NUR2214 Module 6 EAQs
A 12-year-old child being seen in the clinic has not received the hepatitis B (HBV) vaccine. What should the nurse recommend?
The three-dose series of HBV should be started.
Which type of hypersensitivity may be associated with rhinorrhea?
Type I hypersensitivity
The parent of a child with immune thrombocytopenia (ITP) asks the nurse what kind of sport activity will be beneficial for the child. How does the nurse respond?
"Encourage swimming or walking."
A registered nurse is teaching a student nurse regarding the interventions for a client with human immunodeficiency virus (HIV) infection. Which statement by the student nurse indicates the nurse needs to follow up?
"I will ask the client to avoid involvement in community activities."
The parents of a child taking oral iron supplements report that the child's stools are a tarry green color. What is the best response the nurse provides to the parents?
"Tarry green color is expected with oral iron supplements."
An adolescent is brought to the hospital by the parent. The adolescent has a slump and cannot sit upright. On examination, the nurse finds a painless curvature of spine side to side. What should the nurse advise the parent?
"Your child has scoliosis and needs to see the primary health care provider."
The number of CD4+ T-cells is reduced in human immunodeficiency virus (HIV) disease. How many CD4+ T-cells are usually present in a cubic millimeter (mm 3) of a healthy adult's blood?
800-1000
The school nurse is teaching a class on injury prevention. What should be included when discussing firearms?
Adolescence is the peak age for being a victim and/or offender in the case of injury involving a firearm.
A patient is diagnosed with female athlete triad. What characteristics does the nurse expect to find in the patient? Select all that apply.
Amenorrhea Osteoporosis Eating disorder
The nurse is assessing a child with immune thrombocytopenia (ITP). The nurse observes that there is no active bleeding in the child. Which medications does the nurse expect in the child's prescription?
Anti-D antibody
Which term is used to describe the removal of blood from an individual, separation of the blood into its components, retention of one or more of these components, and reinfusion of the remainder of the blood back into the individual?
Apheresis
A patient has developed a type II hypersensitivity reaction. Which condition is associated with this type of hypersensitivity?
Autoimmune hemolytic anemia
A patient presents with severe angioedema of the lips, face, and tongue. Which medication is most likely to have caused this hypersensitivity reaction?
Benanzepril (Lotensin)
In human immunodeficiency virus (HIV) infections, more virus particles are created when the virus enters which type of host cell?
CD4+ T-cell
The nurse is assessing a 16-year-old obese adolescent. The clinical reports indicate high serum triglyceride levels. The nurse advises the adolescent to undergo an electrocardiogram (ECG). The reason behind this is because the adolescent is at risk for what?
Cardiac disorders
When caring for an individual with anorexia nervosa, what is the most important nursing intervention?
Correct malnutrition
A client presents with a localized bacterial infection of mucous membranes. Which organism is most likely responsible for this condition in the client?
Corynebacterium diphtheria
Which type of hypersensitivity is a cell-mediated immunity with T-lymphocyte as the reactive cell?
Delayed hypersensitivity
An adolescent female is admitted to the hospital with anorexia nervosa. What should the nurse monitor in this patient? Select all that apply.
Electrolyte levels in the blood Levels of ketones and protein in urine Blood pressure in sitting and standing position
Which features of the human immunodeficiency virus (HIV) virus assist the viral particle in finding a host?
Gp41 and gp120 docking proteins
The nurse is explaining blood components to an 8-year-old child. The nurse could best describe platelets by explaining that they do what?
Help the body stop bleeding by forming a clot (scab) over the hurt area
Which symptom is seen in a child with disseminated intravascular coagulation (DIC)?
Increased tendency to bleed
The school nurse is discussing prevention of acquired immunodeficiency syndrome with some adolescents. In the discussion, what should the nurse include?
Intravenous drug users should not share needles.
How does the assessment of the financial resources of the patient with AIDS help the nurse?
It helps in assessing the nutritional status of the patient.
A 1-year-old exhibits a runny nose and cough after being administered a vaccine via the intranasal route. Which vaccine may have been administered to the child?
Live attenuated influenza
What class of drugs for human immunodeficiency virus (HIV) infection reduces how well HIV genetic material can be converted into human genetic material?
Nucleoside reverse transcriptase inhibitors (NRTIs)
Which factor distinguishes a diagnosis of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS)?
Number of CD4+ T-cells
An adolescent arrives at the clinic with the parent for a routine examination. The parent reports to the nurse that the adolescent has irregular sleep patterns and watches television until late at night. What nursing intervention will the nurse perform next?
