SATA 23

Which of the following are common sites of visceral involvement of Kaposi's sarcoma? Select all that apply. Lymph nodes Lungs Gastrointestinal tract Heart Brain

a) Lymph nodes b) Gastrointestinal tract c) Lungs -The most common sites of visceral involvement are the lymph nodes, the gastrointestinal tract, and the lungs. Involvement of internal organs may eventually lead to organ failure, hemorrhage, infection, and death. The brain and the heart are not common sites.

What actions should the nurse take when caring for a client having an anaphylactic medication reaction? Select all that apply. 1.Assess vital signs. 2.Administer oxygen. 3.Ensure a patent airway. 4.Contact the primary health care provider (PHCP). 5.Continue the medication but monitor closely and note the reaction in the chart.

1.Assess vital signs. 2.Administer oxygen. 3.Ensure a patent airway. 4.Contact the primary health care provider (PHCP). If anaphylaxis occurs, the nurse immediately assesses the client's respiratory status. The medication is also immediately stopped. If the client's airway needs to be established or stabilized, the Rapid Response Team is called. In addition, the PHCP is contacted. The intravenous (IV) line is not removed because IV access is needed to administer emergency medications such as diphenhydramine or epinephrine. The client is positioned appropriately. The legs and feet are elevated. The head of the bed is elevated to improve ventilation; elevate the head of the bed 10 degrees if hypotension is present and 45 degrees or higher if the blood pressure is normal. The nurse stays with the client and monitors the client's status, including the vital signs. The nurse documents the event, actions taken, and the client's response.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. 1.Back 2.Axilla 3.Eyelids 4.Soles of the feet 5.Palms of the hands

Back Soles of the feet Palms of the hands Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

A nurse is developing a teaching plan for a client with an immunodeficiency. What would the nurse need to emphasize? Select all that apply. Signs and symptoms of bleeding Ways to manage stress Need to interrupt therapy for short periods Prophylactic medication regimens Maintenance of a well-balanced diet

Prophylactic medication regimens Maintenance of a well-balanced diet Ways to manage stress Teaching for clients with immunodeficiency disorders should focus on the signs and symptoms that indicate infection, prophylactic medication regimens, the need for continued therapy without interruptions, ways to manage stress, and measures to ensure optimal nutritional status.

The nurse is conducting discharge teaching for a client who is being discharged from the emergency department after an anaphylactic reaction to peanuts. Which education should the nurse include in the teaching? Select all that apply. Desensitization to allergen Avoiding allergens Use of sedatives to treat reactions Wearing a medical alert bracelet

Wearing a medical alert bracelet Avoiding allergens People who have experienced food, medication, idiopathic, or exercise-induced anaphylactic reactions should make every attempt to strictly avoid the allergen. Additionally, they should wear a medical alert bracelet and carry an emergency kit containing epinephrine for injection to prevent the onset of the reaction on exposure. Sedatives are not used to treat anaphylactic reactions, and desensitization is not used for peanut allergies.

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. semen vaginal secretions blood breast milk urine

semen vaginal secretions blood breast milk lmk if you can find the rationale*

A patient allergic to insect stings is going on a jungle trek. How will you instruct the patient to take precautionary measures? Select all that apply. A. Carry preinjectable epinephrine and a tourniquet. B. Take methdilazine (Tacaryl) orally as a preventive measure. C. Wear a Medic Alert bracelet. D. Learn how to self-inject epinephrine. E. Apply calamine lotion topically as a preventive measure.

A,C,D Wearing a Medic Alert bracelet is important because it gives an indication to the health care provider about the patient's medical history. The patient should carry preinjectable epinephrine and a tourniquet. The patient should be taught the technique of applying a tourniquet and the method of self-injecting epinephrine in case of emergency. Methdilazine is an antipruritic agent that requires a prescription, and it should be used with great caution. Also, as it is antipruritic, it will not protect against insect sting. Calamine lotion is also antipruritic. It will help to relieve itching but will not act as a preventive measure for insect stings.Text Reference - p. 214

An older adult has developed a sacral pressure ulcer. What should the nurse assess in order to ensure adequate wound healing and prevent poor outcomes for this client? Select all that apply. The amount of carbohydrates the client ingests Quality of food ingested Caloric intake The client's ability to perform his or her own wound care Nutritional status

Nutritional status Caloric intake Quality of food ingested Nutritional intake that supports a competent immune response plays an important role in reducing the incidence of infections; clients whose nutritional status is compromised have a delayed postoperative recovery and often experience more severe infections and delayed wound healing. The nurse must assess the client's nutritional status, caloric intake, and quality of foods ingested.

