Exam 1

Abacavir (Ziagen) has been prescribed for a client, who asks the nurse about the side effect of the medication. What should the nurse tell the client is a frequent side effect of this medication? 1. Nausea 2. Sleepiness 3. Constipation 4. Increased appetite

1 . Nausea

The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine (Pentam 300). The client develops a temperature of 101° F. The nurse continues to assess the client, knowing that this sign most likely indicates which condition? 1. That the dose of the medication is too low 2. That the client is experiencing toxic effects of the medication 3. That the client has developed inadequacy of thermoregulation 4. That the client has developed another infection caused by leukopenic effects of the medication

4. That the client has developed another infection caused by leukopenic effects of the medication

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count

4. White Blood Cell Count

The parents of a young adult have expressed concerns about the cognitive and emotional changes they have noted in their child. The nurse recognizes which assessment and diagnostic data as associated with the diagnosis of schizophrenia? Select all that apply. 1. A birthday of March 30 2. A loss of interest in hobbies 3. A suicide attempt 6 months ago 4. Adopted by family at age 14 months 5. Brain scan shows increased blood flow to the frontal lobes 6. Magnetic resonance imaging shows temporal lobe atrophy

1,2,3,6 Rationale: A late winter, early spring birthday (viral theory); apathy and anhedonia (the inability to experience pleasure from activities usually found enjoyable); suicidal ideations; and atrophy of brain tissue are all common to individuals exhibiting symptomatology of schizophrenia. Blood flow within the brain is generally decreased, although no data support that adoption itself increases the risk for schizophrenia.

Mycophenolate mofetil (CellCept) is prescribed for a client for prophylaxis of organ rejection following allogenic renal transplantation. Which instruction should the nurse provide to the client regarding administration of this medication? 1. Administer following meals. 2. Take the medication with a magnesium-type antacid. 3. Open the capsule and mix with food for administration. 4. Contact the health care provider (HCP) if a sore throat occurs.

4. Contact HCP if sore throat

A child is scheduled to receive immunizations. The child's mother reports to the nurse that the child has been receiving long-term immunosuppressive therapy. The nurse prepares the scheduled immunizations knowing that which vaccine is contraindicated? 1. Hepatitis B 2. MMR (measles-mumps-rubella) 3. Hib (Haemophilus influenzae type b) 4. DTaP (diphtheria-tetanus-acellular pertussis)

2. MMR

Abacavir succinate (Ziagen) has been prescribed for a client, and the client asks the nurse about the action of the medication. How should the nurse respond? 1. Promotes viral DNA growth 2. Prevents the production of DNA 3. Splits DNA to prevent its production 4. Inhibits activity of HIV-1 reverse transcriptase

4. Inhibits activity of HIV-1 reverse transcriptase

Muromonab-CD3 (Orthoclone OKT3) is prescribed for a client to manage allograft rejection after renal transplantation. The nurse plans care, knowing that the primary mechanism of action of this medication is what? 1. Suppresses B lymphocytes 2. Inhibits the proliferation of B lymphocytes 3. Cross-links DNA, causing cell injury and death 4. Binds to the CD3 site and blocks all T-cell functions

4. Binds to CD3 Site

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1 Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition

1. 1 Using open-ended questions and silence

The nurse has been assigned to care for a client with an immune disorder. In developing a plan of care for this client, the nurse incorporates knowledge that the immune system consists of specific major types of cells. Which types of cells are associated with the immune system? Select all that apply. 1. Dendritic cells 2. B lymphocytes 3. Red blood cells 4. Helper T lymphocytes 5. Cytolytic T lymphocytes

1, 2, 4 ,5

Tacrolimus (Prograf) is prescribed to a client for prevention of organ rejection after renal transplantation. Which prescription should the nurse anticipate to be prescribed, along with the tacrolimus, for this client? 1. Prednisone 2. Phenytoin (Dilantin) 3. Fluconazole (Diflucan) 4. Erythromycin (Erythrocin)

