Patho Exam 1
Which client's white blood cell count indicates leukocytosis?
C 12,100
Which clients will most likely have wound healing through secondary intention? Select all that apply.
C Stage 4 pressure ulcer E Second degree burns
Which clinical manifestations will the nurse typically find upon assessment of a client with hypokalemia? Select all that apply.
Decreased bowel sounds Skeletal muscle weakness U wave on the electrocardiogram (ECG)
Which clinical manifestations would the nurse expect to find during assessment of the client with extracellular fluid volume excess?
Decreased hematocrit
A client has low albumin levels from malnutrition. Which pathophysiologic process will produce the resultant edema?
Decreased plasma oncotic pressure
If a client in liver failure has a decreased production of protein, what pathophysiologic process will occur, resulting in edema?
Decreased plasma oncotic pressure
A nurse is caring for a client with systemic lupus erythematosus (SLE). Which pathophysiologic process should the nurse consider when planning care for this client?
Deposition of immune complexes in the kidneys and many other body tissues
A nurse is explaining how a leukocyte moves through inter-endothelial junctions to the site of tissue injury. Which term should the nurse use to describe this process?
Diapedesis
A client is receiving intravenous magnesium sulfate to prevent seizures. What assessment finding would indicate to the nurse that the infusion rate is too fast?
Diminished deep tendon reflexes
A client's laboratory test results reveal decreased arterial pH and bicarbonate levels. The nurse interprets these results to determine that the client is experiencing which acid-base imbalance?
Metabolic acidosis
The nurse assesses a client with diarrhea for clinical manifestations of which acid-base imbalance?
Metabolic acidosis
The nurse monitors a client with persistent vomiting for manifestations of which acid-base imbalance?
Metabolic alkalosis
A client injures the left leg. When will the nurse expect substantial numbers of neutrophils to arrive at the site of injury?
Within 6 to 12 hours
Which term should the nurse use to describe the process of "gluing" bacteria with antibodies to promote phagocytosis of the microorganisms?
Opsonization
When a client's complement system is stimulated, which processes will be activated? Select all that apply.
Opsonization Degranulation of mast cells Lysis of cells through membrane disruption
A client lies on a concrete floor for 9 hours after a heroin overdose and develops a deep pressure ulcer on the sacrum. How will the nurse expect this wound to heal?
Secondary intention
A child with ill-fitting shoes developed a small blister that burst, releasing clear watery fluid. How should the school nurse document this type of exudate?
Serous
A nurse is caring for a client that has no antigen presentation because of a lack of major histocompatibility complex (MHC) class I molecules. Which diagnosis will the nurse observe written in the client's medical record?
Bare lymphocyte syndrome
A nurse is teaching about examples of granulocytes. Which cellular class should the nurse include?
Basophils
A client's serum sodium level is 150 mEq/L. The nurse expects which changes in the client's serum chloride and bicarbonate levels? Select all that apply.
Serum chloride, 115 mEq/L Serum bicarbonate, 18 mEq/L
A nurse monitors for central nervous system symptoms in a client with hypernatremia. What is the rationale for the nurse's actions?
Shrinking of brain cells results in these symptoms
nitors for central nervous system symptoms in a client with hypernatremia. What is the rationale for the nurse's actions?
Shrinking of brain cells results in these symptoms.
A nurse is describing phagocytosis. In the figure, which step indicates fusion of the phagosome with lysosome granules?
Step 3
The nurse is caring for a client with arthritis who is scheduled for knee replacement surgery. After reviewing the client's medical history, the nurse finds that the client is at risk for delayed wound healing. Which medication did the nurse find in the client's medical history?
Steroid
Which information from the client indicates that the nurse's teaching about magnesium was successful?
Symptoms of hypomagnesemia include muscle cramps and irritability.
Which laboratory finding should the nurse use to evaluate the effectiveness of protease inhibitors prescribed for a client with a viral infection?
T helper cells = 800/mm3
Which body fluids and secretions contain lysozymes that protect the client from invasion of gram-positive bacteria? Select all that apply.
Tears Saliva Perspiration
A client has type AB+ blood. How should the nurse interpret this finding? Select all that apply.
The client has D antigens. The client has the DD genotype. The client has A and B antigens.
After reviewing the history of a client with recurrent infection, the nurse finds that the client has impaired adaptive immunity. Which finding supports the nurse's conclusion?
The client has a T cell deficiency
After reviewing the history of a client with recurrent infection, the nurse finds that the client has impaired adaptive immunity. Which finding supports the nurse's conclusion?
The client has a T cell deficiency.
A nurse is assessing a client. Which findings will cause a shift of potassium into the client's cells? Select all that apply.
The client has alkalosis. The client received insulin. Aldosterone is released in the client's body. Epinephrine is released in the client's body.
