Test 3 Chpt15,35,37

A nurse is teaching a client how to use their EpiPen autoinjector. What client statement indicates the teaching is understood? Select all that apply.

***"After I administer the injection, I will massage the area for 10 seconds." ***"The needle needs to be at a 90-degree angle." "I will jab the EpiPen autoinjector firmly into my right upper buttock." "The EpiPen autoinjector should be held against the injection site for 20 seconds." ***"The EpiPen autoinjector needs to be pointed downward."

The clinic nurse is caring for a client who has just been diagnosed with a tumor. The client says to the nurse "The doctor says my tumor is benign. What does that mean?" What is the nurse's best response?

***"Benign tumors don't usually cause death." "Benign tumors invade surrounding tissue." "Benign tumors can spread from one place to another." "Benign tumors grow very rapidly."

A nurse is teaching a client about allergic rhinitis. What client statements indicate teaching has been effective? Select all that apply.

***"I should use my medication for allergy exacerbation only when my allergy is apparent." "I am allowed to miss only one desensitization appointment before my treatment is affected." "I can only have one alcoholic drink while I am taking my antihistamine." ***"I need to reduce my exposure to people that have upper respiratory infections." ***"I will remove as much carpet from my house as I can."

The nurse is caring for a client with the diagnosis of colon cancer with metastasis to the liver. Which statement made by the client indicates an understanding of the diagnosis?

***"My cancer has now spread to my liver." "I will be happy once all the cancer is cut out." "Once the colon tumor is removed, I will be fine." "How could I be so unlucky to get cancer twice?"

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. ***Have respiratory therapy provide an albuterol treatment. Monitor international normalized ratio (INR) level. Give metoprolol. ***Insert an intravenous line.

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 Radioallergosorbent testing (RAST) ***Administration of emergency epinephrine ***Avoidance of latex-based products

A client has been transported to the emergency department after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply.

***Assess the client's respiratory rate. ***Assess breath sounds. ***Measure the client's oxygen saturation by oximeter. Facilitate lung function testing. ***Monitor the client's respiratory pattern.

The client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?

***Avoid antihistamines and cold preparations for 48 to 72 hours before the test. Avoid strenuous physical activity for 24 hours before the test. Avoid sunlight for 48 to 72 hours before the test. Avoid red meat for 48 to 72 hours before the test.

A client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer?

***Indigestion Rash Chronic ache or pain Persistent nausea

A client has been brought to the emergency department after being found unresponsive, and anaphylaxis is suspected. The care team should attempt to assess for which potential causes of anaphylaxis? Select all that apply.

***Insect stings Environmental pollutants ***Medications ***Foods Autoimmunity

The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply.

***List symptoms of peanut allergy. ***Wear a medic alert bracelet. ***Carry EpiPen autoinjector at all times. Food labels on baked items are the only labels that need to be read. ***Identify ways to manage allergy while dining out.

A 67-year-old client is admitted for diagnostic studies to rule out cancer. The patient is white, married, has been employed as a landscaper for 40 years, and has a 36-year history of smoking a pack of cigarettes daily. What significant risk factors does the nurse recognize this patient has? Select all that apply.

***Occupation ***Age Race ***Cigarette smoking Marital status

A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment?

***The client will remain in the clinic to be monitored for 30 minutes following the injection. The client will be given a low dose of epinephrine before the treatment. The allergen will be given by the peripheral intravenous (IV) route. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months.

The immune system is a complicated and intricate system that contains specialized cells and tissues that protect us from external invaders and our own altered cells. Which term is used to define any substances capable of inducing a specific immune response and of reacting with the products of that response?

***antigens lymphokines lymphocytes antibodies

The nurse is teaching a client about the symptoms of anaphylaxis. Which client statements indicate no further teaching is needed? Select all that apply.

"Sneezing a lot can be a concern if it continues and does not let up." ***"Peripheral tingling is a symptom of anaphylaxis reaction." "A feeling of fullness in my mouth is okay as long as it does not increase." ***"If I start having difficulty breathing, I need to get help right away." "If I experience recurrent diarrhea after eating, I will need to call my doctor."

A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?

Removal of bacteria and dead blood cells from circulation Conversion of memory cells to plasma cells ***Engulfment and digestion of bacteria and foreign material Release of chemicals to destroy bacteria and foreign material

A client with an allergic disorder calls the nurse and asks what treatment is available for allergic disorders. The nurse explains to the client that there is more than one treatment available. What treatments would the nurse tell the client about?

Sublingual-swallow immunotherapy (SLIT) ***Desensitization Sublingual-topical immunotherapy (STIT) Resensitization

A nurse is reviewing the immune system before planning an immunocompromised client's care. How should the nurse characterize the humoral immune response?

T lymphocytes are assisted by cytokines to fight infection. Lymphocytes are stimulated to become cells that attack microbes directly. ***Antibodies are made by B lymphocytes in response to a specific antigen. Specialized cells recognize and ingest cells that are recognized as foreign.

Which response is a humoral immune response?

Transplant rejection Delayed hypersensitivity Intracellular infections ***Anaphylaxis

Which intervention is the single most important aspect for the client at risk for anaphylaxis?

Use of antihistamines Desensitization ***Prevention Wearing a medical alert bracelet

A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action?

encouraging activity ***maintaining an open airway providing pain relief measures decreasing anxiety

Immunocompetence is the ability of the immune system to cooperatively protect a person from external invaders and the body's own altered cells. Immunocompetence is maintained by white blood cells and:

cytokines. the compliment system. ***lymphoid tissue. antibodies.

