MS EX 2

How does long-term alcohol abuse lead to alteration in the immune system?

It impairs the ability of B lymphocytes to produce antibodies.

A patient diagnosed with a primary brain tumor asks the nurse if this is a common disease. Which response is most appropriate for the nurse to make?

"About 40,000 people a year are diagnosed with a primary brain tumor."

The 75-year-old patient asks the nurse if the Pneumovax immunization he took when he was 65 is still protecting him. Which reply is most accurate?

"After 6 years, you need a repeat dose of Pneumovax for full immunity."

The patient scheduled for a computed tomography (CT) scan with contrast medium questions the nurse why the technologist asked her if she had any food allergies. Which response by the nurse is correct?

"Allergies to shellfish can be a problem because shellfish and CT scan dye are iodine based."

The dysarthric patient seated in the dining room of the long-term care facility yells, "Poon! Poon! Poon!" with increasing frustration. What is the nurse's best response?

"Are you asking for a spoon?"

The nurse is caring for a postoperative patient. After instructing the patient to cough and deep-breathe, what action should the nurse take next?

Perform mouth care.

The nurse documents which sign(s) of epidural hematoma in a patient with a closed head injury? (Select all that apply.)

Periorbital ecchymosis Battle sign Nausea and vomiting

The nurse is educating a patient about his diagnosis of stage II Hodgkin disease. Which statement indicates that the nurse's teaching has been successful?

"Two nodes in my left arm area are affected."

For which individual(s) does U.S. Public Health Service recommend the influenza immunization? (Select all that apply.)

Physicians Older adults Chronically ill Nurses

The patient with acute bronchitis asks if antibiotics will be ordered for the condition. Which response is best for the nurse to make?

"Antibiotics will be given if the sputum culture indicates your bronchitis is caused by bacteria."

The nurse is providing medication teaching to a patient with epilepsy who is taking phenytoin (Dilantin). Which statement best indicates that the nurse's teaching has been successful?

"I should visit the dentist every 3 to 6 months while taking this medication."

Which statement is most important for the nurse to make when caring for an anxious patient with a new tracheostomy?

"I understand that you might be apprehensive."

The clinic nurse is giving discharge instructions to the mother of a 10-year-old boy who has been diagnosed with a mild cold. Which statements indicate that the mother accurately understands the nurse's instructions? (Select all that apply.)

"I will be sure he drinks plenty of apple and orange juice." "I will be sure he washes his hands well so he doesn't pass this cold on to his younger sister." "Since his cold symptoms just started, zinc lozenges may be helpful for him to take."

The nurse is educating a patient who requires daily postural drainage treatments. Which statement indicates that the patient understands when and why treatments will be scheduled?

"I will have treatments first thing in the morning to get rid of fluids that have built up over night."

The nurse is providing teaching to a patient who has undergone a liver transplant. Which statement by the patient demonstrates the need for further patient teaching?

"I will need to take medications to boost my immune system for the next year."

The mother of a young child voices concern about immunizations for her child. Which response is best?

"Immunization is generally a safe method of avoiding certain diseases and the complications that go along with these diseases."

The nurse is caring for an adolescent who has lower limb paralysis after sustaining a spinal injury yesterday. The patient's anxious mother asks if the paralysis is permanent. Which response is most appropriate for the nurse to make?

"It is possible that motor function may or may not return after spinal cord swelling has subsided."

The nurse is evaluating the patient's understanding of his new diagnosis of rheumatoid arthritis. Which statement reflects an understanding of the disease process?

"My body produces an immune response to my own cells and tissues."

The nurse is caring for a pediatric patient recently diagnosed with severe combined immunodeficiency (SCID) disease. The nurse determines that teaching has been effective after the parent makes which statement?

"My child should not attend day care."

The nurse is caring for an anxious 20-year-old college student who just suffered his first seizure in his dorm room. The patient asks the nurse if he is now an epileptic. What is the nurse's best response?

