Adult Health Exam 7 chapter 63, 33, 35

A client with fibromyalgia asks why physical therapy has been prescribed. Which response will the nurse make?

"It will help with the overall deconditioning that has occurred."

A client with an autoimmune disorder asks, "Why is autoimmune disease more prevalent in the women in my family?" Which response will the nurse make to this client?

"It's believed to be caused by the differences in the sex hormones."

The community health nurse is assessing the risk factors for osteoporosis in a female client at a health fair. Which are risk factors for osteoporosis? postmenopausal status takes fluticasone inhaler for asthma walks 2 miles, 3 days/week alcohol intake of 3 drinks/week Asian heritage Nonsmoker large frame 66 years of age

66 years of age Asian heritage postmenopausal status takes fluticasone inhaler for asthma

A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used?

Digestive enzymes destroy its protein structure.

A client comes to the clinic complaining of low back pain radiating down the left leg. After diagnostic studies rule out any pathology, the health care provider orders a serotonin-norepinephrine reuptake inhibitor (SNRI). Which medication does the nurse anticipate educating the client about?

Duloxetine

A nurse is caring for a client who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. Which nursing measure(s) will the nurse implement to control edema? Select all that apply. Elevate the foot on several pillows. Apply warm compresses intermittently to the surgical area. Administer a loop diuretic as ordered. Increase circulation through frequent ambulation. Apply ice to the foot intermittently.

Elevate the foot on several pillows. Apply ice to the foot intermittently.

A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis?

Ensuring adequate exposure to sunlight

Which group is at the greatest risk for osteoporosis?

European American women Small-framed, nonobese European American women are at greatest risk for osteoporosis. Asian American women of slight build are at risk for low peak bone mineral density. African American women, who have a greater bone mass than European American women and Asian American Women, are less susceptible to osteoporosis

The nurse is caring for a client who has been diagnosed with a "rheumatic disease." What nursing diagnoses will most likely apply to this client's care? Select all that apply.

Fatigue Pain Alteration of Self-Concept

In the course of the immune response, circulating lymphocytes containing the antigenic message return to the nearest lymph node. During what stage of the immune response did this occur?

Proliferation stage The recognition stage of antigens as foreign by the immune system is the initiating event in any immune response. The body must first recognize invaders as foreign before it can react to them. In the proliferation stage, the circulating lymphocyte containing the antigenic message returns to the nearest lymph node. Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. In the response stage, the differentiated lymphocytes function either in a humoral or a cellular capacity. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader.

A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this?

The interactions that occur between T cells and B cells

The nurse is planning teaching for a client with gout. Which topics will the nurse include in the teaching? Select all that apply. Weight loss Limiting exercise Decreasing alcohol intake Avoiding purine-rich foods Restricting the intake of water

Weight loss Decreasing alcohol intake Avoiding purine-rich foods

The nurse is collaborating with the health care provider on a plan of care for a 54-year-old male client with osteomyelitis of the left femur secondary to uncontrolled type 1 diabetes. Click to highlight the prescriptions for care that the nurse should anticipate for this client. * Place the left foot in a dependent position. * Perform neurovascular checks of lower extremities every 8 hours. * Administer IV antibiotic based on culture and sensitivity report. * Encourage ambulation with weight-bearing on the left leg. * Administer ibuprofen 400 mg orally three times daily, as needed for pain. * Make referral to dietitian to discuss nutrition for healing and blood glucose control. * Provide education on self-blood glucose monitoring and insulin administration.

*Perform neurovascular checks of lower extremities every 8 hours. *Administer IV antibiotic based on culture and sensitivity report. * Administer ibuprofen 400 mg orally three times daily, as needed for pain. * Make referral to dietitian to discuss nutrition for healing and blood glucose control. * Provide education on self-blood glucose monitoring and insulin administration. (All except encourage ambulation with weight-bearing on the left leg and Place the left foot in dependent position)

The nurse is caring for a client with ankylosing spondylitis (AS). Which medication will the nurse expect to be prescribed for this client? Antibiotics Anticoagulants Oral corticosteroids Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs)

When creating a plan of care for a newly admitted client, the nurse identifies a risk for impaired immune function. Which assessment data is indicative of this risk? Taking levothyroxine for the treatment of hypothyroidism Removal of the spleen after a motor vehicle crash 2 years ago White blood cell count of 8,000 cells per microliter History of diabetes mellitus Type 2, diet controlled

Removal of the spleen after a motor vehicle crash 2 years ago

The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents?

Macrophages Macrophages move toward the antigen and destroy it. Eosinophils are only slightly phagocytic.

A client with carpal tunnel syndrome has had limited improvement with the use of a wrist splint. The nurse knows that which procedure will show the greatest improvement in treatment for this

Open nerve release Evidence-based treatment of acute carpal tunnel syndrome includes the application of splints to prevent hyperextension and prolonged flexion of the wrist. Should this treatment fail, open nerve release is a common surgical management option.

Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply. T4/T8 ratio polymerase chain reaction Western blot p24 antigen test ELISA test

polymerase chain reaction p24 antigen test

When do most perinatal HIV infections occur?

After exposure during delivery

Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?

Liquids

The nurse teaches the client that reducing the viral load will have what effect?

Longer survival

HIV is harbored within which type of cell?

Lymphocyte

A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact her bone marrow is unable to produce a sufficient amount of what?

Lymphocytes

A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:

Lymphocytes migrate to areas of the lymph node

A client has discussed therapy for HIV-positive status. The goal of antiretroviral therapy is to:

keep the CD4 cell count above 350/mm3 and viral load undetectable.

Which immunity type becomes active as a result of infection by a specific microorganism?

naturally acquired active immunity

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:

neutrophils and monocytes.

A client has ankylosing spondylitis (AS), an inflammatory joint disease. The client has been receiving treatment for AS since the age of 14 years. In addition to having AS, the client has recently developed primary immune deficiency disorder and receives immunoglobulin infusions weekly. Which type of immunity develops from receiving immunoglobulin treatments?

passive immunity

What clinical manifestation would the nurse expect to find in a client who has had osteoporosis for several years? Bone spurs Diarrhea Increased heel pain Decreased height

Decreased height

The nurse is performing an admission assessment on a patient with AIDS. When assessing the patient's gastrointestinal (GI) system what is most likely to be the priority nursing diagnosis?

Diarrhea

A client is taking immunosuppressive medications to prevent the rejection of a transplanted kidney. Which adverse effect(s) should the nurse closely monitor in this client?

respiratory or urinary system infections

In the interest of public health, the CDC has developed HIV Transmission Prevention strategies. The strategies address the routes by which HIV can be transmitted and steps that can be taken to reduce or eliminate transmission. Which categories of risk are addressed by these strategies? Select all that apply. sexual activity illegal drugs organ donation sharing eating utensils

sexual activity illegal drugs

The lower the client's viral load,

the longer the survival time. The lower the client's viral load, the longer the time to AIDS diagnosis and the longer the survival time. The key goal of antiretroviral therapy is to achieve and maintain durable viral suppression.

The period from infection with HIV to the development of antibodies to HIV is known as which of the following?

Primary infection

During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse?

"After menopause, the body's bone density declines, resulting in a gradual loss of height."

A client tells the nurse, "You know I have AIDS. I still cannot afford to tell my employer because they will probably cancel my health insurance, then what would I do?" What is the best response by the nurse?

"An employer cannot cancel your currently active health insurance on the basis of AIDS."

A client with a history of gout experiences an attack every 2 to 3 months despite losing weight and stopping all alcohol intake. Which question will the nurse ask when assessing this client?

"Are you taking the medication as prescribed?"

A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client?

"Be sure to take this drug about 1/2 hour before or 2 hours after you eat."

An older adult with rheumatoid arthritis says exercise was not effective. Which response will the nurse make to learn the reason for the failure of this treatment approach?

"What types of exercise were you doing?"

A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?

"I understand your concern. The blood is screened very carefully for different viruses as well as HIV."

The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided?

"I will avoid prolonged sitting or walking."

The nurse provides teaching to a client with osteoarthritis (OA). Which statement(s) indicate that teaching about pain management and functional ability were effective? Select all that apply. "I will spend more time resting." "I will need to lose some weight." "I will avoid using a cane to walk." "I will take the pain medication after exercising." "I will increase the amount of walking I do every day."

"I will need to lose some weight." "I will increase the amount of walking I do every day."

A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement?

"I'll make sure to monitor my body temperature on a regular basis."

The nurse is educating a client just diagnosed with human immunodeficiency virus (HIV) about the use of condoms to prevent sexual transmission. Which statement made by the client indicates the education provided is understood? Select all that apply. "Lambskin condoms are the most effective in preventing transmission." "If I use condoms consistently, they are very effective in preventing transmission." "A condom needs to be used for intercourse but is not necessary for oral contact." "Latex condom use is recommended during vaginal or anal intercourse." "Condoms are not effective during anal intercourse."

"If I use condoms consistently, they are very effective in preventing transmission." "Latex condom use is recommended during vaginal or anal intercourse."

An 18-year-old pregnant client has tested positive for HIV and asks the nurse if the baby is going to be born with HIV. What is the nurse's best response?

"It's possible that your baby could contract HIV, either before, during, or after delivery."

A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." "OA originates with an infection. RA is a result of your body's cells attacking one another." "OA is associated with impaired immune function; RA is a consequence of physical damage."

"OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

A client requires a blood transfusion for anemia and is concerned about the risk of contracting acquired immune deficiency syndrome (AIDS). What is the best response by the nurse?

"The blood is screened very carefully; the risk is 1 in 2,000,000."

The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?

"The client may have cryptococcal meningitis and will need to be evaluated by the health care provider."

