Exam 2 Adult Health 1 (Respiratory, Cellular Regulation, Cardiovascular, Clotting)

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? A. Elevate the client's feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medication infusion

ANS: D. Stop the medication infusion Rationale: The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to this client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen.

A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client's chart that the cancer classification is TISN0M0. What does the nurse conclude about this client's cancer? A. The primary site of the cancer cannot be determined. B. Regional lymph nodes could not be assessed. C. There are multiple lymph nodes involved already. D. There are no distant metastases noted in the report.

ANS: D. There are no distant metastases noted in the report. Rationale: Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

A nurse is planning a presentation for a group of older adults at a community center about risk factors for cancer. Which of the following factors increases the risk of developing cancer after age 60? A. High-protein diet B. Insufficient calcium intake C. Declining muscle mass D. Weakened immune responses

ANS: D. Weakened immune responses Rationale: After age 60, clients have a higher risk of cancer due to hormonal changes, altered immune responses, and the accumulation of free radicals. Age is a significant factor because the longer people are exposed to external carcinogenic factors (e.g. tobacco and alcohol use, environmental pollutants, radiation), the greater their risk of developing cancer becomes.

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? A. Hematocrit of 35% B. Hemoglobin of 11.8 g/dL C. Platelet count of 400000/µL D. White blood cell (WBC) count of 2800/µL

ANS: D. White blood cell (WBC) count of 2800/µL Rationale: Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised, and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.

The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) A. Exposure to carcinogens B. Genetic predisposition C. Immune function D. Normal doubling time E. State of euploidy

ANS: A, B, C Rationale: The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.

The nurse understands that normal cells and benign cells share which characteristics? (Select all that apply.) A. No migration B. Orderly growth C. Tight adherence D. Specific morphology E. Large nuclear-to-cytoplasmic ratio

ANS: A, B, C, D Rationale: Normal cells and benign cells do not migrate, have orderly growth, demonstrate tight adherence, and have specific morphology. A cancerous (malignant) cell's nucleus is larger than that of a normal cell and the cancer cell is smaller than a normal cell. The nucleus occupies much of the space within the cancer cell, creating a large nuclear-to-cytoplasmic ratio.

A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) A. A sore that does not heal B. Changes in menstrual patterns C. Indigestion or trouble swallowing D. Near-daily abdominal pain E. Obvious change in a mole

ANS: A, B, C, E Rationale: The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) A. Type I Examples include hay fever and anaphylaxis B. Type II Mediated by action of immunoglobulin M (IgM) C. Type III Immune complex deposits in blood vessel walls D. Type IV Examples are poison ivy and transplant rejection E. Type V Examples include a positive tuberculosis test and sarcoidosis

ANS: A, C, D Rationale: Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves disease and B-cell gammopathies.

The nurse instructs a patient about modifiable risk factors for coronary artery disease. Which statements indicate that teaching has been effective? (Select all that apply) A. I should stop smoking to reduce my risk of heart disease B. Restricting my activity reduces the onset of heart disease C. I should drink alcohol because this prevents hearts disease D. There is not much that can be done to prevent heart disease E. Obesity is a risk factor that I can change to reduce the onset of heart disease

ANS: A, E Rationale: Modifiable risk factors for the development of coronary artery disease include obesity, smoking, and physical inactivity

A nurse is caring for a client whose surgeon informed him postoperatively that he has a metastasizing malignant neoplasm in the colon. Which of the following statements by the client should the nurse identify as an indication that the client understands this information? A. "I have cancer of the colon that has begun to spread." B. "I have growths in my bowel that the doctor can treat easily." C. "As long as my tumor doesn't get any bigger, I'll be okay." D. "There is not much point in having more treatments."

ANS: A. "I have cancer of the colon that has begun to spread." Rationale: A neoplasm is a continued growth of nonessential cells, and the term "malignant" means that these cells are cancerous. These cells are also metastasizing, or spreading, to adjacent tissues; therefore, the client's statement is accurate.

A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first? A. Administer epinephrine. B. Apply topical hydrocortisone. C. Monitor the patient for lower extremity edema. D. Ask the patient about exposure to any new lotions or soaps.

ANS: A. Administer epinephrine. Rationale: The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. Topical hydrocortisone would not deter an anaphylactic reaction. Exposure to lotions and soaps does not address the immediate concern of a possible anaphylactic reaction. The nurse should not wait and observe for edema. The nurse should act immediately in order to prevent progression to anaphylaxis.

