Ch 19-20
The nurse notes that a patient with AIDS is prescribed trimethoprim-sulfamethoxazole (Bactrim). For which opportunistic infection should the nurse realize that is this medication indicated? a. Tuberculosis b. Cytomegalovirus retinitis c. Mycobacterium avium complex d. Pneumocystis jiroveci pneumonia
d. Pneumocystis jiroveci pneumonia
A patient with AIDS-related wasting syndrome is very weak, lies listlessly in bed, has an intravenous (IV) drip, and receives antiretroviral medications via injection. What should be the priority nursing diagnosis for this patient? a. Pain related to immobility b. Ineffective Individual Coping due to terminal stage of HIV c. Risk for Injury due to impaired mobility, weakness, and weight loss d. Risk for Infection due to weak immune system and parenteral therapy
d. Risk for Infection due to weak immune system and parenteral therapy
A patient is diagnosed with urticaria. For which type of hypersensitivity reaction should the nurse plan care for this patient? a. Type I b. Type II c. Type III d. Type IV
a. Type I
The nurse is caring for a patient with a severe allergic reaction. Which medication and route should the nurse anticipate being ordered for this patient? a. Intramuscular morphine b. Subcutaneous epinephrine c. IV diphenhydramine d. Oral diphenhydramine (Benadryl)
b. Subcutaneous epinephrine
The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness? a. A patient who receives intravenous (IV) penicillin for an infection b. A patient who has a transfusion with packed red blood cells (RBCs) c. A patient who is given cryoprecipitate and factor IX after an abdominal injury d. A patient given steroids and immunosuppressant therapy after organ transplantation
a. A patient who receives intravenous (IV) penicillin for an infection
The nurse is assisting in the planning of care for a patient with chronic serum sickness. Which action should be a priority for this patient? a. Assessing for a decrease in urine output b. Administration of immunosuppressive medications c. Closely monitoring the patient during the transfusion of blood products d. Discussing with the patient and significant other the need for genetic counseling
a. Assessing for a decrease in urine output
The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient? a. Assist with ambulation. b. Teach good hand hygiene. c. Avoid intramuscular injections. d. Obtain manual blood pressures.
a. Assist with ambulation.
The nurse is reviewing laboratory results for a patient who has HIV. Which result would be strongly suggestive of a diagnosis of AIDS? a. CD4+ = 180/µL b. CD4+ percentage = 68% c. CD8+ = 650/µL d. CD4+/CD8+ ratio = 1.5
a. CD4+ = 180/µL
The nurse is monitoring a patient with AIDS. Which manifestation should the nurse expect to observe in this patient? a. Diarrhea b. Chest pain c. Hypertension d. Pustular skin lesions
a. Diarrhea
The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops? a. Hives b. Retinal hemorrhage c. Jugular vein distention d. Pallor around the sting sites
a. Hives
The nurse is caring for a patient at risk for infection. Which immunoglobulin should the nurse consider as being the cause of this patient's infection risk? a. IgA b. IgE c. IgG d. IgM
a. IgA
The nurse is c caring for a patient with angioedema. Which nursing action should have the highest priority? a. Monitor for restlessness. b. Identify cause of the angioedema. c. Identify the presence of skin lesions. d. Teach the patient about immunotherapy.
a. Monitor for restlessness.
The nurse is preparing to care for a patient who is HIV positive. Which action should the nurse take when following standard precautions for protection from HIV exposure? a. Put on gloves before touching body fluids. b. Recap intramuscular needles after injection. c. Wash own open skin lesion after providing care. d. Remove one finger on a glove during venipuncture.
a. Put on gloves before touching body fluids.
A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins the patient reports low back pain and a headache. Which action should the nurse take first? a. Stop the blood infusion. b. Notify the physician STAT. c. Start the new 0.9% normal saline infusion. d. Prepare a new 0.9% normal saline infusion.
a. Stop the blood infusion.
The nurse is reinforcing teaching provided to a patient with Hashimoto's thyroiditis. What should the nurse explain as occurring initially in this health problem? a. Thyroid hormone production increases. b. Thyroid hormone production decreases. c. Thyroid-stimulating hormone production increases. d. Thyroid-stimulating hormone production decreases.
a. Thyroid hormone production increases.
A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient? a. Wear Medic-Alert identification. b. Stay indoors as much as possible. c. Wear insect repellent when outdoors. d. Take corticosteroids before going outdoors.
a. Wear Medic-Alert identification.
