EAQ-Immunology and Infectious Diseases

What is an example of a type I hypersensitivity reaction? 1 Anaphylaxis 2 Serum sickness 3 Contact dermatitis 4 Blood transfusion reaction

1 An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A blood transfusion reaction is a type II cytotoxic reaction.

The nurse is reviewing the laboratory report of four clients. Which does the nurse suspect to have acquired immunodeficiency syndrome (AIDS)? Client A Lymphocyte count of 3,000 Client B lymphocyte count of 5,000 Client C lymphocyte count of 7,000 Client D lymphocyte count of 9,000

Client A The normal lymphocyte count is between 5000 and 10,000 cells/mm3. A client with AIDS is leukopenic and has a lymphocyte count less than 3500 cells/mm3. Therefore, client A has AIDS. Clients B, C, and D have normal lymphocyte counts.

A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the most appropriate nursing action? 1 Applying cold compresses to the affected area 2 Ensuring the client keeps the skin clean and dry 3 Monitoring for neurological and cardiac symptoms 4 Advising the client to launder all clothes with bleach

1 A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse should apply cold compresses to the affected area to reduce the pain in the client. A client with Candida albicans infection should keep his or her skin clean and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may suffer from cardiac, arthritic, and neurologic manifestations. Therefore the nurse has to monitor for these symptoms. Direct contact may transmit a Sarcoptes scabiei infection; the nurse should make sure that the client's clothes are bleached to prevent the transmission of the infection.

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change? 1 The client may have a dysrhythmia 2 The client may have physiologic shock 3 The client underwent surgery earlier in the day 4 The client may have peripheral artery disease

1 A client with dysrhythmia may have an intermittent or abnormal radial pulse. For this condition, the registered nurse should advise the nursing student to assess the apical pulse because it will be more accurate. If the client is in shock, then assessing the carotid or femoral pulse would be appropriate. The femoral pulse is preferred to assess a client with peripheral artery disease.

A client develops a fever after surgery. Ceftriaxone is prescribed. For which potential adverse effect should the nurse monitor the client? 1 Dehydration 2 Heart failure 3 Constipation 4 Allergic response

4 Rash, urticaria, pruritus, angioedema, and other signs and symptoms of an allergic response may occur a few days after therapy is instituted. Ceftriaxone does not cause dehydration, does not affect the heart, and may cause diarrhea, not constipation.

While performing patterned, paced breathing during the transition phase of labor, a client experiences tingling and numbness of the fingertips. What should the nurse do? 1 Tell the client to breathe into a paper bag. 2 Place an oxygen mask over the client's face. 3 Call the primary healthcare provider to report the client's response. 4 Instruct the client to begin taking slow deep breaths.

1 A paper bag enables the client to rebreathe carbon dioxide, which helps correct the respiratory alkalosis resulting from hyperventilation. The client's oxygen level is increased; the client needs to increase the carbon dioxide level and decrease the oxygen level. The client should rebreathe her own exhalations first; if alkalosis persists, more intensive treatment may be needed. Carbon dioxide is too dilute in room atmosphere; deep breaths will not resolve the alkalosis.

Which cytokine medication is administered to treat chemotherapy-induced neutropenia? 1 Filgrastim 2 Oprelvekin 3 Aldesleukin 4 Darbepoetin alfa

1 Colony-stimulating factors such as filgrastim are administered to treat chemotherapy-induced neutropenia. Oprelvekin is used to prevent thrombocytopenia. Aldesleukin is used to treat metastatic renal cell carcinoma. Darbepoetin alfa is administered to treat anemia related to chronic cancer and anemia related to chronic kidney disease.

A male client with the dual diagnosis of major depression and polysubstance abuse has been attending group therapy. One day the client tells the nurse, "The things they talk about in group don't really pertain to me." What is the most therapeutic response by the nurse? 1 Confronting the client with realistic feedback 2 Identifying the client's stress-coping tolerance 3 Informing the client that he needs to get more involved 4 Asking the client what therapy he thinks would be more helpful

1 The client is using denial to separate from group members and needs realistic feedback to prevent withdrawal. Identifying the client's stress-coping tolerance will not help the client become involved with the group. Informing the client that he needs to get more involved is inadequate; the client first needs to recognize that the problems being discussed are applicable. The client is avoiding treatment. Asking about therapy preferences is not helpful.

Which dietary instruction would be most beneficial to a client who has undergone a hypophysectomy and has difficulty passing stools? 1 "Drink plenty of water." 2 "Eat foods rich in protein." 3 "Drink a glass of milk daily." 4 "Eat foods rich in carbohydrates."

1 The client should be instructed to drink plenty of water (roughly 8 to 10 glasses a day) to relieve constipation. Although proteins are required for overall health, proteins will not relieve constipation. Milk may cause constipation in certain individuals. Carbohydrates act as power sources; they do not relieve constipation.

A client with a sexually transmitted disease has developed a condition illustrated in the image. (sore/blister/lesion on lip). Which organism is responsible for this condition in the client? 1 Herpes simplex virus 2 Treponema pallidum 3 Chlamydia trachomatis 4 Condylomata acuminata

1 The image illustrates cold sores on the lips. This is a complication of genital herpes disease, which is caused by the Herpes simplex virus. Treponema pallidum causes syphilis. Chlamydia trachomatis causes chlamydial infections. Condylomata acuminata causes genital warts.

A nurse is preparing a teaching plan for a client with syphilis. In which stage is syphilis not considered contagious? 1 Tertiary stage 2 Primary stage 3 Secondary stage 4 Incubation stage

1 The tertiary stage is noncontagious; tertiary lesions contain only small numbers of treponemes. The primary stage lasts 8 to 12 weeks; the chancre is teeming with spirochetes, and the individual is contagious. The duration of the secondary stage is variable (about 5 years); skin and mucosal lesions contain spirochetes, and the individual is highly contagious. The incubation stage lasts 2 to 6 weeks; spirochetes proliferate at the entry site, and the individual is contagious.

The nursing instructor determines that the student nurse understands the type(s) of hepatitis that most commonly are spread by consuming contaminated food and water or by fecal contamination if the student identifies which of these diseases? Select all that apply. 1 Hepatitis A 2 Hepatitis B 3 Hepatitis C 4 Hepatitis D 5 Hepatitis E

1, 5 Hepatitis A and E most commonly are spread through the fecal-oral route. Hepatitis B most commonly is spread through the sharing of needles and through unprotected sex. Hepatitis C and D most commonly are spread through intravenous (IV) drug needle sharing.

Which cytokine is used to treat multiple sclerosis? 1 β-Interferon 2 Interleukin-2 3 Erythropoietin 4 Colony-stimulating factor

1 β-Interferon is a cytokine used to treat multiple sclerosis. Interleukin-2 is used to treat metastatic melanoma. Erythropoietin is a cytokine used to treat anemia related to chemotherapy. Colony-stimulating factor is a cytokine used to treat chemotherapy-induced neutropenia.

Which parental statements indicate correct understanding related to dental health for the preschool-age client? Select all that apply. 1 "I will need to floss my child's teeth." 2 "My child no longer requires fluoride treatments." 3 "My child only needs to brush the teeth prior to bedtime." 4 "My child does not need to begin flossing until school-age." 5 "I should provide supervision when my child brushes the teeth."