A nurse is planning care for a patient who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include? A. Avoid IM injections B. Assess the client for ecchymosis once per shift C. Do not allow the client to have visitors D. Encourage daily flossing between teeth

ANS: A. Avoid IM injections Rationale: The client's platelet count of 48,000/mm^3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures such as an IM injection which can increase the client's risk of bleeding.

The nurse caring for oncology clients knows that which form of metastasis is the most common? A. Bloodborne B. Direct invasion C. Lymphatic spread D. Via bone marrow

ANS: A. Bloodborne Rationale: Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? A. Elevate the affected leg B. Place the client on bed rest C. Massage the affected leg D. Administer aspirin for discomfort

ANS: A. Elevate the affected leg Rationale: The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.

A nurse is planning an educational program for a group of young adults about reducing the risk of cervical cancer. Which of the following interventions should the nurse include? A. Get the human papillomavirus (HPV) immunization B. Avoid the use of tampons on a routine basis C. Avoid drinking alcohol D. Get a Papanicolaou test every year starting at age 30

ANS: A. Get the human papillomavirus (HPV) immunization Rationale: HPV is the leading cause of cervical cancer in women. A preventive recommendation is to receive the HPV immunization between 9 and 26 years of age.

Which intervention is most important for the nurse to teach the client who is recovering from an allergic reaction to a bee sting? A. How to use an EpiPen B. Wearing a medical alert bracelet C. Avoiding contact with the allergen D. Keeping diphenhydramine (Benadryl) available

ANS: A. How to use an EpiPen Rationale: If an anaphylactic reaction starts, the client will need to self-medicate very rapidly with the EpiPen. He or she should carry it at all times and should be proficient in its assembly and use. This is the highest priority intervention. The client should get a medical alert bracelet and keep away from bees if at all possible. It is also advised that diphenhydramine be kept on hand in case of a less severe reaction.

A nurse is teaching a client about the manifestations of an allergic reaction. The release of histamine causes which of the following reactions? A. Increased mucus secretion B. Bronchial dilation C. Bradycardia D. Vertigo

ANS: A. Increased mucus secretion Rationale: The nurse should instruct the client that increased mucus secretion is a manifestation of histamine release. Histamine is the neurotransmitter the body produces during an allergic reaction.

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

ANS: A. Total lung capacity Rationale: Pulmonary function tests are used to examine the effectiveness of the lungs and to identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. Eliminating environmental triggers that precipitate attacks B. Addressing the client's perception of the disease process and what might have triggered past attacks C. Overviewing the client's medication regimen D. Explaining manifestations of respiratory infections

ANS: B. Addressing the client's perception of the disease process and what might have triggered past attacks Rationale: The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's current knowledge.

A client has angioedema of the lower face. What will the nurse assess next? A. Pulse oximetry B. Airway patency C. Breath sounds D. Chest wall symmetry

ANS: B. Airway patency Rationale: Angioedema of the lower face includes the mouth and can rapidly lead to laryngeal edema and obstruction of the airway. Other assessments of the client's respiratory status could be done after the airway is assessed, such as pulse oximetry, breath sounds, and chest symmetry

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul

ANS: B. Cheyne-Stokes Rationale: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? A. Administering steroids for severe serum sickness B. Correctly identifying the client prior to a blood transfusion C. Keeping the client free of the offending agent D. Providing a latex-free environment for the client

ANS: B. Correctly identifying the client prior to a blood transfusion Rationale: A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.

A nurse is providing teaching to the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include? A. Machine-wash clothing in cold water B. Dry clothing in a hot dryer for at least 20 min C. Soak combs and brushes for 5 min in boiling water D. Seal non washable items in a bag for 7 days

ANS: B. Dry clothing in a hot dryer for at least 20 min Rationale: The nurse should instruct the parent to dry the child's clothing in a hot dryer for at least 20 minutes.

A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? A. Subcutaneous B. Epidermis C. Dermis D. Stratum corneum

ANS: B. Epidermis Rationale: Basal cell carcinoma originates from the epidermal layer of the skin. It is the most common form of skin cancer.

The nurse is reviewing laboratory results and notes an aPTT level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? A. Aspirin B. Heparin C. Warfarin D. Erythropoietin

ANS: B. Heparin Rationale: Activated partial thromboplastin time (aPTT) assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.

A community health nurse is teaching a group of adult clients about factors that influence health behaviors. Which of the following is a modifiable risk factor that the nurse should include in the teaching? A. Family history of diabetes B. Immunization status C. Mental illness D. Air pollution

ANS: B. Immunization status Rationale: Clients can modify their immunization status. A client can receive immunizations at any stage throughout his/her lifespan.