1. Prednisone

The nurse is caring for a client who is receiving immunosuppressant therapy, including corticosteroids, after renal transplantation. The nurse should plan to carefully monitor results of which laboratory test for this client? 1. Blood glucose level 2. Serum calcium level 3. Serum magnesium level 4. Serum albumin concentration

1. blood glucose level

The nurse is providing instructions to a client regarding the side effects of chlorpromazine (Thorazine). The nurse instructs the client that which may occur with the use of this medication? 1. Dry mouth 2. Hand tremors 3. Lip smacking 4. Increased urinary output

1. dry mouth

The nurse is developing a plan of care for the client with a diagnosis of paranoia and should include which interventions in the plan of care? Select all that apply. 1. Provide a warm approach to the client. 2. Ask permission before touching the client. 3. Eliminate physical contact with the client. 4. Defuse any anger or verbal attacks with a nondefensive stance. 5. Use simple and clear language when communicating with the client.

2, 3, 4, 5 Rationale: When caring for a client with paranoia, the nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance.

A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The nurse has explained to the mother the purpose of the blood test. Which comment by the mother indicates the need for further explanation? 1. "The CD4+ count is used to determine the child's immune status." 2. "The CD4+ count identifies the specific diagnosis of HIV infection." 3. "The CD4+ count is a blood test that is used to identify the risk for disease progression." 4. "This test assesses the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age."

2. The CD4 count identifies the specific diagnosis of HIV infection. Rationale: CD4+ counts are used to assess a young child's immune status, risk for disease progression, and need for P. jiroveci pneumonia prophylaxis after 1 year of age. These counts are measured at 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when P. jiroveci pneumonia prophylaxis and antiretroviral therapy are recommended. The CD4+ count is not diagnostic of HIV infection.

A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"

3. "Do you feel afraid that people are trying to hurt you?" Rationale: It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? 1. Fever, hypotension, and polyuria 2. Hypertension, polyuria, and thirst 3. Fever, hypertension, and graft tenderness 4. Hypotension, graft tenderness, and hypothermia

3. Fever, hypertension, and graft tenderness Rationale: Acute rejection usually occurs within the first 3 months after transplantation, although it can occur for up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment with corticosteroids, and possibly also with monoclonal antibodies and antilymphocyte agents, is begun immediately.

A nurse has a prescription to administer foscarnet sodium intravenously to a client with acquired immunodeficiency syndrome (AIDS). What should the nurse plan to do before administering this medication? 1. Obtain a sputum culture. 2. Obtain folic acid (Folvite) as an antidote. 3. Place the solution on a controlled infusion pump. 4. Ensure that liver enzyme levels have been drawn as a baseline.

3. Place the solution on a controlled infusion pump. Rationale: Foscarnet is an antiviral agent used to treat cytomegalovirus (CMV) retinitis in clients with AIDS. Because of the potential toxicity of the medication, it is administered with the use of a controlled infusion device. It is highly toxic to the kidneys, and serum creatinine levels are measured frequently during therapy. A sputum culture is not necessary. Folic acid is not an antidote.

A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine (Videx). When the nurse reviews the client's laboratory test results, which result should be most closely monitored? 1. Protein 2. Glucose 3. Amylase 4. Cholesterol

3. Amylase Rationale: Didanosine is toxic to the pancreas and the liver. A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis and may be fatal in the client with AIDS. Therefore the nurse should monitor the results of amylase and liver function studies closely. Options 1, 2, and 4 are unrelated to this medication.

A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine (Retrovir). The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? 1. Creatinine level 2. Potassium concentration 3. Complete blood count (CBC) 4. Blood urea nitrogen (BUN) level

3. CBC Rationale: Common adverse effects of zidovudine are agranulocytopenia and anemia. The nurse should monitor the CBC result for these changes. Creatinine, potassium, and BUN are unrelated to this medication.