The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA) which can be caused by many factors, or carcinogens. What factors can be carcinogenic? Select all that apply.

gender ***environmental factors ***viruses age ***dietary substances

A client has a known allergy to peanuts, meaning that the client's immune system has identified peanuts as a foreign invader and has produced specific cells to attack if the client should come in contact with peanuts again. The formation of these specific cells is known as:

inflammatory response. memory response. ***humoral response. cell-mediated response.

The nurse is caring for a client with a newly discovered tumor that may be benign or malignant. The client asks, "What makes a malignant tumor different from a benign one?" What should the nurse include in the response? Select all that apply.

"The tumor may regress after its initial growth." ***"The cells of the tumor bear little resemblance to the cells in the tissue where the tumor started." ***"It grows by invasion and infiltrates the surrounding tissues." "It does not spread to other areas of the body through blood and lymph channels." "The tumor grows slowly and may stop."

Which of the following is the most severe form of hypersensitivity reaction?

***Anaphylaxis Cytotoxic Delayed-type Immune complex

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 Chicken ***Shrimp Beef ***Milk

A patient received epinephrine in response to an anaphylactic reaction at 10:00 AM. The nurse knows to observe the patient for a "rebound" reaction that may occur as early as:

6:00 PM. 4:00 PM. ***2:00 PM. 10:00 PM.

Which of the following is the single largest preventable cause of cancer?

Asbestos Pesticides Arsenic ***Tobacco

Which is a primary chemical mediator of hypersensitivity?

Bradykinin ***Histamine Serotonin Heparin

The nurse is describing some of the major characteristics of cancer to a client who has recently received a diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse should explain differences in which of the following aspects? Select all that apply.

Cell size ***Rate of growth ***Ability to spread Cell location ***Ability to cause death

An elderly client is diagnosed with a respiratory infection. While reviewing age-related changes in the immune system, what would the nurse identify as having contributed to this client's infection?

Decreased phagocytosis by Kupffer cells ***Impaired ciliary action from exposure to environmental toxins Failure of the immune system to differentiate "self" from "non-self" Decreased sensation and slowing of reflexes

An office worker eats a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity?

Delayed-type (type IV) ***Anaphylactic (type 1) Cytotoxic (type II) Immune complex (type III)

The nurse is teaching a healthy lifestyle class to a group of adolescents. The nurse recommends

Eating four servings of vegetables and fruits per each day Decreasing caloric intake to maintain a body mass index lower than 24 ***Exercising at least 60 minutes per day doing moderate to vigorous activities at least 5 days per week Increasing proteins to more than 5 1/2 ounces per day for the male students to build muscle mass

The client presents to the emergency department with a suspected allergic reaction to the antibiotic they were given at the quick care clinic to treat their pneumonia. What are the priority actions the nurse should take? Select all that apply.

Evaluate for hypertension. Check for diplopia. ***Take vital signs. ***Insert an intravenous line. ***Place oxygen on the client. Administer Vitamin K.

While completing an admission assessment, the client reports a family history of breast cancer among a maternal grandmother, aunt, and sister. The nurse knows that these cancers are most likely associated with what etiology?

Exposure to chemicals and spermicides Smoking and tobacco use ***Inherited gene mutation Increased tumor suppressor genes

A client presents to the clinic with reports of itching and hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?

Flunisolide ***Diphenhydramine Pseudoephedrine hydrochloride Beclomethasone dipropionate

An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated?

Helper T cells B cells ***Cytotoxic T cells Macrophages

What type of immunoglobulin is most likely involved with allergic reactions?

IgM IgG ***IgE IgA

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective?

Increased salivation Headache ***Reduced sneezing Increased tearing

The nurse is assessing the diet of a female client. To decrease the risk of cancer in general, the nurse instructs the client to

Ingest two to three servings of fruits and vegetables each day. ***Limit alcohol ingestion to one drink per day. Decrease cigarette smoking from one pack/day to 1/2 pack/day. Include at least 6 ounces of meat in meals every day.

What organ is considered lymphoid tissue?

Intestines Pancreas ***Spleen Liver

What are the primary participants in the immune system?

Lymphoblasts and gamma globulins ***T- and B- cell lymphocytes Macrophages and memory cells Stem cells and monocytes

A nurse has given an 8-year-old client the scheduled vaccination for rubella. This vaccination will cause the client to develop which expected and desired condition?

Mild hypersensitivity ***Passive acquired immunity Cellular immunity Natural immunity

The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?

Tape an EpiPen to the head of the bed. Inform the client not to take any medications with those substances in them. ***Apply an allergy bracelet and flag the chart. Call the physician.

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?

The invading antigens precipitate. The invading antigens link together (agglutination). ***T-cell lymphocytes survey proteins in the body and attack the invading antigens. Toxins of invading antigens are neutralized. SUBMIT ANSWER

A client is cutting vegetables for dinner and accidently cuts a finger. What response is desirable to destroy foreign agents such as microorganisms to prevent infection from developing in the finger?

The release of memory cells Passive immunity ***The release of antibodies A cell-mediated response

The nurse is educating a patient with allergic rhinitis about how the condition is induced. What should the nurse include in the education on this topic?

Topical creams or ointments Parenteral medications ***Airborne pollens or molds Ingested foods

The nurse is evaluating the plan of care for a client with an allergic disorder who has a nursing diagnosis of deficient knowledge related to measures for allergy control. What client statement will indicate to the nurse that the outcome has been met?

Client states the need for coughing and deep breathing. Client demonstrates appropriate coping strategies for dealing with a chronic disorder. ***Client identifies methods for reducing exposure risk to allergens. Client reports an absence of symptoms associated with the allergy.