The nurse is taking the health history. Which factors will increase the client's risk for hypokalemia? Select all that apply.
The client has diarrhea. The client is taking a diuretic. The client has chronic alcoholism.
Which treatment should the nurse expect to be prescribed for a client with adenosine deaminase deficiency and low levels of IgM and IgA? Select all that apply.
Transplantation of bone marrow Transfusions of glycerol frozen-packed erythrocytes
A client has an Arthus reaction after an injection. What will the nurse observe upon assessment of this client?
Clotting problems
A client has water excess. Which assessment finding will the nurse expect?
Headache
A client has a significant water deficit. Which assessment findings of dehydration will the nurse observe? Select all that apply.
Headache Decreased urine volume
While reviewing the medical history of a client with X-linked immunodeficiency disorder, the nurse finds that the client has low immunoglobulin M (IgM) antibodies. Which complication should the nurse assess for in the client?
Hemorrhage
An older adult client who had an accidental fall is admitted to the hospital. After reviewing the client's laboratory reports, the nurse believes the client is at risk for impaired wound healing. Which finding supports the nurse's conclusion?
High fasting blood glucose levels
When a client's mast cells degranulate, which substance is released?
Histamine
A client requires a transplant. Which cells become a priority for the nurse to check?
Human leukocyte antigens (HLAs)
A nurse closely monitors for which condition in a client with hyperparathyroidism?
Hypercalcemia
A client with oliguria from renal failure should be closely monitored by the nurse for which electrolyte imbalance?
Hyperkalemia
Which electrolyte imbalance is the client experiencing (see chart)?
Hypocalcemia
A client has metabolic alkalosis. The nurse should monitor for which electrolyte imbalance?
Hypokalemia
. A nurse found during the history that a client has chronically overused magnesium-aluminum antacids for a long period of time. The nurse will expect to find which laboratory result?
Hypophosphatemia
A nurse found during the history that a client has chronically overused magnesium-aluminum antacids for a long period of time. The nurse will expect to find which laboratory result?
Hypophosphatemia
The nurse is assessing a client who has entered anaphylactic shock. Which physiologic condition does the nurse expect to see in the client?
Hypotension
A client has an acid-base imbalance. The nurse would expect the client's renal buffering system to respond in which manner?
If metabolic alkalosis exists, the kidneys conserve H+ions.
A client has an allergic response. When the nurse is checking the laboratory values, which antibody level will be most elevated?
IgE
After a client has a type 1 hypersensitivity response, which laboratory test result will the nurse find the most elevated?
IgE
A client has a type III hypersensitivity reaction. Which pathophysiologic process should the nurse consider when planning care for this client?
Immune complexes activate the complement system and damage tissues
During wound healing a client develops contracture of scar tissue. Which problems should the nurse monitor for in this client? Select all that apply.
Impaired blood flow Limited movement at joints
A nurse is asked by a coworker where one third of a client's total body water is located. How should the nurse respond?
In the extracellular compartment
While assessing a client, the nurse observes a raised scar at the site of injury. What does the nurse suspect to be the cause of this scarring pattern?
Increase in collagen levels
After reviewing the genetic reports of a client, the nurse suspects that the client has hereditary angioedema. Which finding supports the nurse's conclusion?
Increase in plasma protein system
A client is in the later stages of inflammation. The client's mast cells release leukotrienes that perform which function?
Increase vascular permeability
The nurse assesses a client with a large draining pressure ulcer for signs of fluid imbalance. Which findings would the nurse expect to find? Select all that apply.
Increased heart rate Dry mucous membranes
When a client begins to develop metabolic acidosis, the nurse expects to assess which breathing pattern?
Increased rate and increased depth
The nurse is caring for a client with swelling and pain at the site of a wound. Which other physiological changes does the nurse expect to find? Select all that apply.
Increased redness Increased blood flow
Which complication will the nurse monitor for in a client who has been prescribed long-term antibiotic therapy?
Increased risk of Candida albicans infection
A client is hospitalized with a malignant tumor that causes secretion of parathyroid hormone. What assessment findings will alert the nurse that the client is developing an expected electrolyte imbalance?
Increased serum calcium, lethargy, and constipation
A nurse administers an attenuated vaccination. Which type of vaccine did the nurse give to the client?
A live, weakened microorganism
A nurse is caring for a client with mycosis. The nurse is caring for which client?
A man with a fungal infection
A nurse is asked by a coworker what an immature macrophage is called. How should the nurse respond?
A monocyte
For proper pH balance within a client's body, which ratio of bicarbonate ions to carbonic acid molecules needs to occur?
A ratio of 20 bicarbonate ions to 1 carbonic acid molecule
A client has an inappropriate, exaggerated response against a noninfectious environmental substance. Which term should the nurse use when reporting this condition to another healthcare professional?