1, 5 The preschool-age client will require his or her parent to floss the teeth and provide parental supervision during brushing; therefore, these parental statements indicate correct understanding of information related to dental health. Fluoride treatments should continue throughout the preschool years. The preschool-age client should brush teeth at least twice per day. The preschool-age client should floss; however, the parent will be responsible for completing this task.

What is the priority nursing intervention for an infant with a myelomeningocele before surgical correction? 1 Minimizing infection 2 Preventing trauma to the sac 3 Monitoring for increasing paralysis 4 Assessing the degree of bowel and bladder control

2 A meningomyelocele is thinly covered and fragile. Trauma to the sac can damage functioning neural tissue; an intact sac eliminates a potential portal of entry for microorganisms. Although minimizing infection is extremely important, it is not the priority; care of the sac is even more important, because an intact sac bars entry by microorganisms. Although observation for paralysis is an important nursing measure, it is not the priority. The extent of a meningomyelocele will influence the child's ability to control bowel and bladder function, but control is not developed until the toddler and preschool years.

The nurse notes that a client is not adhering to prescribed antibiotic therapy. Which reason should the nurse document? 1 "I skipped some doses because I don't like to take pills." 2 "I left my pills in the bedroom and I forgot to take them with breakfast." 3 "I saw on television what the side effects are and decided to not take the pills." 4 "I had to choose between getting my prescription filled and paying the heating bill."

2 Nonadherence is accidental failure to take a medication. Noncompliance is deliberately failing to take a medication as might be done when skipping doses because of not liking to take pills, choosing to not take a medication because of information seen on television, and not being able to afford medication.

Which intervention is most likely to decrease mortality in the septic client? 1 Oxygen 2 Antibiotics 3 Vasopressors 4 Intravenous fluids

2 Of the interventions listed, administering antibiotics is the only intervention that fights the source of the problem. Intravenous fluids, oxygen, and vasopressors are necessary, but are designed to sustain the body until the antibiotic can kill the pathogen.

A registered nurse assesses clients with dark skin. Which statement made by the registered nurse indicates the need for further teaching? 1 "I should touch the skin to feel its consistency." 2 "I should use a fluorescent light source to assess the skin color." 3 "I should place my hand on the skin to assess the temperature." 4 "I should look for any changes in skin color darker than surrounding skin."

2 The nurse should use natural light or a halogen light source to assess accurately the skin color. Fluorescent light casts a blue color, which can make skin assessment difficult. The nurse should touch the client's skin to feel its consistency. The nurse should assess the area for the skin temperature using his or her hand. The nurse should look for any changes in skin color that are darker than surrounding skin.

Which type of immunity is acquired through the transfer of colostrum from the mother to the child? 1 Natural active immunity 2 Artificial active immunity 3 Natural passive immunity 4 Artificial passive immunity

3 Natural passive immunity is acquired through the transfer of colostrum from the mother to the child. Natural active immunity is acquired when there is a natural contact with an antigen through a clinical infection. Artificial active immunity is acquired through immunization with an antigen. Artificial passive immunity is acquired by injecting serum from an immune human.

A registered nurse is explaining the importance of capitation to a nursing student. What information should the nurse provide? Select all that apply. 1 Capitation is used to review the quality, quantity, and cost of hospital care. 2 Capitation influences the way healthcare providers deliver care in all types of settings. 3 Capitation means that primary healthcare providers are paid a fixed amount per client of a health care plan. 4 Capitation identifies and eliminates the overuse of diagnostic and treatment services ordered by primary healthcare providers for Medicare. 5 Capitation aims to build a payment plan for select diagnoses or surgical procedures that consists of the best standards of care at the lowest cost.

2, 3, 5 Capitation influences the way healthcare providers deliver care in all types of settings. Capitation means that health care providers are paid fixed amount per client enrolled in a health care plan. Capitation aims to build a payment plan for select diagnoses or surgical procedures that consists of the best standards of care at the lowest cost. The professional standards review organizations (PSROs) are responsible for reviewing the quality, quantity, and cost of hospital care. The utilization review (UR) committee identifies and eliminates overuse of diagnostic and treatment services ordered by primary health care providers caring for clients on Medicare.

A client is admitted with a diagnosis of acute pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolytes, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply. 1 Provide a low-fat diet 2 Administer analgesics 3 Teach relaxation exercises 4 Encourage walking in the hall 5 Monitor cardiac rate and rhythm 6 Observe for signs of hypercalcemia

2, 3, 5 Analgesics, histamine-receptor antagonists, and proton pump inhibitors may be administered to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Relaxation will decrease the metabolic rate, which will decrease gastrointestinal activity, including the secretion of pancreatic enzymes. Monitoring cardiac rate and rhythm is necessary to assess for hypokalemia and fluid volume changes. The client would be kept nothing by mouth to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Walking increases the metabolic rate, which will increase gastrointestinal activity, including the secretion of pancreatic enzymes. Hypocalcemia, not hypercalcemia, occurs because of calcium and fatty acids combining during fat necrosis.

Which diseases can be transmitted by air? Select all that apply. 1 Scabies 2 Measles 3 Pediculosis 4 Chicken pox 5 Tuberculosis

2, 4, 5 Measles, chicken pox, and tuberculosis are infectious diseases that are transmitted by air. Scabies and pediculosis are transmitted by direct contact.

Indicate the first step involved in the disposal of sharp wastes of a client with acquired immunodeficiency syndrome (AIDS). 1 Place tape over the container 2 Place the container in a paper bag 3 Place the waste in a puncture-resistant container 4 Pour a 1:10 bleach solution in the container

3 The sharp wastes of a client with AIDS should first be placed in a puncture-resistant container and labelled. Then a 1:10 bleach solution should be poured into the container for disinfection. Next the container should be taped to prevent leakage. The container should be then placed into a paper bag and subsequently disposed of in the regular trash.

Which leukocyte releases vasoactive amines during a client's allergic reactions? 1 Neutrophil 2 Monocyte 3 Eosinophil 4 Macrophage

3 Eosinophils release vasoactive amines during allergic reactions to limit the extent of the allergic reactions. Neutrophils are phagocytes and increase in inflammation and infection. Monocytes are involved in the destruction of bacteria and cellular debris. Macrophages are involved in nonspecific recognition of foreign protein and microorganisms.

What does the nurse infer from this image? (Wart lesion on either palm or sole of foot) 1 Candidiasis 2 Tinea pedis 3 Plantar wart 4 Onychomycosis

3 Plantar warts appear on the bottom surface of the foot, growing inward due to the pressure of walking or standing, with interrupted skin markings. Candidiasis appears as a diffuse papular erythematous rash with pinpoint satellite lesions around the edges of the affected area. Tinea pedis appears as interdigital scaling and maceration with scaly plantar surfaces, sometimes with erythema and blistering. Onychomycosis presents as scaliness under the distal nail plate. Nails appear brittle, thickened, broken, or crumbling with yellowish discoloration.

A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching? 1 Placing the old dressing in a plastic bag 2 Changing the dressing without wearing a mask 3 Donning nonsterile gloves for removing the old dressing 4 Using a back-and-forth motion while cleaning the wound

4 After each swipe, sterile gauze should be discarded, and another sterile gauze should be used for the next swipe. Placing the old dressing in a plastic bag confines the soiled dressing to a leakproof bag, which prevents contamination of the environment or others. A mask is not necessary. Nonsterile gloves are acceptable for dressing removal because the dressing is contaminated; sterile gloves may be required for dressing application.

