologic status is relatively stable, and it is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count.

The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of lymphoma. It is essential for the nurse to observe for which side effect? A. Alopecia B. Allergy C. Fever D. Chills (Chapter 24: Care of Patients with Cancer)

B. A. Monoclonal antibody therapy does not cause alopecia. B. Allergy is the most common side effect. C. Although fever is a side effect of monoclonal antibody therapy, it would not take priority over an allergic response that could potentially involve the airway. D. Although chills are a side effect of monoclonal antibody therapy, they would not take priority over an allergic response that could potentially involve the airway.

Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? A. New onset of fatigue B. Edema of arms and hands C. Dry cough D. Weight gain (Chapter 24: Care of Patients with Cancer)

B. A. New onset of fatigue may likely be an early manifestation of hypercalcemia, which usually develops slowly. Because it is an early manifestation, this is not the priority. B. Edema of the arms and hands indicates worsening compression of the superior vena cava consistent with superior vena cava syndrome. The compression must be relieved immediately, often with radiation therapy, because death can result without timely intervention. C. Dry cough is not a manifestation that is specific to an oncologic emergency; however, it may be a side effect of chemotherapy. D. Weight gain could be an early sign of syndrome of inappropriate antidiuretic hormone. Although this should be addressed, it is an early sign; thus it is not the priority.

Which statement by the nurse best educates the client with strep throat infection about infection control measures? A. "It is better to use disposable paper plates and utensils than regular dishes for meals." B. "You and members of your family should each use separate toothbrushes." C. "You must remain indoors while recovering." D. "All members of your family need to be tested for strep." (Chapter 25: Care of Patients with Infection)

B. A. The use of disposable plates and utensils to control the spread of infection is not necessary. B. It is essential for the client and family members to use separate toothbrushes to prevent the spread of infection. C. It is not necessary for the client with strep throat to remain indoors while recovering. D. All family members do not need to be tested for strep infection unless they are symptomatic.

A client diagnosed with HIV is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon) and asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? A. "This will not make any difference in the viral load." B. "Blood concentrations will be decreased, which will lead to increased viral replication." C. "If only one dose of medication is missed, this will not make a difference." D. "This will cause an increase in opportunistic infections." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. A. The viral load will be affected because blood concentrations will become lower. B. When doses are missed, blood concentrations become lower than what is needed for inhibition of viral replication (often called the inhibitory concentration). When this concentration is too low, the organism can replicate and produce new organisms that are resistant to the drugs being used. Therefore it is critical to ensure that HAART drugs are not missed, delayed, or administered in lower-than-prescribed doses in the inpatient setting. Teach clients the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART drugs. C. This increases the chance of drug resistance. D. The chance of drug resistance is increased.

The nurse is providing care to the client with impaired gas exchange related to anemia. Which nursing intervention has the highest priority? A. Administer antibiotics as prescribed. B. Transfuse ordered packed red blood cells. C. Teach pursed-lip breathing. D. Encourage increased fluid intake. (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. A. Antibiotics improve infection, not gas exchange. B. Packed red blood cells increase hemoglobin molecules; this increases sites at which oxygen can attach and improves gas exchange. C. Mouth breathing does not improve gas exchange related to anemia. D. Fluid intake does not have an effect on improving gas exchange.

When preparing the newly diagnosed client with HIV and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? A. "Condoms should be used when lesions are present on the penis." B. "Always position the condom with a space at the tip of an erect penis." C. "Make sure it fits loosely to allow for penile erection." D. "Use adequate lubrication such as petroleum jelly." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. A. Condoms must be used at all times with sexual activity, with or without the presence of lesions. B. This allows for collection of semen at the tip of the condom. C. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. D. Lubricants should be water-based only.

Which of these does the nurse recognize as the goal of palliative surgery for the client with cancer? A. Cure of the cancer B. Relief of symptoms or improved quality of life C. Allowing other therapies to be more effective D. Prolonging the client's survival time (Chapter 24: Care of Patients with Cancer)

B. A. Curative surgery removes all cancer cells, visible and microscopic. B. The focus of palliative surgery is to improve quality of life during the survival time. C. Debulking is a procedure that removes some cancerous tissue, allowing other therapies to be more effective. D. Many therapies such as surgery, chemotherapy, and biotherapy increase the client's chance of cure and survival. Palliation improves quality of life.

A client who is HIV positive is experiencing anorexia and diarrhea. Which nursing actions will the nurse delegate to a nursing assistant? A. Collaborate with the client to select foods that are high in calories. B. Provide oral care to the client before meals to enhance appetite. C. Assess the perianal skin every 8 hours for signs of skin breakdown. D. Discuss the need to avoid foods that are spicy or irritating. (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. A. Diet planning is a higher level action that requires more broad education and scope of practice; this should be done by licensed staff. B. Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants. C. Assessment is a higher level action that requires more broad education and scope of practice; this should be done by licensed staff. D. Client teaching is a higher level action that requires more broad education and scope of practice; this should be done by licensed staff.

The registered nurse is teaching a group of nursing students about malignant transformation. Which statement about the process of malignant transformation is true? A. Mutation of genes is an irreversible event that always leads to cancer development in the initiation phase. B. Insulin and estrogen enhance the division of an initiated cell during the promotion phase. C. Tumors form when carcinogens invade the gene structure of the cell in the latency phase. D. Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage. (Chapter 23: Cancer Development)

B. A. If cell division is halted, this does not lead to cancer development in the initiation phase. B. These promoters increase cell division. C. In the initiation phase, carcinogens invade the DNA of the nucleus of a single cell. A 1-cm tumor consists of 1 billion cells. The latent phase occurs between initiation and tumor formation. D. This phase consists of progression when the blood supply changes from diffusion to TAF.

Which statement made to the nurse by a health care worker assigned to care for the client with HIV indicates a breach of confidentiality and requires further education by the nurse? A. "I told family members they need to wash their hands when they enter and leave the room." B. "The other health care worker and I were out in the hallway discussing how we were concerned about getting HIV from our client, so no one could hear us in the client's room." C. "Yes, I understand the reasons why I have to wear gloves when I bathe my client." D. "The client's spouse told me she got HIV from a blood transfusion." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. A. Instruction on handwashing to family members or friends is not a breach of confidentiality. B. Discussing this client's illness outside the client's room is a breach of confidentiality and requires further education by the nurse. C. This recognizes Standard Precautions in direct care and is not a breach of confidentiality. D. The health care worker is relaying the conversation to the nurse. This is not a breach of confidentiality.

Which activity performed by the community health nurse best reflects primary prevention of cancer? A. Assisting women to obtain free mammograms B. Teaching a class on cancer prevention C. Encouraging long-term smokers to get a chest x-ray D. Encouraging sexually active women to get annual Papanicolaou (Pap) smears (Chapter 23: Cancer Development)

B. A. Mammogram is part of a secondary level of prevention, defined as screening for early detection. B. Primary prevention involves avoiding exposure to known causes of cancer; education assists clients with this strategy. C. Chest x-ray is a method of detecting a cancer that is present—secondary prevention and early detection. D. A Pap smear is a means of detecting cervical cancer early—secondary prevention.

Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea? A. Morphine B. Ondansetron (Zofran) C. Naloxone (Narcan) D. Diazepam (Valium) (Chapter 24: Care of Patients with Cancer)

B. A. Morphine is a narcotic analgesic or opiate; it may cause nausea. B. Ondansetron is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. C. Naloxone is a narcotic antagonist used for opiate overdose. D. Diazepam is a benzodiazepine, which is an antianxiety medication only. Lorazepam, a benzodiazepine, may be used for nausea.

