Medsurg CAQ #1

The nurse is counseling a client infected with human immunodeficiency virus (HIV) regarding prevention of HIV transmission. Which statement by the client indicates the nurse needs to follow up?

"I can safely have anal sex without any barriers"

The nurse notes that a client is not adhering to prescribed antibiotic therapy. Which reason should the nurse document?

"I left my pills in the bedroom and I forget to take them with breakfast"

A nurse is counseling a client with tuberculosis regarding isoniazid (INH) therapy. Which statement made by the client indicates the nurse needs to follow up?

"I should apply should apply sunscreen and wear sun-protective clothing while going outside"

A registered nurse is teaching a student nurse regarding the interventions for a client with human immunodeficiency virus (HIV) infection. Which statement by the nurse indicates the nurse needs to follow up?

"I will ask the client to avoid involvement in community activities"

The nurse is providing discharge instructions to a client who is recovering from an acute case of viral hepatitis. Which statement by the client indicates a need for further education?

"I will take acetaminophen for pain rather than aspirin"

A nurse is educating a client with human immunodeficiency virus (HIV) about self-management. Which suggestion by the nurse benefits the client?

"Rinse your mouth with normal saline after every meal"

What is the function of IgG in the body?

Activated the classic complement pathway

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2*F (39*C). The temperature was 99.2*F (37.3*C) when it was taken 6 hours ago. What is a priority nursing intervention in this case?

Administer the prescribed antipyretic and notify the primary health care provider

A client presents with sneezing; lacrimation; swelling with an airway obstruction; and pruritus around the eyes, nose, throat, and mouth. The nurse interprets these finding as a Type I hypersensitivity reaction. Which disease might have occurred in the client?

Allergic rhinitis

A pregnant woman presents with a body temperature of 103*F, cough, headache, muscle aches, chest pain, severe joint pain and night sweats and is diagnosed with coccidioidomycosis. Which medication will the nurse most likely observe prescribed on the medication administration record?

Amphotericin B

A client has undergone scratch testing but the causative allergen is yet to be identified. What would be the next step to confirm a strongly suspected allergen?

Begin intradermal testing

Which finding in the client's laboratory report enables the nurse to conclude that the client has a stage 3 human immunodeficiency (HIV) infection according to the Centers for Disease Control and Prevention (CDC) classification? Select all that apply

CD4+ T-cell count 100 cells/mm3 or a percentage of 11% CD4+ T-cell count 150 cells/mm3 or a percentage of 12% and Kaposi's sarcoma

While assessing a client with presence of neurotoxicity, lymphoma, and hypertension, the medical history reveals that the client is on immunosuppressant drug therapy. Which drug class might have caused these conditions?

Calcineurin inhibitors

A client with Lyme disease presents with dyspnea, dizziness, and facial paralysis. Which medication may be included in the prescription?

Ceftriaxone

Client 1- 6.3 million/mm3 (6.3x10^12 cells/L) RBC count Client 2- 4.0 million/mm3 (4.0x10^12 cells/L) RBC count Client 3- 4.8 million/mm3 (4.8x10^12 cells/L) RBC count Client 4- 5.7 million/mm3 (5.7x10^12 cells/L) RBC count The nurse is reviewing the blood test results of four adult male clients. Which client's finding indicates the presence of hemorrhage?

Client 2

Client A- Allergic rhinitis Client B- Goodpasture's syndrome Client C- Rheumatoid arthritis Client D- Contact dermatitis due to poison ivy exposure Which client may have a type II hypersensitivity reaction?

Client B

After assessing an older client's medical report, the nurse finds that the client is at an increased risk for bacterial and fungal infections. Which change in immune function may have occurred?

Decrease in circulating T-lymphocytes

What functions of leukocytes are involved in inflammation? Select all the apply.

Destruction of bacteria and cellular debris Release of vasoactive amines during allergic reactions

Arrange in order the steps involved in skin testing for an allergen causing a type I allergic reaction.

Discontinue corticosteroid medications Clean the inner side of the forearm with soap and water Place drops of sera containing the known allergen on skin Use a skin testing needle to scratch the surface of the skin Observe for a wheal formation on the skin Apply topical steroid on the skin

When assessing the oral cavity of a newly-admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies area of white plaque on the client's tongue and palate. What is the nurse's initial response?

Document the presence of the lesions, describing their size, location, and color

Which disease may occur due to rickettsial infections? Select all that apply.

Epidemic typhus Rocky Mountain spotted fever

A nurse is concerned about the public health implications of gonorrhea in a 16-year-old adolescent. Which should be of most concern to the nurse?

Finding the client's sexual contacts

Which sexually transmitted disease is treated with antiviral drugs?

Genital herpes

Which type of hepatitis virus spreads through contaminated food and water?

Hepatitis A virus

Which type of hypersensitivity reaction is present in a client with a body temperature of 102*F, severe joint pain, rashes on the extremities, and enlarged lymph nodes for serum sickness?

Immune complex-mediated reaction

Which statements indicate a nurse has a correct understanding of interleukin-2? Select all that apply.

It enhances natural killer cells It is used to treat various malignancies It stimulates differentiation of T-lymphocytes

Which immunodeficiency disorders affect polymorphonuclear leukocytes and monocytes? Select all that apply.

Job syndrome Chronic granulomatous disease

The nurse has administered lymphocyte immunoglobulin to a client. Which side effects are most likely to occur? Select all that apply

Leukopenia Tachycardia Serum sickness

A client's laboratory report reveals an antigen-immunoglobulin (IgE) reaction. The nurse suspects the presence of allergic rhinitis. Which type of medication would treat this condition

Mast cell stabilizing

The nurse is caring for a client who is receiving treatment via intrathecal therapy. The client reports a headache and neck stiffness. Upon, assessment, the nurse finds that the client's body temperature is 103*F. Which condition should the nurse suspect in the client?

Meningitis

What causes medications used to treat AIDS to become ineffective?

Missing doses of the prescribed medications

Which leukocyte values should be assessed to determine the adequacy of a client's response to inflammation? Select all that apply.

Monocytes Neutrophils Macrophages

What criteria should the nurse consider when determining if an infection should be categorized as a health care- associated infection?

Occurred in conjunction with treatment for an illness

A client on immunosuppressive therapy is diagnosed with a peptic ulcer. Which medication might have led to this condition?

Prednisone

Which parameter should the nurse consider while assessing the psychologic status of a client with acquired immune deficiency syndrome (AIDS)?

Presence of anxiety

What is the role of the plasma cell in the antigen-antibody response?

Produces antibodies against the sensitizing antigen

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 nurse observes that an unlicensed assistive personnel (UAP) did not use a bag impervious to liquid for contaminated linen from a client who is on contact precautions. What is the nurse's best way to handle this situation?

Review transmission-based precautions with the UAP

A client is admitted with full-blown anaphylactic shock that developed due to a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? Select all that apply.

Stridor Hypotension Dyspnea

Which conditions in clients are examples of cell-mediated immunity? Select all that apply.

Tuberculosis Graft rejection Contact dermatitis

The nurse performs a skin test on a client who has a mosquito bite. The client shows wheal and flare reaction post-skin test. Which type of hypersensitivity reaction most likely has occurred?

Type I

A client has received ABO-incompatible blood from a donor by mistake. Which type of hypersensitivity reaction will occur in the client?

Type II

Which organism causes smallpox?

Variola virus

A nurse is caring for a client with a negative-pressure wound treaterm-3tment device. When should the nurse tell the client to call the wound center about this system?

When the negative pressure seal is broken