Medsurge CH 28-37

A client has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the client will present with what alteration in lab values? -Increased eosinophils -Increased neutrophils -Increased serum albumin -Decreased blood glucose

-Increased eosinophils

An intensive care nurse is aware of the need to identify clients who may be at risk of developing DIC. Which ICU client most likely faces the highest risk of DIC? -a client with extensive burns -a client with a diagnosis of acute respiratory distress syndrome -a client who suffered multiple trauma in a workplace accident -a client who is being treated for septic shock

-a client who is being treated for septic shock

A client comes to the clinic reporting fatigue. Blood work shows an increased bilirubin concentration and an increased reticulocyte count. Which condition should the nurse most suspect the client has? -A hypo proliferative anemia -A leukemia -Thrombocytopenia -A hemolytic anemia

A hemolytic anemia

A nurse is caring for a client who has had a severe antigen-antibody reaction. Which portion of the antigen is involved in binding with the antibody? -Antibody agglutination -Antigenic message -Antigenic determinant -Antibody response

Antigenic determinant

A client with hepatitis B has been admitted to the medical intensive care unit with sepsis. Which immunity function was most likely compromised? -Lymphatic -Passive immunity -Complement system -Monoclonal antibodies

Complement system aka plasma proteins

The results of a client's most recent blood work and physical assessment are suggestive of ITP. The client should undergo testing for which of the following potential causes? SATA -hepatitis -AKI -HIV -malignant melanoma -cholecystitis

Hepatitis and HIV (viral)

A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? -Client must not have received immunization within 7 days -Administer albuterol 30-45 minutes prior -Prophylactic epinephrine should be given before the test -Emergency equipment should be readily available

Emergency equipment should be readily available

A client's electronic health record notes that the client has previously undergone treatment for secondary polycythemia. The nurse should assess for which factor? -Recent blood donation -Evidence of lung disease -A history of venous thromboembolism -Impaired renal function

Evidence of lung disease

A client is vigilant in self-care but is frustrated by recent history of upper respiratory infections and influenza. Which aspect of the client's lifestyle may have a negative effect on immune response? SATA -Exercises twice a day at the gym -Does not consume red meat -Takes OTC daily vitamins -Sleeps seven hours daily -Works as a medical researcher

Exercises twice a day at the gym Works as a medical researcher

A nurse is providing care for a client who has a recent of giant cell Arteritis. Which aspect of physical assessment should the nurse prioritize? - subtle signs of bleeding disorders -The metatarsal and phalangeal joints -Thoracic pain that is exacerbated by activity -headaches and jaw pain

headaches and jaw pain

A nurse is planning care of a client who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. Which nursing diagnosis is most likely to apply to these clients care needs? -ineffective role performance related to pain -risk for impaired skin, integrity related to myalgia -Risk for infection related to tissue alterations -Unilateral neglect related to neuropathic pain

ineffective role performance related to pain

A client with myelodysplastic syndrome (MDS) is being treated on a medical unit. Which priority finding should prompt the nurse to contact the client's primary care provider? -reports of a frontal lobe headache -an episode of urinary incontinence -oral temperature of 37.5C (99.5F) -an oxygen saturation SpO2 of 91% on room air

oral temperature of 37.5C (99.5F)

The nurse is providing care for a client who has multiple sclerosis (MS). The nurse recognizes the autoimmune etiology of the disease and the potential benefits of what treatment? -stem cell transplantation -serial immunizations -immunosuppression -genetic engineering

stem cell transplantation

A nurse is assessing a client with HIV, who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? -oral temperature of 37.2C -tachypnea and restlessness -Frequent loose stools -weight loss of 0.45 KG (1lb) since yesterday.

tachypnea and restlessness

A client is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). Which assessment finding is certain to be present if the client has CLL? -increased numbers of blast cells -increased lymphocytes levels -intractable bone pain -thrombocytopenia with no evidence of bleeding

-increased lymphocytes levels

An infection control nurse is presenting an in-service reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining? -Agglutination -Cellular immune response -Humoral response -Phagocytic immune response

Agglutination

A 68-year-old client with a history of rheumatic disease has persistent swelling, no stiffness, and full range of motion to his left knee after an injury sustained several months ago. X-rays reveal no fracture of the extremity. Which factor is the most likely cause of the client continued swelling? -Degradation of cartilage -aging -An inflammation process -reinjury, not seen an x-ray results