A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which symptoms? Select all that apply. Hunger Flank pain Fatigue Tightness in the chest Shaking chills

b) Tightness in the chest c) Flank pain d) Shaking chills Adverse reactions can include reports of flank and back pain, shaking chills, dyspnea, and tightness in the chest, as well as headache, fever, and local reaction at the infusion site.

A nurse is preparing the discharge plan of a patient who is allergic to latex. What foods should the nurse ask the patient to avoid? Select all that apply. A. Tomatoes B. Leafy vegetables C. Avocados D. Potatoes E. Milk

A,C, D Some of the proteins in rubber latex are similar to food proteins. The patient who is allergic to latex may also be allergic to foods that contain similar food proteins. Tomatoes, potatoes, and avocados should be avoided. Milk and leafy vegetables do not contain proteins similar to those found in latex.

The nurse is teaching a client about the correct use of topical concentrated corticosteroids. The nurse includes which statement(s)? Select all that apply. Avoid prolonged use. Avoid applying to the face. Hypertrichosis is normal. Apply to intertriginous areas.

Avoid applying to the face. Avoid prolonged use. The nurse should teach the client to avoid prolonged use, which could lead to hypertrichosis (excessive hair growth) and/or steroid-induced acne. The nurse should also tell the client to avoid applying the corticosteroid to the face and to intertriginous areas.

The nurse is caring for an older patient who has been receiving antiretroviral therapy for HIV infection for many years. The nurse is aware that complications of long-term antiretroviral use can include: (Select all that apply.) osteoporosis. insulin resistance. cognitive problems. urinary incontinence. cardiovascular disease.

Correct Answer: osteoporosis. insulin resistance. cardiovascular disease. Rationale: Patients receiving HIV antiretroviral therapy are more likely to develop other conditions include osteoporosis, insulin resistance, and cardiovascular disease.

he nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply. A) Contractures B) Hemorrhage C) Pressure ulcers D) Venous thromboembolism E) Pneumonia

Ans: A, C, D, E Feedback: Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. The pathophysiology of decreased LOC does not normally create a heightened risk for hemorrhage.

The nurse recognizes that causes of acquired seizures include what? Select all that apply. Cerebrovascular disease Metabolic and toxic conditions Hyponatremia Brain tumor Drug and alcohol withdrawal

Cerebrovascular disease Metabolic and toxic conditions Hyponatremia Brain tumor Drug and alcohol withdrawal The specific causes of seizures are varied and can be categorized as idiopathic (genetic, developmental defects) and acquired. Causes of acquired seizures include cerebrovascular disease; hypoxemia of any cause, including vascular insufficiency; fever (childhood); head injury; hypertension; central nervous system infections; metabolic and toxic conditions (e.g., renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure); brain tumor; drug and alcohol withdrawal; and allergies.

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. 1. Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. 4.Leave the client briefly to contact a primary health care provider (PHCP). 5.Keep the client supine regardless of the blood pressure readings. 6.Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1, Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. Rationale:An anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. Although the PHCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per PHCP prescription. Documentation of the event, actions taken, and client outcomes needs to be performed. The head of the bed should be elevated if the client's blood pressure is normal.

The nurse works with high-risk clients in an urban outpatient setting. Which groups should be tested for human immunodeficiency virus (HIV)? Select all that apply. Injection drug abusers 2.Prostitutes and their clients 3.People with sexually transmitted infections (STIs) 4.People who have had frequent episodes of pneumonia 5.People who recently received a blood transfusion for a surgical procedure

1. Injection drug abusers 2.Prostitutes and their clients 3.People with sexually transmitted infections (STIs) Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Injection drug abusers, those engaged in prostitution, and people with STIs are high-risk groups that should be tested for HIV per the Centers for Disease Control and Prevention's recommendations. Those who have had frequent episodes of pneumonia and those who recently received a blood transfusion for a surgical procedure are not at risk for HIV unless another compounding factor places them at risk. However, if a blood transfusion was received between 1978 and 1985, the client should be tested.