Which sexually transmitted disease is caused by the human papilloma virus? 1 Gonorrhea 2 Genital herpes 3 Chlamydia infection 4 Condylomata acuminata

4 Condylomata acuminata is a sexually transmitted disease caused by the human papilloma virus. Gonorrhea is caused by Neisseria gonorrhoeae. Genital herpes is causes by the herpes simplex virus. Chlamydia infection is caused by Chlamydia trachomatis.

Which is an example of a nurse-initiated intervention? 1 Preparing a client for endoscopy 2 Coordinating with an x-ray technician for imaging 3 Starting an intravenous line for a blood transfusion 4 Keeping edematous lower extremities elevated on pillows

4 Nurse-initiated interventions do not require an order from another healthcare professional. Keeping edematous lower extremities elevated on pillows can be initiated by the nurse and does not need an order. Preparing a client for endoscopy, coordinating with an x-ray technician for imaging, and starting an intravenous line for a blood transfusion are physician-initiated interventions.

A client with human immunodeficiency virus reports dyspnea on exertion, increased heart rate, a persistent dry cough, and a persistent low-grade fever. The nurse observes crackles during an auscultation of the breath sounds. Which organism is responsible for this condition in the client? 1 Cryptosporidium 2 Candida albicans 3 Toxoplasma gondii 4 Pneumocystis jiroveci

4 Pneumocystis jiroveci causes pneumonia, which is the most common opportunistic infection in clients infected with the human immunodeficiency virus. Symptoms of Pneumocystis jiroveci pneumonia include dyspnea on exertion, tachypnea, a persistent dry cough, and a persistent low-grade fever. An auscultation of the breath sounds indicates crackles. Cryptosporidium causes diarrhea and weight loss. Candida albicans causes mouth pain and difficulty swallowing. Toxoplasma gondii causes speech and vision difficulty.

Which type of hypersensitivity reaction is associated with rheumatoid arthritis? 1 Delayed 2 Cytotoxic 3 IgE-mediated 4 Immune-complex

4 Rheumatoid arthritis is an autoimmune disorder associated with an immune-complex type of hypersensitivity reaction. Contact dermatitis caused by poison ivy is associated with a delayed type of hypersensitivity reaction. Goodpasture's syndrome is associated with a cytotoxic type of hypersensitivity reaction. Asthma is associated with an IgE-mediated type of hypersensitivity reaction.

Which disease is caused by Coronaviruses? 1 Pertussis 2 Inhalation anthrax 3 Coccidioidomycosis 4 Severe acute respiratory syndrome

4 Severe acute respiratory syndrome is a respiratory infection caused by Coronaviruses. Pertussis is caused by the bacterium Bordetella pertussis. Inhalation anthrax is caused by Bacillus anthracis. Coccidioidomycosis is caused by Coccidioides.

A nurse is teaching a client with pruritus about personal care interventions. Which statement made by the client indicates the nurse needs to intervene? 1 "I will trim my fingernails regularly." 2 "I will wear mittens or splints at night." 3 "I will apply moisturizing lotion after bath." 4 "I will not file the edges of fingernails."

4 The nurse should intervene if the client states that fingernail edges will not be filed to correct this misconception. Rough edges of fingernails should regularly be filed to prevent skin damage and secondary infection. All the other statements are correct and require no follow up. Regular trimming of the nails, wearing of splints at night, and application of moisturizing lotion after bath are some interventions to be taken by the client to protect skin in pruritus.

A client has 4 ounces (120 mL) of apple juice, 6 ounces (180 mL) of tea, and 8 ounces (240 mL) of chicken broth. How many mL of fluid will the nurse document the client ingested? Record your answer using a whole number. _____ mL

540 mL

Four clients are admitted to a hospital with different symptoms associated with depression. Which client would benefit from mirtazapine? Client 1 with fatigue Client 2 with insomnia Client 3 with chronic pain Client 4 with sexual dysfunction

Client 2 Mirtazapine causes substantial sedation. Therefore, client 2 would benefit from mirtazapine. Client 1 requires a central nervous system stimulant such as fluoxetine. Client 3 will benefit from duloxetine, which is a drug relieves chronic pain. Client 4 would benefit from bupropion, which enhances a person's libido.

Four clients with tuberculosis are prescribed medications. Which client is at risk for optic neuritis? Client A: Isoniazid Client B: Rifampin Client C: Pyrazinamide Client D: Ethambutol

Client D Ethambutol is an antitubercular medication that causes optic neuritis. Therefore client D is at risk for optic neuritis. Client A is at risk for vitamin B deficiency. Client B is at risk for liver toxicity. Client C is at risk for sunburn.

The primary healthcare provider has prescribed different drugs for four clients with tuberculosis. Which client is at a risk of sunburn? Client 1 prescribed Rifampin Client 2 prescribed isoniazid Client 3 prescribed ethambutol Client 4 prescribed pyrazinamide

Client 4 Client 4, who has been prescribed pyrazinamide, is at increased risk of sunburn. Pyrazinamide is a first-line anti-tubercular drug; it can cause photosensitivity and greatly increases the risk of sunburn. Client 1, prescribed rifampin, is at risk for unplanned pregnancy if also using an oral contraceptive. Client 2, prescribed isoniazid, is at risk for vitamin B-complex deficiency. Client 3, prescribed ethambutol, is at risk for optic neuritis.

The nurse is caring for four clients with hypersensitivity reactions. Which client should the nurse suspect to have a type IV hypersensitive reaction? Client A IgE, wheal and flare skin reaction Client B IgM, no skin reaction Client C IgG, erythema and edema skin reaction after 4 hours Client D No Ig, erythema and edema skin reaction after 24 hrs

Client D Type IV or delayed hypersensitive reactions are cell-mediated immune responses that involve T lymphocytes, not antibodies. These cause erythema and edema in client D within 24 to 48 hours after a skin test. Type I hypersensitivity reaction is known as an anaphylactic reaction mediated by IgE antibodies; it shows wheal and flare around the site of injection in client A. Type II hypersensitivity reactions are known as cytotoxic reactions that involve IgM and IgG antibodies and show no response to the skin test in client B. Type III hypersensitivity reactions are known as immune-complex reactions that involve IgG and IgM antibodies. These show erythema and edema after 3 to 8 hours of a skin test in client C.

A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan? 1 "Wash used dishes in hot, soapy water." 2 "Let dishes soak in hot water for 24 hours before washing." 3 "You should boil the client's dishes for 30 minutes after use." 4 "Have the client eat from paper plates so they can be discarded."

1 A person cannot contract human immunodeficiency virus (HIV) by eating from dishes previously used by an individual with AIDS; routine care is adequate. Washing used dishes in hot, soapy water is sufficient care for dishes used by the AIDS client. Dishes do not need to soak for 24 hours before being washed. The client's dishes do not need to be boiled for 30 minutes after use. Paper plates are fine to use but are not indicated to prevent the spread of AIDS.

A nurse administers the first series of immunizations to a 2-month-old infant. The nurse tells the mother that if the site becomes inflamed, she should give the prescribed acetaminophen (Tylenol). What else should the nurse instruct the mother to do? 1 Place a warm compress on the area. 2 Put a witch hazel compress on the site. 3 Give a cool sponge bath for 15 minutes. 4 Apply an ice pack to the area for 2 minutes.

1 A warm compress will promote circulation, reduce swelling, and relax muscles, thereby easing the inflammation. Witch hazel will not ease inflammation or promote muscle relaxation. Fever is not an expected response; therefore the cooling effect of a sponge bath is not necessary. The application of cold will not provide relief because it reduces circulation to the area.