The nurse reviews the chart of the client admitted with a diagnosis of glioblastoma with a T1NXM0 classification. Which explanation does the nurse offer when the client asks what the terminology means? A. "Two lymph nodes are involved in this tumor of the glial cells, and another tumor is present." B. "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." C. "This type of tumor in the brain is small with some lymph node involvement; another tumor is present somewhere else in your body." D. "Glioma means this tumor is benign, so I will have to ask your health care provider the reason for the chemotherapy and radiation." (Chapter 23: Cancer Development)

B. A. NX means that no regional lymph nodes can be assessed, and M0 means that no distant metastasis is present. B. T1 means that the tumor is increasing in size to about 2 cm, and that no regional lymph nodes are present in the brain. M0 means that no distant metastasis has occurred. C. T1 means small, but NX means no regional lymph node involvement. M0 means that no distant metastasis has occurred. D. A glioma is a benign tumor of the brain, but the client is diagnosed with a glioblastoma, which means a malignant tumor of the glial cells of the brain.

The nurse suspects metastasis from left breast cancer to the thoracic spine when the client has which symptom? A. Vomiting B. Back pain C. Frequent urination D. Cyanosis of the toes (Chapter 23: Cancer Development)

B. A. Signs of metastasis to the spine may include numbness, pain, paresthesias and tingling, and loss of bowel and bladder control. B. Typical sites of breast cancer metastasis include bone, manifested by back pain, lung, liver, and brain. C. Although frequent urination may be a sign of bladder cancer, incontinence is more indicative of spinal metastasis. D. Cyanosis of the toes indicates decreased tissue perfusion, often related to atherosclerotic disease.

A client is admitted to the hospital with suspected Goodpasture's syndrome. Which findings will the nurse expect to observe? A. Bradycardia B. Hemoptysis C. Increased urine output D. Weight loss (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

B. A. Tachycardia is a manifestation of Goodpasture's syndrome. B. Hemoptysis is a manifestation of Goodpasture's syndrome. Goodpasture's syndrome usually is not diagnosed until serious lung and kidney problems are present. C. Decreased urine output is a manifestation of Goodpasture's syndrome. D. Weight gain is a manifestation of Goodpasture's syndrome.

A client has been ordered norepinephrine (Levophed) for treatment of severe hypotension. The nurse plans to monitor the client for which adverse effect? A. Bradycardia B. Headache C. Infection D. Metabolic alkalosis (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

B. A. Tachycardia is an adverse effect of norepinephrine (Levophed). B. Norepinephrine (Levophed) is a vasopressor and can cause headache. C. Norepinephrine (Levophed) does not suppress the immune system. D. Metabolic acidosis is an adverse effect of norepinephrine (Levophed).

The client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse? A. Taking the antibiotic before jogging 2 miles daily B. Taking the antibiotic most days C. Taking the antibiotic as prescribed D. Taking the antibiotic with a full glass of water (Chapter 25: Care of Patients with Infection)

B. A. Taking the antibiotic before jogging is not a contributing factor to the client's relapse. B. Antibiotics not taken as prescribed can result in reoccurring symptoms, as well as the development of drug-resistant infections and other emerging infections. C. The client who is taking antibiotics as prescribed is not likely to develop reoccurring symptoms. D. Taking antibiotics with a full glass of water neither hinders nor promotes antimicrobial therapy.

The client who is exposed to invaders recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client? A. Intact skin and mucous membranes B. Self-tolerance C. Inflammatory response against invading foreign proteins D. Antibody-antigen interaction (Chapter 19: Inflammation and the Immune Response)

B. A. The body has some defenses to prevent organisms from gaining access to the internal environment, such as intact skin and mucous membranes. However, they are not perfect. Invasion of the body's internal environment by organisms often occurs. B. The ability to recognize self versus non-self is necessary to prevent healthy body cells from being destroyed along with the invaders. This meets the client's protection needs. C. Inflammation provides immediate protection against the effects of tissue injury and invading foreign proteins. The inflammatory response is immediate but short-term against injury or invading organisms; it does not provide true immunity. D. Seven steps are needed to produce a specific antibody directed against a specific antigen whenever the person is exposed to that antigen.

The home health nurse is making an initial home visit to the client currently living with family members after being hospitalized with pneumonia and newly diagnosed with AIDS. Which statement by the nurse best acknowledges the client's fear of discovery by his family? A. "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" B. "Is there somewhere private in the home we can go and talk?" C. "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick." D. "It is your duty to protect your family members from getting AIDS." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. A. The client has a right to privacy and can make the decision whether to post handwashing signs. Caution signs invade the client's right to privacy. B. A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. C. Protection from infection is important, but this approach is not respectful of the client's right to privacy. D. This statement by the nurse is rather intimidating. It is the client's right to make the decision whether to inform or not inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently.

The nurse is teaching the client about cyclosporine (Sandimmune) therapy after a liver transplantation. Which client statement indicates the need for further teaching? A. "I will be on this medicine for the rest of my life." B. "I must undergo regular kidney function tests." C. "I must regularly monitor my blood sugar." D. "My gums may become swollen because of this drug." (Chapter 19: Inflammation and the Immune Response)

B. A. The client must take cyclosporine for the rest of his or her life. B. Kidney dysfunction is a side effect of cyclosporine, so regular monitoring is required. C. Blood sugar is not affected by taking cyclosporine. D. Swollen gums are a side effect of taking cyclosporine.

Which postoperative kidney transplantation client does the nurse assess first for signs and symptoms of hyperacute rejection? A. Older adult with Parkinson disease receiving a donation from an identical twin B. Grand multipara female with a history of subsequent blood transfusions C. Middle-aged man with a 20-pack-year history D. Young adult with type 1 diabetes (Chapter 19: Inflammation and the Immune Response)

B. A. This client has less chance of hyperacute rejection because his donor is an identical twin. B. Multiple pregnancies and blood transfusions greatly increase the risk of a hyperacute rejection. C. Smoking places this client at higher risk for postoperative respiratory difficulties, but not for hyperacute rejection. D. Type 1 diabetes requires close postoperative monitoring of blood sugar but does not predispose the client to a hyperacute rejection.

The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity? A. "It is a reaction of immune globulin (Ig)G with the host cell membrane or antigen." B. "The reaction of sensitized T-cells with antigen and release of lymphokines activate macrophages and induce inflammation." C. "It results in release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells." D. "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels." (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

B. A. This describes type II hypersensitivity. B. This is a delayed hypersensitivity reaction, as is seen with poison ivy (type IV hypersensitivity). C. This describes a type I hypersensitivity reaction. D. This describes a type III hypersensitivity reaction.

A client diagnosed with HIV is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions will the nurse recommend to the client? A. Clean toothbrush once a week. B. Bathe daily, using an antimicrobial soap. C. Eat salad at least once a day. D. Wash dishes in cool water. (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. A. Toothbrushes should be cleaned daily through the dishwasher or by rinsing in liquid laundry bleach. B. Bathing daily and using an antimicrobial soap will help decrease the risk for opportunistic infections by reducing the number of bacteria found on the skin. C. Salads and raw fruits and vegetables could be contaminated and should be avoided. D. Dishes should be washed in hot, soapy water or in a dishwasher.