Obtain a history of sleep patterns
Which term describes infections caused by organisms that are present as part of the body's microbiome and usually are kept in check by normal immunity but may cause infection in patients with acquired immunodeficiency syndrome (AIDS)?
Opportunistic infections
A patient has developed a type II hypersensitivity. Which mechanism is involved in this type of allergic reaction?
Phagocytosis of self cells
Which type of hypersensitivity is anaphylaxis?
Rapid hypersensitivity
What do nursing responsibilities include when caring for the suicidal adolescent?
Recognizing the warning signs that indicate a young person might attempt suicide
Which features of the human immunodeficiency virus (HIV) virus convert HIV's RNA into DNA and insert it into the host's DNA?
Reverse transcriptase and integrase enzymes
The nurse is assessing a patient with allergic rhinitis. What assessment finding does the nurse anticipate?
Runny nose with itchy, watery eyes
What is the most common manifestation of severe combined immunodeficiency disease (SCID)?
Susceptibility to infection
What is the most important nursing consideration when caring for a child with sickle cell anemia?
Teach parents and child how to minimize crises
An adolescent is brought to the emergency department after sustaining a small clean cut to his right thumb. The nurse learns that the adolescent sustained injury with a clean, unused knife. On examination, the nurse finds that the cut measured 1 x 1 cm and is not contaminated. The adolescent has been immunized against tetanus in childhood but has never taken a booster dose. The most appropriate step of the nurse would be to inform the parent of what?
The adolescent requires a tetanus booster dose.
What defines the concept known as treatment as prevention (TAP) of human immunodeficiency virus (HIV)?
What defines the concept known as treatment as prevention (TAP) of human immunodeficiency virus (HIV)?
What safer sex methods can reduce the risk of human immunodeficiency virus (HIV) transmission? Select all that apply.
abstinence monogamy condom use
In patients with human immunodeficiency virus (HIV), which type of laboratory test measures the patient's response to the virus rather than parts of the virus?
anitbody testing
A client receiving chemotherapy asks the nurse why an antibiotic was prescribed. Which tissue affected by chemotherapy should the nurse consider when formulating a response?
bone marrow
Occupational exposure of the health care worker's broken skin or mucous membranes to which body fluids from a patient with human immunodeficiency virus (HIV)-positive status requires postexposure prophylaxis? Select all that apply.
breast milk amniotic fluid
Consensual and nonconsensual sexual exposures involving insertive and receptive types of sex with oral, vaginal, or anal contact are considered which type of exposure to human immunodeficiency virus (HIV)?
non-occupational
According to the Centers for Disease Control and Prevention (CDC) classifications, what stage of human immunodeficiency virus (HIV) is marked by CD4+ T-cell count between 200-499 cells/mm 3 (0.2-0.449 × 109/L) or 14-28%?
stage 2
The nurse has been exposed to the blood of a patient who is human immunodeficiency virus (HIV) positive. What is the window of opportunity to begin postexposure prophylaxis (PEP) for the best possible outcome in preventing HIV infection?
two hours
The nurse is instructing a group of obese adolescents about managing obesity. What instructions will the nurse include in the teachings? Select all that apply.
"Eat plenty of vegetables." "Eat a healthful breakfast daily." "Avoid eating at fast food joints."
A diagnosis of acquired immunodeficiency syndrome (AIDS) requires the patient to meet which criteria? Select all that apply.
CD4+ T-cell count less than 14% Diagnosis of an opportunistic infection CD4+ T-cell count less than 200 cells/mm 3 (0.2 × 109/L)
What laboratory changes are most likely in a patient whose immune system is being overwhelmed by human immunodeficiency virus (HIV)?
CD4+ T-cell counts fall, viral numbers rise
The nurse is caring for a child with severe anemia. The child has to undergo several blood tests. What actions does the nurse take to prepare the child for the test? Select all that apply.
Describes the test step by step Demonstrates the procedure on a doll Explains why all the tests are necessary
A nurse is educating an immunocompromised patient about preventing infection. Which should the patient report to the health care provider immediately?
Foul-smelling or cloudy urine
What is the most appropriate action for stopping an occasional episode of epistaxis (nose bleeding)?
Have the child sit up and lean forward
Which condition in a child indicates a deficiency of one of the factors (proteins) necessary for blood coagulation?
Hemophilia
A patient is diagnosed with a type I hypersensitivity. Which antibody level increases during this type of allergy?
IgE
The nurse is assessing a patient with suspected serum sickness. Which symptoms are consistent with serum sickness? Select all that apply.