A client with a discoid facial rash caused by systemic lupus erythematosus (SLE) asks why a urine sample is needed. Which response will the nurse make to the client?

"The lupus can affect your kidney function."

A nurse is aware of the important role that interferons (IFNs) perform in the normal function of the immune system. As well, the nurse has provided care for patients who have benefited from interferon therapy. IFN therapy is most likely to be effective in the treatment of which of the following patients? An 80-year-old man who is debilitated from Clostridium difficile-related diarrhea A 68-year-old woman who is being treated for chronic myeloid leukemia (CML) A 60-year-old man with motor and sensory deficits resulting from an ischemic stroke A 36-year-old woman who is in danger of developing sepsis after suffering full-thickness burns

A 68-year-old woman who is being treated for chronic myeloid leukemia (CML)

An emergency department (ED) nurse has provided care for many patients who have primary and secondary diagnoses of immune dysfunction. Which of the following patients likely has the highest risk of a disruption to normal immune functioning?

A man who has recently completed medical treatment for prostate cancer

During a mumps outbreak at a school, a teacher is exposed. Because of a previous immunization for mumps, what type of immunity does the teacher possess?

Acquired immunity.

A client sustained a deep laceration while gardening and requires sutures. The client received a tetanus immunization that allows for the release of what protective agent?

Antibodies

A hospital client is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test?

Arrange for a portable x-ray machine to be used. A client who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the client's room.

A client with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the client appears to have lost some ability to function since the last office visit. What is the nurse's most appropriate action?

Arrange for the client to be assessed in the home environment.

The nurse is preparing to start an IV for a client who is combative. What precautionary measure should the nurse take in order to avoid a needlestick?

Ask for assistance.

What is the priority intervention for a client who has been admitted repeatedly with attacks of gout?

Assess diet and activity at home Clients with gout need to be educated about dietary restrictions in order to prevent repeated attacks. Foods high in purine need to be avoided, and alcohol intake has to be limited. Stressful activities should also be avoided. The nurse should assess to determine what is stimulating the repeated attacks of gout.

What intervention is a priority when treating a client with HIV/AIDS?

Assessing fluid and electrolyte balance

A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client?

Bank autologous blood.

A client's health care provider suspects the client has developed an immune system disorder. What will most likely be the first test ordered?

CBC with differential

A client with a history of IV drug use is HIV-positive. The client has been following an antiretroviral medication regimen faithfully and is doing well, attending college to get a social work degree, and focused on a bright future. In regular CD counts, what factor will indicate that this client has progressed from HIV to AIDS?

CD count <200/mm

Which is usually the most important consideration in the decision to initiate antiretroviral therapy?

CD4+ counts

Which of the following inhibits bone resorption and promotes bone formation?

Calcitonin

A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching?

Caregiver cleans the client's anal area without wearing gloves

A client tells the nurse about pain and numbness in the thumb, first finger, and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the client has what health problem?

Carpel tunnel syndrome

Which microorganism is known to cause retinitis in people with HIV/AIDS?

Cytomegalovirus

A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize what intervention?

Educational programs that focus on control and prevention

On admission to a medical unit, a client with human immunodeficiency virus (HIV) tests positive for benzodiazepine. The client denies using this medication. Which medication is likely causing a false-positive result?

Efavirenz

A client is administered foscarnet to treat a case of CMV retinitis. Which adverse effect should the nurse closely monitor in the client?

Electrolyte imbalances

A nurse on a medical unit is providing care for a patient who has been admitted because of the simultaneous development of several complications of AIDS. For the past several days, the patient has been experiencing six to eight watery bowel movements each day. The nurse should consequently assess the patient's:

Electrolyte levels

Which blood test confirms the presence of antibodies to HIV?

Enzyme immunoassay (EIA)

A client underwent an antibody test for human immunodeficiency virus (HIV) as part of a screening process and has just been told that the results were positive. Which anticipatory guidance regarding the next step should the nurse provide to the client?

Follow-up testing will be promptly performed to confirm the result. always test twice

A client's natural immunity is enhanced by processes that are inherent in the physical and chemical barriers of the body. What is a chemical barrier that enhances natural immunity?

Gastric secretions

A client who was just diagnosed with scleroderma will be undergoing tests to assess for systemic involvement. Which system should the nurse prioritize in assessment?

Gastrointestinal

The nurse is caring for a client who sustained a laceration to the lower left leg. Which initial invasion will occur at the site of the injury to prevent infection? Select all that apply. Interferons (IFNs) Granulocytes Apoptosis Cytokines Macrophages

Granulocytes Macrophages

The nurse is reviewing the medical record of a client who is positive for human immunodeficiency virus (HIV). The nurse notes that the client is classified as HIV asymptomatic based on which CD4+ T lymphocyte count?

Greater than 500/mm3

When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic?

HIV-1 is more prevalent than HIV-2 subtypes

Since the emergence of the human immunodeficiency virus (HIV), there have been significant changes in epidemiologic trends. At present, members of which group are most affected by new cases of HIV?