The nurse anticipates administering which medication to treat hyperuricemia associated with tumor lysis syndrome (TLS)? A. Recombinant erythropoietin (Procrit) B. Allopurinol (Zyloprim) C. Potassium chloride D. Radioactive iodine 131 (Chapter 24: Care of Patients with Cancer)

B. A. Tumor lysis syndrome results in hyperuricemia (elevation of uric acid in the blood), hyperkalemia, and other electrolyte imbalances; Procrit is used to increase red blood cell (RBC) production and is not a treatment for hyperuricemia. B. Tumor lysis syndrome results in hyperuricemia, Allopurinol decreases uric acid production and is indicated in TLS. C. Tumor lysis syndrome results in hyperuricemia, hyperkalemia, and other electrolyte imbalances; administering additional potassium is dangerous. D. Radioactive iodine 131 is indicated in the treatment of thyroid cancer, not TLS.

The nurse understands that which factor relates most directly to a diagnosis of primary immune deficiency? A. History of viral infection B. Full-term infant surfactant deficiency C. Contact with anthrax toxin D. Corticosteroid therapy (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. A. Viral infection can cause a secondary immune deficiency. B. Genetic mutation causes surfactant deficiency. This is a primary immune deficiency. C. Anthrax is an example of a secondary immune deficiency. D. Medical therapy is an example of a secondary immune deficiency.

The nurse is assessing a client with lung cancer. Which symptom does the nurse anticipate finding? A. Easy bruising B. Dyspnea C. Night sweats D. Chest wound (Chapter 23: Cancer Development)

B. A. Easy bruising is a nonspecific finding. B. Dyspnea is a sign of lung cancer, as are cough, hoarseness, shortness of breath (SOB), bloody sputum, arm or chest pain, and dysphagia. C. Night sweats is a symptom of the lymphomas. D. A chest wound is not specific to lung cancer.

Which of these nursing activities can the nurse delegate to a home health aide? A. Changing the dressing for a client with a low absolute neutrophil count B. Assisting with bathing for a client with chronic rejection of a liver transplant C. Teaching a client with bacterial pneumonia how to take the prescribed antibiotic D. Assessing incisional tenderness for a client who had a recent kidney transplant (Chapter 19: Inflammation and the Immune Response)

B. A. This care of a client requires the RN and should not be delegated owing to the high risk for infection. B. This care can be delegated to the home health aide. C. Teaching about medications is within the scope of the RN. D. Assessments are within the scope of practice of the RN.

Because of a flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner? A. Older adult client with a history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 15.5, segs 8.0, bands 5, lungs with slight crackles in bases, able to assist with activities of daily living (ADLs), and afebrile B. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, white blood cell count (WBC) 9.5, segs 6.0, bands 1.0, oxygen saturation of 93% on room air, and afebrile C. Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, white blood cell count (WBC) 20.0, segs 7.0, bands 10.0, oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4° F (38° C) D. Older adult client with recent history of right hip replacement, with productive cough, white blood cell count (WBC) 3.4, segs 6.2, bands 5, lungs with crackles right mid-lobe posterior chest wall, oxygen saturation of 89% with O2 at 2 L, and afebrile (Chapter 19: Inflammation and the Immune Response)

B. A. WBC and segs are elevated. This client is not ready for discharge. B. This client is ready for discharge. CBC is within normal limits. C. This client is not ready for discharge because of elevated WBCs, left shift, and febrile status. D. This client's WBC is below normal, but all other parts of the differential are within normal limits. This could indicate a viral infection, but crackles and low oxygen saturation are still present in the lungs.

The nurse is conducting a community health education class on diet and cancer risk reduction. What should be included in the discussion? A. Limit sodium intake. B. Avoid beef and processed meats. C. Increase consumption of whole grains. D. Eat "colorful fruits and vegetables," including greens. E. Avoid gas-producing vegetables such as cabbage. (Chapter 23: Cancer Development)

B. C. D. Reducing sodium is helpful in the treatment of hypertension and heart and renal failure. No evidence suggests that lowering of sodium intake decreases the incidence of cancer.

The nurse is teaching a group of clients about cancers related to tobacco or tobacco smoke. Identify the common cancers related to tobacco use. Select all that apply. A. Cardiac cancer B. Lung cancer C. Cancer of the tongue D. Skin cancer E. Cancer of the larynx (Chapter 23: Cancer Development)

B. C. E. The heart does not contain cells that divide; therefore cardiac cancer is unlikely.

When caring for a client who has had a colostomy created as part of a regimen to treat colon cancer, which activities would help to support the client in accepting changes in appearance or function? Select all that apply. A. Explain to the client that the colostomy is only temporary. B. Encourage the client to participate in changing the ostomy. C. Obtain a psychiatric consultation. D. Offer to have a person who is coping with a colostomy visit. E. Encourage the client and family members to express their feelings and concerns. (Chapter 24: Care of Patients with Cancer)

B. D. E. Ostomies may be temporary for bowel rest, such as after a perforation, but are typically permanent for cancer treatment.

Which actions aid in the prevention and early detection of infection in the client at risk? Select all that apply. A. Inspect the skin for coolness and pallor. B. Promote sufficient nutritional intake. C. Encourage fluid intake, as appropriate. D. Monitor the red blood cell (RBC) count. E. Obtain cultures as needed. (Chapter 25: Care of Patients with Infection)

B. E. Inspecting the skin is a nursing action and assessment of a system but does not prevent or detect systemic infections.

A client's complete blood count (CBC) with differential has the following values. Which value indicates to the nurse that the client is having some type of allergic reaction? A. Total white blood cell (WBC) count 100% B. Eosinophils 11% C. Lymphocytes 38% D. Neutrophils 66% (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

B. Eosinophils have granules that contain enzymes to degrade histamine and other vasoactive amines and thereby limit allergic and inflammatory responses. Normally, eosinophils compose only 1% to 2% of the total white blood cell population. This value rises in response to an allergic reaction of any type. Reference: p. 386, Physiological Integrity

Which snack choice does the nurse recommend to the client with AIDS to help improve nutritional status? A. An ice cream sandwich B. Two soft-cooked eggs C. A wand of cotton candy D. A serving of French fried potatoes (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

B. If you got this wrong you should be ashamed. A. The ice cream sandwich has plenty of calories but a relatively small amount of protein. In addition, many clients with AIDS become intolerant of lactose. Reference: p. 377, Health Promotion and Maintenance B. The client with AIDS needs a high-protein and high-calorie diet to support or improve nutrition and should avoid fat, which can cause diarrhea and lead to a loss of nutrients. Eggs are a high-quality protein choice. Reference: p. 377, Health Promotion and Maintenance C. The cotton candy is pure carbohydrates. Although it can add calories, it does not add protein. Reference: p. 377, Health Promotion and Maintenance D. The French fries consist of carbohydrates and fat and contain calories but no protein. Reference: p. 377, Health Promotion and Maintenance

Which precaution is most important for the nurse to teach a client receiving long-term immunosuppressive therapy for an autoimmune disease? A. Avoid crowds and people who are ill. B. Call your health care provider at the first sign of an infection. C. Assess your response to this medication at least once per month. D. Be sure to tell your dentist you are taking this therapy before having any dental work. (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

B. The client should be taught all of these precautions. However, because anyone who is immunosuppressed is unable to adequately defend against an infection, even a minor infection has the potential to lead to life-threatening sepsis. No infection, no matter how minor, should be ignored in a client who is immunosuppressed. Reference: p. 394, Health Promotion and Maintenance

