PCC3- Exam 3

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with Multiple Sclerosis which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?

A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"

The pediatric nurse understands that the most common cancer found in children is:

ALL

Which statement is accurate regarding the Mantoux skin test?

An induration of 10mm or greater indicates a positive skin test

A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea, and vomiting. What does the nurse do first?

Ask the client to place his chin on his chest

During a physical examination of a 13-year-old boy, the nurse observes a single, enlarged, rubbery-feeling cervical lymph node in the armpit. The boy also reports unexplained loss of weight and malaise. Which condition should the nurse most suspect in this client?

Hodgkin Lymphoma

The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement indicates that additional teaching is needed?

I will be sure to eat lots of fresh fruits and vegetables every day

A client who has had a mastectomy and her spouse are asking the nurse questions about reconstructive surgery. Which of the following is the best response by the nurse?

Reconstructive surgery may require multiple surgeries.

The nurse has been exposed to HIV through splashing of urine from a client who is HIV positive with a low viral load. The urine came into contact with the nurse's face. Which drug regimen does the nurse prepare to initiate?

Retrovir (zidovudine) and Epivir (lamivudine) for 28 days

A nurse should wear a fit-tested HEPA mask when entering the room of a patient with which disease?

TB

The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in confirming progression of the client's diagnosis to AIDS?

Thick white patches on the client tongue and oral mucosa

Which of the following laboratory values could indicate that a child has leukemia?

WBC: 32,000

The nurse is working with a client at a public health clinic. The client says to the nurse, "The doctor said that my CD4+ count is 450. Is that good?" What is the nurse's best response?

Your count is a bit low and you are susceptible to infection. NR: 800-1000 AIDS: <200

A client with a diagnosis of sepsis has received intravenous immune globulin (IVIg) as partial treatment. The nurse knows that which client response would best suggest an accurate understanding of IVIg treatment?

a big part of my IVIg treatment is actually stimulating and supplementing my immune system to do the work itself

A client is admitted with glomerulonephritis. Which psychosocial problems could likely affect this client?

anxiety related to poorly functioning kidneys and body image disturbance

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

avoid hot baths & showers

Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis?

azotemia

A nurse is caring for a 52-year-old client who has been diagnosed with a latent tuberculosis infection. The health care provider is considering ordering isoniazid (INH). The preexistence of what condition would require cautious use of INH in this client?

cirrhosis of the liver

For an HIV positive client, toxoplasmosis is an opportunistic infection. One way to prevent this infection is to avoid which of the following.

cleaning cat litter

A client is receiving radiation therapy for lesions in the abdomen from non-Hodgkin's lymphoma. Because of the effects of the radiation treatments, what will the nurse assess for?

diarrhea

How is multiple sclerosis (MS) diagnosed? Select all that apply.

hx & physical MRI

A client with leukemia has developed stomatitis and is on neutropenic precautions. Mouthwash every two hours has been ordered for the client. The nurse would question which of the following if ordered by the physician?

hydrogen peroxide

The nurse is required to manage and minimize sepsis in a client with severe infection. Which would be an appropriate nursing intervention?

monitor client vital signs

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective?

reduced muscle spasticity

The nurse reviews the laboratory results of a client and finds that the white blood cell (WBC) count is 1500/mm3. What is the priority action of the nurse?

reverse isolation precautions (protective isolation)

A patient with non-Hodgkin's lymphoma (NHL) will be starting a course of doxorubicin shortly. When planning this patient's care, what nursing diagnosis should the nurse prioritize?

risk for infection r/t suppressed bone marrow function

The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis. Which is the best nursing intervention for this client?

seizure precautions with padded siderails

The nurse is caring for a client diagnosed with systemic inflammatory response syndrome. Which illness is likely responsible for this diagnosis?

sepsis

A client is to have an amputation. The client is acutely ill and diagnosed with a gangrenous limb and related fever, disorientation, and electrolyte imbalances. Which of the following would be most important for the nurse to monitor in this client

signs of sepsis

A client's absolute neutrophil count (ANC) is 550/mm3. What is the nurse's best action?

use standard precautions

Which of the following would the nurse recognize as a sign of a local infection during data collection?

warm skin

A client is placed in isolation for suspected tuberculosis. Which action should the nurse take when entering the client's room?

wear an N95 respirator

A nurse is caring for a client on a four-medication regimen to treat tuberculosis. The nurse discovers that the client isn't taking all medications. What is appropriate for the nurse to say to the client?