Allergy
A client has an organ transplant from another person. The client's body mounts an aggressive response against the organ transplanted. Which type of reaction did the client experience?
Alloimmune
A client has a reaction to a liver transplant. Which term will the nurse use to describe this event?
Alloimmunity
Which substances will the nurse include when teaching about the kidney's ability to properly maintain a client's serum pH? Select all that apply.
Ammonia (NH3) Phosphate (HPO42-) Bicarbonate (HCO3-) Carbonic acid (H2CO3
Which substances will the nurse include when teaching about the kidney's ability to properly maintain a client's serum pH? Select all that apply.
Ammonia (NH3) Phosphate (HPO42-) Bicarbonate (HCO3-) Carbonic acid (H2CO3)
A nurse hears that a client is sensitized and is predisposed to a type I hypersensitivity reaction. How should the nurse interpret this finding?
Attachment of large amounts of IgE to mast cell membranes has occurred
A nurse hears that a client is sensitized and is predisposed to a type I hypersensitivity reaction. How should the nurse interpret this finding?
Attachment of large amounts of IgE to mast cell membranes has occurred Correct 4
The nurse is caring for a client who has undergone bone marrow transplantation. After assessing the client, the nurse suspects that the client is at risk for graft-versus-host disease (GVHD). Which client statement supports the nurse's conclusion?
"I always feel thirsty.
The nurse is caring for a client who has undergone bone marrow transplantation. After assessing the client, the nurse suspects that the client is at risk for graft-versus-host disease (GVHD). Which client statement supports the nurse's conclusion?
"I always feel thirsty."
While interacting with a client who was in a motor vehicle accident, the nurse suspects that the client is at risk for impaired wound healing. Which statement made by the client supports the nurse's suspicion?
"I hate fruit, especially citrus.
The nurse is teaching safety measures to a client with systemic lupus erythematosus (SLE). Which client statement indicates effective learning? Select all that apply.
"I should avoid sun exposure." "I should take nonsteroidal antiinflammatory drugs."
After interacting with a client, the nurse believes the client has a risk of delayed wound healing due to impaired collagen synthesis and fibroblast proliferation. Which statement made by the client supports the nurse's conclusion?
"I'm a vegetarian, but I rarely eat beans or legumes.
An older adult client had a myocardial infarction yesterday. The client asks, "I understand that part of my heart muscle is dead, but will it grow back?" What is the best response by the nurse?
"No, but it will heal by forming a scar where the heart muscle died."
The nurse is assessing a child who has wide-set eyes, low-set ears, and a shortened structure of the upper lip. The child's laboratory reports indicate a decrease in the number of T cells. Which instruction should the nurse give to the child's parents to prevent further complications?
"Provide calcium-rich food to your child.
Which nursing assessment data increase the client's risk for wound dehiscence?
5'3" tall with weight 189 lb
A client has type A blood. Which type of blood can the nurse administer to this client? Select all that apply.
A O
A client has type A blood. Which type of blood can the nurse administer to this client? Select all that apply.
A O AB
The nurse will monitor which clients for the release of antidiuretic hormone (ADH)? Select all that apply.
A client with diarrhea A client with a drop in blood pressure A client with decreased blood volume A client with increased plasma osmolality
Which client has the highest risk for developing hypernatremia?
A comatose client receiving gastric tube feedings
Which information indicates the nurse has an accurate understanding of clients' total body water (TBW)? Select all that apply.
A full-term newborn infant is about 70% to 80% TBW by weight. Healthy men have a greater percentage of body water than do healthy women.
A client asks, "Why do people who have AIDS get Kaposi sarcoma but not people who have normal immune systems?" What is the best response from the nurse?
A healthy immune system can destroy abnormal cells that can develop into cancers, but the suppressed immune system in a person who has AIDS is not able to do so as effectively.
The nurse anticipates that the client with which injury will be most at risk for developing chronic inflammation?
A wood splinter
A nurse is teaching about the functions of macrophages. Besides phagocytosis, which information should the nurse include in the teaching session? Select all that apply.
Activation of fibroblasts Release of growth factors Promotion of collagen formation Stimulation of new blood vessel growth
Which intervention will the nurse question for a client with immunodeficiencies?
Administer attenuated vaccine
A client has hyperkalemia. Which actions will the nurse take? Select all that apply
Administer glucose Administer calcium gluconate Administer sodium bicarbonate Administer cation exchange resins
A client has hyperkalemia. Which actions will the nurse take? Select all that apply.
Administer glucose Administer calcium gluconate Administer sodium bicarbonate Administer cation exchange resins
A client has hyperkalemia. Which actions will the nurse take? Select all that apply.