Which action is most important for the nurse to implement to prevent nausea and vomiting in a client who is prescribed to receive the first round of IV chemotherapy? A. Keep the client NPO during the time chemotherapy is infusing. B. Administer antiemetic drugs before administering chemotherapy. C. Ensure that the chemotherapy is infused over a 4- to 6-hour period. D. Assess the client for manifestations of dehydration hourly during the infusion period. (Chapter 24: Care of Patients with Cancer)

B. When emetogenic chemotherapy drugs are prescribed, the client should receive antiemetic drugs before the chemotherapy drugs are administered. This allows time for prevention of chemotherapy-associated nausea and vomiting; however, the antiemetic therapy cannot stop until all risks for nausea and vomiting have passed. Clients become nauseated and vomit even if they are NPO. Reference: p. 422, Safe and Effective Care Environment

The nurse manager for a long-term care facility is in charge of implementing a plan to decrease the spread of infection within the facility. Which part of the plan is most appropriate to delegate to nursing assistants working at the facility? A. Evaluating each other's handwashing technique B. Deciding which brand of handwashing soap to use C. Reinforcing the need for handwashing after caring for clients D. Determining which clients are most likely to infect other residents (Chapter 25: Care of Patients with Infection)

C. A. A higher level of administration is required to evaluate the performance of another worker. B. This is done at the facility level by the infection control department. C. All health care providers have a responsibility to reinforce education on basic handwashing, including that provided for nursing assistants. D. This requires a higher level of education for client management.

Assessment findings reveal that the client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client? A. Report the need for desensitization therapy. B. Convey the need for pharmacologic therapy to the health care provider. C. Communicate the need for avoidance therapy to the health care team. D. Discuss symptomatic therapy with the health care provider. (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

C. A. Desensitization therapy is administered via allergy shots when allergens have been identified and cannot easily be avoided. B. Medications might be indicated if signs of type I or type IV hypersensitivity exist, but this is not a preventive measure. C. Contact hypersensitivities can occur with latex, pollens, foods, and environmental proteins. Avoidance therapy is the recommended nursing intervention. D. Symptomatic therapy interventions such as epinephrine pen, antihistamines, and corticosteroids are effective only after the hypersensitivity reaction has already occurred.

Which client is at greatest risk for developing an infection? A. 54-year-old man with hypertension B. 17-year-old woman with a fractured tibia in a cast C. 65-year-old woman who had coronary bypass surgery 4 days ago D. 71-year-old man in a nursing home (Chapter 25: Care of Patients with Infection)

C. A. No coexisting conditions are present for this client to be at risk for infection. B. A fractured tibia at 17 years of age does not present risk for developing an infection. C. Older clients with decreased vascularity to the integumentary system are at risk for infection. D. The older client in a nursing home is not at highest risk because no coexisting conditions make this client most vulnerable to infection.

The nurse is conducting a health assessment interview with a client who is HIV positive. Which statement by the client will the nurse immediately address? A. "When I injected heroin, I was exposed to HIV." B. "I don't understand how the antiretroviral drugs work." C. "I remember to take my antiretroviral drugs almost every day." D. "My sex drive is weaker than it used to be since I started taking my antiviral medications." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

C. A. The nurse should assess whether the client is still injecting drugs and should make certain the client understands the risks for infection with another strain of HIV or other bloodborne pathogens and the risk for spreading HIV, but this does not need to be addressed immediately. B. The nurse needs to provide further education about how the medications work, but this does not need to be addressed immediately. C. Because inconsistent use of antiretroviral medications can lead to unsuccessful therapy and the development of drug-resistant HIV strains, it is important that clients take these drugs consistently. The nurse should immediately assess the reasons why the client does not take the medications daily and then should implement a plan to improve adherence. D. The nurse should provide further education about medications to assess how lack of knowledge or decreased libido influences compliance, but this does not need to be addressed immediately.

Which intervention will be most helpful in preventing disseminated intravascular coagulation (DIC)? A. Monitoring platelets B. Administering packed red blood cells C. Using strict aseptic technique to prevent infection D. Administering low-dose heparin therapy for clients on bedrest (Chapter 24: Care of Patients with Cancer)

C. A. This intervention will help detect DIC but will not prevent it. B. Red blood cells are used for anemia, not for bleeding/coagulation disorders. C. Sepsis is a major cause of DIC, especially in the oncology client. D. Heparin may be administered to clients with DIC who have developed clotting, but this has not been proven to prevent the disorder.

A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which of these clients would be most appropriate to assign to the new graduate? A. A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today B. A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours C. A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) D. A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr (Chapter 24: Care of Patients with Cancer)

C. A. This is a complex client requiring a nurse certified in chemotherapy administration. B. This client is developing acute renal failure and requires complex assessment and treatment. C. A new nurse after a 6-week oncology orientation possesses the skills to care for clients with pancytopenia and with administration of medications to stimulate the bone marrow. D. This client has complicated needs for assessment and care and should be cared for by RNs with more oncology experience.

A client who is HIV positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which physician request will the nurse implement first? A. Obtain a 12-lead electrocardiogram (ECG). B. Call for a portable chest x-ray. C. Obtain blood cultures from two sites. D. Give cefazolin (Kefzol) 500 mg IV. (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

C. A. A 12-lead ECG can be obtained after other priority requests have been carried out. B. Calling for a portable chest x-ray can be done after other priority requests are carried out. C. Antibiotics should be given as soon as possible to immune compromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic. D. Antibiotic therapy should be initiated as rapidly as possible in immune compromised clients but should be given after blood cultures are taken so that laboratory results will not be affected by the antibiotic.

A client who is scheduled to undergo radiation for prostate cancer is admitted to the hospital by the registered nurse. Which statement by the client is most important to communicate to the physician? A. "I am allergic to iodine." B. "My urinary stream is very weak." C. "My legs are numb and weak." D. "I am incontinent when I cough." (Chapter 23: Cancer Development)

C. A. Allergy to iodine should be reported when contrast media will be used; dye is not used in radiation therapy. B. A weak urinary stream and incontinence are common clinical manifestations of prostate cancer. C. Numbness and weakness should be reported to the physician because paralysis caused by spinal cord compression can occur. D. Incontinence associated with coughing is typical in stress incontinence and is not a complication of cancer.

The registered nurse would correct the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? A. Student scrubs the hub of IV tubing before administering an antibiotic. B. Nurse overhears the student explaining to the client the importance of handwashing. C. Student teaches the client that symptoms of neutropenia include fatigue and weakness. D. The nurse observes the student providing oral hygiene and perineal care. (Chapter 24: Care of Patients with Cancer)

C. A. Asepsis with IV lines is an appropriate action; the student does not require correction. B. Handwashing is an essential component of client care, especially when the client is at risk for neutropenia; the student does not require correction. C. Symptoms of neutropenia include low neutrophil count, fever, and signs and symptoms of infection; the student should be corrected. D. Hygiene and perineal care help prevent infection and sepsis; the student does not require correction.

Which intervention will be most helpful for the client with mucositis? A. Administering a biological response modifier B. Encouraging oral care with commercial mouthwash C. Providing oral care with a disposable mouth swab D. Maintaining NPO until the lesions have resolved (Chapter 24: Care of Patients with Cancer)

C. A. Biological response modifiers are used to stimulate bone marrow production of immune system cells; mucositis or sores in the mouth will not respond to these medications. B. Commercial mouthwashes should be avoided because they may contain alcohol or other drying agents that may further irritate the mucosa. C. Mouth swabs are soft and disposable and therefore clean. D. Keeping the client NPO is not necessary; nutrition is important during cancer treatment; a local anesthetic may be prescribed for comfort.