"No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made."

he nurse is educating a patient with lymphoma. Which statement indicates that the patient correctly differentiates Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL)?

"Non-Hodgkin lymphoma is less predictable and can spread faster."

The nurse is caring for a patient with sleep apnea. The patient complains that he is constantly fatigued. Which response is most appropriate for the nurse to make?

"Patients with sleep apnea often wake frequently during the night."

The nurse is explaining Parkinson disease to the student nurse. Which statement indicates that the student nurse correctly understands the pathophysiology of the disease?

"Regardless of the actual etiology, Parkinson disease is caused by depletion of dopamine and excess of acetylcholine."

The nurse is caring for a patient who has had a cold for 1 week. The patient questions why the health care provider issued a prescription for an antibiotic. Which explanation is best?

"The antibiotic will treat the secondary bacterial infection that has developed."

The patient with sleep apnea is fitted with a continuous positive airway pressure (CPAP) mask and asks the nurse how this device will help. How should the nurse respond?

"The device delivers constant positive pressure to keep your airway open."

The nurse is caring for a patient with Huntington disease. The patient asks if his disease will affect future children. Which reply is most appropriate?

"The genetic nature of the disease means that 50% of your children will inherit it."

The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). Family members ask the nurse why their father had a seizure. Which response is best for the nurse to make?

"The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain."

The nurse is caring for a patient with flaccid paralysis after sustaining a spinal cord injury 3 days earlier. The family excitedly notifies the nurse that the patient has flexed his arm. Which response is best for the nurse to make?

"These muscles spasms are a type of involuntary movement that happens frequently in patients with spinal cord injuries."

The nurse is caring for a patient who reports feeling very stressed about her new diagnosis of fibromyalgia. Which response is most beneficial in addressing the patient's stress?

"What worries you the most about your fibromyalgia?"

The patient scheduled for a PET (positron emission tomography) scan of the brain asks if there is any special preparation for the test. The nurse correctly responds with which statement(s)? (Select all that apply.)

"You should avoid any tranquilizers or sedatives the night before and the day of the test." "You will need to sign a consent form for this test to be performed." "You will have two IVs inserted for the examination."

The nurse is providing teaching to a patient newly diagnosed with simple partial seizure disorder. Which statement by the nurse is most accurate?

"Your seizures will typically only affect one side of your body."

Signs and symptoms of Guillain-Barré syndrome (GBS) usually appear within how many days after a viral infection?

10 to 21 days

The patient is caring for a patient who spontaneously opens his eyes, localizes pain, and carries out confused conversation. The nurse correctly documents which Glasgow Coma Scale (GCS) rating for this patient?

13

The nurse reading a tuberculin skin test (TST) on a new employee who lives in the Midwest, is 20-years-old, and has no known history of contact with any people with tuberculosis (TB). The nurse should interpret the reading as positive if the area around the injection site has an induration of how many millimeters?

15 mm

The unconscious patient with a closed head injury is on mechanical ventilation. To improve brain perfusion through increased blood pressure, the carbon dioxide (CO2) should be maintained at what level?

25 to 30 mm Hg

What is the contagion period of a cold?

3 days

The nurse reinforces the information given by the physician that endarterectomy as an intervention for stroke prevention is reserved for people who have carotid obstruction of greater than what percentage?

60%

The nurse is caring for a patient with brain tumor-related hydrocephalus who is scheduled to undergo placement of a ventriculoperitoneal (V-P) shunt. Which information is most important for the nurse to include when explaining the purpose of the procedure?

A V-P shunt redirects the cerebrospinal fluid (CSF) from the ventricles to the peritoneum.

The nurse is performing an occupational history as part of the respiratory assessment. Which occupation(s) place the patient at increased risk for an occupational lung disorder? (Select all that apply.)

A firefighter A cotton gin worker A construction contractor

Which symptom is a key sign of a brain tumor?