Administer glucose Administer calcium gluconate Administer sodium bicarbonate Administer cation exchange resins
The nurse plans care for a client with a serum potassium level of 3.0 mEq/L. The care should include which treatments?
Administer potassium intravenously at 20 mEq/hr
A nurse is caring for a client with an alloimmune disease. The nurse is caring for which client?
An infant with hemolytic disease of the newborn
A child who has a congenital immunodeficiency that impairs B lymphocyte function will have primarily a deficiency of which immune component?
Antibodies
A client has activated the complement system during an inflammatory response to an injury. When planning care, which information should the nurse remember about which substance activates complement?
Antibodies
Which information indicates the nurse has a correct understanding of the causes for type II hypersensitivity tissue injury? Select all that apply.
Antibody opsonization of cells leads to subsequent phagocytosis. Neutrophils attach to cell receptors, causing release of granules into cells. Antibodies activate complement, and subsequent lysis of target cells occurs
A client with an upper respiratory tract infection has nasal congestion. During the assessment, the nurse finds that the client's blood pressure is 120/80 mm Hg and rate of respiration is 15 breaths/minute. The nurse should check the client's prescription for which category of medication to help with the congestion?
Antihistamines
A nurse is teaching about HIV. Which area (see diagram) should the nurse choose to illustrate the structure that incorporates viral DNA into the
Area 2
A nurse is teaching the staff about the human immunodeficiency virus (HIV). Which area (see diagram) should the nurse choose to illustrate the substance that combines with the CD4 molecule?
Area 2
Which assessment findings will the nurse expect to observe in a client with systemic lupus erythematosus (SLE)?
Arthralgias, mouth ulcers, and facial rash
A client with arthritis has severe inflammation in the knee, along with fever and anxiety. During the follow-up visit, the nurse finds that the client still has inflammation and swelling in the knee, but the fever and anxiety have subsided. Which medication does the nurse anticipate finding in the client's prescription?
Aspirin
The nurse assessing the client with metabolic alkalosis will expect to find which signs and symptoms? Select all that apply.
Atrial tachycardia Hyperactive reflexes Shallow, slow respirations
The nurse assessing the client with metabolic alkalosis will expect to find which signs and symptoms? Select all that apply.
Atrial tachycardia Hyperactive reflexes Shallow, slow respirations
A nurse is teaching about the mechanisms of action for antibiotics. Which information should the nurse include? Select all that apply.
Block DNA replication Inhibit protein synthesis Inhibit synthesis of cell wall Interfere with folic acid metabolism
A client who is HIV positive receives a reverse transcriptase inhibitor drug. The drug produces a therapeutic effect by which action?
Blocks the conversion of viral RNA into double-stranded DNA
When a client's body releases natriuretic peptides, which piece of equipment should the nurse obtain to determine a therapeutic effect?
Blood pressure cuff
While reviewing the laboratory reports of a client with otitis media, the nurse finds that the client has no circulating B cells and a normal number of T cells. Which condition will the nurse expect to see written in the client's medical record?
Bruton agammaglobulinemia
After reviewing the laboratory reports of a client with a T cell deficiency, the nurse suspects that the client has acquired immunodeficiency syndrome. Which laboratory finding is consistent with this condition?
CD4+ cell levels are 150/mm3
A client's laboratory results indicate an increase in tumor necrosis factor α, interleukin 6, and prostaglandin. Which condition does the nurse expect to find in the client?
Cachexia
A hospitalized client complains of tingling in the hands and feet. The nurse assesses hyperactive bowel sounds and muscle spasms of the hands and face. Which serum laboratory value would the nurse check before contacting the primary healthcare provider?
Calcium
Which term should the nurse use to describe a client's major buffer in the extracellular fluid?
Carbonic acid-bicarbonat
Which term should the nurse use to describe a client's major buffer in the extracellular fluid?
Carbonic acid-bicarbonate
A client has hyperkalemia. Which body system is the priority for the nurse to monitor?
Cardiac
Client has hyperkalemia. Which body system is the priority for the nurse to monitor?
Cardiac
The nurse is caring for a client who is receiving antibiotic therapy. The laboratory reports indicate the presence of pyrogenic bacteria and cytokines in the client's blood. Which conditions should the nurse suspect in the client? Select all that apply.
Cardiovascular shock Intravascular coagulation
The nurse is monitoring four clients who require blood transfusions. Which client will receive safe and effective treatment?
Client A
The nurse is assessing clients who have symptoms of hypersensitivity reactions. Which client has an immune complex-mediated hypersensitivity reaction?
Client A Developed an allergic ration after eating what products
The nurse is reviewing the blood reports of four pregnant clients and their fetuses. Which client requires an immediate administration of RhoGAM?
Client C
A nurse is caring for a client with hypernatremia. Which central nervous system assessment findings will the nurse typically observe? Select all that apply.