Malaise Arthralgia Lymphadenopathy
The community nurse is conducting a teaching session on good dietary habits to prevent obesity in adolescents for a group of parents and adolescents. What information does the nurse include in the teaching? Select all that apply.
Perform mild to moderate intensity exercises regularly. Have frequent meals with other family members. Limit eating at fast food restaurants.
When discussing sex and sexual activities with adolescents, what should the nurse do?
Present normal body functions in a straightforward manner
What class of drugs for human immunodeficiency virus (HIV) infection prevents new virus particles from splitting into functional pieces?
Protease inhibitors
During the physical examination, the patient reports a history of latex allergy. Which item may cause this reaction?
Surgical gloves
What is true regarding the risk of human immunodeficiency virus (HIV) transmission from patients receiving combination antiretroviral therapy (cART)?
The patient's viral load may drop to undetectable levels, but there is still a risk of transmission.
The parents of a child with leukemia are anxious during a nose bleeding episode and request platelet transfusions for the child. What action does the nurse take?
Tries to stop the bleeding by applying pressure at the site
Which sexual act carries the highest risk for the transmission of human immunodeficiency virus (HIV)?
anal sex
Which is an example of a type I hypersensitivity reaction?
angioedema
Which are common means of human immunodeficiency virus (HIV) transmission? Select all that apply.
sexual perinatal parenteral
An adolescent female has a moderate flow of menstrual blood, and there are no clots in it. She has frequent menses. On examination, her skin is pale. What should the nurse advise this girl?
"Take iron-rich foods such as green leafy vegetables."
A nurse is assessing clients who are to be given the smallpox vaccination. Which client should the nurse remove from the immunization line for medical counseling?
45-year-old woman with breast cancer
What is the most important strategy to use when teaching about smoking prevention in teenagers?
Emphasize the immediate effects of smoking
How often should the patient taking tenofovir/emtricitabine for pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) be tested for HIV?
Every three months
The nurse is educating a group of adolescents about body piercing. Which infections that can be transmitted by body piercing should the nurse include in patient teaching for this group? Select all that apply.
Hepatitis B virus Hepatitis C virus Human immunodeficiency virus
Which medications act by binding with integrase enzyme and prevent human immunodeficiency virus (HIV) from incorporating its genetic material into the client's cell? Select all that apply.
Raltegravir Elvitegravir
A patient is undergoing a skin test for allergies. Which symptoms are associated with an anaphylactic reaction? Select all that apply.
Red blotches Itching and urticaria Erythema and angioedema
An infant with sickle cell anemia (SCA) is prescribed the hemoglobin electrophoresis test. What is the purpose of this test?
To detect different types of hemoglobin
A patient has developed serum sickness. What is the most likely cause?
antibiotic therapy
Abnormal functioning of which body system is responsible for the signs and symptoms of human immunodeficiency virus (HIV) disease?
immune
A child is administered a RotaTeq vaccine. What adverse drug effect should the nurse monitor for?
intussusception
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?
risk factor
The nursing instructor is teaching a student how to administer iron dextran injections to a child with severe anemia. Which instruction does the nurse give after the student administers the injection?
"Do not massage the injection site."
The nurse educates a client on decreasing the risk of developing antibiotic-resistant infections. Which statement made by the nurse will be most significant?
"Do not skip any dose of your antibiotics."
The nurse is interviewing an obese adolescent. What questions does the nurse ask the patient during the assessment? Select all that apply.
"Do you have pain in your joints?" "Do you have skin discoloration?" "Do you have difficulty swallowing?"
Parents report that their 13-year-old child is eating excessive amounts of food. What does the nurse suggest to the parents?
"Encourage the child to have nutritious food regularly."
The nurse is assessing an adolescent who has suicidal ideation and is habituated to alcohol and drugs. During counseling, which statement given by the adolescent indicates that he feels guilty?
"I wish I had never used alcohol in the first place."
The parent of a 6-month-old infant asks the nurse about the food that can be included in the child's diet. What does the nurse suggest?
"Include cereals in the diet."
The nurse is reviewing the laboratory results of a 1-year-old child who has been diagnosed with sickle cell anemia (SCA) during infancy and is now presenting with symptoms of the disease. The parent says to the nurse, "I don't understand. My child did not have any symptoms at all up until now." Which is the best response by the nurse?
"Infants usually do not have symptoms, but the symptoms become apparent as children get older."
The parents tell the nurse that their child has frequent nosebleeds that usually stop within 5 to 10 minutes. Which intervention does the nurse suggest to the parents to prevent nosebleeds?