A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate? A. Basal cell carcinoma B. Melanoma C. Actinic keratosis D. Squamous cell carcinoma

ANS: B. Melanoma Rationale: Melanomas are malignant neoplasms with atypical melanocytes in the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases in the bone, liver, lungs, spleen, CNS, and lymph nodes.

A nurse is assessing a patient with a genetic history of cancer. Which nursing assessment finding is most concerning? A. Nasal congestion for 2 weeks B. Nagging cough with hoarseness C. Muscle tension in the cervical spine D. Blood pressure 138/60

ANS: B. Nagging cough with hoarseness Rationale: A nagging cough with hoarseness is one of the seven warning signs of cancer. Given the genetic predisposition combined with the assessment data, there is cause for concern.

A nurse is assessing a patient with a genetic history of cancer. Which nursing assessment finding is most concerning? A. Nasal congestion for 2 weeks B. Nagging cough with hoarseness C. Muscle tension in the cervical spine D. Blood pressure 138/60

ANS: B. Nagging cough with hoarseness. Rationale: A nagging cough with hoarseness is one of the seven warning signs of cancer. Given the genetic predisposition combined with the assessment data, there is cause for concern.

A nurse is monitoring the laboratory values of a male client who has leukemia and is receiving weekly chemotherapy with methotrexate via IV infusion. Which of the following laboratory values should the nurse report to the provider? A. BUN 18 mg/dL B. Platelets 78,000/mm C. Hemoglobin 14.2 g/dL D. Aspartate aminotransferase (AST) 35 units/L

ANS: B. Platelets 78,000/mm Rationale: The nurse should monitor the platelet count of a client who is taking methotrexate because the medication can cause thrombocytopenia. This client's platelet count is very low and puts the client at risk of severe bleeding. The nurse should report this finding promptly to the provider.

A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The client reports itching and hives 30 min after the infusion begins. Which of the following actions should the nurse take first? A. Maintain IV access with 0.9% sodium chloride B. Stop the infusion of blood C. Send the blood container and tubing to the blood bank D. Obtain a urine sample

ANS: B. Stop the infusion of blood Rationale: Using the urgent vs. non-urgent priority-setting framework, the nurse should consider urgent needs the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.

Which activity performed by the community health nurse best reflects primary prevention of cancer? A. Assisting women to obtain free mammograms B. Teaching a class on cancer prevention C. Encouraging long-term smokers to get a chest x-ray D. Encouraging sexually active women to get annual Papanicolaou (Pap) smears

ANS: B. Teaching a class on cancer prevention Rationale: Primary prevention involves avoiding exposure to known causes of cancer; education assists clients with this strategy. Mammography is part of a secondary level of prevention, defined as screening for early detection. Chest x-ray is a method of detecting a cancer that is present—secondary prevention and early detection. A Pap smear is a means of detecting cervical cancer early—secondary prevention.

A nurse is caring for a client who has testicular cancer and is experiencing peripheral neuropathy as an adverse effect of chemotherapy. Which of the following client manifestations is an expected finding of peripheral neuropathy? A. Thinning of the scalp of hair B. Tingling of the hands and feet C. Reduced ability to concentrate D. Sores in mucous membranes

ANS: B. Tingling of the hands and feet Rationale: Several chemotherapeutic agents might cause peripheral neuropathy. One of the major manifestations of peripheral neuropathy is numbness and tingling of an extremity.

The nurse is observing the AP provide care to a client who is neutropenic. Which action by the AP requires the nurse to intervene? A. Performing a bed bath because the client is too tired to get into the shower B. Using the unit mobile blood pressure machine to assess the client's vitals C. Using alcohol-based hand foam before touching the client D. Cleaning the client's bathroom with disinfectant

ANS: B. Using the unit mobile blood pressure machine to assess the client's vitals Rationale: pg. 388 best practice for patient safety and quality care. Box: Care of the patient with myelosuppression and neutropenia.

A nurse is providing teaching to a client who is receiving chemotherapy and has developed neutropenia. Which of the following statements indicates that the client needs further instructions? A. "I'll keep an antibacterial hand gel in my purse." B. "My partner will have to take care of the cat's litter boxes for a while." C. "I'm planning a large gathering of friends and family for the holidays." D. "I will eat canned fruits and vegetables."

ANS: C. "I'm planning a large gathering of friends and family for the holidays." Rationale: A client who has neutropenia should avoid exposure to infection, so this statement warrants more teaching. A client who has neutropenia should avoid large crowds of people because a large gathering increases the client's risk for exposure to infection.