Coma Confusion Convulsions
Which information from the staff indicates effective teaching by the nurse for substances that act as opsonins?
Complement proteins
A client has a serum potassium level of 3.0 mEq/L. The nurse monitors the client for which assessment findings? Select all that apply.
Confusion Decreased bowel sounds Weak, irregular pulse rate
A client has a serum phosphate concentration of 1.8 mg/dl. Which assessment findings will the nurse expect to observe? Select all that apply.
Confusion Muscle weakness
A nurse is caring for a client that has no antigen presentation because of a lack of major histocompatibility complex (MHC) class I molecules. Which diagnosis will the nurse observe written in the client's medical record?
Correct 3 Bare lymphocyte syndrome
A client with arthritis has a malar rash, oral ulcers, seizures, and a discoid rash. Which class of medication should be included in the client's prescriptions to provide effective treatment?
Corticosteroids
Which findings will the nurse observe in a client with local inflammation of the eye? Select all that apply.
Edema Redness
A client experiencing an isotonic fluid excess would have which clinical manifestations when the nurse performs an assessment? Select all that apply.
Edema Weight gain Distended neck veins
Which change in laboratory values will the nurse assess as evidence of renal compensation for a client's respiratory acidosis?
Elevated bicarbonate ion concentration
A nurse is discussing antimicrobial peptides, defensins, collectins, and mannose-binding lectin. What is the nurse describing?
Epithelial cell-derived chemicals
A nurse is providing wound care and observes that the client is healing normally and is in the proliferative phase of wound healing. What will the nurse observe?
Epithelialization
A client is in phase II of wound healing. Which cells produce collagen during tissue healing?
Fibroblasts
The nurse identifies that a client is experiencing an isotonic fluid loss, based on the presence of which assessment findings? Select all that apply.
Flat neck veins Rapid heart rate Decreased urine output Decreased blood pressure
A client has an immune deficiency. While the nurse is taking the history, which finding will be typical?
Frequent, severe Infection
A client, who has acquired immune deficiency syndrome (AIDS), receives treatment for prevention of Pneumocystis pneumonia. The client states, "I don't understand why I'm getting treatment for an infection I don't have yet." The best response by the nurse is that people with immunosuppression get Pneumocystis pneumonia under which conditions?
From microorganisms that usually are harmles
A client has drainage from an intestinal fistula that is being managed at home while it heals. A home health nurse visits regularly to change the dressing. Today the client is already lying down when the nurse arrives, complaining of feeling "weak and dizzy" when standing up. Supine blood pressure is 92/70, and the heart rate is 78. When the client sits up, the client slumps sideways and is temporarily unresponsive. Systolic blood pressure was 77 before the client fell sideways, and the heart rate was very fast. The client has regained consciousness. What is the most appropriate action by the nurse before contacting the client's primary healthcare provider?
Give water to drink
Which action by the new nurse will cause the charge nurse to intervene?
Giving type AB blood to a person with type O blood
A client is admitted to the hospital with an infection producing endotoxins. When the nurse checks the culture and sensitivity test, which type of microorganism will the nurse observe?
Gram-negative bacteria
A client has a chronic infection of Listeria that the body cannot fight. Which pathophysiologic process should the nurse monitor for in this client?
Granuloma
A client breaks the first line of defense against infection. The next response the nurse should consider involves which mechanism?
Inflammation
The nurse is inspecting a client's abdominal incision the day after surgery. What does the nurse expect to observe?
Inflammation
Which order indicates the nurse has an accurate understanding of a client's defense mechanisms, from the first line of defense to the last?
Innate immunity Inflammatory response Adaptive immunity
How should the nurse explain to the staff the process of human immunodeficiency virus (HIV) replication?
Insertion of viral RNA into helper T cells leads to conversion to viral DNA and provides genetic instructions to make new virions
Which cytokine deficiency does the nurse suspect is causing delayed wound healing in a client?
Interleukin 6
nurse is assessing an infant who has dehydration. Which assessment findings will support this condition? Select all that apply.
Irritability Sunken fontanels Decreased urine output Decreased skin elasticity
A client has hyperaldosteronism. Which fluid and electrolyte imbalance will the nurse monitor for in this client?
Isotonic fluid volume excess and hypokalemia
How should the nurse describe the role of chemotaxis in inflammation to a coworker?
It causes migration of leukocytes to the site of injury
A nurse is asked about the primary function of plasmin in the body. What is the nurse's best response?
It degrades blood clots
When a nurse is asked which microorganism causes AIDS, how should the nurse answer?
It is a retrovirus
Which information from the nurse indicates a correct understanding of the physiologic factor that has the most impact on the reabsorption of water into the client's capillary space from the interstitial space?
It is capillary oncotic pressure.