Which statement(s) accurately describe(s) mild cognitive impairment (select all that apply)? a. Always progresses to AD b. Caused by a variety of factors and may progress to AD c. Should be aggressively treated with acetylcholinesterase drugs d. Caused by vascular infarcts that, if treated, will delay progression to ADe. Patient is usually not aware that there is a problem with his or her memory

b. Caused by a variety of factors and may progress to AD Although some individuals with mild cognitive impairment (MCI) revert to normal cognitive function or do not go on to develop Alzheimer's disease (AD), those with MCI are at high risk for AD. No drugs have been approved for the treatment of MCI. A person with MCI is often aware of a significant change in memory.

Which individuals are most likely to be at risk for development of psoriasis? Select all that apply. 1.A 32-year-old African American 2.A woman experiencing menopause 3.A client with a family history of the disorder 4.An individual who has experienced a significant amount of emotional distress 5.A female client with a thin body frame who adheres to a regular exercise program

2.A woman experiencing menopause 3.A client with a family history of the disorder 4.An individual who has experienced a significant amount of emotional distress Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches. Various forms exist, with psoriasis vulgaris being the most common type. Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be a cause. The disorder also may be exacerbated by the use of certain medications. Psoriasis occurs equally among women and men, although the incidence is lower in darker-skinned races and ethnic groups.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. Keep liquids at the bedside. 2.Place a towel over the pillowcase. 3.Make sure the pillow has a plastic cover. 4.Keep a change of bed linens nearby in case they are needed. 5.Administer an antipyretic after the client has a spike in temperature.

Keep liquids at the bedside. 2.Place a towel over the pillowcase. 3.Make sure the pillow has a plastic cover. 4.Keep a change of bed linens nearby in case they are needed. Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is profuse. The client should have liquids at the bedside to drink.

A nurse is caring for a client with atopic dermatitis. Which suggestions for the client by the nurse would be appropriate? Select all that apply. Keep the room temperature at approximately 70 degrees Fahrenheit (21 degrees Celsius). Use a strong antibacterial detergent for the laundry. Wear clothing made from synthetic fabrics. Humidify the home when the heat is on during the winter. Apply topical moisturizers to the skin.

Keep the room temperature at approximately 70 degrees Fahrenheit (21 degrees Celsius). Apply topical moisturizers to the skin. Humidify the home when the heat is on during the winter. The nurse would suggest that the client use a mild detergent for laundry and keep the room temperature between 68 to 72 degrees Fahrenheit (20 to 22 degrees Celsius) to decrease itching and scratching. Other suggestions include applying topical moisturizers to the skin, wearing clothes made from cotton fabrics, and humidifying the home when dry home heating is used during the winter.

The nurse is completing a physical assessment with an older adult client. Which findings indicate to the nurse that the client is experiencing age-related changes to the immune system? Select all that apply. Muscle cramps Crepitus Pain with voiding Diarrhea Skin tears

Pain with voiding Diarrhea Skin tears Age-related changes in many body systems contribute to impaired immunity. Decreased gastric secretions and motility lead to the proliferation of intestinal organisms that cause gastroenteritis and diarrhea. Thinning of the skin with less elasticity and loss of adipose tissue increases the risk of skin injuries and tears. Decreased kidney function and changes in lower urinary tract function increase the incidence of urinary tract infections. Crepitus is associated with osteoarthritis. Muscle cramps can be caused by a variety of conditions however they are not directly linked to age-related changes in immune function. Chapter 31: Assessment of Immune Function - Page 997

What are expected client outcomes the nurse would include in a plan of care for a client with allergic rhinitis? Select all that apply. The client's lungs will have occasional crackles or rhonchi The client will wear a dampened mask if dust is a problem The client reports no symptoms of peripheral tingling The client controls outdoor precipitating factors The client develops cachexia

The client will wear a dampened mask if dust is a problem The client reports no symptoms of peripheral tingling The client controls outdoor precipitating factors Wearing a dampened mask if there is a dust problem, reporting no symptoms of peripheral tingling, and controlling outdoor precipitating factors are all expected client outcomes that would be included in a plan of care. Lungs should be absent of crackles or rhonchi. Cachexia is seen in clients with a chronic illness, such as AIDS, chronic obstructive pulmonary disease, or heart failure.