A headache that awakens patient

Which analogy best describes the action of killer T cells?

A mad hornet flying through circulating fluids seeking and killing antigens.

he nurse is caring for multiple patients. After reviewing the patients' histories, the nurse determines that which patient possesses the highest risk of throat cancer?

A male patient who drinks four vodka tonics per day

The nurse is performing an assessment on a patient admitted for diagnostic testing to rule out fibromyalgia. Which assessment finding indicates that the patient actually may have the disorder?

A pain response to nonpainful stimuli

Which patient would the nurse consider to be immunosuppressed? (Select all that apply.)

A patient on chemotherapy for cancer A patient using corticosteroids A patient recovering from joint replacement A patient diagnosed with human immunodeficiency virus (HIV)

The nurse is working in a flu immunization clinic. Which situation would require a postponement of immunization?

A patient received immune globulin 2 weeks ago.

The nurse is preparing a presentation on the inflammatory response. While preparing a cartoon picture of lysis, the nurse correctly draws which scenario?

A phagocyte eating an antigen

A vaccination or immunization gives a patient which type of immunity?

Active acquired immunity

The nurse is caring for an immunosuppressed patient. Which care considerations should the nurse include? (Select all that apply.)

Adhere to Standard Precautions. Avoid bringing potted plants into the patient's room. Employ reverse isolation. Use filters on air conditioner vents.

A patient was recently diagnosed as having Bell palsy. Which nursing intervention is most important for the nurse to include in the patient's care plan?

Administer artificial tears and aclyclovir.

The nurse is aware that an epidural hematoma warrants immediate intervention based on which criteria? (Select all that apply.)

An epidural hematoma can increase intracranial pressure (ICP) quickly. An epidural hematoma changes overall condition quickly. An epidural hematoma can cause death. An epidural hematoma can cause irreversible brain damage.

The nurse caring for a patient with advanced AIDS. While collecting data, the nurse notes a weight loss of several pounds, poor food consumption, and complaint of no appetite. Based on these findings, the nurse should carefully monitor the patient for development of which problem?

Anasarca

The nurse has just administered a new antibiotic to a patient. Which manifestation is the best early indicator that the patient may be experiencing an anaphylactic reaction?

Angioedema

The nurse is educating a patient with systemic lupus erythematosus (SLE). Which information is most important for the nurse to include in the teaching plan?

Apply fragrance-free lotions to dry areas twice

The nurse is caring for a patient who requires neurologic checks. When performing an assessment, how should the nurse best evaluate the patient's thinking?

Ask the patient to add three numbers together in his head.

The nurse is performing a neurologic assessment on a patient. Which action should the nurse take to adequately test the effectiveness for the hypoglossal nerve?

Ask the patient to touch the tip of the tongue to each cheek.

The nurse carefully applies suction prior to deflating the cuff on a cuffed tracheostomy in order to prevent which complication?

Aspiration

The nurse is caring for a patient with systemic lupus erythematosus (SLE). The patient complains of severe fatigue, a butterfly rash, and joint pain. Which nursing intervention(s) is/are most appropriate for this patient? (Select all that apply.)

Assess pain control measures that have helped the patient in the past. Assist the patient with planning rest periods throughout the day. Remind the patient to avoid contact with people who have an infection. Ensure the patient understands the importance of her medication regimen.

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) who has been in the hospital for several days. The patient complains of shortness of breath and asks the nurse to turn up his oxygen to compensate for his labored breathing. What is the best nursing response?

Assess the patient in an attempt to identify the cause of the shortness of breath.

The 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, and agitated. The patient's temperature is 100° F, and his pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago. What action should the nurse take first?

Assess the patient's oxygen saturation.

The nurse is caring for a patient with Guillain-Barré syndrome (GBS). Which area(s) should the care plan address? (Select all that apply.)