Azathioprine (Imuran) is prescribed for a client to suppress rejection of a renal transplant. In planning for administration of the medication, the nurse understands that which description is the mechanism of action of this medication? 1. It cross-links DNA. 2. It blocks all T-cell functions. 3. It inhibits the proliferation of B and T lymphocytes. 4. It decreases the activity of thymus-derived lymphocytes.

3. it inhibits the proliferation of B and T lymphocytes

The nurse understands that schizophrenia hinders a client's cognitive ability to appropriately process data from external stimuli. This dysfunctional processing can result in which problem? 1. Catatonia 2. Hallucinations 3. Magical thinking 4. Delusional beliefs

4. delusional beliefs

A nurse reinforces medication instructions to a client who has received a kidney transplant about therapy with cyclosporine (Sandimmune). Which statement by the client would indicate a need for further instruction? 1. "I need to obtain a yearly influenza vaccine." 2. "I need to have dental checkups every 3 months." 3. "I need to self-monitor my blood pressure at home." 4. "I need to call the health care provider if my urine volume decreases or it becomes cloudy."

1. Rationale: Cyclosporine is an immunosuppressant medication. Because of the effects of the medication, the client should not receive any vaccinations without first consulting the health care provider. The client should report decreased urine output or cloudy urine, which could indicate kidney rejection or infection, respectively. The client needs meticulous oral care and dental cleaning every 3 months to help prevent gingival hyperplasia. The client must be able to self-monitor blood pressure to check for the side effect of hypertension.

The nurse is providing discharge instructions to a client who will be taking tacrolimus (Prograf) daily following allogenic liver transplantation. The nurse instructs the client that which is a frequent side effect related to this medication? 1. Diarrhea 2. Confusion 3. Loss of memory 4. A decrease in urine output

1. Diarrhea

A mental health nurse notes that a client with schizophrenia is exhibiting an immobile facial expression and a blank look. Which should the nurse document in the client's record? 1. The client has a flat affect. 2. The client has an inappropriate affect. 3. The client is exhibiting bizarre behavior. 4. The client's emotional responses exhibit a blunted affect.

1. The client has a flat affect

Pyrimethamine (Daraprim) has been added to the medication regimen for a client with acquired immunodeficiency syndrome. On review of the client's record, the nurse notes this new prescription and plans care knowing that it has been prescribed to treat which condition? 1. Toxoplasmosis 2. Kaposi's sarcoma 3. Cardiac irregularities 4. Nausea and vomiting

1. Toxoplasmosis

A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of his enzyme-linked immunosorbent assay (ELISA) has been positive. The nurse should formulate a response based on which information? 1. A Western blot will be done to confirm these findings. 2. The client probably will have a bone marrow biopsy done. 3. A CD4+ cell count will be done to measure T-helper lymphocytes. 4. The client will be diagnosed definitively as positive for HIV infection at this point.

1. Western blot to confirm findings

A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas exchange. Which finding indicates that the expected outcome of care has yet to be achieved? 1. The client limits fluid intake. 2. The client has clear breath sounds. 3. The client expectorates secretions easily. 4. The client is free of complaints of shortness of breath.1.

1. client limits fluid intake Rationale: The status of the client with a problem concerning gas exchange would be evaluated against the standard outcome criteria for a Pneumocystis jiroveci infection. These would include options 2, 3, and 4 where breath sounds are clear, the nurse noting that secretions are being coughed up effectively, and the client's states that breathing is easier. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

The nurse is planning relapse prevention information for a client with schizophrenia who is being discharged. The nurse understands that it is important to ensure which primary intervention in the plan whenever possible? 1. Including the client's support system in the teaching 2. Facilitating weekly maintenance therapy for the client 3. Having the client restate discharge goals and strategies 4. Stressing the importance of client compliance with the medication plan

1. including client's support system in the teaching plan

A client with human immunodeficiency virus infection has signs and symptoms of cryptosporidiosis. The nurse should prepare the client for which test that will assist in confirming the diagnosis? 1. Stool culture 2. Bronchoscopy 3. Sputum culture 4. Chest x-ray study

1. stool culture Rationale: The client with cryptosporidiosis will present with signs and symptoms of watery diarrhea, flatus, abdominal distention, pain, and fever. Diagnostic tests include a stool culture with a bowel biopsy. The other options are incorrect.