Male-to-male sexual contact

A client with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in clients with AIDS, by increasing body fat stores?

Megestrol

A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client?

NSAIDS

A middle-aged woman will soon begin treatment for a gastric tumor that has just been discovered by endoscopy. The woman's natural killer (NK) cells are already actively opposing the tumor cells, because the tumor cells lack "self" markers of major histocompatibility complex (MHC) class I. This aspect of the patient's immune response is characteristic of:

Natural immunity

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?

Naturally acquired active immunity

A client comes in to get an EIA test done because the health care provider suspects HIV. Which nursing action is essential before an EIA test is performed? Performing Western blotting Performing a polymerase chain reaction test Obtaining a general consent for medical care from the client Obtaining a written consent from the client

Obtaining a general consent for medical care from the client

A client with AIDS is having a recurrence of 10 to 12 loose stools a day. What medication may help this client with controlling the chronic diarrhea?

Octreotide

A client diagnosed with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this client should expect the health care provider to prescribe what medication for the management of the client's diarrhea?

Octreotide acetate

Which of the following occurs when the antigen-antibody molecule is coated with a sticky substance what also facilitates phagocytosis?

Opsonization

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem?

Osteomyelitis

A patient had unprotected sex with an HIV-infected person and arrives in the clinic requesting HIV testing. Results determine a negative HIV antibody test and an increased viral load. What stage does the nurse determine the patient is in?

Primary infection The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection, or stage 1. Initially, there is a period during which those who are HIV positive test negative on the HIV antibody blood test, although they are infected and highly infectious, because their viral loads are very high.

A nurse is preparing to administer saquinavir, which is prescribed for a client who is HIV positive. What type of drug does the nurse identify saquinavir as?

Protease inhibitor (PI)

The nurse's plan of care for a client with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to candidiasis. What nursing intervention best addresses this risk?

Providing thorough oral care before and after meals

A client is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication?

Take the medication with food to avoid stomach upset.

A client's current antiretroviral regimen includes emtricitabine. What dietary counseling will the nurse provide based on the client's medication regimen?

Take this medication without regard to meals.

When assisting the client to interpret a negative HIV test result, what does the nurse tell the client that this result means?

The body has not produced antibodies to the AIDS virus.

A client has been tested for possible HIV. The client asks the nurse what it means that the antigen/antibody testing shows that they have antibodies to the AIDS virus. What fact about the testing result should the nurse base the response on?

The client has been infected with HIV.

A client who is HIV/AIDS positive has orders for laboratory tests to be performed. What precautions should the nurse observe whenever there is a risk of exposure to the blood and body fluids of an infected client?

Transport the specimens of body fluids in leak-proof containers.

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the:

Upper left quadrant of the abdomen.

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse knows which body fluid is not a means of transmission?

Urine

A 38-year-old client has begun to suffer from rheumatoid arthritis and is being assessed for disorders of the immune system. The client works as an aide at a facility that cares for children infected with AIDS. Which is the most important factor related to the client's assessment? Age Diet Use of other drugs Home environment

Use of other drugs

What test will the nurse assess to determine the client's response to antiretroviral therapy?

Viral load

Which diagnostic test measures HIV RNA in the plasma?

Viral load

A client has been diagnosed with HIV and has been placed on antiretroviral therapy. What does the nurse inform the client will be required for determining the progression of the disease as well as guiding drug therapy?

Viral load and T4-cell counts will be performed every 2 to 3 months.

A client with a diagnosis of HIV presents with pharyngitis, rash on the palms and soles of the feet, and diarrhea. The nurse suspects the client is suffering from:

acute retroviral syndrome (ARS).

When teaching a client how to prevent low back pain as a result of lifting, the nurse should instruct the client to: avoid overreaching. place the load away from the body. use a narrow base of support. bend the knees and loosen the abdominal muscles.

avoid overreaching.

A client has experienced increasing pain and progressing inflammation of the hands and feet. The rheumatologist has prescribed NSAID use to treat the condition. What client education is most important for the nurse to address with the use of these medications? common adverse effects dietary restrictions activity restrictions loading-dose schedule

common adverse effects

Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that:

filter bacteria from tissue fluid.

A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to:

infection because the spleen removes bacteria from the blood.

What types of cells are the primary targets of the healthy immune system? Select all that apply. infectious cells foreign cells cancerous cells typical cells

infectious cells foreign cells cancerous cells

A client comes to the clinic to obtain HIV test results. The physician states that the client has a CD4 cell count of 300 cells/mm3 and a high viral load. What will the physician discuss with the client?

initiation of antiretroviral therapy

The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?

interferons Interferons are chemicals that primarily protect cells from viral invasion. They enable cells to resist viral infection and slow viral replication.

A client with rheumatoid arthritis wants to participate in water aerobics classes for arthritis at the community center. Which statement will the nurse respond to this client?

"Be sure to wear nonslip footwear for safety."

When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask?