Which statement about the transmission of hepatitis C is true? A. Feces are a likely body fluid by which to transmit the disease. B. Airborne Precautions are used for the prevention of hepatitis C. C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. D. No precautions are necessary with the use of nail clippers or scissors. (Chapter 25: Care of Patients with Infection)

C. A. Feces are not a likely source of transmission. B. The hepatitis C virus is not airborne, so Airborne Precautions are not necessary. C. Equipment or linen that is soiled with blood or body fluids can be a likely source of infection. Washing with bleach or a disinfectant will help prevent the spread of infection. D. Hepatitis C can be spread by contact with contaminated items, such as clippers or scissors.

Which of the following findings would alarm the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3? A. Increasing shortness of breath B. Diminished bilateral breath sounds C. Change in mental status D. Weight gain of 4 pounds in 1 day (Chapter 24: Care of Patients with Cancer)

C. A. Increasing shortness of breath is typically related to anemia, not to thrombocytopenia. B. Diminished breath sounds may be related to many factors, including poor respiratory excursion, infection, and atelectasis, which is not related to thrombocytopenia. C. A change in mental status could result from spontaneous bleeding; in this case, a cerebral hemorrhage may have developed. D. A large weight gain in a short period may be related to renal or heart failure; bleeding is the major complication of thrombocytopenia.

The nurse is instructing an unlicensed health care worker on care of the client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? A. "I need to know my HIV status, so I must get tested before caring for any clients." B. "Putting on a gown and gloves will cover up the itchy sores on my elbows." C. "Washing my hands and putting on a gown and gloves is what I must do before starting care." D. "I will wash my hands before going into the room, and then will put on gown and gloves only for direct contact with the client's genitals." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

C. A. Knowing HIV status is important for preventing transmission of HIV but is not a Standard Precaution. B. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of gown and gloves. C. Standard Precautions include whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes. D. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.

Which of these nurses would be assigned to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? A. An experienced LPN/LVN who has worked on the medical unit for 10 years B. An RN with experience in the operating room who transferred a month ago to the medical unit C. A float RN with 7 years of experience on the inpatient oncology unit D. An RN who has worked mostly on the same-day surgery unit since graduating a year ago (Chapter 25: Care of Patients with Infection)

C. A. LVN/LPNs do not have the scope of practice to provide care to this client. B. This RN does not have the experience needed to care for an unstable client on an unfamiliar unit. C. This RN would be familiar with complications and assessment for IV fluids and pneumonia. D. This RN does not have the experience to care for an unstable client on an unfamiliar unit.

In planning care for the client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? A. Loss of social contact related to misunderstanding of acquiring secondary immune deficiency transmission and the social stigma B. Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency C. Potential for infection transmission related to recurring opportunistic infections D. High risk for inadequate nutrition less than body requirements related to acquired secondary immune deficiency and Candida albicans (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

C. A. Loss of social contact is not a priority problem with an opportunistic infection. B. This would be the secondary concern because Candida albicans causes mouth sores. C. Protecting the client from further opportunistic infection such as Candida albicans is a priority. D. Nutrition will be affected because of Candida albicans. However, it is not a priority.

A 52-year-old client relates to the nurse that she has never had a mammogram because she is terrified that she will have cancer. Which response by the nurse is therapeutic? A. "Don't worry, most lumps are discovered by women during breast self-examination." B. "Does anyone in your family have breast cancer?" C. "Finding a cancer in the early stages increases the chance for cure." D. "Have you noticed a lump or thickening in your breast?" (Chapter 23: Cancer Development)

C. A. Mammogram can detect lumps smaller than those discovered by palpation. B. This is not therapeutic because it does not address the client's fear of cancer. C. Providing truthful information addresses the client's concern. D. This is not therapeutic because it does not address the client's fear of cancer.

Which activity is most appropriate for the nurse to eliminate or modify to prevent excessive fatigue in the client with reduced oxygenation as a result of respiratory infections and AIDS? A. Mouth care B. Meal times C. Complete bath D. Dressing changes (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

C. A. Mouth care and meal times are too important to eliminate because the client is at high risk for oral infections and nutritional deficiencies. Reference: p. 375, Safe and Effective Care Environment B. Mouth care and meal times are too important to eliminate because the client is at high risk for oral infections and nutritional deficiencies. Reference: p. 375, Safe and Effective Care Environment C. A complete bath can be very tiring, as well as drying to fragile skin. Keeping skinfold areas clean and dry and keeping the perineal area clean are critical. The rest of the bath can be skipped to prevent excessive fatigue. Reference: p. 375, Safe and Effective Care Environment D. Dressing changes are also needed as scheduled to prevent a superficial infection from becoming deeper or leading to sepsis. Reference: p. 375, Safe and Effective Care Environment

The nurse plans to assess the client with type I hypersensitivity for which clinical manifestation? A. Poison ivy B. Autoimmune hemolytic anemia C. Allergic asthma D. Rheumatoid arthritis (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

C. A. Poison ivy is a type IV delayed mechanism of hypersensitivity. B. Autoimmune hemolytic anemia is a type II cytotoxic mechanism of hypersensitivity. C. Allergic asthma is a manifestation of type I hypersensitivity. D. Rheumatoid arthritis is a type III immune complex-mediated mechanism of hypersensitivity.

Which statement made by the client allows the nurse to recognize whether the client who is receiving brachytherapy for ovarian cancer understands the treatment plan? A. "I may lose my hair during this treatment." B. "I must be positioned in the same way during each treatment." C. "I will have a radioactive device in my body for a short time." D. "I will be placed in a semiprivate room for company." (Chapter 24: Care of Patients with Cancer)

C. A. Side effects of radiation therapy are site specific. B. The client undergoing teletherapy (external beam radiation) must be positioned precisely in the same position each time. C. Brachytherapy refers to short-term insertion of a radiation source. D. The client who is receiving brachytherapy must be in a private room.

Which teaching is most appropriate for a client with chemotherapy-induced neuropathy? A. Bathe in cold water. B. Wear cotton gloves when cooking. C. Consume a diet high in fiber. D. Make sure shoes are snug. (Chapter 24: Care of Patients with Cancer)

C. A. The client should bathe in warm water, not greater than 96° F. B. Cotton gloves may prevent harm from scratching; protective gloves should be worn for washing dishes and gardening. Wearing cotton gloves while cooking can increase the risk for burns. C. A high-fiber diet will assist with constipation due to neuropathy. D. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.

A client who is receiving an intravenous antibiotic begins to cough and states, "My throat feels like it is swelling." Which action will the nurse take next? A. Infuse normal saline at 200 mL/hr. B. Administer epinephrine (Adrenalin) 1:1000, 0.3 mL subcutaneously. C. Discontinue infusing the antibiotic. D. Give diphenhydramine (Benadryl) 100 mg IV. (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

C. A. The nurse must first assess the client, and although infusing normal saline may be indicated, it is not the nurse's first action. B. The nurse must first assess the client, and although administering epinephrine may be indicated, it is not the nurse's first action. C. Because the antibiotic is the most likely cause of the client's anaphylactic reaction, the nurse's first action should be to discontinue the antibiotic. D. The nurse must first assess the client, and although administering diphenhydramine (Benadryl) may be indicated, it is not the nurse's first action.