"Insert petroleum jelly in the nostril after a nosebleed."
The nurse educates the mother of an 8-year-old girl about the sequences of maturational changes. Which response of the mother indicates effective learning?
"Menstruation begins 2 years after the appearance of the first signs of maturation."
The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity?
"The reaction of sensitized T-cells with antigen and release of lymphokines activate macrophages and induce inflammation."
A first-born 7-month-old of African-American heritage has a sudden onset of uncontrollable screaming and crying and is brought to the emergency room. The infant and his or her parents are visiting from a country in the Caribbean. After determining that there is no injury present, what actions would the nurse expect to take?
Ask the parents if their child had any recent vomiting, diarrhea, or fever recently
The nurse is caring for a patient with a poison ivy skin rash. What type of hypersensitive reaction is the patient experiencing?
Delayed reaction
What is an important consideration for the school nurse planning a class on injury prevention for adolescents?
During adolescence a need exists for discharging energy, often at the expense of logical thinking.
Jacob is a 2-year-old outpatient with hemophilia A. He will be coming to the emergency department (ED) for an outpatient infusion after a tumble from his high chair. There are a number of bleeding disorders that may require infusion with clotting factors or blood products. Which blood component will Jacob need replaced?
Factor VIII
Girls experience an increase in weight and fat deposition during puberty. What do nursing considerations related to these changes include?
Giving reassurance that these changes are normal
A client presents to the emergency department with shortness of breath, bloody sputum, weight gain, generalized edema, and a blood pressure of 150/110. The nurse reviews the client's laboratory results and determines that the client has impaired renal function. Which diagnosis will the nurse most likely observe written in the client's electronic medical record?
Goodpasture syndrome
When the human immunodeficiency virus (HIV) virus enters the patient's CD4+ T-cell, what is the new role served by the immune cell?
HIV factory
What are the most common triggers for allergic rhinitis? Select all that apply.
Plant pollens Animal dander Dust and molds
What is administered to a child who presents with hemophilia A and is at risk for joint bleeding?
Primary prophylaxis
While assessing a patient, the nurse notes that the patient's vagina and buccal and nasal mucous membranes are dry. The laboratory reports indicate the presence of elevated levels of IgM rheumatoid factor. The nurse suspects what syndrome?
Sjögren's syndrome
The nurse suspects that a child is having an adverse reaction to a blood transfusion. What should be the first action by the nurse?
Stop transfusion and maintain a patent intravenous line with normal saline and new tubing
A patient has developed a type IV hypersensitivity reaction. Which immune cells or components are involved in this type of reaction?
T-cells
In planning sex education and contraceptive teaching for adolescents, what information should the nurse consider?
Teenagers need contraception education in both oral and written form.
An adolescent female is unusually preoccupied by her appearance. When the nurse asks the adolescent, "Do you make yourself sick because you feel uncomfortably full?" the adolescent replies no. The nurse asks her if she has lost control over how much she eats; the adolescent says no. The child says that she has lost more than 8 kg of weight in the last 3 months and she believes that she is fat, whereas her parents tell her that she is too thin. She does not think that food dominates her life. What can the nurse interpret about this girl?
The child most likely has anorexia nervosa or bulimia nervosa.
A newborn is Rh positive, and the mother is Rh negative. The infant is to receive an exchange transfusion. When the parents ask why their baby will receive Rh-negative blood, what explanation does the nurse provide?
The red blood cells will not be destroyed by maternal anti-Rh antibodies.
The nurse is caring for a child with epistaxis. The parent asks how nosebleeds can start. What does the nurse understand about the common causes of epistaxis in children? Select all that apply.
They can be caused by nose picking. They can be caused by trauma to the nose. They can be caused by inflammation from allergies. They can be caused by foreign bodies lodged in the nostrils
Which approaches can be used to classify anemia? Select all that apply.
etiology morphology
The nurse suspects the Jarisch-Herxheimer reaction in a client with syphilis who is on antibiotic therapy. Which symptoms in the client support the nurse's suspicion? Select all that apply.
fever generalized ache pain at the injection site
Some adults develop an acute infection within four weeks of first being infected with human immunodeficiency virus (HIV). What symptoms may indicate this acute HIV infection? Select all that apply.
fever night sweats muscle aches
According to the Centers for Disease Control and Prevention (CDC) classifications, what stage of human immunodeficiency virus (HIV) is marked by CD4+ T-cell count less than 200 cells/mm 3 (0.2 × 109/L) or less than 14%?
stage 3