"Taking several medications can be difficult. Tell me about the difficulties you're having

Which statement by a student nurse needs follow-up regarding precautions for a patient with possible tuberculosis?

"The patient will wear a N95 mask when leaving the room."

The nurse knows which of the following symptoms are early clinical manifestations of leukemia. Select all that apply.

-anorexia -petechiae -unsteady gait -falling hematuria & ulcerations of mouth- late signs

Which of the following statements indicates that the patient diagnosed with tuberculosis understands appropriate care measures?

"Medication will need to be taken for a 6-12 month duration."

A child with leukemia who is being treated with chemotherapy is visited by a grandmother who has brought flowers from her garden for the child. Which of the following is the appropriate response by the nurse?

"The flowers are beautiful, but the child cannot have them right now."

A nurse has a client with multiple sclerosis who, after attending a meeting with the Multiple Sclerosis Society, states complementary therapies would work better. What is the best response by the nurse?

"You have a right to search out options and make decisions to help manage your symptoms. Share with me what you've learned."

A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide?

"You must avoid stress and extreme fatigue, because these can trigger a relapse."

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

positive reaction indicates exposure to disease

A nurse is caring for a full-term neonate who is 24 hours old. Assessment findings include axillary temperature of 96.8° F (36° C), apical heart rate of 188 beats/minute, and respiratory rate of 48 breaths/minute. The mother reports that the neonate is lethargic when she tries to breast-feed and looks "like a rag doll." Pulse oximetry reveals saturation of 89% on room air, and the neonate has dusky mucous membranes. The mother also has a low-grade fever. What are the most appropriate nursing interventions? Select all that apply.

-Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. -Provide blow-by oxygen and monitor the neonate's respiratory status. -Inform the parents that she wants to monitor the neonate closely.

The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select all that apply.)

-Provide an incentive spirometer to encourage coughing and deep breathing by the client. -Keep a blood pressure cuff, thermometer, and stethoscope in the clients room for his or her use only. -Request that the family take home the fresh flowers that are at the clients bedside. -Assist the client with meticulous oral care after meals and at bedtime.

Tuberculosis responds well to long-term treatment with a combination of three or more antitubercular drugs. Which is true regarding the duration of treatment for clients with tuberculosis? Select all that apply.

-The initial treatment phase should last for a minimum of two months. -The continuation treatment phase should last for four to seven months. -Prophylactic treatment should be given for six to 12 months.

Which clinical manifestations are consistent with active tuberculosis (TB)? Select all that apply.

-dyspnea (late) -night sweats -fatigue -low-grade fever -productive bloody sputum (late); dry cough or mucopurulent sputum more common -unexplained weight loss -anorexia

Which assessment findings support that the patient with HIV currently has AIDS? (Select all that apply.)

-esophageal candidiasis -recurrent infectious pneumonia -Kaposi's sarcoma -wasting syndrome

Which strategies for alleviating fatigue should the nurse provide a patient with multiple sclerosis (MS)? Select all that apply.

-maintain adequate sleep regimen -uphold routine exercise -avoid alcohol & tobacco -consume fresh fruits & veggies daily

The patient develops thrombocytopenia after receiving chemotherapy. Which of the following should the nurse do? Select all that apply.

-monitor for signs of bleeding -avoid unnecessary venipunctures

Select the common routes by which HIV can be transmitted. Select all that apply.

-sexual contact -contact with blood

Which clinical manifestations are associated with multiple sclerosis (MS)?

-weak -fatigue -vertigo -visual disturbances -paresthesia -muscle spasms -pain -impaired memory -depression

Which of the provider's orders should be implemented immediately?