Which information from the staff indicates that the nurse's teaching about hyperkalemia was successful? Select all that apply.
It often occurs in acidosis Serum potassium concentration is above 5.5 mEq/L
Which information indicates the nurse has an accurate understanding of the function of viral protease in an HIV virus?
It processes newly synthesized viral proteins.
A client has metabolic acidosis and is breathing deeply and rapidly. How will the nurse report this finding to the oncoming shift?
Kussmaul respirations are present
A client receiving antibiotics is experiencing perineal discomfort when urinating. Which microorganism should the nurse suspect is causing this client's problem?
Lactobacillus
A child developed hives soon after eating homemade strawberry jam. The child's mother states, "I don't understand what happened. He didn't break out last month when I made this jam." Which information should the nurse consider before answering?
Last month, antibodies against antigens normally in strawberries bound to mast cells, making the child sensitized. More jam today caused these mast cells to degranulate and release mast cell products.
Which assessment findings are early manifestations of uncompensated metabolic acidosis in a client? Select all that apply
Lethargy Headache
Which assessment findings are early manifestations of uncompensated metabolic acidosis in a client? Select all that apply.
Lethargy Headache
Which laboratory test result will the nurse expect to find in a client with acute inflammation?
Leukocytosis
When the nurse is taking the client's history, which finding will cause the nurse to monitor for signs of hypophosphatemia?
Long-term alcohol abus
When the nurse is taking the client's history, which finding will cause the nurse to monitor for signs of hypophosphatemia?
Long-term alcohol abuse
A nurse has administered a cation exchange resin to a client with hyperkalemia. Which response will indicate a therapeutic effect?
Loss of potassium in the stool
A client has an infection. Which cells provide long-term phagocytosis against infectious agents?
Macrophages
A nurse is teaching a client about magnesium. Which information should the nurse include? Select all that apply.
Magnesium is mainly stored in the bones. Alcohol-related diseases frequently cause low magnesium levels. Magnesium has an important role in smooth muscle contraction and relaxation
Which conditions would require the nurse to administer magnesium replacement therapy? Select all that apply.
Malnutrition Chronic alcoholism Malabsorption syndromes
Several days before abdominal surgery, the client experiences nausea and vomiting and is unable to eat any food. The nurse closely monitors this client's wound healing after surgery. What is the rationale for the nurse's actions?
Malnutrition causes reduced tensile strength
A client sprains the left ankle. Before assessing the client for the classic signs of inflammation, the nurse remembers which cell type is responsible for the changes?
Mast Cell
A client has a type I hypersensitivity reaction. Which cells release the chemical mediators of inflammation in the immediate phase?
Mast cells
A client sprains the left ankle. Before assessing the client for the classic signs of inflammation, the nurse remembers which cell type is responsible for the changes?
Mast cells
A nurse is caring for a client with Dengue fever. Which route of transmission will the nurse consider when planning care?
Mosquito vector
A client has a serum potassium level of 3.0 mEq/L. Which findings is the nurse most likely to observe upon assessment?
Muscle weakness and cardiac dysrhythmias
What is a similarity between a type I hypersensitivity reaction in a male client and a type IV hypersensitivity reaction in a female client?
Neither involves the participation of complemen
A client recently tested positive for human immunodeficiency virus (HIV). The client's fever, muscle aches, and swollen nodes have gone away. Which assessment findings should the nurse expect to see over time before the client develops any acquired immunodeficiency syndrome (AIDS) indicator conditions?
No signs and symptoms
The client in early-stage human immunodeficiceny virus (HIV) infection will exhibit which clinical manifestations upon assessment?
Nonspecific flu-like symptoms including fever, headache, and fatigu
Which client should the nurse monitor carefully for signs of metabolic acidosis?
One that has had diarrhea for over a week
A nurse is teaching about the role of C3b. Which information should the nurse include?
Opsonin
Which process should the nurse include when teaching about how antibodies promote phagocytosis?
Opsonization
Which assessment findings are classic for a client with inflammation of the knee? Select all that apply.
Painful knee Warmth of the knee Swelling of the knee Loss of knee movement
A client has ascites. Which area should the nurse assess?
Peritoneal space
A client has an infection and the neutrophil level is elevated. Which function are the neutrophils providing for the client?
Phagocytosis
A nurse is teaching the staff about acid/base buffers and their locations within the body. Which information indicates teaching was successful? Select all that apply.
Phosphate buffers are found in the intracellular space Bicarbonate buffers are found in the extracellular space. Hemoglobin buffers are found in the intracellular compartment
The nurse is caring for a client after an accident. Which interventions should be included in the client's care plan to prevent contracture of tissue at the site of injury? Select all that apply.
Placing the client in a proper position Performing range-of-motion exercises
Which situation would cause the nurse to assess the client for metabolic acidosis?
