Med-surg Immune practice question

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? a) Swelling in the genital area b) Swelling in the lower extremities c) Positive punch biopsy of the cutaneous lesions d) Appearance of reddish-blue lesions noted on the skin

c

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? a) Hairdressers b) The homeless c) Children in day care centers d) Individuals living in a group home

a

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? a) Protecting the client from infection b) Providing emotional support to decrease fear c) Encouraging discussion about lifestyle changes d) Identifying factors that decreased the immune function

a

The nurse provides home care instructions to a client with svstemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? a) "I should take hot baths because they are relaxing." b) "I should sit whenever possible to conserve my energy." c) "I should avoid long periods of rest because it causes joint d) "I should do some exercises, such as walking, when I am not fatigued."

a

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

a, b

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. a) Administer oxygen. b) Quickly assess the client's respiratory status. c) Document the event, interventions, and client's response. d) Leave the client briefly to contact a primary health care provider (PHCP). e) Keep the client supine regardless of the blood pressure readings. f) Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

a, b, c

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

a, b, d, e

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

b

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

b

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

b

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? a) Wearing gloves b) Wearing a gown and gloves c) Wearing a gown, gloves, and a mask d) Wearing a gown and gloves to change the bed linens, and gloves only for the bath.

b

A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate? Select all that apply. a) Tell the client that testing is not necessary unless arthralgia develops. b) Tell the client to avoid any woody, grassy areas that may contain ticks. c) Instruct the client to immediately start to take the antibiotics that are prescribed. d) Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence o the disease. e) Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic.

b, c, d

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

c

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction? a) "I need to bring a hat to wear during the trip." b) "I should wear long-sleeved tops and long pants." c) "I should not use insect repellents because it will attract the ticks." d) "I need to wear closed shoes and socks that can be pulled up over my pants."

c

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? a) Eggs b) Milk c) Yogurt d) Bananas

d