A patient who developed hemolytic anemia related to the administration of penicillin asks for an explanation of this condition. What is the most appropriate response by the nurse? a. "The red blood cells are being produced inappropriately." b. "An antigen-antibody reaction is causing destruction of red blood cells." c. "An allergy to penicillin is destroying your platelets for unknown reasons." d. "Allergens are invading the bone marrow and interfering with red blood cell production."
b. "An antigen-antibody reaction is causing destruction of red blood cells."
The nurse is reinforcing teaching provided to a patient with pernicious anemia. Which patient statement indicates that teaching has been effective? a. "I can miss a month or two of injections if I am feeling better." b. "I will need to take vitamin B12 injections for the rest of my life." c. "I will take the vitamin B12 injections until my strength returns." d. "I can take a vitamin B12 injection when I feel tired or fatigued."
b. "I will need to take vitamin B12 injections for the rest of my life."
A patient who has AIDS expresses concern about telling others about the illness. Which response would be appropriate by the nurse? a. "It would be best to tell everyone you know." b. "You should tell those who have a reason to know." c. "Your diagnosis will be discovered anyway by those you know." d. "Secrecy is a poor idea because it will erode your self-esteem."
b. "You should tell those who have a reason to know."
The nurse is reviewing data collected on several patients. Which patient should the nurse identify as being most likely to exhibit signs and symptoms of systemic lupus erythematosus? a. A 16-year-old Caucasian man b. A 20-year-old Hispanic woman c. A 45-year-old Caucasian woman d. A 42-year-old Asian American man
b. A 20-year-old Hispanic woman
A patient is diagnosed with hypogammaglobulinemia. Which of immune cell should the nurse realize is defective in this disorder? a. T cells b. B cells c. Mast cells d. Plasma cells
b. B cells
A health care worker is exposed to blood from a patient who has HIV. What action should the worker take after the exposure? a. Apply alcohol to the site. b. Cleanse the site with soap and water. c. Flush the site with hot running water. d. Apply a topical antibiotic to the site.
b. Cleanse the site with soap and water
The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms? a. Installing a hot air heater b. Cover heating ducts with filters c. Installing wall-to-wall carpeting d. Using heavy draperies on sunny windows
b. Cover heating ducts with filters
A patient is suspected as having a blood transfusion reaction. Which laboratory test should the nurse expect to be done to confirm this diagnosis? a. Skin testing b. Direct Coombs' test c. White blood cell count d. C-reactive protein level
b. Direct Coombs' test
The nurse is collecting data for a patient with suspected exposure to HIV. Which symptoms would be most concerning in this patient? a. Tremors, edema, coughing b. Fever, diarrhea, sore throat c. Urticaria, sneezing, pruritus d. Abdominal pain, anorexia, and vomiting
b. Fever, diarrhea, sore throat
The nurse is assisting in a teaching plan for the family of a patient with HIV. Which explanation about the transmission of HIV should the nurse include in this plan? a. HIV is spread by casual contact with others. b. HIV spreads by contact with infected blood. c. HIV can be spread by sharing eating utensils. d. HIV is commonly transmitted by tears or saliva.
b. HIV spreads by contact with infected blood.
The nurse is collecting data from a patient with skin eruptions. What should the nurse recall to differentiate urticaria from angioedema? a. It is less pruritic. b. It lasts a shorter period of time. c. It includes mucous membrane edema. d. It causes more widespread skin lesions.
b. It lasts a shorter period of time.
The nurse is caring for a patient who has had a portion of stomach removed. Which manifestations should the nurse expect to determine if the patient has a vitamin B12 deficiency? a. Fever, malaise, muscle soreness, and diarrhea b. Numbness and tingling, weakness, and glossitis c. Urticaria, angioedema, anorexia, pruritus, and blistered lesions d. Frequent infections, fever, malaise, vertigo, and lymphadenopathy
b. Numbness and tingling, weakness, and glossitis
The nurse provides teaching on nevirapine (Viramune) for a patient who is HIV positive. Which patient statement indicates that teaching has been effective? a. Monitor for rash. b. Observe urine color. c. Report extremity pain. d. Monitor for flulike symptoms.
b. Observe urine color.