Poor tissue perfusion
situation would cause the nurse to assess the client for metabolic acidosis?
Poor tissue perfusion
A client inhales a microorganism that causes an infection. Which term should the nurse use to describe the inhalation of the microorganism?
Portal of entry
Which information from the nurse indicates a correct understanding of the difference between primary and secondary immunodeficiency disorders?
Primary immunodeficiencies are congenital, whereas secondary immunodeficiencies are acquired
Which information from the nurse indicates a correct understanding of the difference between primary and secondary immunodeficiency disorders?
Primary immunodeficiencies are congenital, whereas secondary immunodeficiencies are acquired.
A client had surgery two days ago. As part of the postoperative discharge education, the nurse teaches the client about prescribed activity limitations for the next few weeks. The client lets the nurse know that going back to work quickly is essential. Which principle should underlie the nurse's response?
Proliferation and remodeling stages are necessary for a healing wound to be strong
A woman presents with diminished colonization of Lactobacillus, which the primary healthcare provider diagnoses as vaginosis. Which finding will be typical when the nurse takes the history?
Prolonged antibiotic treatment
A client has Wiskott-Aldrich syndrome. Which nursing goal takes priority?
Protection from IgM deficiency Infection
A nurse's assessment in the middle of a shift reveals various changes from this morning for four clients. Which change should be reported to the client's primary healthcare provider immediately?
Serum potassium concentration is increasing, and cardiac dysrhythmias have developed, but the client says, "My breathing is fine."
The parents of an infant with which condition will need the most complex teaching about protecting their infant from infection?
Severe combined immunodeficiencies (SCIDs
A client presents to the healthcare clinic with a malar rash, oral ulcers, photosensitivity, and pleurisy. Which complications should the nurse expect to find in the client? Select all that apply.
Proteinuria Thrombocytopenia
A client's osmoreceptors are stimulated. Which action should the nurse take?
Provide a glass of water
While reviewing the laboratory reports of a newborn, the nurse finds that the newborn has α1-antitrypsin deficiency. Which test should be prescribed later in the child's life to determine effects?
Pulmonary functioning test
A child is diagnosed with starvation ketoacidosis (a metabolic acidosis). What clinical manifestations should the nurse anticipate when assessing the child?
Rapid, deep breathing, lethargy, abdominal pain
Which finding in the history will indicate to the nurse that the client may have a deficiency of humoral immune cells?
Recurrent bacterial Infection
The primary healthcare provider prescribes bone marrow transplantation to a client with a leukocyte adhesion defect. Which treatment strategy will the nurse prepare the client for before surgery can be performed?
Removing mature T cells
After reviewing the chart, the nurse determines the client is experiencing which acid/base imbalance?
Respiratory alkalosis
Which manifestations will the nurse expect to find when assessing a client who is experiencing a type I hypersensitivity reaction?
Rhinitis, urticaria, and wheezing
"My feet swell if I eat salt," says a client who has chronic compensated heart failure, "so I stopped eating it like my nurse practitioner said, but I don't understand how salt causes swelling." What is the nurse's best response?
Salt holds water in your blood and makes more pressure against your blood vessels, so fluid leaks out into your tissues and makes them swell.
Which client needs teaching about increasing dietary intake of potassium to help prevent hypokalemia?
The client with chronic heart failure taking a loop diuretic
A client has a low pH of urine and stomach contents. How should the nurse interpret these findings?
The first line of defense is working
A client has a low pH of urine and stomach contents. How should the nurse interpret these findings?
The first line of defense is working.
A nurse is caring for a newborn. Which age-related factor will the nurse consider that affect innate immunity?
The inflammatory responses is transiently depressed.
The nurse is assessing a client with low-set ears, a fish-shaped mouth, and shortened structure of the upper lip. The client's laboratory reports indicate the presence of low circulating T cell levels. Which treatment strategy will be most beneficial for the client?
Transplantation of fetal thymus tissue
A nurse is discussing ART with the oncoming nurse for the next shift. What is the nurse describing?
Treatment for AIDS
A client is experiencing acute inflammation and releases interleukin-1 (IL-1). Which piece of equipment should the nurse obtain to determine the effects of IL-1?
Thermometer
A nurse is caring for a client with an infection that produces endotoxins. Which piece of equipment will the nurse obtain to monitor for the clinical manifestation of this type of disease?
Thermometer
To help a client's wound heal, the nurse suggests eating foods high in vitamins A and C. What is the rationale for the nurse's action?
These vitamins are required for collagen synthesis.
A nurse is teaching about parasitic diseases. Which information should the nurse include in the teaching session?
They are rarely transmitted from human to human.
While planning care for a client with inflammation, the nurse recalls that vasodilation and increased vascular permeability include which benefits? Select all that apply.