A client reports sustaining an insect bite. The initial symptoms were edema and itching at the site of the bite. Which immunological reaction may have occurred? 1 Anaphylaxis 2 Atopic reaction 3 Goodpasture syndrome 4 Systemic lupus erythematosus

1 Anaphylaxis occurs when the mediators of injury are released systemically after an insect bite or when a drug is injected. The initial symptoms (in this case, edema and itching) may occur at the site of exposure to the allergen. Atopic reactions such as allergic rhinitis or hay fever are the most common type I hypersensitivity reactions. Goodpasture's syndrome is an antibody-mediated autoimmune reaction that involves the glomerular and alveolar basement membranes. Systemic lupus erythematosus is an autoimmune disorder that results from an immune complex reaction.

A client newly diagnosed with rheumatoid arthritis is admitted to the hospital with bilateral painful knee and wrist joints. The nurse identifies impaired physical mobility related to painful, swollen joints. What should the nurse teach the client to do during the acute phase of the disease? 1 Avoid exercises to the involved joints. 2 Engage in passive exercises to the involved joints. 3 Increase isometric exercises to the involved joints slowly. 4 Participate in progressive, resistive exercises to the involved joints.

1 During the acute phase, immobilization of the joints reduces pain and inflammation. Active exercises are contraindicated during the acute inflammatory phase; joints need to be immobilized. Isometric exercises involve muscles, not joints. Progressive, resistive exercises are contraindicated during the acute inflammatory phase because joints need to be immobilized to reduce pain and inflammation.

While conducting a health interview with a client who has human immunodeficiency virus, the nurse inquires about papilledema and the presence of exudates. Which body system may the nurse be assessing? 1 Ocular 2 Respiratory 3 Neurological 4 Cardiovascular

1 Exudates and papilledema are conditions that involve the eyes (ocular system). A respiratory system assessment might reveal crackles, wheezing, or a productive or nonproductive cough. The neurological system is assessed for the presence of sensory loss, slurred speech, and aphasia. The cardiovascular system is assessed to identify murmurs, pericardial friction rub, bradycardia, or tachycardia.

A client at 16-weeks' gestation calls the nurse at the prenatal clinic and states that her partner just told her that he has genital herpes. What should the nurse include when teaching the client regarding sexual activity? 1 Latex or polyurethane condoms must be used when the couple is having intercourse. 2 Mutual monogamy must be practiced. 3 It will be necessary to refrain from sexual contact during pregnancy. 4 Meticulous cleaning of the vaginal area after intercourse is essential.

1 Latex or polyurethane condoms must be used when the couple is having intercourse to reduce the risk of the spread of genital herpes. Mutual monogamy can be practiced, but genital herpes will be spread to the client without protection during sexual activity. Abstinence is necessary only when disease symptoms are present in the partner and during the last four to six weeks of pregnancy. Washing is not sufficient to prevent contraction of this virus; contact already has been made.

A client is hospitalized with an overdose of benzodiazepines and presents with a respiratory rate less than 10 breaths per minute. Which nursing intervention should be provided as the first priority? 1 Give oxygen. 2 Secure airway. 3 Administer flumazenil. 4 Assess the intravenous site.

1 Oxygen should be given as the first priority intervention for clients with a respiratory rate below 10 breaths per minute due to an overdose of benzodiazepines. Securing the airway is done before starting benzodiazepine antagonist therapy. Drugs such as flumazenil should be administered after providing the client with a sufficient oxygen supply. An intravenous site should be assessed because flumazenil can cause thrombophlebitis at the injection site.

The 8-year-old son of migrant farm workers is brought to the county health clinic. He has no history of immunizations. After measles is diagnosed, the public health nurse goes to the migrant camp to search for people with a greater-than-average chance of contracting the disease. What is the name of this variable? 1 Risk factor 2 Frequency rate 3 Probability rate 4 Causative factor

1 Risk factor is the term given to those factors that identify the target population so community resources may be used in the best interest of all. Frequency rate is an incorrect term for this variable; the nurse is not interested in how frequently measles occurs in migrant workers' camps, which involves epidemiological research. Probability rate is the incorrect term for this variable; the correct term is risk factor, not probability rate. Causative factor is the term given to the cause of a given disease if it is known.

Which sexually transmitted infection (STI) is caused by Treponema pallidum? 1 Syphilis 2 Gonorrhea 3 Genital warts 4 Vulvovaginitis

1 Syphilis is an STI caused by Treponema pallidum. Neisseria gonorrhoeae causes gonorrhea. Haemophilus ducreyi and Klebsiella granulomatis cause genital warts. Herpes simplex virus, Trichomonas vaginalis, and Candida albicans may cause vulvovaginitis.

A nurse is performing an admission health history and physical assessment for a client who has severe rheumatoid arthritis. When assessing the client's hands, the nurse identifies that they are similar to the hand in the illustration. What should the nurse document in the medical record when describing this typical physiologic change associated with rheumatoid arthritis? 1 Ulnar drift 2 Hallux valgus 3 Swan-neck deformity 4 Boutonnière deformity

1 Ulnar drift occurs when the long axis of the fingers makes an angle with the long axis of the wrist so that the fingers are deviated to the ulnar side of the hand; it is caused by changes in the metacarpophalangeal joints. Hallux valgus occurs when the great toe is angulated away from the midline of the body toward the other toes. Swan-neck deformity occurs with flexion of the distal interphalangeal joint and hyperextension of the proximal interphalangeal joint. Boutonnière deformity occurs with fixed flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint.

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply. 1 Providing oxygen immediately 2 Notifying the rapid response team 3 Considering it a normal observation 4 Initiating an intravenous (IV) line and beginning fluid replacement 5 Obtaining an electrocardiogram (ECG) of the client

1, 2 Hoarseness of voice, difficulty in swallowing, or an audible breath sound on exhalation after a burn injury indicates an impaired airway. Therefore the client should be given oxygen immediately. The rapid response team should also be notified for further management. This occurrence should not be considered a normal observation. An IV line should be initiated for fluid replacement only once the client's airway is patent. An ECG is obtained when the client suffers from electrical burns.

An infant who underwent revision of a ventriculoperitoneal shunt is found to have meningitis, the result of an infected shunt. What clinical manifestations support this conclusion? Select all that apply. 1 Fever 2 Lethargy 3 Stiff neck 4 Poor feeding 5 Depressed fontanels

1, 2, 3, 4 A low-grade fever progressing to a high fever occurs in meningitis. An infectious process that causes meningitis may result in rigidity and hyperextension of the neck (opisthotonos). Central nervous system irritation results in irritability, lethargy, and anorexia. The fontanels will be tense or bulging as intracranial pressure increases.

A child is admitted with a diagnosis of acute poststreptococcal glomerulonephritis. While performing a physical assessment and reviewing the child's laboratory reports, what clinical findings does the nurse expect? Select all that apply. 1 Hematuria 2 Proteinuria 3 Periorbital edema 4 Increased specific gravity 5 Mildly elevated blood pressure

1, 2, 3, 4, 5 The inflammatory process in the kidney allows red blood cells to enter the urine, which manifests as hematuria. Capillary permeability in the kidney allows protein to pass into the urine. The glomerular filtration rate is reduced, resulting in sodium retention; fluid accumulation is evidenced by periorbital edema in the morning that spreads to the rest of the body as the day progresses. When the glomerular filtration rate is reduced, fluid is retained as evidenced by a decreased urinary output; with a decreased urinary output the specific gravity will increase (1.030). The retention of fluid causes an increase in the intravascular volume, resulting in an increased blood pressure.