The client receiving chemotherapy will experience the lowest level of bone marrow activity and neutropenia during which period? A. Peak B. Trough C. Nadir D. Adjuvant (Chapter 24: Care of Patients with Cancer)

C. A. The peak of bone marrow function occurs when the client's blood levels are at their highest. B. Trough, which means low, is typically used in reference to drug levels. C. The lowest point of bone marrow function is referred to as the nadir. D. Adjuvant refers to use of radiation therapy or surgery along with chemotherapy in cancer treatment.

The client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client's discharge teaching plan? A. Wash fruits and vegetables with mild soap and water before eating. B. Intermittent exposure to known allergens will produce immunity. C. Remove cloth drapes, carpeting, and upholstered furniture. D. Be cautious when eating unprocessed honey. (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

C. A. Washing fruits and vegetables pertains to food allergies. B. Clients do not develop immunity to known allergens by direct exposure. Common interventions include avoidance therapy, desensitization therapy, and symptomatic therapy. C. Removing cloth drapes, carpet, and upholstery will reduce airborne pollen, dust mites, and mold. D. Honey is said to help with allergies to pollen only. It does not have an impact on airborne allergens.

The client who is prescribed highly active antiretroviral therapy (HAART) is flying to a wedding and will be gone 1 day. He asks if he can skip his drugs that day so that he doesn't have to show them all at the airport. What is the nurse's best response? A. "Yes, just 1 day off your drugs will not make any difference." B. "Yes, as long as you avoid direct contact with anyone who is ill." C. "No, even 1 day off the drugs can help the virus become drug resistant." D. "No, even 1 day off the drugs increases the chances that you can spread the disease." (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

C. An important issue with HAART is the development of drug-resistant mutations in the HIV organism. When resistance develops, viral replication is no longer suppressed by the drugs. Several factors contribute to the development of drug resistance to HAART, with the most important being missed doses of drugs. When doses are missed, the blood concentrations become lower than what is needed to inhibit viral replication, allowing the virus to replicate and produce new viruses that are resistant to the drugs being used. Reference: p. 375, Health Promotion and Maintenance

A client receiving high-dose chemotherapy who has bone marrow suppression has been receiving daily injections of epoetin alfa (Procrit). Which assessment finding indicates to the nurse that today's dose should be held and the health care provider notified? A. Hematocrit of 28% B. Total white blood cell count of 6200 cells/mm3 C. Blood pressure change from 130/90 mm Hg to 148/98 mm Hg D. Temperature change from 99° F (37.2° C) to 100° F (37.8° C) (Chapter 24: Care of Patients with Cancer)

C. Epoetin alfa and other erythropoiesis-stimulating agents (ESAs) such as darbepoetin alfa (Aranesp) and epoetin alfa (Epogen, Procrit) increase the production of many blood cell types, not just erythrocytes, which increases the client's risk for hypertension, blood clots, strokes, and heart attacks, especially among older adults. Dosing is based on individual client hemoglobin and hematocrit levels to ensure that just enough red blood cells are produced to avoid the need for transfusion but not to bring hemoglobin or hematocrit levels up to normal. The increased blood pressure is an indication to stop this therapy immediately. Reference: p. 421, Physiological Integrity

Which statement by the nursing assistant indicates a need for further teaching by the nurse regarding infection control? A. "I will wash my hands after direct client care." B. "I will wear gloves when emptying the Foley bag." C. "I don't need to wash my hands if I wear gloves." D. "I will use a hand sanitizer when I can't wash my hands." (Chapter 25: Care of Patients with Infection)

C. It is essential to decontaminate hands before donning and after removing gloves, either by handwashing or the use of alcohol-based hand rubs. A combination of hand hygiene and wearing gloves is the most effective strategy for preventing infection transmission. If hands are not visibly soiled or soap and water is not immediately available, using an alcohol-based hand rub for decontaminating hands is acceptable. Reference: p. 440, Safe and Effective Care Environment

Which precaution is most important for the nurse to teach a client receiving radiation therapy for head and neck cancer? A. Avoid eating red meat during treatment. B. Pace your leisure activities to prevent fatigue. C. See your dentist twice yearly for the rest of your life. D. Avoid using headphones or headsets until your hair grows back. (Chapter 24: Care of Patients with Cancer)

C. Radiation therapy that is directed in or around the oral cavity has a variety of actions that increase the risk for dental caries (cavities) and tooth decay. The salivary glands are affected, which changes the composition of the person's saliva and often causes "dry mouth." This result allows rapid bacterial overgrowth, which leads to cavity formation. In addition, the radiation damages the integrity of the enamel and also damages some of the living cells in the tooth. All contribute to an increased risk for dental infections and cavities. Reference: p. 414, Health Promotion and Maintenance

A client being treated for advanced breast cancer with chemotherapy reports that she must be allergic to one of her drugs because her entire face is swollen. What assessment does the nurse perform? A. Asks whether the client has other known allergies B. Checks the capillary refill on fingernails bilaterally C. Examines the client's neck and chest for edema and engorged veins D. Compares blood pressure measured in the right arm with that in the left arm (Chapter 24: Care of Patients with Cancer)

C. The client's swollen face indicates possible superior vena cava syndrome, which is an oncologic emergency. Manifestations result from the blockage of venous return from the head, neck, and upper trunk. Early manifestations occur when the client arises after a night's sleep and include edema of the face, especially around the eyes, and tightness of the shirt or blouse collar. As the compression worsens, the client develops engorged blood vessels and erythema of the upper body, edema in the arms and hands, dyspnea, and epistaxis. Interventions at this stage are more likely to be successful. Late manifestations include hemorrhage, cyanosis, mental status changes, decreased cardiac output, and hypotension. Death results if compression is not relieved. Reference: p. 433, Physiological Integrity

The nurse presents a cancer prevention program to teens. Which of the following will have the greatest impact in cancer prevention? A. Avoid asbestos. B. Wear sunscreen. C. Get the human papilloma virus (HPV) vaccine. D. Do not smoke cigarettes. (Chapter 23: Cancer Development)

D. A. Although asbestos may present a risk for lung cancer, it is not a likely exposure for teens. B. Lifetime exposure to the sun will increase the risk for cancer, but not as much as tobacco use. C. The HPV vaccine will decrease the risk for cervical cancer, but not as much as avoiding tobacco. D. Tobacco is the single most important source of preventable carcinogenesis.

A priority problem of hyperpyrexia is identified by the long-term care RN who is caring for a client with a urinary tract infection. Which of these interventions is most appropriate to delegate to a nursing assistant? A. Monitor for improvement after antibiotic therapy is initiated. B. Teach the client the reason for taking antibiotics as prescribed. C. Administer acetaminophen (Tylenol) 650 mg orally for elevated temperature. D. Increase fluid intake by assisting the client to choose preferred beverages. (Chapter 25: Care of Patients with Infection)

D. A. This requires advanced education and is in the scope of the RN. B. This requires advanced education and is in the scope of the RN. C. This action is in the scope of the licensed nurse. D. Nursing assistants can provide dietary choices to clients, and allowing them to select the beverage of their choice will improve the oral intake. When clients become dehydrated, they can develop a fever (hyperpyrexia) secondary to an infection and dehydration. They also would not want to void due to pain. Offering a choice of beverage may increase oral intake and help prevent/treat hyperpyrexia.