A client with human immunodeficiency virus (HIV) infection has a fever, and histoplasmosis is suspected. The nurse should prepare the client for which diagnostic test to confirm the presence of histoplasmosis? 1. Skin biopsy 2. Sputum culture 3. Western blot test 4. Upper gastrointestinal series

2 sputum culture

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is receiving Didanosine (Videx). The nurse understands that adverse effects associated with this medication include which findings? Select all that apply. 1. Fatigue 2. Diarrhea 3. Pancreatitis 4. Lactic acidosis 5. Peripheral neuropathy

2, 3, 4, 5 - Diarrhea, Pancreatitis, Lactic acidosis, peripheral neuropathy Rationale: Didanosine (Videx) is used to treat human immunodeficiency virus (HIV). Adverse effects of this medication include diarrhea, pancreatitis, lactic acidosis, peripheral neuropathy, hepatic steatosis, chills or fever, and rash or pruritus. Fatigue is a side effect of this medication.

A CD4 T-cell count is measured in a client newly diagnosed with human immunodeficiency virus (HIV). The nurse understands that which is accurate regarding the CD4 T-cell count? Select all that apply. 1. Falls in response to a declining viral load 2. Is a primary marker of immunocompetence 3. Plays a role in the cell-mediated immune response 4. Is a direct measure of the magnitude of HIV replication 5. Guides decision making regarding timing of initiation of treatment

2, 3, 5

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse should teach the client about which side/adverse effects of this medication? Select all that apply. 1. Diarrhea 2. Sedation 3. Dry mouth 4. Weight loss 5. Orthostatic hypotension 6. Presence of a fixed stare

2, 3, 5, 6 Rationale: Clozapine (Clozaril) is an antipsychotic medication used to treat schizophrenia. Hallucinations, delusions, and altered thought processes are characteristic of this disorder and should decrease with effective treatment. Fixed stare, dry mouth, orthostatic hypotension, and sedation are side/adverse effects of therapy. The other options are unrelated to this medication.

The nurse is monitoring a client receiving muromonab-CD3 (Orthoclone OKT3). Which finding is a priority assessment required in monitoring for adverse effects of this medication? 1. Assessing pedal pulses 2. Assessing lung sounds 3. Assessing for pain in the calf 4. Assessing for positive bowel sounds

2. Assessing lung sounds Rationale: Muromonab-CD3 is an immunosuppressant. Potentially fatal anaphylactic reactions can occur with this medication. Manifestations include pulmonary edema, cardiovascular collapse, and cardiac or respiratory arrest. Assessing lung sounds is a priority.

A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication? 1. Western blot 2. CD4+ cell count 3. Enzyme-linked immunosorbent assay (ELISA) 4. Complete blood cell (CBC) count with differential

2. CD 4+ Cell count

An emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely supports this suspicion? 1. Poor hygiene 2. Difficulty walking 3. Fear of the parents 4. Bald spots on the scalp

2. Difficulty walking Rationale: Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, or emotional maltreatment. Sexual abuse can involve incest, molestation, exhibitionism, pornography, prostitution, or pedophilia. Many times the findings associated with sexual abuse may not be easily apparent in the child. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Bald spots on the scalp and fear of the parents most likely are associated with physical abuse.