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. 1 Rye 2 Oats 3 Rice 4 Corn 5 Wheat

1, 2, 5 Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.

What important teaching strategies should the nurse take into consideration to bring a change in the client's lifestyle? Select all that apply. 1 Use written resources at an appropriate reading level. 2 Practice active listening, and ask the client how he or she prefers to learn. 3 Refrain from including family member in efforts to bring a change in the client's lifestyle. 4 Provide timelines for modification of eating and exercise lifestyle habits without consulting with the client. 5 Start with identifying what information the client knows regarding health risks related to poor lifestyle choices.

1, 2, 5 To bring a change in the client's lifestyle, the nurse should use written resources at an appropriate reading level. The nurse should practice active listening and ask the client how he or she prefers to learn. The nurse should start by identifying what information the client knows regarding health risks related to poor lifestyle choices. The nurse should include family members to help bring changes in the client's lifestyle. The nurse should provide timelines for modification of eating and exercise lifestyle habits after consulting with the client.

A client with psoriasis is prescribed corticosteroids. What should be taught to the client for a positive outcome? Select all that apply. 1 "Apply the drug directly to the skin." 2 "Stop the drug when symptoms subside." 3 "Apply the drug using warm or moist dressings." 4 "Apply the drug for shorter periods to each lesion." 5 "Prevent the drug from coming into contact with uninvolved skin."

1, 3 Corticosteroids should be applied directly to the skin using warm or moist dressings to enhance the action of the drug. The drug should not be discontinued even if the symptoms subside, as abruptly stopping the drug may cause adverse effects. Anthralin should be applied for shorter periods to each lesion while avoiding coming into contact with uninvolved skin to prevent chemical burns.

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply. 1 Scaly lesions 2 Pruritic pustules 3 Reddened papules 4 Multiple petechiae 5 Erythematous macules

1, 3 Psoriasis is characterized by dry, scaly lesions that occur most frequently on the elbows, knees, scalp, and torso. Sharply defined reddened papules or plaques covered by scales occur because of dermal inflammation; the inflammation occurs because of an abnormal growth of epidermal cells related to an autoimmune reaction. Pustules or vesicles filled with purulent fluid do not occur in psoriasis. Petechiae are not characteristic of psoriasis. Macules are erythematous flat spots on the skin, as in measles.

Which reason should the nurse request that the healthcare provider increase the intravenous fluid infusion for an older client with an infection? 1 Pruritus 2 Erythema 3 Acute confusion 4 General malaise

3 The nurse should consider the development of dehydration if acute confusion occurs in an older client with an infection. Additional fluids would not be helpful if pruritus, erythema, or general malaise develop in a client with an infection.

Which data should the nurse anticipate when conducting a developmental assessment for a 5-year-old client? Select all that apply. 1 Names coins correctly 2 Has a vocabulary of 1500 words 3 Participates in parallel play 4 Ties shoe laces independently 5 Has hand dominance established

1, 4, 5 When conducting a developmental assessment for a 5-year-old client, the nurse anticipates the client to be able to name coins correctly, tie shoe laces independently, and have established hand dominance. A vocabulary of 1500 words would indicate a language delay; the 5-year-old client is expected to have a vocabulary of 2100 words. Participation is associative, not parallel play, and is expected by 5 years of age.

A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness? 1 Hepatitis A 2 Rheumatic fever 3 Spinal meningitis 4 Rheumatoid arthritis

2 Antibodies produced against group A beta-hemolytic streptococci sometimes interact with antigens in the heart's valves, causing damage and symptoms of rheumatic heart disease; early recognition and treatment of streptococcal infections have limited the occurrence of rheumatic heart disease. Hepatitis A, an inflammation of the liver, is caused by the hepatitis A virus (HAV), not by bacteria. The most common causes of meningitis, an infection of the membranes surrounding the brain and spinal cord, include Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Rheumatoid arthritis is believed to be an autoimmune disorder; it is not caused by microorganisms.

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F (39° C). The temperature was 99.2° F (37.3° C) when it was taken 6 hours ago. What is a priority nursing intervention in this case? 1 Assess the amount and color of urine; obtain a specimen for a urinalysis. 2 Administer the prescribed antipyretic and notify the primary health care provider. 3 Note the consistency of respiratory secretions and obtain a specimen for culture. 4 Obtain the respirations, pulse, and blood pressure; recheck the temperature in 1 hour.

2 Because an elevated temperature increases metabolic demands, the pyrexia must be treated immediately. The practitioner should be notified because this client is immunodeficient from both the disease and the chemotherapy. A search for the cause of the pyrexia then can be initiated. More vigorous intervention than obtaining the respirations, pulse, and blood pressure is rechecking the temperature in 1 hour. This client has a disease in which the immunoglobulins are ineffective and the therapy further suppresses the immune system. Assessing the amount and color of urine and obtaining a specimen for a urinalysis is not the immediate priority, although it is important because the cause of the pyrexia must be determined. Also, the increased amount of calcium and urates in the urine can cause renal complications if dehydration occurs. Noting the consistency of respiratory secretions and obtaining a specimen for culture is not the priority, although important because respiratory tract infections are a common occurrence in clients with multiple myeloma.

A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will the nurse most likely observe written in the medical record? 1 Botulism 2 Bell palsy 3 Trigeminal neuralgia 4 Guillain-Barré syndrome

2 Bell palsy is a cranial nerve disorder characterized by inflammation of the facial nerve on one side of the face. Botulism is a type of polyneuropathy caused by food poisoning due to Clostridium botulinum that can be fatal. Trigeminal neuralgia is a cranial nerve disorder characterized by pain in the distribution of the trigeminal nerve. Guillain-Barré syndrome is an acute, rapidly progressing, potentially fatal polyneuritis.

A mother with the diagnosis of acquired immunodeficiency syndrome (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine? 1 If she has kissed the baby 2 If the baby is breast-feeding 3 When the baby last received antibiotics 4 How long she has been caring for the baby

2 Epidemiologic evidence has identified breast milk as a source of human immunodeficiency virus (HIV) transmission. Kissing is not believed to transmit HIV. When the baby last received antibiotics is unrelated to transmission of HIV. HIV transmission does not occur from contact associated with caring for a newborn.

A nurse in a summer day camp that has access to a local beach has cared for several children with impetigo. What is the best nursing intervention to prevent complications? 1 Use of an oil-based soap for bathing 2 Administration of a systemic oral antibiotic and a topical antibiotic may be used as well 3 Removal of crusts with an antimicrobial liquid 4 Application of an antibiotic ointment to the lesions

2 Glomerulonephritis may occur as a result of impetigo, a streptococcal infection. Systemic antibiotics are necessary to eradicate the streptococcal organism that caused the primary infection. Ointments such as mupirocin (Bactroban) may be prescribed for topical application as well. Bathing the child with a special soap will not prevent glomerulonephritis. Although removing the crusts is part of the local therapy for impetigo, using an antimicrobial liquid will not prevent glomerulonephritis; nor will applying an antibiotic ointment.