The nurse is providing care to a patient who has had diagnostic testing for HIV. Which test should the nurse review to monitor the response to antiretroviral therapy? a. Western blot b. Viral load testing c. P24 antigen testing d. Enzyme-linked immunosorbent assay
b. Viral load testing
The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus. Which adverse effect should the nurse encourage the patient to report when taking this medication? a. Tarry stools b. Vision changes c. Any weight gain d. Changes in joint movement
b. Vision changes
The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease? a. Gardening outdoors on dry, windy days b. Wearing a mask when mowing the lawn c. Driving the car with the windows open during high pollen counts d. Taking frequent walks outside in spring when the weather is warm
b. Wearing a mask when mowing the lawn
A patient with HIV asks the nurse if thinking about dying frequently is common with HIV. What is an appropriate response by the nurse? a. "HIV is a serious disease that results in death." b. "Thinking about death will not change the prognosis." c. "HIV is now considered a chronic disease with treatment." d. "HIV has a very high mortality rate, so it is realistic to plan for death."
c. "HIV is now considered a chronic disease with treatment."
The nurse contributed to a staff education program about transmission precautions to use when caring for a patient who has AIDS. Which statement by a staff member indicates a correct understanding of the teaching? a. "Wear a mask for any patient contact." b. "Wear a waterproof gown at all times." c. "Wear clean gloves for body fluid contact." d. "Wear sterile gloves for any patient contact."
c. "Wear clean gloves for body fluid contact."
A patient is being started on a blood transfusion. For how many minutes should the nurse stay with the patient during this transfusion? a. 5 b. 10 c. 15 d. 20
c. 15
The nurse is caring for a patient who has AIDS. For which opportunistic lung infection caused by a fungus should the nurse monitor in this patient? a. Tuberculosis b. Cytomegalovirus c. Candida albicans d. Pneumocystis jiroveci pneumonia
d. Pneumocystis jiroveci pneumonia
The nurse has been caring for a patient with pernicious anemia. Which finding should indicate to the nurse that treatment has been successful? a. Decreased folic acid level and an increase in enlarged RBCs b. A decrease in intrinsic factor and increased vitamin B12 excreted in the urine c. An increase in vitamin B12 levels and decrease in number of enlarged RBCs d. A decrease in hydrochloric acid levels in gastric secretion and decrease in production of RBCs
c. An increase in vitamin B12 levels and decrease in number of enlarged RBCs
The nurse is caring for a patient with HIV. For which common opportunistic infection should the nurse observe when caring for this patient? a. Toxoplasmosis b. Cryptococcosis c. Candida albicans d. Cryptosporidiosis
c. Candida albicans
The nurse is caring for a patient with a severe allergic reaction. Which medication should the nurse anticipate being administered to control the itching? a. Morphine b. Epinephrine c. Diphenhydramine (Benadryl) d. Hydrocortisone sodium succinate (Solu-Cortef)
c. Diphenhydramine (Benadryl)
The family of a patient with AIDS has been instructed on patient manifestations to report to the health care provider (HCP). Which manifestation should be reported indicating that teaching has been effective? a. Fever b. Dry mouth c. Night sweats d. Constipation
c. Night sweats
The nurse is caring for a patient with severe ankylosing spondylitis. What nursing action would be most appropriate? a. Provide tepid tub soaks. b. Encourage a high-fiber diet. c. Provide activity every 2 hours. d. Administer narcotic analgesics.
c. Provide activity every 2 hours.
The nurse recommends the diagnosis Disturbed Body Image for a patient with systemic lupus erythematosus. What would be an appropriate long-term outcome for this patient? a. Engages in diversional activities b. Uses normal coping mechanisms c. Returns to previous social involvement d. Verbalizes feelings about body changes
c. Returns to previous social involvement
A patient is experiencing an episode of urticaria. Which intervention should the nurse recommend to include in the teaching plan to assist the patient in controlling the symptoms of urticaria? a. Avoiding tub baths b. Taking one aspirin daily c. Using relaxation techniques d. Drinking decaffeinated coffee
c. Using relaxation techniques
A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take? a. Verify the patient's kidney function. b. Verify the patient's hematocrit level. c. Verify blood type of the patient and donor. d. Verify the patient's admitting medical diagnosis.
c. Verify blood type of the patient and donor.
An HIV-infected patient reports being a cat lover and says, "I always get my pets from a known sanitary source." What should the nurse instruct the patient about cats and the risk of infection? a. "Keep cats outdoors most of the time." b. "Obtain only cats that are less than 1 year old." c. "Remove all pets from your home. Avoid all contact with cats." d. "Be sure all the cats have up-to-date immunizations, and avoid their feces."
d. "Be sure all the cats have up-to-date immunizations, and avoid their feces."