Which statement best exemplifies the client's protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos? A. Cytotoxic and cytolytic T-cells destroy cells that contain the major histocompatibility complex of a processed antigen. B. Helper and inducer T-cells recognize self-cells versus non-self-cells and secrete lymphokines that can enhance the activity of white blood cells. C. Suppressor T-cells prevent hypersensitivity when a client is exposed to non-self-cells or to proteins. D. Balance elicits protection when helper or inducer T-cells outnumber suppressor T-cells by a ratio of 2:1. (Chapter 19: Inflammation and the Immune Response)

D. A. The activity of cytotoxic and cytolytic T-cells is most effective against self-cells infected by parasites. B. Overreactions can cause tissue damage if an imbalance exists between helper and inducer T-cells. C. When suppressor T-cells are increased, immune function is suppressed and the risk for infection increases. D. Optimal function of CMI requires a balance between helper and inducer T-cells and suppressor T-cells. This balance occurs when helper and inducer T-cells outnumber suppressor T-cells by a ratio of 2:1.

The nurse is reviewing discharge teaching with the client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching? A. "I must wear a medical alert bracelet stating that I am allergic to bee stings." B. "I need to carry epinephrine with me." C. "My spouse must learn how to give me an injection." D. "I am immune to bee stings now that I have had a reaction." (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

D. A. The client should wear at all times a medical alert bracelet that states all allergies. B. The client should carry epinephrine (Epi-Pen) at all times. C. Someone (spouse, neighbor, or family member) must learn how to give the client an injection in case the client is unable to do so himself or herself. D. No immunity develops after an anaphylactic reaction. In fact, the next reaction could be more severe. This statement indicates more teaching is needed.

A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which intervention is indicated at this time? A. Explain that this occurs in some clients and is usually permanent. B. Encourage the client that a small glass of wine may help her relax. C. Protect the client from infection. D. Allow the client an opportunity to express her feelings. (Chapter 24: Care of Patients with Cancer)

D. A. Although evidence on this topic is not complete, the current thinking is that this process is usually temporary. B. The client is advised to avoid the use of alcohol and recreational drugs at this time because they also impair memory. C. The pharmacologic agents are implicated in central nervous system (CNS) function, not infection. D. Although no specific intervention for the side effect is known, therapeutic communication and listening may be helpful to the client.

The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. The nurse understands that zafirlukast works by which mechanism? A. Blocking histamine from binding to receptors B. Preventing synthesis of mediators C. Preventing mast cell membranes from opening D. Blocking the leukotriene receptor (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

D. A. Antihistamines such as diphenhydramine (Benadryl) block histamines from binding to receptors. Zafirlukast is not an antihistamine. B. Corticosteroids prevent synthesis of mediators. Zafirlukast is not a corticosteroid. C. Mast cell-stabilizing drugs such as cromolyn sodium (Nasalcrom) prevent mast cell membranes from opening when an allergen binds to IgE. Zafirlukast is not a mast cell-stabilizing drug. D. Zafirlukast is a leukotriene antagonist that prevents the occurrence of allergic rhinitis by blocking the leukotriene receptor.

A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? A. Anxiousness B. Urticaria C. Pruritus D. Stridor (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

D. A. Anxiousness may be a symptom of a reaction but is not the nurses's highest priority. B. Urticaria is a symptom of a reaction but is not the nurse's highest priority. C. Pruritus is a symptom of a reaction but is not the nurse's highest priority. D. Stridor indicates airway involvement and warrants immediate intervention such as use of oxygen and administration of epinephrine. Maintaining the client's airway is the high-test priority.

The outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? A. Storing drugs in dark locations at room temperature B. Wearing soft clothing C. Wearing a hat and sunglasses when going outside D. Reducing all direct and indirect sources of light (Chapter 24: Care of Patients with Cancer)

D. A. Any drug that the client is prescribed should be considered for its photosensitivity properties. Drugs should be stored according to the recommendations, but this is not the primary concern for this client. B. Clothing must cover the skin to prevent burns from direct or indirect light. Texture is not a concern for the client receiving this treatment. C. The client will be homebound for 1 to 3 months after the treatment and should not go outside. D. Lighting of all types must be kept to a minimum. It can lead to burns of the skin and damage to the eyes because they are sensitive to light.

The middle-aged client, who is alert, is admitted to the emergency department (ED) with wheezing, difficulty breathing, angioedema, blood pressure (BP) of 70/52, and apical pulse of 122 and irregular. The nurse makes an immediate assessment using the ABCs for any client experiencing anaphylaxis. What nursing intervention is the immediate priority? A. Raise the lower extremities. B. Start intravenous (IV) administration of normal saline. C. Reassure the client that appropriate interventions are being instituted. D. Apply oxygen using a high-flow non-rebreather mask at 40% to 60%. (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

D. A. Assessing respiratory status is an immediate priority. Raising the lower extremities is not the first priority. B. Starting an intravenous (IV) infusion is not the first priority because the client is in respiratory distress. C. Reassuring the client is important, but it is not the priority action by the nurse. D. Oxygen application helps to provide adequate oxygenation for the client who is in respiratory distress.

The nurse is caring for an adult client with Down syndrome who reports fatigue and shortness of breath. Which type of cancer has been identified in clients with Down syndrome? A. Breast cancer B. Colorectal cancer C. Malignant melanoma D. Leukemia (Chapter 23: Cancer Development)

D. A. Breast cancer is often found clustered in families, not in association with Down syndrome. B. Colorectal cancer is associated with familial polyposis, not with Down syndrome. C. Malignant melanoma is associated with familial clustering and sun exposure. D. Leukemia is associated with Down syndrome and Turner syndrome.

The nurse is giving a group presentation on cancer prevention and recognition. Which statement by an older adult client indicates understanding of the nurse's instructions? A. "Cigarette smoking always causes lung cancer." B. "Taking multivitamins will prevent me from developing cancer." C. "If I have only one shot of whiskey a day, I probably will not develop cancer." D. "I need to report the pain going down my legs to my health care provider." (Chapter 23: Cancer Development)

D. A. Cigarette smoking is implicated in causing lung cancer and other types of cancer, but it does not always cause cancer. B. Investigation is ongoing about the efficacy of vitamins A and C in cancer prevention. C. Limiting alcohol to one drink per day is only one preventive measure. D. Pain in the back of the legs could indicate prostate cancer in an older man.

Situation: The client with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed? A. Cromolyn sodium (Nasalcrom) B. Desloratadine (Clarinex) C. Fexofenadine (Allegra) D. Zafirlukast (Accolate) (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

D. A. Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug. B. Desloratadine (Clarinex) is a non-sedating antihistamine. C. Fexofenadine (Allegra) is a non-sedating antihistamine. D. Zafirlukast (Accolate) is a leukotriene receptor antagonist; it works by blocking the leukotriene receptor and is used to prevent allergic rhinitis.

The nurse is reviewing the medical record of a client who is prescribed a decongestant. The nurse plans to contact the client's health care provider if the client has which condition? A. Cataracts B. Crohn's disease C. Diabetes mellitus D. Hypertension (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

D. A. Decongestants are not contraindicated in clients with cataracts. B. Decongestants are not contraindicated in clients with Crohn's disease. C. Decongestants are not contraindicated in clients with diabetes mellitus. D. Decongestants have actions similar to adrenergic drugs, causing vasoconstriction, which can increase blood pressure.