A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? A. "Platelets help the body fight infection" B. "Platelets help break down clots in the body" C. "Platelets plug breaks in blood vessels" D. "Platelets produce the molecules that carry oxygen"

ANS: C. "Platelets plug breaks in blood vessels" Rationale: Platelets help maintain homeostasis and coagulation by plugging in disruptions in the integrity of blood vessels. When an injury occurs to a blood vessel, platelets collect at the edge of the break and adhere to each other to plug the injured area and limit blood loss.

A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include? A. Apply a broad-spectrum sunscreen 5 min before sun exposure B. Wear a sun visor instead of a hat when outside in the sun C. Avoid exposure to the midday sun D. Use a tanning booth instead of sunbathing outdoors

ANS: C. Avoid exposure to the midday sun Rationale: The nurse should instruct clients to avoid skin exposure to the sun, especially during the midday hours of 1000 to 1600 when the sun rays are the strongest.

The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? A. Ask the patient about any clear nasal discharge. B. Obtain the patients' blood pressure and heart rate. C. Check for swelling of the patients' lips and tongue. D. Assess the patients' extremities for wheal and flare lesions.

ANS: C. Check for swelling of the patients' lips and tongue. Rationale: Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

A nurse in a dermatology clinic is using the ABCDE method while screening several skin lesions for skin cancer on a client. Which of the following findings should the nurse report to the provider? A. Symmetric shape B. Border regularity C. Color variation within a lesion D. Diameter >4 mm

ANS: C. Color variation within a lesion Rationale: The C in the ABCDE method of screening for skin cancer stands for color variation within a lesion. The E stands for evolving or changing in any feature of the lesion.

A nurse is screening a client for skin cancer. When teaching the client about skin cancer risk, which of the following risk factors should the nurse include? A. Cigarette smoking B. Low-fiber diet C. Excessive exposure to ultraviolet light D. Human papillomavirus

ANS: C. Excessive exposure to ultraviolet light Rationale: Excessive exposure to ultraviolet light (e.g. from sunlight or tanning beds), occupational exposure to chemical carcinogens, and chronic skin irritation are risk factors for skin cancer.

The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells? A. Benign tumors grow through invasion of other tissue. B. Benign tumors have lost their cellular regulation from contact inhibition. C. Growing in the wrong place or time is typical of benign tumors. D. The loss of characteristics of the parent cells is called anaplasia.

ANS: C. Growing in the wrong place or time is typical of benign tumors. Rationale: Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

A 33-year-old patient has recently been diagnosed with stage II cervical cancer. The nurse would understand that the patient's cancer A. Is in situ. B. Has metastasized. C. Has spread locally. D. Has spread extensively.

ANS: C. Has spread locally. Rationale: Stage II cancer is associated with local spread. Stage 0 denotes cancer in situ; stage III denotes extensive regional spread, and stage V denotes metastasis.

How does the type V hypersensitivity reaction differ from other reactions? A. It is cell mediated rather than antibody mediated. B. It is an immediate response rather than a delayed response. C. It produces a stimulatory response to normal tissues. D. It results in more severe tissue damage than is caused by other types of reactions.

ANS: C. It produces a stimulatory response to normal tissues. Rationale: Type V hypersensitivity reactions are known as stimulatory responses. The classic example of type V hypersensitivity is Graves disease, in which the person makes a large amount of antibody that binds to the thyroid-stimulating hormone receptor antibody (TSHr-Ab) on thyroid tissue. The binding of this antibody to the TSH receptor activates the receptor, greatly stimulating the thyroid gland and causing severe hyperthyroid symptoms. This type of reaction is not cell mediated. It is not an immediate response, nor does it cause more severe tissue damage.

A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse effects should the nurse anticipate from the chemotherapy? A. Gingival hyperplasia B. Hirsutism C. Pancytopenia D. Weight gain

ANS: C. Pancytopenia Rationale: Pancytopenia (a deficiency of WBCs, RBCs, and platelet count) is an expected adverse effect of chemotherapy.

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis

ANS: C. Tachycardia Rationale: Tachycardia, dyspnea, restlessness, headaches, and increased blood pressure are indications of impending respiratory failure.

Which condition is a type II hypersensitivity reaction? A. Allergic rhinitis B. Positive purified protein derivative (PPD) test for tuberculosis C. Transfusion reaction to improper blood type D. Serum sickness after receiving immune globulin

ANS: C. Transfusion reaction to improper blood type Rationale: Common clinical situations caused by type II hypersensitivities include hemolytic transfusion reactions. Type II hypersensitivity reactions are caused by antibodies directed against body tissues that have some form of non-self (foreign) protein attached to them. Allergic rhinitis is an example of a type I hypersensitivity. A positive PPD test is an example of a type IV reaction. Serum sickness is a type III reaction.