The nursing student is assigned to care for a client with an immune disorder. The student is reviewing information related to the immune response and the classes of human antibodies. The student should plan care knowing that what is the major serum antibody? 1. Immunoglobulin E (IgE) 2. Immunoglobulin G (IgG) 3. Immunoglobulin A (IgA) 4. Immunoglobulin M (IgM)

2. IgG

A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? 1. Positive for HIV 2. Indicates the presence of maternal infection 3. Indicates that the newborn will develop AIDS later in life 4. Positive for acquired immunodeficiency syndrome (AIDS)

2. Indicates presence of maternal infection Rationale: A positive antibody test in a child younger than 18 months of age indicates only that the mother is infected because maternal immunoglobulin G antibodies persist in infants for 6 to 9 months and, in some cases, as long as 18 months. A positive ELISA does not indicate true HIV infection or the development of AIDS, nor does it indicate that the newborn will develop AIDS later in life.

Abacavir (Ziagen) has been prescribed for a client. The nurse tells the client that which blood test will be done periodically while the client is taking this medication? 1. Platelet count 2. Liver function tests 3. Serum creatinine assay 4. Blood urea nitrogen determination

2. LFTs Rationale: Abacavir is an antiretroviral agent that can increase liver enzymes, triglycerides, and the blood glucose level. Baseline liver function studies will be done at the initiation of therapy and at periodic intervals during therapy. The tests identified in the other options are unnecessary.

A 2-year-old with Pneumocystis jiroveci pneumonia is to begin treatment with highly active antiretroviral therapy (HAART). The nurse anticipates that the health care provider will prescribe which combination? 1. One immunoglobulin and one nucleoside analogue 2. Two nucleoside analogues and one protease inhibitor 3. Two protease inhibitors and one broad-spectrum antibiotic 4. One nucleoside reverse transcriptase inhibitor and one non-nucleoside reverse transcriptase inhibitor

2. Two nucleoside analogues and one protease inhibitor

During the admission assessment process, the nurse observes that a client with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor? 1. Apathy 2. Impaired pain perception 3. Distrust of authority figures 4. Poor verbal communication skills

2. impaired pain perception

The mental health nurse is reviewing the discharge plan for a hospitalized client. In reviewing the plan, the nurse recognizes that which is the most prominent problem in the management of a client with a mental health problem in the community? 1. The community's opposition 2. The client's noncompliance with medication therapy 3. The associated increased incidence of social problems 4. The family's reaction to keeping the client in the community

2. noncompliance

The nurse taking a medication history for a client who has been admitted to the nursing unit notes that the client is receiving olanzapine (Zyprexa). The nurse interprets that this client most likely has a history of which disorder? 1. Hypertension 2. Schizophrenia 3. Diabetes mellitus 4. Diabetes insipidus

2. schizophrenia

A nurse is monitoring a client receiving cyclosporine (Sandimmune). Which sign or symptom should indicate to the nurse that the client is experiencing an adverse effect from this medication? 1. Nausea 2. Tremors 3. Alopecia 4. Hypotension

2. tremors Rationale: The most common adverse effects of cyclosporine are nephrotoxicity, infection, hypertension, tremors, and hirsutism. Of these, nephrotoxicity and infection are the most serious.

A mental health nurse is assigned to care for a client with a diagnosis of acute schizophrenia. The nurse should use which approach when planning care for this client? 1. Allow the client to set the goals for the plan of care. 2. Let the client act out initially, and use the quiet room and restraints as needed. 3. Provide assistance with grooming and nutrition until the client's thinking has cleared. 4. Repeatedly point out inconsistencies in the client's communication during initial treatment.

3. Provide assistance with grooming and nutrition until the client's thinking has cleared.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. Adhering to the mandatory abuse-reporting laws 2. Notifying the case worker of the family situation 3. Removing the client from any immediate danger 4. Obtaining treatment for the abusing family member

3. Removing client from danger Rationale: Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions, but are not the priority.