A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause? A. A diagnosis of diabetes treated with insulin and diet B. An exercise regimen of jogging 3 miles four times a week C. A history of cardiac disease D. Advancing age (Chapter 23: Cancer Development)

D. A. Diabetes is not known to cause lung cancer. B. Regular exercise is not a risk factor for lung cancer. C. Having cardiac disease does not predispose a client to lung cancer. D. Advancing age is the single most important risk factor for cancer. As a person ages, immune protection decreases.

The home health RN is caring for a client who has a history of a kidney transplant and takes cyclosporine (Sandimmune) and prednisone (Deltasone) to prevent rejection. Which assessment data would be most important to communicate to the transplant team? A. The temperature is 96.6° F. B. The client reports joint pain. C. The oral mucosa appears pink and dry. D. A lump is palpable in the client's axilla. (Chapter 23: Cancer Development)

D. A. Fever should be reported to the physician; this is a normal temperature. B. It is not necessary to report joint pain to the transplant team; it is not a sign of rejection and is not a complication of transplant. C. This may be a sign of dehydration, but it is not necessary to report it to the transplant team. D. Clients taking immune suppressive drugs to prevent rejection are at increased risk for development of cancer; any lump should be reported to the physician.

Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? A. Carefully washes hands that are visibly soiled B. Wears a mask and gloves when the client's body secretions or body fluids are likely to be handled C. Wears a mask with eye protection and performs proper handwashing D. Wears gloves when contact with body secretions or body fluids is expected (Chapter 25: Care of Patients with Infection)

D. A. Hands must be properly washed before and after any contact with the client with C. difficile infection. B. It is not necessary to wear a mask when caring for clients with C. difficile infection. C. A mask and eye protection are not necessary to prevent transmission of the infection. Handwashing is a Standard Precaution when caring for all clients. D. The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids.

The nurse teaches the client that intraperitoneal chemotherapy will be delivered where? A. Into the veins of the legs B. Into the lung C. Into the heart D. Into the abdominal cavity (Chapter 24: Care of Patients with Cancer)

D. A. Intravenous drugs are delivered through veins. B. Chemotherapy delivered into the lungs is typically placed in the pleural space or is intrapleural. C. Chemotherapy is not typically delivered into the heart. D. Intraperitoneal chemotherapy is placed in the peritoneal cavity or the abdominal cavity.

A client diagnosed with widespread lung cancer asks the nurse why he must be careful to avoid crowds and people who are ill. What is the nurse's best response? A. "With lung cancer, you are more likely to develop pneumonia and could pass this on to other people who are already ill." B. "When lung cancer is in the bones, it becomes a bone marrow malignancy, which stops producing immune system cells." C. "The large amount of mucus produced by the cancer cells is a good breeding ground for bacteria and other microorganisms." D. "When lung cancer is in the bones, it can prevent production of immune system cells, making you less resistant to infection." (Chapter 24: Care of Patients with Cancer)

D. A. Other people are not at risk for becoming infected as a result of contact with a person who has lung cancer. Reference: p. 410, Health Promotion and Maintenance B. Lung cancer that has spread to the bone is still lung cancer; it is not a bone marrow malignancy. Reference: p. 410, Health Promotion and Maintenance C. It is true that the person with lung cancer may produce more mucus, which can harbor microorganisms, but this is not the main reason why the client should avoid crowds and people who are ill. Reference: p. 410, Health Promotion and Maintenance D. Tumor cells that enter the bone marrow reduce the production of healthy white blood cells (WBCs), which are needed for normal immune function. Therefore clients who have cancer, especially leukemia, are at an increased risk for infection. Reference: p. 410, Health Promotion and Maintenance

Which of these nursing actions is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? A. Plan the schedule for desensitization therapy for a client with allergies. B. Monitor the client who has just received skin testing for signs of anaphylaxis. C. Educate a client with a latex allergy about other substances with cross-sensitivity to latex. D. Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing. (Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity)

D. A. Planning of care requires broader education and scope of practice and should be done by the registered nurse. B. Assessing for complications requires broader education and scope of treatment and should be done by the registered nurse. C. Client education is a registered nursing responsibility, which requires broader education and scope of practice. D. Reminding a client about safety policies is within the scope of practice of a nursing assistant.

Which is a common clinical manifestation of infectious disease? A. Dry and pink skin B. Hypothermia C. Decreased respiratory rate D. Decreased level of consciousness (Chapter 25: Care of Patients with Infection)

D. A. Skin tends to be warm and moist when an infectious disease is present. B. Clients typically have hyperpyrexia when an infectious disease is present. C. Respiratory rate typically increases, as does the heart rate, when an infectious disease is present. D. Hyperpyrexia, which usually accompanies infection, is a cause of a decreased level of consciousness.

The nurse receives report on a client with a glioblastoma. Recognizing that cancers are classified by their tissue of origin, the nurse begins to plan care for a client with which type of cancer? A. Liver B. Smooth muscle C. Fatty tissue D. Brain (Chapter 23: Cancer Development)

D. A. The prefix "hepato-" is included when cancers of the liver are named. B. The prefix "leiomyo-" is included when cancers of smooth muscle are named. C. The prefix "lipo-" is included when cancers of fat or adipose tissue are named. D. The prefix "glio-" is used when cancers of the brain are named.

The client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? A. Therapeutic highly active antiretroviral therapy (HAART) level B. Positive HIV, enzyme-linked immunosorbent assay (ELISA), Western blot C. Positive Papanicolaou (Pap) test D. Improved CD4+ T-cell count and reduced viral load (Chapter 21: Care of Patients with HIV Disease and Other Immune Deficiencies)

D. A. This is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. B. This test, if positive, indicates that the client is HIV positive (a fact already known for this client) and does not indicate response to prescribed medication. C. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication. D. Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication.

A complete blood count with differential is performed in the client with chronic sinusitis. Which finding does the nurse expect? A. Segmented neutrophils, 62% B. Lymphocytes, 28% C. Bands, 5% D. Basophils, 4% (Chapter 19: Inflammation and the Immune Response)

D. A. Segmented neutrophils (segs) are mature neutrophils, which, along with macrophages, eliminate invaders (infection) by phagocytosis. This is a normal neutrophil count. B. This is a normal count for lymphocytes (lymphs) in the differential. Lymphocytes are involved in immunity. C. This is a normal count for bands. Bands are elevated only when an infection is present and the bone marrow cannot keep up with mature segmented neutrophils. D. The normal count for basophils (baso) is 0.5%. An elevated count indicates inflammation, which is common with chronic sinusitis.

Which of these home health nurses should the nurse manager assign to care for an 18-year-old client with a kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)? A. An RN who has worked for the home health agency for 5 years in maternal-child health B. An RN who has extensive critical care nursing experience and has worked in home health for a year C. An RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit D. An RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency (Chapter 19: Inflammation and the Immune Response)

D. A. This nurse would not have knowledge and information on the care provided and medications used in post-transplantation clients. B. This nurse would not have knowledge and information on the care provided and medications used in post-transplantation clients. C. This nurse would not have knowledge and information on the care provided and medications used in post-transplantation clients. D. This nurse has experience and understanding of the needs of a post-transplantation client and knowledge of the drug.

The nurse is teaching a client who is receiving an anti-estrogen drug about the side effects she may encounter. Which of these should the nurse include in the discussion? Select all that apply. A. Heavy menses B. Smooth facial skin C. Hyperkalemia D. Breast tenderness E. Weight loss F. Deep vein thrombosis (DVT) (Chapter 24: Care of Patients with Cancer)

D. F. Irregular menses or no menstrual period is the typical side effect.