"Have you ever received a blood transfusion?"

An infection control nurse presenting an in-service is reviewing the immune response and describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining?

Agglutination

The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given?

Alendronate

A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of his last tetanus shot, which he tells the nurse was more than 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what? An antibody An antigen A bacteria A virus

An Antibody

A client with pneumonia is diagnosed with agranulocytosis. To which medications will the nurse suspect the client is experiencing an adverse effect? Select all that apply. Digoxin Warfarin Aspirin Propylthiouracil Gentamicin sulfate

Aspirin Propylthiouracil Gentamicin sulfate

A nurse is monitoring the client's progression of human immunodeficiency virus (HIV). What debilitating gastrointestinal condition found in up to 90% of all AIDS clients should the nurse be aware of?

Chronic diarrhea

The nurse practitioner who is monitoring the patient's progression of HIV is aware that the most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is:

Chronic diarrhea.

The nurse intervenes to assist the client with fibromyalgia to cope with which symptoms?

Chronic fatigue, generalized muscle aching, and stiffness

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?

Cytotoxic T cells

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.

Cytotoxic T cells The cytotoxic T cells (also known as killer T cells) attack the antigen directly and release cytotoxic enzymes and cytokines.

Which immunoglobulin assumes a major role in bloodborne and tissue infections?

IgG

The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response?

Decrease in estrogen

The nurse is creating a plan to assist an older adult to manage rheumatoid arthritis. Which areas will the nurse include in this plan? Select all that apply. Exercise Medication Financial assistance Psychological support Modification of daily activities

Exercise Medication Psychological support Modification of daily activities

A nurse is teaching a health education class to a group of young adults and perceives that misinformation exists about the signs, symptoms, and trajectory of HIV infection. The nurse should inform participants that the first symptoms of HIV exposure include:

Fever, headache, and malaise

Which is the most important guideline for a nurse caring for immunosuppressed clients?

Follow the guidelines of the agency for controlling infections.

In which deformity does the great toe deviate laterally?

Hallux valgus

Which condition is an early manifestation of HIV encephalopathy?

Headache

A client's exposure to which microorganism is most likely to trigger a cellular response? Herpes simplex Staphylococcus aureus Pseudomonas aeruginosa Beta hemolytic Streptococcus

Herpes simplex Viral, rather than bacterial, antigens induce a cellular response. Herpes simplex is a virus.

Which of the following indicates that a client with HIV has developed AIDS?

Herpes simplex ulcer persisting for 2 months

The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, which instruction should the nurse give the attendees?

Hold the condom during withdrawal so it doesn't come off.

A 44-year-old man has come to the clinic with an asthma exacerbation. He tells the nurse that his father and brother also suffer from asthma, as does his 15-year-old son. The nurse explains that this is an allergic response based on a genetic predisposition. The specific allergen initiated by immunological mechanisms is usually mediated by what?

Immunoglobulin E

The nurse is caring for a client with palindromic rheumatism. The nurse knows that this type of rheumatism can lead to which diagnosis?

Rheumatoid arthritis

A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with which health problem?

Rheumatoid arthritis (RA)

The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client? Select all that apply. Safe exercise Narcotic safety Medication dosages and side effects Dressing changes Assistive devices

Safe exercise Medication dosages and side effects Assistive devices

A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?

Sciatica

A client who is has been HIV positive for 10 years has a CD4+T-lymphocyte count of 2600 cells/L. For which stage of the virus will the nurse provide care when the client is diagnosed with invasive cervical cancer?

Stage 3 because an opportunistic infection has occurred

A hospital educator is reiterating the importance of Standard Precautions to a group of nursing students who will soon begin a clinical rotation on the unit. Which of the following statements best describes the application of Standard Precautions?

Standard Precautions should be applied to patients regardless of diagnosis or presumed infectious status.

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing? Wound packing Wound irrigation Vitamin supplements Surgical debridement

Surgical debridement

A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function? Previous organ transplantation Surgical removal of the appendix History of radiation therapy Surgical history of a splenectomy

Surgical removal of the appendix

A nurse provides care for a client who has a rheumatic disorder. The nurse's comprehensive assessment includes the client's mood, behavior, LOC, and neurologic status. What is this client's most likely diagnosis?

Systemic lupus erythematosus (SLE)

The nurse is working with an Unlicensed Assistive Personnel (UAP) to care for a client. In which situation will the nurse intervene to discuss standard precautions with the UAP? Select all that apply. The UAP wears face protection, gloves, and a gown when assisting with wound irrigation. The UAP performs hand hygiene after removing a pair of soiled gloves. The UAP applies a second pair of nonsterile gloves over soiled gloves while assisting with a bloody procedure. The UAP places a used needle and syringe in the puncture-resistant container without capping the needle. The UAP applies a mask on a client who is coughing during a procedure.

The UAP applies a second pair of nonsterile gloves over soiled gloves while assisting with a bloody procedure.