Administer D5½NS at 125 mL/hr

Which action by the nurse is most effective to prevent becoming exposed to the human immune deficiency virus (HIV)?

Always use Standard Precautions with all clients in the workplace.

A 50-year-old woman was recently diagnosed with non-Hodgkin's lymphoma (NHL) and has begun a treatment regimen that includes simultaneous radiation therapy and chemotherapy. The combination of severe symptoms and aggressive therapy has necessitated admission to the hospital. When providing care for this patient, which of the following actions should the nurse implement?

Applying standard precautions conscientiously to reduce the patient's risk of infection

The nurse is conducting a seminar about breast cancer at a community center for women from diverse backgrounds. Which of the following would the nurse include about cultural risks of breast cancer to encourage breast self-exam?

Asian, Hispanic, and Native American women have a lower incidence of breast cancer.

A hospital client with a diagnosis of sepsis is in need of a specific response to microorganisms and a long-lasting immunity to the pathogens in question. Which component of the client's immune system is most able to meet these criteria?

lymphocytes

A client who is receiving highly active antiretroviral therapy (HAART) tells the nurse, "The doctor said that my viral load is reduced. What does this mean?" What is the nurse's best response?

meds are working well right now

An 8-year-old boy and his father visit the pediatrician's office with reports of a sudden onset of abdominal pain and reddish-brown urine. A urinalysis shows 4+ protein. On taking the boy's health history, the nurse learns that he had strep throat a little over a week ago. Which condition should the nurse suspect?

acute glomerulonephritis

The nurse is caring for a newly diagnosed HIV-positive client who will be taking enfuvirtide (Fuzeon). Which precaution is important for the nurse to communicate to this client?

Rotate the sites where you will be giving the injections.

To decrease the risk of developing resistance to the antiretroviral medication, the client should:

Take at least three different antiretroviral medications at one time

An undetectable viral load means:

The amount of virus in the clients blood is so low it cannot be found using the current lab tests

In patients with multiple sclerosis (MS), the MRI scan reveals:

multiple bright white lesions -multiple bright white or dark lesions dependent upon type of MRI scan used

A client is receiving baclofen for the management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?

muscle spasms

A nurse is assessing a neonate with sepsis. The nurse understands that most commonly the cause involves:

bacteria

The nurse is reviewing the medical record of a child diagnosed with Hodgkin's lymphoma. Which would the nurse identify as typically the first sign reported by the child?

painless, enlarged lymph node

The nurse is admitting four clients with infections to the medical-surgical unit, but only one negative pressure room is available. Which client is it most appropriate to assign to the negative pressure room?

client with cough who may have TB

A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should:

collaborate with the social worker to investigate possible availability of funds.

A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. The client's purified protein derivative (PPD) test, placed 3 days ago in the clinic, is negative. Which action by the nurse is most appropriate?

place in airborne precautions

The nurse is caring for a client who is in the hospital for diagnostic testing. On physical assessment, the nurse notes an enlarged spleen, oral ulcerations, and a decreased level of consciousness. Which of the following laboratory results would the nurse anticipate for this client?

increased WBC

The nurse is assessing a client who cannot synthesize suppressor T-cells. For what other condition does the nurse assess the client?

increased seasonal allergies

The nurse is planning care for a client who has just undergone a radical mastectomy. Which of the following would the nurse include in that plan?

keep affected arm above level of the heart

An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal pain, and diarrhea. What orders does the nurse anticipate?

liver enzymes

The nurse is teaching a client diagnosed with Hodgkin's lymphoma about metastasis. What type of cancer is the most likely to appear as a secondary malignancy in clients with Hodgkin's lymphoma disease?

lung

You are discussing discharge instructions with a patient who has been diagnosed with Tuberculosis. The patient indicates that she is anxious to go home. Which statement by the nurse is correct?

pt D/C after 3 negative acid-fast bacilli smears

A child diagnosed with acute glomerulonephritis will most likely have a history of:

recent illness such as strep throat

An infection or the products of infection carried throughout the body by the blood is called:

septicemia

A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?

temperature instability