An inflammation process

The nurse in an allergy clinic is educating a new patient about the pathology of the patient's health problem. What response should the nurse describe as a possible consequence of histamine release? A) Constriction of small venules B) Contraction of bronchial smooth muscle C) Dilation of large blood vessels D) Decreased secretions from gastric and mucosal cells

B) Contraction of bronchial smooth muscle

An emergency department nurse is triaging a 77-year-old client who presents with uncharacteristic fatigue as well as back and rib pain. The nurse should recognize the need for this client to be assessed for which health problem? -Hodgkin disease -Non-Hodgkin lymphoma -Multiple myeloma -Actue thrombocythemia

Multiple myeloma

A client with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the client to do? A. Elevate the affected extremity to shoulder level when at rest. B. Engage in exercises that strengthen the unaffected muscles. C. Apply topical anesthetics to accessible skin surfaces as needed. D. Avoid using analgesics so that further damage is not masked.

B. Engage in exercises that strengthen the unaffected muscles.

A client's injury has initiated an immune response the involves inflammation. What are the first cells to arrive at the client's site of inflammation? -Eosinophils -RBCs -Lymphocytes -Neutrophils

Neutrophils

A client's recent diagnostic testing including a total lymphocyte count. The results of this test will allow the care team to gauge what aspect of the client immunity? -Humoral immune function -Antigen recognition -Cell-mediated immune function -Antibody production

Cell-mediated immune function

A client has a diagnosis of multiple myeloma and the nurse is preparing health education in preparation for discharge from the hospital. What action should the nurse promote? -Daily performance of weight-bearing exercise to prevent muscle atrophy -Close monitoring of urine output and kidney function -Daily administration of warfarin, as prescribed -Safe use of supplementary oxygen

Close monitoring of urine output and kidney function

On admission to a medical unit, a client with HIV tests positive for benzodiazepine. The client denies using this medication. Which medication is likely causing a false-positive result? -Efavirenz -Doravirine -Nevirapine -Etravirine

Efavirenz

A client is being treated for bacterial pneumonia initially experienced dyspnea and a high fever but now claims to be feeling better and is afebrile. The client is most likely in which stage of the immune response? -Recognition -Proliferation -Response -Effector

Effector

A client diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the condition. The nurse explains to this client that this condition occurs due to which factor? -An attack on the platelets by antibodies -Decreased production of platelets -Impaired communication between platelets -An autoimmune process causing platelet malfunction

Decreased production of platelets

A client is undergoing testing to determine the overall function of the clients immune system. Which test will best identify the functioning of the clients cellular immune system? -Immunoglobulin testing -Delayed hypersensitivity skin test -Specific antibody response -Total serum globulin assessment

Delayed hypersensitivity skin test aka cell-mediated

A client is fighting an active infection. What function will cytokines perform in this immune response? -Determine whether a cell is foreign -Determine if lymphokines will be activated -Determine whether the T cells will remain in the nodes and retain a memory of the antigen -Determine whether the immune response will be the production of antibodies or cell-mediated

Determine whether the immune response will be the production of antibodies or cell-mediated

A nurse is providing care to a client with multiple myeloma with reports of nausea, diarrhea, alopecia, and red urine. The client's recent intervention include ECG, MUGA, and a central line venous access placed on the right chest wall. Which medication is the client most likely receiving? -Dexamethasone -Lenalidomide -Doxurobicin -Etoposide

Doxurobicin

A nurse is caring for a client who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the client to monitor closely for what post procedure complication? -fever -Crepitus -Fasciculations -Synovial fluid leakage

Fever

A clinic nurse is working with a client who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the client's disease? -Document the color of the client's palms and face during each visit -Follow the client's erythrocyte sedimentation rate over time -Document the client's response to erythropoietin injections -Follow the trends of the clients hematocrit

Follow the trends of the clients hematocrit

A client who is diagnosed with scleroderma will be undergoing tests to assess for systemic involvement. Which system should the nurse prioritize in Assessment? -hepatic -Gastrointestinal -Genitourinary -Neurologic

Gastrointestinal

A client diagnosed with acute myeloid leukemia has just been admitted to the oncology unit. When writing this client's care plan, which potential complication should the nurse address? -Pancreatitis -Hemorrhage -Arteritis -Liver dysfunction

Hemorrhage

A 25-year-old client comes to the emergency department with excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged prothrombin time (PT), but a vitamin K deficiency is ruled out. When assessing the client, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the client's signs and symptoms? -Lymphoma -Leukemia -Hemophilia -Hepatic Dysfunction