The nurse is gathering data from laboratory studies for a client who has HIV. The client's CD4+ cell count is 200/mm³, and the client has been diagnosed with pneumocystis pneumonia. What does this indicate to the nurse?

The client has converted from HIV infection to AIDS.

A client's antibody test for HIV showed no antibodies. For which reason would the client need to have a nucleic acid test completed before being told that testing for HIV is negative?

The client may be in stage 0 of the disease

A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize? The client will express satisfaction with the ability to perform ADLs. The client will recover from OA within 6 months. The client will adhere to the prescribed plan of care. The client will deny signs or symptoms of OA.

The client will express satisfaction with the ability to perform ADLs.

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor?

The client's body mass index is 34 (obese).

A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have? The nurse ensures a written consent is obtained prior to testing. The nurse should send the client to have the blood drawn without informing him about the specific screening test. The nurse will call the client with the results of the test. The nurse will inform the client that the results will have to be reported to the Centers for Disease Control and Prevention (CDC).

The nurse ensures a written consent is obtained prior to testing

A male patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows antibodies to the AIDS virus are present in the blood, this indicates what?

The patient has been infected with HIV.

A nurse is teaching a client about preventing osteoporosis. Which teaching point is correct?

The recommended daily allowance of calcium may be found in a wide variety of foods

Which statement accurately reflects current stem cell research?

The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.

The nurse is planning teaching for a client with gout. Which topics will the nurse include in the teaching? Select all that apply.

Weight loss Decreasing Alcohol intake Avoiding Purine-Rich Foods

A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test?

Western blot assay A positive EIA test indicates seropositivity. To confirm this, a Western blot assay would be done.

The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?

A 65-year-old client who had chicken pox when he was 12 years old Explanation: Half of individuals living to age 65 years have had or will develop shingles and may not understand the potential seriousness and risk for complications. Nurses as client advocates should determine and provide health information regarding the shingles vaccine. The other clients are not candidates for the vaccine

An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response?

B lymphocytes produce antibodies that are specific to the pathogen.

The nurse is performing an admission interview for a client with rheumatoid arthritis. Which finding will the nurse document as abnormal for this client? Select all that apply. Pain Nausea Stiffness Weakness Joint swelling

Pain Stiffness Weakness Joint Swelling

A nurse is assessing the skin integrity of a client who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?

Perianal region and oral mucosa

A client with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education?

Importance of personal hygiene

What intervention is a priority for a client diagnosed with osteoarthritis?

Physical therapy and exercise

A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold?

200 cells/mm3 of blood

A patient is on highly active antiretroviral therapy (HAART) for the treatment of HIV. What does the nurse know would be an adequate CD4 count to determine the effectiveness of treatment for a patient per year?

50 mm3 to 150 mm3

A client has discussed therapy for his HIV-positive status. What does the nurse understand is the goal of antiretroviral therapy?

Bring the viral load to a virtually undetectable level

A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise?

Avoid fibrous foods, lactose, fat, and caffeine.

A nurse has administered a child's scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following?

Active acquired immunity

A client with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?

Administer antidiarrheal medications on a scheduled basis, as prescribed.

The nurse is reviewing prescriptions written for a client with giant cell arteritis (GCA). Which medication will the nurse expect to be prescribed with a corticosteroid to preserve the client's vision? Aspirin Antibiotics Anticoagulants Antihypertensives

Aspirin The treatment for clients with GCA is rapid initiation of and strict adherence to a regimen of corticosteroids. This is essential to avoid the complication of blindness. Aspirin is an adjunctive treatment that may help reduce the risk of visual loss.

What intervention is a priority when treating a client with HIV/AIDS? Assessing neurologic status Monitoring skin integrity Assessing fluid and electrolyte balance Monitoring psychological status

Assessing fluid and electrolyte balance Fluid and electrolyte deficits are a priority in monitoring clients with HIV/AIDS, and assessment of fluid loss and electrolyte imbalance is essential. Skin integrity should be monitored but is a lower priority. Neurologic and psychological status should also be monitored, but this is not as high a priority as fluid and electrolyte imbalance.

A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?

Assure the client that this is a normal reaction

A client has come into contact with HIV. As a result, HIV glycoproteins have fused with the client's CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle? Integration Attachment Cleavage Budding

Attachment During the process of attachment, glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane. Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life cycle.

A client is experiencing painful joints and changes in the lungs, heart, and kidneys. For which condition will the nurse schedule this client for diagnostic tests? Heart disease Vascular diseases Metabolic disorders Autoimmune disorders

Autoimmune disorders

A client with rheumatoid arthritis (RA) is prescribed a topical analgesic medication to help reduce joint pain. Which information will the nurse emphasize with the client about this medication? Select all that apply. Avoid areas of open skin. Use the medication sparingly. Avoid contact with mucous membranes. Wrap gauze over the area after applying. Wash hands after applying the medication.

Avoid areas of open skin. Use the medication sparingly. Avoid contact with mucous membranes. Wash hands after applying the medication.