A client who has stage II breast cancer asks the nurse about sites of metastasis for this cancer. Which of the following responses should the nurse provide? A. "It's too soon to worry about something that might not happen." B. "Breast cancer tends to metastasize to the stomach." C. "Metastasis is unlikely since we detected your cancer early." D. "Breast cancer tends to metastasize to the bones."

ANS: D. "Breast cancer tends to metastasize to the bones." Rationale: Common sites of breast cancer metastasis are the bones, lungs, brain, and liver.

A nurse is teaching a 70-year-old client about risk factors for heart failure. The client has mild asthma, diabetes mellitus, and coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? A. "My diabetes will not increase my risk of heart failure." B. "My asthma makes it more likely for me to have heart failure." C. "My age does not increase my risk of heart failure." D. "My coronary artery disease is a risk factor for heart failure."

ANS: D. "My coronary artery disease is a risk factor for heart failure." Rationale: Coronary artery disease is a primary risk factor for the development of heart failure. Other risk factors include hypertension, cardiomyopathy, tobacco use, family history, and hyperthyroidism.

A nurse is caring for a client who has regular occupational exposure to sunlight and presents for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A. A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder B. Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose C. A raised, circumscribed lesion on the face that contains yellow-white purulent material D. An irregularly shaped brown lesion with light blue areas on the neck

ANS: D. An irregularly shaped brown lesion with light blue areas on the neck Rationale: Malignant melanoma (the leading cause of death from skin cancer) is a neoplasm of dermal or epidermal cells. Exposure to sunlight increases the risk of this condition, and fair-skinned people have the highest risk. Malignant melanoma commonly starts in exposed skin areas like the back, scalp, face, and neck and metastasizes readily to other areas. Manifestations include a change in the color, size, or shape of a skin lesion with irregular borders in hues of blue, white, and red tones.

A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm^3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? A. Provide foods high in iron B. Avoid people who have infections C. Administer PRN oxygen D. Encourage quiet play

ANS: D. Encourage quiet play Rationale: A platelet count of 20,000/mm^3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk of injury, thereby reducing chances of hemorrhage.

A nurse is caring for a client who underwent radioallergosorbent (RAST) testing due to seasonal allergies. The nurse should anticipate an elevation in which of the following immunoglobulin laboratory values? A. IgM B. IgA C. IgG D. IgE

ANS: D. IgE Rationale: RAST testing involves measuring the quantity of IgE present in serum after exposure to specific antigens selected on a basis of the client's symptom history. An elevated IgE indicates a positive response and is common among clients who have a history of allergic manifestations, anaphylaxis, and asthma.

A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? A. Smoking cessation B. Benefits of a diet high in cruciferous vegetables C. New types of ostomy appliances D. Importance of colonoscopy screening starting at age 50 years old

ANS: D. Importance of colonoscopy screening starting at age 50 years old Rationale: Screening examinations for colorectal cancer are secondary prevention (an action that promotes early detection of disease).

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? A. One solid color B. Symmetrical shape C. <6 mm in diameter D. Irregular border

ANS: D. Irregular border Rationale: The nurse should identify that skin cancer lesions, including melanoma, are expected to exhibit border irregularity. The nurse should instruct clients on the use of the ABCDE pneumonic when monitoring skin lesions: asymmetry of shape, border irregularity, color variation within one lesion, diameter of >6 mm, and evolution of any feature.

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? A. Soft blowing B. Loud bubbling C. Dry grating D. Noisy wheezing

ANS: D. Noisy wheezing Rationale: Asthma causes the bronchioles of the lungs to constrict, creating a wheezing sound.

A nurse is collecting a client's health history. Which of the following findings is the highest risk factor for the client developing skin cancer? A. Age over 60 B. Genetic predisposition C. Light-skinned race D. Overexposure to sunlight

ANS: D. Overexposure to sunlight Rationale: The nurse should apply the safety and risk-reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should identify overexposure to the sun as the greatest risk factor for developing skin cancer.

Which of the following does the nurse recognize as a primary cancer prevention strategy? A. Fecal occult blood annually for adults of all ages. B. Yearly mammography for women over 40 years. C. Colonoscopy at age 50 years. D. Removal of mole on the shoulder

ANS: D. Removal of mole on the shoulder Rationale: Primary prevention of cancer involves removal of "at risk" tissue. The other choices listed are secondary prevention strategies, which involve screening for early detection of cancer.