Which hypersensitivity reaction may occur in a newborn with hemolytic disease? 1 Type I 2 Type II 3 Type III 4 Type IV

2 Hemolytic disease in a pregnant woman may result in erythroblastosis fetalis, a type II hypersensitivity reaction. Type I reactions involve immunoglobulin E (IgE)-mediated reactions such as anaphylaxis and wheal-and-flare reactions. Type III reactions are immune complex reactions such as rheumatoid arthritis or systemic lupus erythematosus. Type IV reactions are delayed hypersensitivity reactions such as contact dermatitis.

A client with Meniere disease is advised to eat a sodium-restricted diet to reduce endolymphatic fluid. Which food selection provides evidence that the nurse's teaching was effective? 1 Cake 2 Macaroni 3 Baked clams 4 Grilled cheese

2 Macaroni, boiled in unsalted water, has the least sodium of the food choices offered. Cake has a high sodium content, which promotes fluid retention and increases endolymphatic fluid in the cochlea of a client with Meniere disease. Baked clams have a high sodium content, which promotes fluid retention and increases endolymphatic fluid in the cochlea of a client with Meniere disease. Grilled cheese has a high sodium content, which promotes fluid retention and increases endolymphatic fluid in the cochlea of a client with Meniere disease.

A client reports painful urination and profuse purulent urethral discharge. After assessment, the nurse finds that his testicles are swollen. The primary healthcare provider asks the client to undergo a nucleic acid amplification test. Which organism may be responsible for this condition in the client? 1 Treponema pallidum 2 Neisseria gonorrhoeae 3 Chlamydia trachomatis 4 Condylomata acuminata

2 Neisseria gonorrhoeae causes gonorrhea. The symptoms of gonorrhea include dysuria, profuse purulent urethral discharge, and swollen testicles. The diagnostic test for gonorrhea is nucleic acid amplification test (NAAT). Treponema pallidum causes syphilis. The symptoms of syphilis include the presence of painless, indurated lesions on the penis, vulva, lips, mouth, vagina, and rectum. The diagnostic test for syphilis is direct fluorescent antibody test. Chlamydia trachomatis causes chlamydial infection, the symptoms of which are urethritis, rectal discharge, and pain during defecation. The diagnostic test for chlamydial infection is also NAAT, done by testing urine or collecting swab specimens from the urethra. Condylomata acuminata causes genital warts. Genital warts are small fleshy growths, bumps, or skin changes that appear near the genital or anal area. The diagnosis of genital warts is made based on the gross appearance of the lesions.

The primary healthcare provider prescribed antitubercular medication to a client with tuberculosis. During a follow-up visit, the client reports reddish-orange urine. Which medication might have led to this condition? 1 Isoniazid 2 Rifampin 3 Ethambutol 4 Pyrazinamide

2 Rifampin is an antitubercular medication that stains the skin and urine. A client with reddish-orange urine may be prescribed rifampin. Isoniazid is an antitubercular medication that depletes vitamin B from the body. Ethambutol is an antitubercular medication that causes optic neuritis. Pyrazinamide is an antitubercular medication that causes sunburn.

A registered nurse is teaching a nursing student about the various mechanisms that antiviral drugs use to control human immune deficiency (HIV) infections. Which statement made by the nursing student needs correction? 1 "Maraviroc blocks CCR5 receptors on CD4+ T-cells." 2 "Saquinavir blocks the fusion between HIV and the host cell." 3 "Zidovudine acts as a counterfeit base for reverse transcriptase." 4 "Nelfinavir prevents the breakup of viral protein strand into smaller fragments."

2 Saquinavir is a protease inhibitor that works by blocking the HIV enzyme protease; it is not a fusion inhibitor. Saquinavir prevents the viral protein strand from being lysed into active smaller fragments. Entry inhibitors such as maraviroc block CCR5 receptors on CD4+ T-cells. Zidovudine is a nucleoside reverse transcriptase inhibitor that acts as a counterfeit base for the HIV enzyme reverse transcriptase. Protease inhibitors such as nelfinavir prevent the breakup of viral protein strand into smaller active viral particles.

A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. A lumbar puncture is performed to confirm the diagnosis. What laboratory report on the cerebrospinal fluid (CSF) supports this diagnosis? 1 Decreased cell count 2 Increased protein level 3 Increased glucose level 4 Low spinal fluid pressure

2 The blood-brain barrier is affected in bacterial meningitis, permitting the passage of protein into the CSF. The cell count will be increased. The glucose level is decreased in proportion to the duration of the disease. Spinal fluid pressure will be increased.

A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? 1 Albumin 2 Globulin 3 Thrombin 4 Hemoglobin

2 The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen.

Which organism is responsible for the condition illustrated in the image? (Diseased heart valves) 1 Sporothrix schenckii 2 Streptococcus viridians 3 Legionella pneumophila 4 Cryptosporidium parvum

2 The image depicts infective endocarditis, which is caused by bacteria such as Streptococcus viridians and Staphylococcus aureus. Sporothrix schenckii is a fungus that causes sporotrichosis of the skin and lymph nodes. Legionella pneumophila is bacteria that causes Legionnaires' disease. Cryptosporidium parvum is a parasite that causes acute and chronic diarrhea.

A client who is experiencing acute alcohol withdrawal delirium appears frightened, points toward the bed, and says, "Bugs are crawling all over me and my bed!" What is the most therapeutic response by the nurse? 1 "Just try to brush them off." 2 "I don't see any bugs on you or your bed." 3 "They'll go away when you start feeling better." 4 "The bugs that you see are just the design on the bedspread."

2 The response "I don't see any bugs on you or your bed" points out reality and does not support the client's hallucinations. The response "Just try to brush them off" supports the client's hallucination and provides false reassurance. The response "They'll go away when you start feeling better" supports the client's hallucination and provides false reassurance. The response "The bugs that you see are just the design on the bedspread" constitutes false information. If the client said that the bugs were only on the bed and the bedspread had a design, then the client might have been experiencing an illusion.

A spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test. The nurse reads the test and identifies an area of induration greater than 10 mm. What does this result indicate to the nurse? 1 No further action is required. 2 Additional tests are necessary. 3 Repeating the skin test is indicated. 4 Results are positive, indicating infection.

2 The test does not indicate whether TB is dormant or active. However, a client with an induration of 5 mm or greater is considered positive if there is repeated close contact with a person diagnosed with pulmonary tuberculosis or if the client has a disease causing decreased resistance; this requires further diagnostic study, such as chest x-rays and sputum culture. A newly infected client will receive preventive therapy with isoniazid (INH). Isoniazid will be continued for 6 months if chest x-rays are normal, or 12 months if chest x-rays are abnormal. Repeating the skin test is not necessary; the test is considered positive.

A client was admitted to the hospital with blunt trauma as a result of a collision with the steering wheel during a motor vehicle accident. The client was treated for a lacerated liver and abdominal hemorrhage. Which clinical findings should the nurse be alert for when assessing the client for peritonitis during the recovery period? Select all that apply. 1 Jaundice 2 Boardlike abdomen 3 Abdominal tenderness 4 Decreased bowel sounds 5 Rapid decrease in coagulation ability

2, 3, 4 A boardlike abdomen is associated with the inflammatory process in the peritoneum. Abdominal tenderness is caused by the local inflammatory process and resulting bowel distention and irritation of the peritoneum. A decrease or absence of bowel sounds occurs in response to bowel distention caused by gas and shifting of fluid into the bowel. Jaundice is not a sign of peritonitis; it is caused by a disturbance in bilirubin metabolism. A rapid decrease in coagulation ability is associated with acute liver failure, not peritonitis.