An HIV-infected client presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/mL, and the nurse recognizes the client's increased risk for Mycobacterium avium complex (MAC disease). The nurse should anticipate the administration of what drug?

Azithromycin

A client is diagnosed with giant cell arteritis (GCA) and is placed on corticosteroids. A concern for this client is that the client will stop taking the medication as soon as the client starts to feel better. The nurse must emphasize the need for continued adherence to the prescribed medication so that the client can avoid which complication?

Blindness

A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication?

Bone fracture

A client has undergone treatment for septic shock and received high doses of numerous antibiotics during treatment. When planning the client's subsequent care, the nurse should be aware of what potential effect on the client's immune function?

Bone marrow suppression

A client asks the nurse how their rheumatoid arthritis is diagnosed. The nurse knows that which finding from diagnostic tests can be used to diagnose rheumatoid arthritis?

Boney erosions on x-ray

Diagnostic testing has revealed a deficiency in the function of a client's complement system. This client is likely to have an impaired ability to do what action?

Bridge natural and acquired immunity.

A clinic nurse is caring for a client admitted with AIDS. The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication?

Human immunodeficiency virus (HIV) encephalopathy

A nurse has admitted a client who has been diagnosed with urosepsis. Which immune response predominates in sepsis?

Humoral

Which of the following protective responses begin with the B lymphocytes?

Humoral A second protective response, the humoral immune response, begins with the B lymphocytes, which can transform themselves into plasma cells that manufacture antibodies. The first line of defense, the phagocytic immune response, involves the white blood cells (WBCs; granulocytes and macrophages), which have the ability to ingest foreign particles. The third mechanism of defense, the cellular immune response, also involves T lymphocytes, which can turn into special cytotoxic (or killer) T cells that can attack the pathogens.

A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse NOT say when teaching the client and family information about managing the disease?

If you have problems with a medication, you may stop it until your next physician visit.

When the body is in contact with an allergen, this lymphocyte, located in the respiratory and intestinal mucosa, triggers the release of histamine. Choose that lymphocyte.

Ig E IgE lymphocytes bind together to an allergen and trigger basophils to release chemical mediators such as histamine and leukotrienes.

At 39 weeks' gestation, a pregnant client visits the physician for a scheduled prenatal checkup. The physician determines that the fetus has developed an infection in utero and sends the client for an emergency cesarean delivery. The client is very concerned about the health of her unborn child. Based on knowledge of the immune system, the delivery room nurse explains about which immunoglobulin that will be increased in the fetus at the time of birth and will be actively fighting the infection?

IgG IgG composes 75% of total immunoglobulin. It appears in serum and tissues, assumes a major role in bloodborne and tissue infections, and crosses the placenta.

The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses?

Immunosenescence Immunosenescence is the term for age-related changes in the immune system.

A client who has acquired immunodeficiency syndrome (AIDS) has been admitted for the treatment of Kaposi sarcoma. Which nursing diagnosis should the nurse associate with this complication of AIDS?

Impaired skin integrity related to Kaposi sarcoma

Which aspect should a nurse include in the teaching plan for a client with osteomalacia?

Include calcium, phosphorus, and vitamin D supplements

A patient with a recent diagnosis of HIV is soon to begin highly active antiretroviral treatment (HAART). When performing health education related to the patient's new medication regimen, the nurse should prioritize interventions relevant to which of the following nursing diagnoses?

Ineffective adherence

A nurse is planning the care of a client diagnosed with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which issue would be the highest priority for this client?

Ineffective airway clearance

A client with a history of rheumatoid arthritis takes corticosteroids on a regular basis. Which complications with corticosteroid use will the nurse monitor for? Select all that apply. Inhibited interleukin synthesis Agranulocytosis Anemia Thrombocytopenia Cell-mediated immune reaction suppression

Inhibited interleukin synthesis Cell-mediated immune reaction suppression

A female client is at risk for developing osteoporosis. Which action will reduce the client's risk?

Initiating weight-bearing exercise routines

A female client is at risk for developing osteoporosis. Which action will reduce the client's risk? Living a sedentary lifestyle to reduce the incidence of injury Stopping estrogen therapy Taking a 300-mg calcium supplement to meet dietary guidelines Initiating weight-bearing exercise routines

Initiating weight-bearing exercise routines

A 34-year-old client is diagnosed with chronic hepatitis C. Testing reveals that the client is a candidate for treatment. The nurse anticipates that which therapy could be used to treat the client's condition? Erythropoietin Interleukin-5 Monoclonal antibodies Interferon

Interferon Interferons are used to treat immune-related disorders (e.g., multiple sclerosis) and chronic inflammatory conditions (e.g., chronic hepatitis).

What specific drug group has both antiviral and anti-proliferative actions?

Interferons

A 6-year-old client is diagnosed with a viral infection of the respiratory system. Which will most likely be trying to fight the antigen?