A nurse is administering thioridazine hydrochloride. The nurse should monitor the client carefully for which adverse effect? 1. Weight gain 2. Photosensitivity 3. Cardiac dysrhythmias 4. Extrapyramidal movements

3. cardiac dysrhythmias

The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking two packs of cigarettes and drinking 10 cups of coffee daily. The nurse recognizes that which is the greatest risk for injury these behaviors present for this client? 1. Developing lung cancer and/or other respiratory disorders 2. Withdrawal symptoms triggering a stress-induced relapse 3. Diminishing the effectiveness of psychotropic medication 4. Developing gastrointestinal disorders, including bleeding ulcers

3. diminishing effectiveness of psychotropic medication Rationale: Both caffeine and nicotine can inhibit the action of psychotropic medications, which are commonly prescribed for schizophrenia. Although each of the remaining options presents a risk for injury, ineffective medication therapy presents the greatest risk for injury that currently affects this client.

A nurse is caring for a client with human immunodeficiency virus infection and notes a diagnosis of cryptococcosis in the client's medical record. The nurse understands that this opportunistic infection most likely was diagnosed by which test? 1. Skin biopsy 2. Viral culture 3. Sputum culture 4. Bone marrow biopsy

3. sputum Rationale: Cryptococcosis can occur in the lungs or the gastrointestinal tract. Diagnostic tests to confirm its presence in the lungs include chest x-ray studies and a sputum culture. A stool culture may be prescribed to test for cryptococcosis in the gastrointestinal tract.

A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine (Retrovir). The nurse assesses the complete blood count (CBC), knowing that which is an adverse effect of this medication? 1. Polycythemia 2. Leukocytosis 3. Thrombocytosis 4. Agranulocytopenia

4. Agranulocytopenia

A client with a diagnosis of schizophrenia is taking haloperidol (Haldol). The nurse understands that this medication will exert its therapeutic effect through which mechanism? 1. Blocking serotonin reuptake 2. Inhibiting the breakdown of released acetylcholine 3. Blocking the uptake of norepinephrine and serotonin 4. Blocking dopamine from binding to postsynaptic receptors in the brain

4. Blocking dopamine from binding to postsynaptic receptors in the brain

Dapsone is prescribed to treat toxoplasmosis in a client with acquired immunodeficiency syndrome. The nurse reinforces medication instructions and tells the client to perform which action? 1. Report to the clinic weekly for the injections. 2. Plan to take the medication every 6 hours around the clock. 3. Discontinue the medication if nausea and vomiting develop. 4. Contact the health care provider (HCP) if fever or a sore throat occurs.

4. Contact hcp if fever or sore throat occurs

A client has been receiving foscarnet sodium as part of therapy for the treatment of cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS). The home care nurse should periodically review results of which laboratory blood test to assess for adverse effects to this medication? 1. CD4+ cell count 2. Lymphocyte count 3. Albumin concentration 4. Creatinine concentration

4. Creatinine concentration

A 10-year-old girl who has been referred for evaluation for drawing sexually explicit scenes in her textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms? 1. "Well, a picture paints a thousand words." 2. "You just felt like destroying your textbooks?" 3. "Your parents and teachers are very concerned about your drawings." 4. "I am concerned about you. Are you now or have you ever been abused?"

4. I am concerned Rationale: The behaviors that this child engaged in are a warning signal of distress. The correct option is the only one that specifically addresses abuse. In option 1, the nurse is insensitive, sarcastic, and intrusive. In option 2, the nurse is assessing the client's destructive behaviors, not the possible sexual abuse history. In option 3, although the nurse is trying to assess the client's abuse-related symptoms, the nurse uses indirect means rather than straightforward expressions of the nurse's concern.

