305 immunity practice questions for final exam

A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse should monitor which most closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. Gastrointestinal function

1. Gait Rationale: Stavudine is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client's gait closely and ask the client about paresthesia. Options 2, 3, and 4 are unrelated to this medication.

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? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1. Protecting the client from infection Rationale: The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night.

2. Administer corticosteroids as prescribed for inflammation. Rationale: Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated, and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present.

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. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity

2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias Rationale: Aminoglycosides are administered to inhibit the growth of bacteria. Adverse effects of this medication include confusion, ototoxicity, renal toxicity, gastrointestinal irritation, palpitations or dysrhythmias, blood pressure changes, and hypersensitivity reactions. Therefore, the remaining options are incorrect.

The nurse is caring for a postrenal transplantation client taking cyclosporine. 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? 1. Pulse 2. Respirations 3. Blood pressure 4. Pulse oximetry

3. Blood pressure Rationale: Hypertension can occur in a client taking cyclosporine, and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.

The 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? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

4. Bananas Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen. Options 1, 2, and 3 are unrelated to latex allergy.

Which questions are most important for the nurse to first ask a client who comes to the emergency department with signs of severe angioedema? Select all that apply. A. "Are you able to swallow?" B. "When did you last eat or drink?" C. "Do you have an allergy to cortisone?" D. "What drugs do you take on a daily basis?" E. "Is there any possibility that you may be pregnant?" F. "Do any members of your family also have allergies?"

A. "Are you able to swallow?" D. "What drugs do you take on a daily basis?"

A client had a left anterior total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? Select all that apply. A. "Avoid extending your left hip behind you when you sit." B. "Do not flex your hips more than 90 degrees when toileting." C. "You may cross your legs to be more comfortable in a chair." D. "Avoid twisting your body when moving or performing ADLs." E. "Stand on your right leg and pivot into the chair when getting out of bed."

A. "Avoid extending your left hip behind you when you sit." D. "Avoid twisting your body when moving or performing ADLs." E. "Stand on your right leg and pivot into the chair when getting out of bed."

The primary health care provider prescribes acetaminophen for a client with osteoarthritis. Which health teaching will the nurse provide for the client regarding this drug? Select all that apply. A. "Don't take more than 3000-4000 mg of this drug each day." B. "Stop taking the drug if unusual bleeding occurs and call your primary health care provider." C. "Tell your primary health care provider if you notice any yellowing of your skin or eyes." D. "Expect fluid accumulation in your legs and feet that usually gets worse during the day." E. "Check over-the-counter drugs to see if they contain acetaminophen."

A. "Don't take more than 3000-4000 mg of this drug each day." C. "Tell your primary health care provider if you notice any yellowing of your skin or eyes." E. "Check over-the-counter drugs to see if they contain acetaminophen."

Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing the newly created viral particle with the infected cell's membrane

B. Binding the virus to the CD4+ receptor and either of the two co-receptors

With which activities does the nurse teach unlicensed assistive personnel (UAP) and nursing students caring for a client who is HIV positive to wear gloves to prevent disease transmission? Select all that apply. A. Applying lotion during a back rub B. Brushing the client's teeth C. Emptying a Foley catheter reservoir D. Feeding the client E. Filing the client's fingernails F. Providing perineal care

B. Brushing the client's teeth C. Emptying a Foley catheter reservoir F. Providing perineal care

A client who recently had laparoscopic surgery to treat a ruptured appendix has developed subsequent peritonitis. The client currently has two Jackson Pratt drains placed in the abdomen. Which finding(s) would the nurse report immediately to the surgeon? Select all that apply. A. Serosanguineous drainage B. Fever C. Cloudy drainage D. Painful abdominal distention E. Pain level 3 on a scale of 1 to 10

B. Fever C. Cloudy drainage D. Painful abdominal distention

The nurse is preparing to give medications to a group of clients. Which drug is not appropriate to treat the disease with which it is matched? A. Rheumatoid arthritis—leflunomide B. Osteoarthritis—acetaminophen C. Acute gout—allopurinol D. Systemic lupus erythematosus—prednisone

C. Acute gout—allopurinol

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 most at risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

1. Hairdressers Rationale: Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; or those who have had multiple surgeries, have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

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 instruction? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

1. "I should take hot baths because they are relaxing." Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

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? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant."

1. "I will clean up any spills from the diaper with diluted alcohol." Rationale: HIV is transmitted through blood, semen, vaginal secretions, and breast milk. The mother of an infant with HIV should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the child's diaper. Alcohol would not be effective in destroying the virus. Options 2, 3, and 4 are accurate instructions related to basic infection control.