A nurse is assessing a client with a new skin disorder. Which questions would the nurse include when asking the client about the change in skin condition? Select all that apply. When did the disorder first begin, and where did it first appear? Where are the lesions located? Has the problem spread? Have you tried to treat the lesions? Do you exercise daily?

When did the disorder first begin, and where did it first appear? Where are the lesions located? Has the problem spread? Have you tried to treat the lesions? The nurse would ask the client when and where the disorder started, where the lesions are located and if they have spread, and if the client has attempted to treat them. The client's exercise habits would not affect the skin disorder.

Which of the following are assessment findings associated with thrombocytopenia? Select all that apply. Hematemesis Bradypnea Epistaxis Hypertension Bleeding gums

Bleeding gums Epistaxis Hematemesis Pertinent findings of thrombocytopenia include: bleeding gums, epistaxis, hematemesis, hypotension, and tachypnea.

A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply. Eggs Milk Chicken Beef Shrimp

Eggs Milk Shrimp lmk if you can find the rationale*

A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply. Administer Diphenhydramine. Insert an intravenous line. Give metoprolol. Have respiratory therapy provide an albuterol treatment. Monitor international normalized ratio (INR) level.

Have respiratory therapy provide an albuterol treatment. Administer Diphenhydramine. Insert an intravenous line. Administering diphenhydramine reverses the effect of histamine. Inserting an intravenous line will allow access to administer medications quickly. Metoprolol is a medication used to treat hypertension or chest pain. Administering an albuterol treatment reverses histamine-induced bronchospasm. The international normalized ratio (INR) level is monitored for warfarin treatment. Chapter 33: Assessment and Management of Patients with Allergic Disorders - Page 1049

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. 1.Nuts 2.Corn 3.Liver 4.Apples 5.Lentils 6.Bananas

Nuts, Liver, Lentils

12. A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. A) Antihypertensives B) Penicillins C) Sulfa-containing medications D) Aspirin-based drugs E) NSAIDs

Ans: C, D, E Feedback:The nurse must be alert for sulfa-containing medications and others that alter platelet function (e.g., aspirin-based or other NSAIDs). Antihypertensive drugs and the penicillins do not alter platelet function.

The nurse is creating a discharge teaching plan for a client with a latex allergy. Which information should be included? Select all that apply. Administration of antihistamines Avoidance of latex-based products Administration of emergency epinephrine Radioallergosorbent testing (RAST)

Avoidance of latex-based products Administration of antihistamines Administration of emergency epinephrine

healthy 65-year-old man who lives at home is at the clinic requesting a "flu shot." When assessing the patient, what other vaccinations should the nurse ask the patient about receiving? Select all that apply. A. Haemophilus influenzae type b (Hib) B. Measles, mumps, and rubella (MMR) C. Meningococcal D. Shingles E. Pneumonia

D, E The patient should receive the shingles (herpes zoster) vaccine, Pneumovax, and influenza. Meningococcal, Hib, and MMR vaccinations do not apply to this patient. Meningococcal vaccination is recommended for adults at risk (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies). Adults born before 1957 generally are considered immune to measles and mumps. Hib vaccination is considered only for adults with selected conditions (e.g., sickle cell disease, leukemia, human immunodeficiency virus [HIV] infection, or for those who have anatomic or functional asplenia) if they have not been vaccinated previously.Text Reference - p. 208

A client is diagnosed with common variable immunodeficiency (CVID). What would the nurse identify as potential infections for this client? Select all that apply. Staphylococcus aureus Streptococcus pneumoniae Pneumocystis jiroveci pneumonia Hemophilus influenzae

Hemophilus influenzae Streptococcus pneumoniae Staphylococcus aureus Clients with CVID are susceptible to infections with Hemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. Opportunistic infections with Pneumocystis jiroveci pneumonia are seen only in clients with a concomitant deficiency in T-lymphocyte immunity.