A patient who has HIV asks the nurse why blood work has to be done so frequently. Which response should the nurse make to the patient? a. "B-lymphocyte levels increase if you have an acute infection." b. "Phagocytes are decreased when the disease is in an active phase." c. "Neutrophil counts help the doctor titrate medication levels to keep you healthy." d. "CD4+ lymphocyte counts are monitored to determine the progression of the disease."
d. "CD4+ lymphocyte counts are monitored to determine the progression of the disease."
The nurse is reinforcing teaching on transmission of HIV for a family of a patient diagnosed with HIV. Which explanation by the nurse would be correct? a. "HIV can be spread by casual contact." b. "HIV lives for long periods outside the body." c. "HIV is most commonly transmitted via tears and saliva." d. "HIV enters the body through breaks in the skin or mucous membranes."
d. "HIV enters the body through breaks in the skin or mucous membranes."
A patient asks, "What is the main purpose of these medications I take for my HIV?" Which response should the nurse make? a. "They encapsulate the virus-infected cells." b. "They mark the virus for natural killer cells to destroy." c. "They attract macrophages to the cells making the virus." d. "They inhibit enzymes to interfere with viral production."
d. "They inhibit enzymes to interfere with viral production."
The nurse is preparing to read the Mantoux tuberculin skin test placed on the forearm of a patient with HIV. Which finding should the nurse report as a positive test for this patient? a. 2 mm b. 3 mm c. 4 mm d. 5 mm
d. 5 mm
The nurse is contributing to a teaching plan. What should the nurse emphasize as being the most effective method known to control the spread of HIV infection? a. Premarital serological screening b. Prophylactic exposure treatment c. HIV screening for pregnant women d. Education about preventive behaviors
d. Education about preventive behaviors
The nurse notes that a patient has an elevated lactate dehydrogenase, fragmented RBCs seen on microscopic examination, and low RBC count, hematocrit (Hct), and hemoglobin (Hgb) levels. For which health problem should the nurse consider planning care for this patient? a. Serum sickness b. Pernicious anemia c. Hemolytic transfusion reaction d. Idiopathic autoimmune hemolytic anemia
d. Idiopathic autoimmune hemolytic anemia
The nurse is participating in the planning of care for a patient who has HIV. Which therapeutic action should the nurse recognize as the treatment goal for HIV? a. Stimulating the immune system b. Treating opportunistic infections c. Killing the virus with medication d. Keeping the virus from replicating
d. Keeping the virus from replicating
The nurse is caring for a patient who has AIDS. Which outcome should receive priority? a. Remain socially active. b. Report high self-esteem. c. Remain free of infection. d. Maintain baseline weight.
d. Maintain baseline weight
The nurse is caring for a patient who had a kidney transplant 5 days ago. The patient had been very outgoing and jovial, but this morning the patient is very quiet and refusing breakfast, and ambulation. What would be the most appropriate nursing action at this time? a. Notify the physician for laboratory orders. b. Notify the social worker for discharge follow-up care. c. Inform the patient that kidney rejection signs are appearing. d. Spend extra time with the patient, allowing verbalization of feelings.
d. Spend extra time with the patient, allowing verbalization of feelings.
The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how the disease process occurred. What should the nurse explain to the mother? a. It rarely occurs in males. b. It occurs after exposure to pesticides. c. It is because the infant was premature. d. There are no known causes for this disorder.
d. There are no known causes for this disorder.
A patient comes into the emergency department with a fear of developing poison ivy after falling while walking through a wooded area earlier in the day. What should the nurse instruct the patient to do if exposure to poison ivy occurs again? a. Flood the area with cold water. b. Wrap the area with a thick towel. c. Cover the area with cotton gauze. d. Wash the area with brown soap or any soap.
d. Wash the area with brown soap or any soap.
The nurse is reviewing the use of a condom to prevent the transmission of HIV with a young adult patient seeking testing for HIV. Which patient statement indicates an understanding of how to use a condom? a. Use a non-latex condom. b. Apply adequate oil-based lubricant. c. Apply condom before penile erection occurs. d. Withdraw from partner while the penis is erect.
d. Withdraw from partner while the penis is erect.
The nurse is caring for the newborn of a mother who is HIV positive. What treatment should the nurse expect to be prescribed for the infant? a. Bacitracin b. Erythromycin c. Protease inhibitor d. Zidovudine (AZT)
d. Zidovudine (AZT)