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 is caring for a child diagnosed with erythemia infectiosum (fifth disease). Which clinical manifestation should the nurse expect to note in the child? 1. An intense fiery red edematous rash on the cheeks 2. Pinkish-rose maculopapular rash on the face, neck, and scalp 3. Reddish and pinpoint petechiae spots found on the soft palate 4. Small bluish-white spots with a red base found on the buccal mucosa

1. An intense fiery red edematous rash on the cheeks Rationale: Fifth disease is characterized by the presence of an intense fiery red edematous rash on the cheeks, which gives an appearance that the child has been slapped. Options 2 and 3 are manifestations related to rubella (German measles). Koplik's spots (option 4) are found in rubeola (measles).

An infant of a mother infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign? 1. Cough 2. Liver failure 3. Watery stool 4. Nuchal rigidity

1. Cough Rationale: Acquired immunodeficiency syndrome (AIDS) is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. The most common opportunistic infection of children infected with HIV is Pneumocystis jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cough is a common sign of this opportunistic infection. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection. Liver failure is a common sign of this complication. Although gastrointestinal disturbances and neurological abnormalities may occur in a child with HIV infection, options 3 and 4 are not specific opportunistic infections noted in the HIV-infected child. Watery stool is noted with gastroenteritis, and nuchal rigidity is seen in meningitis.

Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Monitor the child's weight. 2. Frequent hand washing is important. 3. The child should avoid exposure to other illnesses. 4. The child's immunization schedule will need revision. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.

1. Monitor the child's weight. 2. Frequent hand washing is important. 3. The child should avoid exposure to other illnesses. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). Rationale: AIDS is a disorder caused by human immunodeficiency virus (HIV) infection and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, and diarrhea and notifying the pediatrician if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications and other medications as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; monitoring weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding sharing eating utensils. Gloves are worn for care, especially when in contact with body fluids and changing diapers; diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with the tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution (10:1 ratio of water to bleach).

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. 1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. 3. Estimate the size of the wheal and document the finding. 4. Tell the client to return to have the site inspected only if there is a reaction. 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. Rationale: Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected. A list of potential allergens is identified and reviewed and given to the client. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients only need to be monitored for about 30 minutes to assess for any adverse effects.

A nursing assistant (NA) is assigned to care for a client who had a cemented total knee arthroplasty. Which statement by the NA indicates a need for further teaching and supervision by the nurse? A. "I'll keep an abduction pillow in place at all times." B. "I'll tell the client not to place a pillow under the surgical knee." C. "I'll apply ice packs to decrease swelling in the knee as ordered." D. "I'll check to make sure the client's leg is not rotated."

A. "I'll keep an abduction pillow in place at all times."

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1. Use nonlatex gloves. 2. Use medications from glass ampules. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

A client presents at the primary health care provider's office with complaints of a ring-like rash on his upper leg. Which question should the nurse ask first? 1. "Do you have any cats in your home?" 2. "Have you been camping in the last month?" 3. "Have you or close contacts had any flu-like symptoms within the last few weeks?" 4. "Have you been in physical contact with anyone who has the same type of rash?"

2. "Have you been camping in the last month?" Rationale: The nurse should ask questions to assist in identifying a cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ring-like rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? 1. Advise the client to soak the site in hydrogen peroxide. 2. Ask the client if he ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency department. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

2. Ask the client if he ever sustained a bee sting in the past. Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

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. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.

2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 5. Instruct the client to avoid exposure to the sun. Rationale: Ketoconazole is an antifungal medication. There is no reason for the client to restrict fluid intake; in fact, this could be harmful to the client. The medication is hepatotoxic, and the nurse monitors liver function. It is administered with food (not on an empty stomach), and antacids are avoided for 2 hours after taking the medication to ensure absorption. The client is also instructed to avoid alcohol. In addition, the client is instructed to avoid exposure to the sun, because the medication increases photosensitivity.

A 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 actions are most appropriate? Select all that apply. 1. Tell the client that testing is not necessary unless arthralgia develops. 2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5. Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic.

2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic. Options 1 and 5 are incorrect.

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? 1. The hepatitis B vaccine will not be given to the child. 2. The inactivated influenza vaccine will be given yearly. 3. The varicella vaccine will be given before 6 months of age. 4. A Western blot test needs to be performed and the results evaluated before immunizations.

2. The inactivated influenza vaccine will be given yearly. Rationale: Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. The inactivated influenza vaccine that is given intramuscularly will be administered (influenza vaccine should be given yearly). The hepatitis B vaccine is administered according to the recommended immunization schedule. Varicella-zoster virus vaccine should not be given, because it is a live virus vaccine; varicella-zoster immunoglobulin may be prescribed after chickenpox exposure. Option 4 is unnecessary and inaccurate.

The nurse provides health teaching for a client beginning glatiramer acetate therapy. Which statement by the client indicates a need for additional teaching? A. "I'll take this drug with food every morning." B. "I'll look for signs of skin reaction at the injection site." C. "I'll stay away from kids who have colds." D. "I'll avoid large crowds so I don't get sick."