What should the nurse assess for to determine if a patient using corticosteroids for a dermatologic condition is having local side effects? Select all that apply. Striae Skin atrophy Comedones Telangiectasia Ecchymosis

Skin atrophy Striae Telangiectasia Local side effects of topical corticosteroids may include skin atrophy and thinning, striae (bandlike streaks), and telangiectasias (small, red lesions caused by dilation of blood vessels).

The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? Select all that apply. The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle. The goal of antiretroviral therapy is to prevent opportunistic infections. Medication therapy is rarely effective. Clients rarely respond to medication therapy.

The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle. lmk if you can find the rationale*

The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply. 1."I may continue to use an electric shaver." 2."I will not blow my nose if I get a cold." 3."I should use an enema instead of laxatives for constipation." 4."I definitely will play football with my friends this weekend." 5."I should use a soft-bristled toothbrush to avoid mouth trauma."

1."I may continue to use an electric shaver." 2."I will not blow my nose if I get a cold." 5."I should use a soft-bristled toothbrush to avoid mouth trauma." Bleeding precautions are used to protect the client with thrombocytopenia from bleeding. The client with thrombocytopenia may experience internal and external bleeding. Bleeding is frequently provoked by trauma, but it also may be spontaneous. The client with thrombocytopenia should be educated about activities that increase the risk for bleeding, such as contact sports and trauma to oral, nasal, and rectal mucosa. This will help to eliminate options 3 and 4.

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. Presence of striae 2.Palpable radial pulses 3.Absence of any ecchymosis on the extremities 4.Thinner and decrease in number of reddish papules 5.Scarce amount of silvery-white scaly patches on the arms

4.Thinner and decrease in number of reddish papules 5.Scarce amount of silvery-white scaly patches on the arms Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis.

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse assess first? A 60-yr-old patient with a blood pressure of 92/64 mm Hg and hemoglobin of 9.8 g/dL A 50-yr-old patient with a respiratory rate of 26 breaths/minute and an elevated D-dimer A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL A 30-yr-old patient with a pulse of 112 beats/min and a white blood cell count of 14,000/µL

A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL Rationale: A low-grade fever greater than 100.4° F (38° C) in a patient with a neutrophil count below 500/µL is a medical emergency and may indicate an infection. An infection in a neutropenic patient could lead to septic shock and possible death if not treated immediately.

The nurse is caring for a patient in the hospital who is receiving a vitamin D supplement. What does the nurse understand is the importance of supplementation with this vitamin? (Select all that apply.) Vitamin D deficiency is associated with increased risk of common cancers. Vitamin D deficiency is associated with increased risk of inflammatory disorders. Vitamin D deficiency is associated with increased risk of celiac disease. Vitamin D deficiency is associated with increased risk of autoimmune disease. Vitamin D deficiency is associated with increased risk of congenital anomalies.

A. Vitamin D deficiency is associated with increased risk of common cancers B. Vitamin D deficiency is associated with increased risk of autoimmune disease D. Vitamin D deficiency is associated with increased risk of inflammatory disorders lmk if you can find the rationale*

A client is experiencing severe anaphylactic shock. What actions should the nurse take first? Select all that apply. A. Administer diphenhydramine. B. Ask the client if they are lightheaded. C. Give intravenous fluids.D. Give metoprolol. E. Prepare for insertion of an endotracheal tube. F. Check for hematuria.

Administer diphenhydramine. Prepare for insertion of an endotracheal tube. Give intravenous fluids. Ask the client if they are lightheaded. lmk if you can find the rationale*

An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply? A) Are you exposed to any toxins or chemicals at work? B) How would you describe your ability to cope with stress? C) What medications are you currently taking? D) When was the last time you were hospitalized? E) Does anyone else in your family struggle with headaches?

Ans: A, B, C, E Feedback:Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches.

The results of a patient's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This patient should undergo testing for which of the following potential causes? Select all that apply. A) Hepatitis B) Acute renal failure C) HIV D) Malignant melanoma E) Cholecystitis

Ans: A, C Feedback:Viral illnesses have the potential to cause ITP. Renal failure, malignancies, and gall bladder inflammation are not typical causes of ITP.