Hepatic Dysfunction

A nurse has admitted a client who had been diagnosed with urosepsis. Which immune response predominated in sepsis? -Mitigated -Nonspecific -Cellular -Humoral

Humoral

A nurse at a long-term care facility is amending the care plan of a resident who has just been diagnosed with essential thrombocythemia (ET). The nurse should anticipate the administration of which medication? -Dalteparin -Allopurinol -Hyrdroxyurea -Hydrochlorothiazide

Hyrdroxyurea

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

Immunosuppression

An older adult women's current medication regimen includes alendronate. What outcome would indicate successful therapy? -Increased bone mass -Resolution of infection -Relief of bone pain -Absence of tumor spread

Increased bone mass

A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results are most suggestive of this diagnosis? -High chloride, calcium and magnesium levels -High parathyroid and calcitonin levels -Low serum calcium and magnesium levels -Low serum calcium and low phosphorus levels

Low serum calcium and low phosphorus levels

A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. Which topics should the nurse address string health education? Select all that apply. -Surgical treatment options -Weight loss -Management of Raynaud-type symptoms -exercise -Skin care

Management of Raynaud-type symptoms Exercise Skin care

A client is learning about a new diagnosis of asthma. What medication will best prevent the onset of acute asthma exacerbations? -Diphenhydramine -Montelukast -Albuterol sulfate -Epinephrine

Montelukast

A 20-year-old client with no medical history arrives at a walk-in clinic reporting swelling on the left side of the neck. On palpation, the lymph nodes on the neck are painless, firm but not hard. What is the next appropriate intervention? -Recommend immediate and urgent transfer to nearest trauma center -Perform diagnostic studies to rule out any infectious origin at a hospital -Refer the client to a primary health provider for a non urgent appointment -Complete a CT scan because the client has Hodgkin lymphoma

Perform diagnostic studies to rule out any infectious origin at a hospital

A client's blood work reveals a platelet of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level? -Dermatitis -Petechiae -Uticaria -Alopecia

Petechiae

A client has been brought to the emergency department by the parents after falling through the glass of a patio door, sustaining a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of which type of cell? -Interferons -Phagocytic cells -Helper T cells -Cytokines

Phagocytic cells

A client has been diagnosed with a lymphoid stem cell defect. This client has the potential for a problem involving which of the following? -Plasma cells -Neutrophils -RBC -Platelets

Plasma cells

A client with Wiskott-Aldrich syndrome (WAS) is admitted to the medical unit. The nurse caring for the client should prioritize which intervention? -Protective isolation -FFP administration -Chest physiotherapy -Nutritional supplementation

Protective isolation

A client's most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis? -Risk for imbalanced fluid volume r/t low albumin -Risk for infection r/t low albumin -Ineffective tissue perfusion r/t low albumin -Impaired skin integrity r/t low albumin

Risk for imbalanced fluid volume r/t low albumin

A client has been living with a diagnosis of anemia for several years and has experienced recent declines in hemoglobin despite active treatment. Which assessment finding would signal complications of anemia? -Venous ulcers and visual disturbances -Fever and signs of hyperkalemia -Epistaxis and gastroesophageal reflux -SOB and peripheral edema

SOB and peripheral edema

The nurse should recognize a client's risk for impaired immune function if the client has undergone surgical removal of which of the following? -Thyroid gland -Spleen -Kidney -Pancreas

Spleen

A client has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse perform following this procedure? -Wrap the joint in a compression dressing -Perform passive range of motion exercises -Maintain the knee inflection for up to 30 minutes -apply heat to the knee

Wrap the joint in a compression dressing

Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult client who is otherwise healthy. The client and care team have collaborated and will soon begin induction therapy. The nurse should prepare the client for: -daily treatment with targeted therapy medications -radiation therapy on a daily basis -hematopoietic stem cell transplantation -an aggressive course of chemotherapy

an aggressive course of chemotherapy

Which of the following individuals would be the most appropriate candidate for immunotherapy? -client who had an anaphylactic reaction to an insect sting -child with allergies to eggs and dairy -client who had had a positive TB skin test -client with severe allergies of grass and pollen

client with severe allergies of grass and pollen

A nurse educator is developing a care plan concerning a risk of infection r/t vascular insufficiency. Which disease and/or injury would most likely align with this nursing care plan? -transient ischemic attack (TIA) -major burns -COPD -diabetes

diabetes