Immunity and Infection (70,71, 47)

The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should plan care with the understanding that which childhood psychosocial need occurs at this age?

Beginning to conceptualize the death process as involving physical harm

The nurse is caring for a postrenal transplantation client taking cyclosporine (Sandimmune). The nurse notes an increase in one of the client's vital signs and the client is complaining of a headache. What vital sign is most likely increased?

Blood pressure

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate for the nurse to perform? Select all that apply.

Record site, date, and time of the test, Give the client a list of potential allergens if identified.

The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching?

"I can send my child to day care if he has a fever, as long as it is a low-grade fever."

A 6-year-old child with human immunodeficiency virus (HIV) has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child?

"I know it must hurt, but if you tell me when it does, I will try and make it hurt a little less."

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions?

"I should not use insect repellents because it will attract the ticks."

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions?

"I should take hot baths because they are relaxing."

The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction?

"I will clean up any spills from the diaper with diluted alcohol."

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. The nurse should make which most appropriate response to the mother?

"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

A client who is human immunodeficiency virus seropositive has been taking stavudine (d4T, Zerit). The nurse should monitor which most closely while the client is taking this medication?

Gait

The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item?

Bananas

In assessing patients for STI's the nurse needs to know that many STI's can be asymptomatic. Which STI's can be asymptomatic? Select all that apply

Genital Warts, Chlamydial infection, Syphilis, Genital herpes, and Gonorrhea

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed?

Administer corticosteroids as prescribed for inflammation

A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply.

Administer oxygen, Quickly assess the client's respiratory status, and Document the event, interventions, and client's response

A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which description of this condition?

An autoimmune disease that causes blistering in the epidermis

A client calls the nurse in the emergency department and states that he was just stung by a bumble bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which nursing action should the nurse take?

Ask the client if he ever sustained a bee sting in the past

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy?

Hairdressers

Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the health care provider (HCP) immediately if which occurs?

Hearing loss

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?

Lyme disease is caused by a tick carried by deer

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply.

Monitor liver function studies, Instruct the client to avoid alcohol, and Instruct the client to avoid exposure to the sun

Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

Monitor the child's weight, Frequent hand-washing is important, The child should avoid exposure to other illnesses, and Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach)

The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs/symptoms of which side/adverse effects of the medication? Select all that apply.

Nephrotoxicity, Bone marrow depression, and Gastrointestinal (GI) effects

The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply

Ototoxicity, Renal toxicity, and Dysrhythmias

An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for symptoms indicative of human immunodeficiency virus (HIV) infection. The nurse assesses the infant, knowing that which infection is the most common opportunistic infection of children infected with HIV?

Pneumocystis jiroveci pneumonia

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding?

Positive punch biopsy of the cutaneous lesions

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan?

Protecting the client from infection

The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the health care provider if which elevated result is noted?

Serum amylase level

The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication?

Serum creatinine level

A primary herpes simplex virus (HSV) infection differs from recurrent HSV episodes in that: Select all that apply.

Symptoms are less severe during recurrent HSV episodes, Systemic manifestations such as fever and myalgia are more common in primary infection

A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which nursing actions are most appropriate? Select all that apply.

Tell the client to avoid any woody, grassy areas that may contain ticks, Instruct the client to immediately start to take the antibodies that are prescribed, and Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease

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?

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

The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent?

The inactivated influenza vaccine will be given yearly

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

Use non latex gloves, Use medications from glass ampules, Keep a latex-safe supply cart available in the client's area, and Avoid the use of medication vials that have rubber stoppers.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

Wearing a gown and gloves

The nurse is obtaining a subjective data assessment from a woman reported as a sexual contact of a man with chlamydial infection. The nurse understands that symptoms of chlamydial infection in women

are frequently absent

A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant?

p24 antigen assay