A child has been transported to the emergency department (ED) after a severe allergic reaction. The ED nurse is evaluating the patients respiratory status. How should the nurse evaluate the patients respiratory status? Select all that apply. A) Facilitate lung function testing. B) Assess breath sounds. C) Measure the childs oxygen saturation by oximeter. D) Monitor the childs respiratory pattern. E) Assess the childs respiratory rate.

Ans: B, C, D, E Feedback: The respiratory status is evaluated by monitoring the respiratory rate and pattern and by assessing for breathing difficulties, low oxygen saturation, or abnormal lung sounds such as wheezing. Lung function testing is a lengthy procedure that is not appropriate in an emergency context.

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. Destruction of normally formed red blood cells Inadequate formed white blood cells Blood loss Abnormal erythrocyte production Infection

Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells.

While undergoing a cerebral computed tomography (CT) scan, a contrast dye is injected. After administering a few mL of contrast media, the health care provider assesses the patient and immediately stops the infusion. What reasons could have led the health care provider to discontinue the contrast dye? Select all that apply. A. Nasal discharge B. Sneezing C. Dyspnea D. Rapid, weak pulse E. Hypotension

C,D,E Anaphylaxis is a significant adverse reaction that is life threatening in response to the iodinated dye that was used as a contrast. As anaphylaxis is manifested by respiratory distress, a rapid weak pulse, hypotension, and shock, counteractive measures must be implemented immediately. Nasal discharge and sneezing are not associated with contrast dye-related complications; these are minor manifestations of atopic reactions.Text Reference - p. 214

A patient is admitted to the emergency department (ED) with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing actions will help identify the need for further assessment of the cause of this patient's manifestations if the nurse suspects the patient is at risk for HIV infection? (Select all that apply.) Assessment of lung sounds Reviewing living conditions Assessment of sexual behavior Assessment of drug and syringe use Evaluating for exposure to an ill person

Correct Answer: Assessment of sexual behavior Assessment of drug and syringe use Rationale: With these symptoms, assessing this patient's sexual behavior and possible exposure to shared drug equipment will identify if further assessment for HIV infection should be made or the manifestations are from some other illness (e.g., lung sounds and living conditions may indicate further testing for TB).

A patient has developed multiple chemical sensitivities. What line of treatment would be appropriate for this patient? Select all that apply. A. Start narcotic drugs. B. Start anti-anxiety drugs. C. Start antidepressants. D. Avoid chemicals that may trigger symptoms. E. Create an odor-free and chemical-free home and workplace.

D, E The patient should be instructed to avoid chemicals known to trigger symptoms. Creating a chemical- and odor-free environment is the most appropriate treatment to prevent symptoms related to chemical sensitivity. Narcotic drugs, anti-anxiety drugs, and antidepressant drugs are used only to treat the symptoms temporarily. These drugs do not desensitize the patient toward the chemicals. TEST-TAKING TIP: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option.Text Reference - p. 216

A CD4 T-cell count is measured in a client newly diagnosed with human immunodeficiency virus (HIV). In planning care, the nurse understands that which is accurate regarding the CD4 T-cell count? Select all that apply. 1.Falls in response to a declining viral load 2.Is a primary marker of immunocompetence 3.Plays a role in the cell-mediated immune response 4.Is a direct measure of the magnitude of HIV replication 5.Guides decision making regarding timing of initiation of treatment

Is a primary marker of immunocompetence Guides decision making regarding timing of initiation of treatment Plays a role in the cell-mediated immune response Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. CD4 T-cells are a subgroup of lymphocytes that play an important role in the cell-mediated immune response; as such, CD4 T-cells are a primary marker of immunocompetence. Viral load is the direct measure of the magnitude of HIV replication. The CD4 T-cell count rises in response to a declining viral load. CD4 T-cell counts also guide decision making regarding initiation of treatment, when to change medications when treatment is failing, and the need for initiation of treatment against opportunistic infections.