A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food borne disease would be suspected in this client? 1 Listeriosis 2 Shigellosis 3 Salmonellosis 4 Staphylococcus

3 A client with salmonellosis will experience severe diarrhea, abdominal cramps, and vomiting; these symptoms last as long as 5 days after the intake of contaminated food. This disorder may be caused by Salmonella typhi or Salmonella paratyphi. The causative organism is usually present in such foods as eggs, salad dressings, and sandwich fillings. A client with listeriosis will experience severe diarrhea, fever, headache, pneumonia, meningitis, and endocarditis 3 to 21 days after infection. The symptoms of shigellosis range from cramps and diarrhea to a fatal dysentery that lasts for 3 to 14 days. Pain, vomiting, diarrhea, perspiration, headache, fever, and prostration lasting for 1 or 2 days are the symptoms of a Staphylococcus infection.

Parents are considering a bone marrow transplant for their child who has recurrent leukemia. The parents ask the nurse for clarification about the procedure. What is the best response by the nurse? 1 "Bone marrow transplantation is rarely performed in children these days." 2 "The hematopoietic stem cells are surgically implanted in the bone marrow." 3 "Your child's immune system must be destroyed before the transplantation can take place." 4 "It is a simple procedure with little preparation needed, and the stem cells are infused as in a blood transfusion."

3 An intensive preparatory regimen is needed to destroy the child's immune system. The procedure is performed in children for recurrent malignancies. Once the process is started, no rescue therapy except for the transplant is provided. The child's bone marrow must be clear of all cells before transfusion of the stem cells is performed

The parent of a child with hemophilia asks the nurse, "If my son hurts himself, is it all right if I give him two baby aspirins?" What is the best response by the nurse? 1 "You seem concerned about giving drugs to your child." 2 "It's all right to give him baby aspirin when he hurts himself." 3 "Aspirin may cause more bleeding. Give him acetaminophen instead." 4 "He should be given acetaminophen every day. It'll prevent bleeding."

3 Aspirin, which has an anticoagulant effect, is contraindicated because it may harm a child with bleeding problems; in addition, aspirin is contraindicated for all children because of its relationship to Reye syndrome. Stating that the parent seems concerned about giving drugs to the child does not answer the mother's question and may cause the mother to feel defensive. Acetaminophen cannot prevent bleeding episodes; it is an analgesic.

The nurse is providing education about care of the residual limb to a client who had a below-the-elbow amputation. Which information will the nurse include in the teaching session? 1 "Wear a sling to bed every night." 2 "Apply skin lotion and massage it at least twice a day." 3 "Wash and dry the residual limb at least once a day." 4 "Soak the residual limb in warm water for 30 minutes each day."

3 Bathing removes microorganisms and promotes circulation, which facilitates wound healing; drying prevents maceration of skin and reduces moisture, which limits bacterial growth. A sling will interfere with comfort and mobility and can result in elbow or shoulder contractures. Lotion may facilitate adherence of bacteria to wound edges and promote maceration of the skin, which interferes with wound healing. Soaking may cause maceration of the skin and interfere with wound healing.

Which sexually transmitted disease is treated with antiviral drugs? 1 Syphilis 2 Gonorrhea 3 Genital herpes 4 Chlamydial infection

3 Genital herpes is a sexually transmitted disease caused by herpes simplex virus. Therefore antiviral drugs are used to treat this condition. Bacteria cause syphilis, gonorrhea, and chlamydial infections.

What is a manifestation of tertiary syphilis? 1 Chancre 2 Alopecia 3 Gummas 4 Condylomata lata

3 Gummas which are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and condylomata lata occur during secondary syphilis.

What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection? 1 Originated primarily from an exogenous source 2 Is associated with a drug-resistant microorganism 3 Occurred in conjunction with treatment for an illness 4 Still has the infection despite completing the prescribed therapy

3 Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a drug-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a drug-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.

A client with advanced cancer of the bladder is scheduled for a cystectomy and ileal conduit. What intervention does the nurse anticipate the healthcare provider will prescribe to prepare the client for surgery? 1 Intravesicular chemotherapy 2 Instillation of a urinary antiseptic 3 Administration of an antibiotic 4 Placement of an indwelling catheter

3 Intestinal antibiotics and a complete cleansing of the bowel with enemas until returns are clear are necessary to reduce the possibility of fecal contamination when the bowel is resected to construct the ileal conduit. Intravesicular chemotherapy is unnecessary because the urinary bladder is removed with this surgery. Instillation of a urinary antiseptic is not necessary. There is no evidence of a urinary tract infection. The urinary bladder will be removed, so there is no need for an indwelling urinary catheter. No data indicate that the client is experiencing urinary retention before surgery.

A group of clients who were in a bus accident is admitted to the emergency department with injuries. Which group is considered urgent according to the three-tier triage system? 1 Sprains 2 Simple fractures 3 Severe abdominal pain 4 Chest pain with diaphoresis

3 Severe abdominal pain is triaged under urgent type of tier level. It requires quick treatment but is not immediately life threatening. Sprains and simple fractures are triaged as nonurgent, which indicates the client could wait several hours if necessary without fear of the condition worsening. Chest pain with diaphoresis is triaged under emergent tier level as it is life threatening.

A nurse is caring for a 9-year-old child with juvenile idiopathic arthritis (JIA). What is most important for the nurse to attempt to prevent? 1 Infection 2 Hemarthrosis 3 Contracture deformities 4 Delayed intellectual development

3 Severe joint pain and swelling cause the child with JIA to immobilize the affected parts for prolonged periods, resulting in joint deformities. The disease process is inflammatory but usually noninfectious. Bleeding into the joints (hemarthrosis) is not part of the disease process. JIA is not related to the mental development of the child, but it may contribute to a physical developmental delay.

Which bacteria causes toxic shock syndrome in female clients? 1 Treponema pallidum 2 Streptococcus faecalis 3 Staphylococcus aureus 4 Neisseria gonorrhoeae

3 Staphylococcus aureus causes toxic shock syndrome. Treponema pallidum causes syphilis. Streptococcus faecalis causes genitourinary tract infections and infection of surgical wounds. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease.

Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling). Which of these is evidence of a stress ulcer? 1 Unexplained shock 2 Melena for several days 3 A sudden massive hemorrhage 4 A gradual drop in the hematocrit value

3 Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding. Shock is the outcome of massive hemorrhage; it is not unexplained because the sudden gastrointestinal bleeding will be identified. Sudden massive bleeding occurs, not the slow oozing that causes melena. A gradual drop in the hematocrit value indicates slow blood loss.

A nurse discovers the condition depicted in the image upon assessment of a client. Which organism may lead to this condition? (clusters of bruise-like spots on the skin all over body) 1 Cytomegalovirus 2 Varicella-zoster virus 3 Human herpes virus-8 4 Human papilloma virus

3 The client in the image has Kaposi's sarcoma (KS). The risk for KS appears to be related to co-infection with human herpes virus-8. KS is the most common acquired immune deficiency syndrome-related malignancy. Cytomegalovirus may lead to retinitis, encephalitis, pneumonitis, adrenalitis, hepatitis, and disseminated infection. Varicella-zoster virus causes chicken pox and shingles. Human papilloma virus causes multiple types of malignancies such as cervical and anal cancer.