Interferons Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body and is capable of activating other components of the immune system. Interferons have antiviral and antitumor properties. In addition to responding to viral infection, interferons are produced by T lymphocytes, B lymphocytes, and macrophages in response to antigens. They are thought to modify the immune response by suppressing antibody production and cellular immunity.

A client has a serum study that is positive for the rheumatoid factor. What will the nurse tell the client about the significance of this test result?

It is suggestive of rheumatoid arthritis.

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA?

Joint stiffness, especially in the morning

A patient presents to a clinic on May 1 and tells the nurse practitioner that he had a 1-month sexual relationship with a friend who did not disclose that he was HIV positive. The relationship ended last week. The nurse tells the patient that after infection with HIV, the immune system responds by making antibodies against the virus; therefore the patient should expect this to happen by:

June 5 An antibody response to an HIV infection usually occurs 4 to 6 weeks after exposure.

While caring for a patient with pneumocystis pneumonia, the nurse assesses flat, purplish lesions on the back and trunk. What does the nurse suspect these lesions indicate?

Kaposi's sarcoma

Which type of immunity becomes active as a result of infection by a specific microorganism?

Naturally acquired active immunity

Upon reviewing the results of a complete blood count on a patient who is diagnosed with an acute infection what will the nurse expect to see elevated?

Neutrophil count During an acute infection, the neutrophils are rapidly produced in response to the interleukins released by active white blood cells.

A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand?

Neutrophils

A client's injury has initiated an immune response that involves inflammation. Which are the first cells to arrive at a site of inflammation? Select all that apply. Eosinophils Red blood cells (RBCs) Lymphocytes Neutrophils Macrophages

Neutrophils Macrophages Neutrophils and macrophages are the first cells to arrive at the site where inflammation occurs. Eosinophils increase in number during allergic reactions and stress responses but are not always present during inflammation. RBCs do not migrate during an immune response. Lymphocytes become active but do not migrate to the site of inflammation.

A hospice nurse has been providing care for a patient with AIDS. Among the manifestations of the disease has been a profound weight loss over the past several weeks. Consequently, the nurse is adjusting the patient's plan of care to reprioritize this problem. When planning interventions for the patient's weight loss, the nurse should be aware of which fact?

Nutritional interventions may not necessarily resolve the patient's weight loss.

Which nursing actions essential before an ELISA test is performed?

Obtain a written consent from the client.

A client with diabetes has been diagnosed with osteomyelitis. The nurse observes that the client's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis? Hematogenous osteomyelitis Osteomyelitis with vascular insufficiency Contiguous focus osteomyelitis Osteomyelitis with muscular deterioration

Osteomyelitis with vascular insufficiency

Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment?

Past substance abuse

The nurse is completing the physical assessment of a client with systemic lupus erythematosus (SLE). Which finding will the nurse recognize is most likely to indicate that the client is experiencing a change to the cardiovascular system because of the condition?

Pericardial friction rub

A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a storm door. The fall resulted in a 6 cm laceration of the right antecubital. The nurse caring for this patient knows that the site of the injury will have an invasion of what?

Phagocytic cells

A patient is admitted with an infected leg, and the nurse notes an increase in his white blood cell (WBC) count. The nurse is aware that, during the immune response, pathogens are engulfed by WBCs that ingest foreign particles. What is this process known as?

Phagocytosis

The nurse is aware that during the immune response, pathogens are engulfed by white blood cells that ingest foreign particles. What is this process known as?

Phagocytosis

The nurse is caring for a client who has been admitted for the treatment of AIDS. In the morning, the client tells the nurse that he experienced night sweats and recently "coughed up some blood." What is the nurse's most appropriate action?

Place the client on respiratory isolation and inform the physician. Explanation: These signs and symptoms are suggestive of tuberculosis, not Kaposi sarcoma; prompt assessment and treatment is necessary. There is no indication of a need for oral suctioning and the client's blood work will not reflect the onset of this opportunistic infection.

A client with human immunodeficiency virus (HIV) develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this client?

Pneumocystis pneumonia

During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?

Pneumocystis pneumonia

A hospital nurse has experienced percutaneous exposure to an HIV-positive client's blood because of a needlestick injury. The nurse has informed the supervisor and identified the client. What action should the nurse take next?

Report to the emergency department or employee health department.

A nurse is assessing a client for risk factors known to contribute to osteoarthritis (OA). Which assessment finding(s) would the nurse interpret as a risk factor? Select all that apply. The client's body mass index is 34 (obese). The client has primary hypertension. The client is 58 years old. The client has a history of dysplasia of the hip. The client has a 30 pack-year smoking history.

The client's body mass index is 34 (obese). The client has a history of dysplasia of the hip.

A client will be having a hysterectomy and wants her daughter to provide directed donor blood. What factor would eliminate her daughter from donating the blood?

The daughter is 15 years of age. The donor must be at least 17 years of age, weigh 110 lb. or more, and test negative for HIV; and the client's physician must be informed of the procedure.