A nurse cares for a client with anemia after having a total gastrectomy a year ago. Which unique assessment findings will the nurse likely find when assessing this client that may not be present in another client with anemia? Select all that apply. Weakness Tingling in the fingers Poor coordination Fatigue Shortness of breath

Poor coordination Tingling in the fingers The client likely has pernicious anemia, caused by a lack of intrinsic factor, found in the stomach. Paresthesias (tingling in the fingers) and poor coordination are unique to pernicious anemia. Shortness of breath, fatigue, and weakness are common to other anemias and not unique assessment findings.

A nurse is caring for a child in acute sickle cell crisis. Which laboratory values does the nurse expect to see? Select all that apply. negative Howell-Jolly bodies positive hemoglobin (Hb) SS low mean corpuscular hemoglobin (MCH) positive metabisulfite test high platelet count

positive hemoglobin (Hb) SS positive metabisulfite test low mean corpuscular hemoglobin (MCH) Sickle cell crisis typically presents with low MCH and a positive metabisulfite test. MCV (mean corpuscular volume) will be low in sickle cell anemia. Presence of hemoglobin (Hb) SS is a definitive indicator for sickle cell anemia. A positive, not negative, Howell-Jolly bodies test is a definitive indicator of sickle cell anemia.

The nurse is planning care for a client with atopic dermatitis. Which information will the nurse include when teaching the client self-care for the condition? Select all that apply. Wear clothing made of cotton. Apply a skin cream that contains glycerol. Use a mild soap when bathing. Take antihistamines early in the day. Crusting of lesions is a sign of healing.

Use a mild soap when bathing. Take antihistamines early in the day. Apply a skin cream that contains glycerol. Atopic dermatitis is a type I immediate hypersensitivity disorder involving IgE antibodies that causes dry, pruritic, hypersensitive skin. It often begins with small, red, pruritic papules that stimulate intense itching, leaving erythematous, excoriated areas of skin. This often triggers an "itch-scratch cycle" where rubbing or scratching the skin causes further irritation, redness, and skin breakdown. Treatment of clients with atopic dermatitis involves avoidance of irritative agents, use of anti-inflammatory topical agents, and moisturization of the skin. The client should be advised to use mild soap when bathing and to wear clothing made of cotton. Thick cream moisturizers and emollients that contain glycerol should be used as these will keep the skin hydrated. Antihistamines may be used however should be taken at bedtime because they are sedating. The presence of purulence or honey-colored crusts suggests S. aureus infection and antibiotics are needed to eradicate infection.

A heterosexual patient is concerned that they may contract human immunodeficiency virus (HIV) from a bisexual partner. What should the nurse include when teaching about preexposure prophylaxis? (Select all that apply.) Take fluconazole (Diflucan). Take amphotericin B (Fungizone). Use condoms for risk-reducing sexual relations. Take emtricitabine and tenofovir (Truvada) regularly. Have regular HIV testing for herself and her husband.

Use condoms for risk-reducing sexual relations. Take emtricitabine and tenofovir (Truvada) regularly. Have regular HIV testing for herself and her husband. Rationale: Using male or female condoms, having regular HIV testing for the patient and partner, and taking emtricitabine and tenofovir regularly have shown to decrease the infection of heterosexual women having sex with a partner who participates in high-risk behavior. Fluconazole and amphotericin B are taken for Candida albicans, Coccidioides immitis, and Cryptococcus neoformans, which are all opportunistic diseases associated with HIV infection.

A nurse is assessing a client with a new skin disorder. Which questions would the nurse include when asking the client about the change in skin condition? Select all that apply. Has the problem spread? Where are the lesions located? When did the disorder first begin, and where did it first appear? Do you exercise daily? Have you tried to treat the lesions?

When did the disorder first begin, and where did it first appear? Where are the lesions located? Has the problem spread? Have you tried to treat the lesions? The nurse would ask the client when and where the disorder started, where the lesions are located and if they have spread, and if the client has attempted to treat them. The client's exercise habits would not affect the skin disorder.

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. Providing for privacy Positioning the patient on his or her side with head flexed forward Restraining the patient to avoid self injury Opening the patient's jaw and inserting a mouth gag Loosening constrictive clothing

Positioning the patient on his or her side with head flexed forward Providing for privacy Loosening constrictive clothing During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.