They dilute bacterial toxins They transport neutrophils to the area of injury They bring macrophage cells to the area of injury.
While planning care for a client with inflammation, the nurse recalls that vasodilation and increased vascular permeability include which benefits? Select all that apply.
They dilute bacterial toxins. They transport neutrophils to the area of injury. They bring macrophage cells to the area of injury
The nurse plans care to manage edema for a client with which conditions? Select all that apply.
Thrombophlebitis Protein malnutrition Cirrhosis of the liver
A nurse is caring for an older adult with a fluid imbalance. Which principle should the nurse consider when planning care for this client?
Total body water in older adults is decreased owing to decreased adipose tissue and decreased muscle mass
How should a nurse support a hospitalized client's first line of defense against microorganisms?
Turn frequently
A person who has an allergic reaction to a bee sting comes to the clinic. The nurse will monitor the client for which type of hypersensitivity reaction?
Type I
For a client with Graves disease, which type of hypersensitivity reaction should guide nursing care?
Type II
A client has a hypersensitivity reaction that is mediated primarily by T lymphocytes. Which type of reaction did the client experience?
Type IV
A client has poison ivy. Which type of reaction did the client experience?
Type IV
A nurse administers a skin test for tuberculosis. The nurse reads the results of the skin test based on which type of hypersensitivity reaction?
Type IV
While reviewing the medication history of a client, the nurse finds that the client is receiving long-term therapy with broad-spectrum antibiotics. Which complications does the nurse expect to find? Select all that apply.
Vaginosis Pseudomembranous colitis
A client has an inflammatory response. Upon assessment, the nurse finds edema in the client's foot. What caused the edema?
Vascular permeability
A client has gastroenteritis from eating spinach contaminated with E. coli. While planning care, the nurse should remember that the severity of the client's illness is determined by which characteristic of the bacteria?
Virulence
A client's immune system activates interferons. Which type of organism should the nurse suspect is causing this reaction?
Viruses
A client with an intestinal infection is receiving prolonged treatment with antibiotics. Which deficiencies are likely to occur in the client? Select all that apply.
Vitamin K Bacteriocins
A nurse is teaching the staff about body fluid movement. Which information should the nurse include in the teaching session?
Water moves between ICF and ECF compartments by osmotic forces
Which assessment finding will indicate to the nurse that the client is having a life-threatening type I hypersensitivity reaction?
Wheezing, difficulty breathing, and hypotension
A client says, "I have been learning about human immunodeficiency virus (HIV) replication. I know that integrase puts the HIV DNA into the host cell DNA, but I don't understand where integrase comes from in the first place." What is the nurse's best response?
When HIV enters a host cell, it brings integrase with it
When should the nurse chart that the client has fibrinous exudate?
When thick, clotted exudate, from severe inflammation, occurs
When should the nurse chart that the client has serous exudate?
When watery exudate, containing few cells and not much protein occurs
When should the nurse chart that the client has purulent exudate?
When whitish-yellow exudate, containing many leukocytes, occurs
Which client is most at risk for developing systemic lupus erythematosus (SLE)?
Which client is most at risk for developing systemic lupus erythematosus (SLE)?
A nurse is caring for a client that had an organ transplant rejection. Which information indicates the nurse has a correct understanding of transplant rejection? Select all that apply.
White graft indicates hyperacute rejection Acute rejection is a type IV hypersensitivity reaction
Which term will the nurse use to describe the time between infection and the appearance of antibodies to human immunodeficiency virus (HIV)?
Window period
A client has an X-linked recessive immunodeficiency disease characterized by decreased immunoglobulin M (IgM) production. Which medical diagnosis will the nurse observe written in the chart?
Wiskott-Aldrich syndrome
A camp nurse meets with a young male camper who states that he touched poison ivy accidentally but is perfectly fine. The camper seems to think that he is not allergic to poison ivy. What is the nurse's best response?
You will likely get an itchy blistering rash in the next few days. Let me check your hand every day this week
A client with a B-cell deficiency is receiving intravenous immune globulin. When the client asks about the drug therapy, how should the nurse respond?
You will need repeated treatments.
A client states, "I have a sore throat, and it's red." When the client asks why it is red, how should the nurse respond?
Your blood vessels in the area have relaxed to allow more blood into the area to promote healing.
"My doctor said I have an autoimmune disease. What does that mean?" asks a client. How should the nurse respond?
Your immune system is creating antibodies that are destroying your own cells
The nurse is reviewing the laboratory reports of four clients who each underwent an appendectomy for appendicitis. Which client is at the highest immediate risk for wound dehiscence?
cilent A
The nurse evaluates which arterial blood gas values as evidence that the client has uncompensated metabolic alkalosis?
pH 7.53, increased HCO3-