A. "I'll take this drug with food every morning."

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? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wearing a gown and gloves to change the bed linens, and gloves only for the bath

2. Wearing a gown and gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage, or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment? 1. "Has your child had difficulty urinating?" 2. "Has your child been exposed to anyone with chickenpox?" 3. "Has any family member had a sore throat within the past few weeks?" 4. "Has any family member had a gastrointestinal disorder in the past few weeks?"

3. "Has any family member had a sore throat within the past few weeks?" Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the respiratory tract. Initially the nurse determines whether any family member has had a sore throat or unexplained fever within the past few weeks. The remaining options are unrelated to the assessment findings of rheumatic fever.

The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 1. "My skin will have tiny red vesicles." 2. "The presence of the skin vesicles is caused by a virus." 3. "I have an autoimmune disease that causes blistering in the skin." 4. "Red, raised papules and large plaques covered by silvery scales will be present on my skin."

3. "I have an autoimmune disease that causes blistering in the skin." Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis.

Amikacin is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches

3. Hearing loss Rationale: Amikacin is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the PHCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the PHCP immediately if nausea occurs. If nausea persists or results in vomiting, the PHCP should be notified.

A 6-year-old child with human immunodeficiency virus (HIV) infection 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? 1. "The pain will go away if you lie still and let the medicine work." 2. "Try not to think about it. The more you think it hurts, the more it will hurt." 3. "I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less." 4. "Every time it hurts, press on the call button and I will give you something to make the pain go all away."

3. "I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less." Rationale: The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. The nurse must acknowledge the child's pain and let the child know that everything will be done to decrease the pain. Telling the child that movement or lack thereof would eliminate the pain is inaccurate. Allowing a child to think that he or she can control the pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken "all away" is neither truthful nor realistic.

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 Scouts indicates a need for further instruction? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellents because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants."

3. "I should not use insect repellents because it will attract the ticks." Rationale: In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs and symptoms of which adverse effects of the medication? Select all that apply. 1. Ototoxicity 2. Palpitations 3. Nephrotoxicity 4. Bone marrow suppression 5. Gastrointestinal (GI) effects 6. Increased white blood cell (WBC) count

3. Nephrotoxicity 4. Bone marrow suppression 5. Gastrointestinal (GI) effects Rationale: Adverse effects of sulfonamides include nephrotoxicity, bone marrow suppression, GI effects, hepatotoxicity, dermatological effects, and some neurological symptoms including headache, dizziness, vertigo, ataxia, depression, and seizures. Options 1, 2, and 6 are unrelated to these medications.

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? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3. Positive punch biopsy of the cutaneous lesions Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine. The nurse interprets that the client may have the medication discontinued by the health care provider if which elevated result is noted? 1. Serum protein level 2. Blood glucose level 3. Serum amylase level 4. Serum creatinine level

3. Serum amylase level Rationale: Didanosine can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. What instruction should the nurse give to the mother? 1. To continue to monitor the child 2. That lethargy and vomiting are normal with mumps 3. To bring the child to the clinic to be seen by the pediatrician 4. That, as long as there is no fever, there is nothing to be concerned about

3. To bring the child to the clinic to be seen by the pediatrician Rationale: Mumps generally affects the salivary glands, but it can also affect multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the pediatrician.

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? 1. "I will wash my hands frequently." 2. "I will keep my child's immunizations up to date." 3. "I will avoid direct unprotected contact with my child's body fluids." 4. "I can send my child to day care if he has a fever, as long as it is a low-grade fever."

4. "I can send my child to day care if he has a fever, as long as it is a low-grade fever." Rationale: AIDS is a disorder caused by human immunodeficiency virus (HIV) and characterized by generalized dysfunction of the immune system. A child with AIDS who is sick or has a fever should be kept home and not brought to a day care center. Options 1, 2, and 3 are correct statements and would be actions a caregiver should take when the child has AIDS.

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The pediatrician 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 infection. The nurse should make which most appropriate response to the mother? 1. "I am so pleased also that everything has turned out fine." 2. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection." 3. "Everything looks great, but be sure to return with your infant next month for the scheduled visit." 4. "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."

4. "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." Rationale: Acquired immunodeficiency syndrome (AIDS) is caused by HIV infection and characterized by generalized dysfunction of the immune system. Most children infected with HIV develop symptoms within the first 9 months of life. The remaining infected children become symptomatic sometime before age 3 years. With their immature immune systems, children have a much shorter incubation period than adults. Options 1, 2, and 3 are incorrect. Additionally, these options offer false reassurance.

The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? 1. "We need to encourage our child to drink fluids." 2. "Coughing spells may be triggered by dust or smoke." 3. "Vomiting may occur when our child has coughing episodes." 4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."