A 1-year-old infant is receiving zidovudine for management of human immunodeficiency (HIV) infection. The nurse determines that the infant is exhibiting signs of life-threatening zidovudine toxicity. What clinical finding supports this conclusion? 1 Weight loss 2 Extreme lethargy 3 Bruises over the body 4 Increased urine output

3 Zidovudine can cause life-threatening blood dyscrasias, including thrombocytopenia. Weight loss is a response to the disease rather than the therapy. With zidovudine toxicity the infant will demonstrate agitation, restlessness, and insomnia, not lethargy. Urine output is unrelated to zidovudine toxicity.

A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply. 1 Polyuria 2 Jaundice 3 Azotemia 4 Hypertension 5 Polycythemia

3, 4 Azotemia is an increase in nitrogenous waste, particularly urea, in the blood; this is common in end-stage renal disease. Hypertension occurs as a result of fluid and sodium overload and dysfunction of the rennin-angiotensin-aldosterone system. Excessive nephron damage in end-stage renal disease causes oliguria, not polyuria; excessive urination is common in early kidney insufficiency from an inability to concentrate urine. Jaundice is common with biliary obstruction, not end-stage renal disease. Anemia, not polycythemia, occurs because of decreased erythropoietin, decreased red blood cell (RBC) production, and decreased RBC survival time.

A client is diagnosed with celiac disease. Which foods should the nurse teach the client to avoid? Select all that apply. 1 Corn 2 Cheese 3 Oatmeal 4 Rye bread 5 Fruit juice

3, 4 Gluten is found in rye, oats, wheat, and barley, which should be avoided because gluten in these grains is irritating to the gastrointestinal mucosa in clients with celiac disease. Gluten is found in oatmeal and rye bread and should be avoided. Gluten is not found in corn. Gluten is not found in milk and dairy products. Gluten is not found in fruit.

Which organs are affected by Candida albicans? Select all that apply. 1 Ears 2 Lungs 3 Vagina 4 Mouth 5 Intestines

3, 4, 5 Candida albicans causes thrush in the mouth, vaginitis in the vagina, and candidiasis in the intestines. The fungus Aspergillus fumigatus affects the ears. Lungs are affected by Coccidioides immitis.

A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) has a protozoal infection and is receiving pentamidine. The nurse should monitor the client for which common side effects? Select all that apply. 1 Leukocytosis 2 Hypokalemia 3 Hypoglycemia 4 Increased serum calcium 5 Decreased blood pressure

3, 5 Hypoglycemia is a side effect of pentamidine. Hypotension and dysrhythmias are common side effects of this medication. Neutropenia, not leukocytosis, is associated with this drug. Hyperkalemia, not hypokalemia, may occur. Hypocalcemia, not hypercalcemia, may occur.

Which diseases may occur due to rickettsial infections? Select all that apply. 1 Leprosy 2 Lyme disease 3 Epidemic typhus 4 West Nile fever 5 Rocky Mountain spotted fever

3, 5 Typhoid fever and Rocky Mountain spotted fever are caused by rickettsial infections. Spirochetes and Mycobacterium leprae cause leprosy. Borrelia burgdorferi cause Lyme disease. The West Nile virus causes West Nile fever.

Which drug is most appropriate for relieving a painful muscle spasm in the back of a client with osteoarthritis (OA)? 1 Tramadol 2 Hyaluronate 3 Diclofenac epolamine patch 4 Cyclobenzaprine hydrochloride

4 Cyclobenzaprine hydrochloride is a muscle relaxant administered to relieve painful muscle spasms, especially those resulting from OA of the vertebral column. While tramadol is a weak opioid drug that may also be given to relieve pain in clients with OA, it is not as effective against painful muscle spasms. Hyaluronate is a specific injection for knee and hip pain associated with OA. The diclofenac epolamine patch is used in clients with signs and symptoms of knee OA.

A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. What would be the best response from the nurse? 1 "I don't know. I will ask the health care provider for a prescription." 2 "Antibiotics are used to treat viruses and you have a bacterial infection." 3 "Antibiotics are ineffective for treating the bacteria that cause upper respiratory infections." 4 "Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics."

4 Generally, upper respiratory infections are viral; therefore antibiotics should not be used. Overuse of antibiotics results in antibiotic-resistant strains of bacteria. Antibiotics are used to treat bacteria, not viruses.

Which cytokine increases growth and maturation of myeloid stem cells? 1 Interleukin-2 2 Thrombopoietin 3 Granulocyte colony-stimulating factor 4 Granulocyte-macrophage colony-stimulating factor

4 Granulocyte-macrophage colony-stimulating factor is a cytokine that increases growth and maturation of myeloid stem cells. Interleukin-2 is a cytokine that increases growth and differentiation of T-lymphocytes. Thrombopoietin is a cytokine that increases growth and differentiation of platelets. Granulocyte colony-stimulating factor is a cytokine that increases numbers and maturity of neutrophils.

When reviewing the history of a client admitted in preterm labor during her thirtieth week of gestation, the nurse suspects a risk factor associated with this client's preterm labor. Which risk factor does the nurse suspect? 1 Primigravida 2 Android-shaped pelvis 3 Anticonvulsant medication therapy 4 Multiple urinary tract infections

4 Infections, especially urinary tract infections, are a risk factor for preterm labor. The number of pregnancies is not a risk factor for preterm labor. An android-shaped pelvis is more likely to cause dystocia than preterm labor. Clients receiving anticonvulsant medications are not at an increased risk for preterm labor.

A client seeking advice regarding contraception asks a nurse to explain how an intrauterine device (IUD) prevents pregnancy. How should the nurse respond? 1 "It covers the entrance to the cervical os." 2 "The openings to the fallopian tubes are blocked." 3 "The sperm are kept from reaching the vagina." 4 "It produces a spermicidal intrauterine environment."

4 Intrauterine devices produce a spermicidal intrauterine environment. A copper IUD inflames the endometrium, damaging or killing sperm and preventing fertilization and/or implantation. A levonorgestrel-releasing IUD damages sperm and causes the endometrium to atrophy, thus preventing fertilization and/implantation. A diaphragm blocks the cervical os. The IUD does not act by blocking the openings to the fallopian tubes. Preventing sperm from reaching the vagina is the function of a condom.

Which virus can cause encephalitis in adults and children? 1 Rubella virus 2 Parvovirus 3 Rotaviruses 4 West Nile virus

4 The West Nile virus causes encephalitis. German measles is caused by rubella. Gastroenteritis is caused by parvovirus. Rotavirus also causes gastroenteritis.

A client is admitted to the hospital for medical treatment of bronchopneumonia. Which test result should the nurse examine to help determine the effectiveness of the client's therapy? 1 Bronchoscopy 2 Pulse oximetry 3 Pulmonary function studies 4 Culture and sensitivity tests of sputum

4 The aim of therapy is to eliminate the causative agent, which is determined from culture and sensitivity tests of sputum. Bronchoscopy shows the appearance of the bronchi but does not indicate the presence or absence of microorganisms. Pulse oximetry is used to assess for hypoxemia; it does not provide data on the condition of the lung tissue itself or on the presence or absence of microorganisms. Pulmonary function studies indicate air volume that may be within the expected range despite the presence of bronchopneumonia.

Which viral infection will cause the nurse to observe for warts? 1 Pox virus 2 Rhabdovirus 3 Epstein-Barr virus 4 Papillomavirus

4 Warts are caused by papillomavirus. Pox viruses cause smallpox. Rhabdovirus causes rabies. Epstein-Barr causes mononucleosis and Burkitt's lymphoma.