The nurse is monitoring a client with a diagnosis of schizophrenia. The nurse notes that the client's emotional responses to situations occurring throughout the day are incongruent with the tone of the situation. The nurse should document the findings using which description of the client's behavioral response? 1. Flat affect 2. Bizarre affect 3. Blunted affect 4. Inappropriate affect

4. Inappropriate affect Rationale: An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.

A client who has been receiving pentamidine (Pentam 300) intravenously now has a fever with a temperature of 102° F. Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition? 1. Inadequate thermoregulation 2. Insufficient medication dosing 3. Toxic nervous system effects from the medication 4. Infection caused by leukopenic effects of the medication

4. Infection caused by leukopenic effects of medication

A client with acquired immunodeficiency syndrome is suspected of having cutaneous Kaposi's sarcoma. The nurse should prepare the client for which test to confirm the presence of this type of sarcoma? 1. Liver biopsy 2. Sputum culture 3. White blood cell count 4. Punch biopsy of the cutaneous lesions

4. Punch biopsy of cutaneous lesions

The client with acquired immunodeficiency syndrome (AIDS) has been prescribed raltegravir (Isentress). The nurse determines that the client may be experiencing an adverse effect related to this medication if which assessment finding is noted? 1. Itching sensation 2. Nausea and diarrhea 3. Headache and fatigue 4. Temperature of 101.2° F

4. Temperature Rationale: Raltegravir (Isentress) is classified as an integrase inhibitor and acts by inhibiting human immunodeficiency virus (HIV) replication. Side effects of this medication include itching, nausea and diarrhea, headache, and fatigue. A temperature of 101.2° F is indicative of potential infection, which is an adverse effect of this medication.

The 26-year-old female client with schizophrenia has been prescribed chlorpromazine hydrochloride (Thorazine). The client calls the mental health clinic and tells the nurse that her urine has become dark. The client has no other urinary symptoms. The nurse should provide which information to the client? 1. To seek treatment for a urinary tract infection 2. That this symptom indicates medication toxicity 3. To increase her intake of acid-ash foods and liquids 4. That this is an expected side effect of the medication

4. This is an expected side effect of the medication

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse reviews the result of which laboratory study to detect which adverse effect of this medication? 1. Platelet count 2. Liver function 3. Blood glucose level 4. White blood cell (WBC) count

4. WBC

A hospitalized client is receiving clozapine (Clozaril) for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1. Platelet count 2. Cholesterol level 3. Blood urea nitrogen 4. White blood cell (WBC) count

4. WBC count Rationale: Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The WBC count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 3 are incorrect and unrelated to this medication.

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic? 1. "Only you can help?" 2. "You decided not to take your medication?" 3. "If you can make this wise observation, you probably don't need your medication any longer." 4. "Your health care provider wants you to continue with this medication because it is helping you. Do you recall needing to be hospitalized because you stopped your medication?"

4. Your health care provider wants you to continue with this medication because it is helping you. Do you recall needing to be hospitalized because you stopped your medication?"

The nurse is caring for a client with neuroleptic malignant syndrome (NMS) that resulted from the use of antipsychotic medications. Which assessment finding would the nurse anticipate to note resulting from this syndrome? 1. Dysphagia 2. Bradycardia 3. Hypotension 4. Hyperpyrexia

4. hyperpyrexia

A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? 1. Provide large, nutritious meals. 2. Serve foods while they are hot. 3. Add spices to food for added flavor. 4. Remove dairy products and red meat from the meal.

4. remove dairy products and red meat from meal

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 1. Increase socialization of the client with peers. 2. Avoid laughing or whispering in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.

Avoid laughing or whispering in front of the client. Rationale: Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.

The nursing instructor is evaluating a nursing student for knowledge of antibody classes. What should the student state when asked which antibody is the first produced in response to an antigen? 1. Immunoglobulin G (IgG) 2. Immunoglobulin A (IgA) 3. Immunoglobulin D (IgD) 4. Immunoglobulin M (IgM)

IgM

The nurse is monitoring a client who has been placed in restraints because of violent behavior. When should the nurse determine that it will be safe to remove the restraints? 1. Administered medication has taken effect. 2. The client verbalizes the reasons for the violent behavior. 3. The client apologizes and tells the nurse that it will never happen again. 4. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.

No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. Rationale: The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. Options 1, 2, and 3 do not ensure that the client has controlled the behavior.