4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks." Rationale: Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are accurate components of home care instructions.

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? 1. CD4+ T cell count 2. Lymphocyte count 3. Serum albumin level 4. Serum creatinine level

4. Serum creatinine level Rationale: Foscarnet is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency.

The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected? 1. Pinpoint petechiae noted on both legs 2. Whitish vesicles located across the chest 3. Petechiae spots that are reddish and pinpoint on the soft palate 4. Small, blue-white spots with a red base found on the buccal mucosa

4. Small, blue-white spots with a red base found on the buccal mucosa Rationale: In rubeola (measles), Koplik's spots appear approximately 2 days before the appearance of the rash. These are small, blue-white spots with a red base that are found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off. Based on this information, the remaining options are all incorrect.

The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to assess the client, knowing that this sign most likely indicates which condition? 1. That the dose of the medication is too low 2. That the client is experiencing toxic effects of the medication 3. That the client has developed inadequacy of thermoregulation 4. That the client has developed another infection caused by leukopenic effects of the medication

4. That the client has developed another infection caused by leukopenic effects of the medication Rationale: Frequent adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

A pediatrician prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray 2. Western blot 3. CD4+ cell count 4. p24 antigen assay

4. p24 antigen assay Rationale: Infants born to HIV-infected mothers need to be screened for the HIV antigen. The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia.

The nurse is teaching a client about self-management measures to help prevent low back pain. Which teaching should be included? Select all that apply. A. "Losing weight can decrease strain on your back." B. "Avoid twisting at your waist." C. "Exercise on a regular basis, including walking." D. "Don't bend at your waist when lifting a heavy object." E. "Eat foods high in calcium and vitamin D to prevent bone loss."

A. "Losing weight can decrease strain on your back." B. "Avoid twisting at your waist." C. "Exercise on a regular basis, including walking." D. "Don't bend at your waist when lifting a heavy object." E. "Eat foods high in calcium and vitamin D to prevent bone loss."

Which health teaching by the nurse is important for clients diagnosed with systemic lupus erythematosus? Select all that apply. A. "Take frequent rest periods to prevent fatigue." B. "Avoid green leafy vegetables to prevent bleeding." C. "Avoid sun exposure to prevent disease flare-ups." D. "Report fever to your health care provider immediately" E. "Use a mild soap for bathing to prevent skin irritation."

A. "Take frequent rest periods to prevent fatigue." C. "Avoid sun exposure to prevent disease flare-ups." D. "Report fever to your health care provider immediately" E. "Use a mild soap for bathing to prevent skin irritation."

Which assessment findings will the nurse expect for the client with late-stage rheumatoid arthritis? Select all that apply. A. Bony nodes in finger joints B. Subcutaneous nodules C. Severe weight loss D. Joint deformity E. Thrombocytosis

A. Bony nodes in finger joints B. Subcutaneous nodules C. Severe weight loss D. Joint deformity E. Thrombocytosis

The nurse is caring for an older adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea that have lasted a week. For which complications will the nurse assess? Select all that apply. A. Dehydration B. Hypokalemia C. Skin breakdown D. Deep vein thrombus E. Hyperkalemia

A. Dehydration B. Hypokalemia C. Skin breakdown

The nurse is teaching a client about nutrition and diverticulosis. Which food will the nurse teach the client to avoid? A. Popcorn B. Oatmeal C. Bran D. Lettuce

A. Popcorn

The nurse is caring for a client who has celiac disease. Which food will the nurse remove from the client's dietary tray? Select all that apply. A. Rice B. Graham crackers C. Croissant D. Fresh peaches E. Chicken breast

B. Graham crackers C. Croissant

A nurse is caring for a client who has a hard cervical collar for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air

B. Painful pressure injury under the collar

The nurse is caring for a client who has just been prescribed a glucocorticoid to treat an exacerbation of ulcerative colitis. What teaching will the nurse provide? A. Decrease the drug dose during the next exacerbation. B. Report fever to health care provider immediately. C. Determine if the client's insurance covers payment for this medication. D. This drug will act as an antidiarrheal.

B. Report fever to health care provider immediately.

A client who sustained a recent cervical spinal cord injury reports feeling flushed. The client's blood pressure is 180/100. What is the nurse's best action at this time? A. Perform a bladder assessment. B. Insert an indwelling urinary catheter. C. Turn on a fan to cool the patient. D. Place the patient in a sitting position.

D. Place the patient in a sitting position.

A client diagnosed with AIDS who is receiving combination antiretroviral therapy (cART) now has a CD4+ T-cell count of 525 cells/mm3. How will the nurse interpret this result? A. The client can reduce the dosages of the prescribed drugs. B. The virus is resistant to the current combination of drugs. C. The client no longer has AIDS. D. The drug therapy is effective.

D. The drug therapy is effective.