Assessment of advancing paralysis Provision for ventilation support Maintenance of adequate nutrition Prevention of complications of immobility

The nurse is completing a care plan for a stroke patient who is at risk for impaired physical mobility. Which interventions should the nurse include in the care plan? (Select all that apply.)

Assist the patient to stand. Ensure that the call light is within reach. Coach the patient in active range-of-motion (ROM). Reinforce the use of a walker or cane.

The nurse is setting up the environment for tracheal suction on a newly postoperative tracheostomy patient. Which action(s) should the nurse perform? (Select all that apply.)

Auscultate lungs for retained secretions. Wash hands and open sterile suction kit. Inform the patient about the procedure. Perform suction with sterile supplies.

The nurse is teaching an adult post-tonsillectomy patient. Which dietary instructions are most important for the nurse to include? (Select all that apply.)

Avoid hot fluids. Avoid foods with red dye.

The nurse is teaching a patient with a newly resolved episode of epistaxis. Which information is important for the nurse to include? (Select all that apply.)

Avoid sneezing. Rest for several hours until all threat of epistaxis is gone. Avoid rubbing the nose.

Which type of lymphocytes actually produces either sensitized lymphocytes or antibodies?

B lymphocytes

The nurse is aware that the patient seeking antibiotic treatment for pharyngitis will only receive the desired medication if the condition is caused by what type of pathogen?

BActeria

Which reflex indicates an abnormality in the motor control pathways from the cerebral cortex?

Babinski reflex

The nurse is assessing the patient with influenza. The patient reports having general malaise and aching muscles over the past 2 weeks. The nurse suspects that the patient may have developed which complication of influenza?

Bacterial pneumonia

The nurse is caring for a patient with a respiratory disorder who complains of anorexia. Which factor(s) may contribute to the patient's anorexia? (Select all that apply.)

Bad taste in mouth Fear of exacerbate coughing by eating Fatigue Altered sense of smell

The nurse is caring for a patient who was recently admitted with a traumatic head injury. The nurse anticipates that the patient may display which type of respirations?

Biot

The nurse explains that the mechanism that triggers rate and depth of respiration is based on which factor?

Blood pH

The patient with asthma is prescribed a leukotriene modifier drug, montelukast (Singulair). Which statement describes an advantage of this medication?

Bronchodilation and anti-inflammatory effects

When the nurse places the diaphragm of the stethoscope over one of the main bronchi, which expected normal breath sound should the nurse hear?

Bronchovesicular sounds

The nurse is caring for a patient with a neurologic injury who is awake. On assessment, the patient displays mild disorientation to surroundings and time and needs additional verbal cues to stimulate response to commands. The nurse correctly documents the patient's level of consciousness (LOC) by using which term?

Confused

The nurse is caring for a patient with a closed head injury. Which finding causes the nurse to suspect that the patient has developed diabetes insipidus (DI)?

Copious pale urine output

The nurse is caring for a patient with (AD). The nurse should assess the patient for which conditions or situations? (Select all that apply.)

Distended bladder Constipation Wrinkles in bed linens Abrupt environmental temperature changes

The nurse is caring for a first-day postoperative thoracotomy patient. The nurse assesses that the level of drainage has not increased over the last 3 hours. After assessing the patient's respiratory status, what should the nurse do next?

Check the tubing for kinks

Which condition(s) that can cause acquired immune deficiency? (Select all that apply.)

Chemotherapy Viral infections Smoking Malnutrition

The nurse is caring for a patient with an obstructive respiratory disorder. Which of these conditions is an example of an obstructive lung disorder?

Chronic bronchitis

When doing routine cleaning of a double-lumen tracheostomy tube, the nurse should include which action?

Clean the inner cannula with a pipe cleaner.

The nurse is caring for the patient who has had an injury to the hypothalamus. Which intervention is most important for the nurse to implement?

Closely control room temperature.

A patient with emphysema presents to the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26. The nurse positions the patient in high Fowler. What action should the nurse take next?

Coach the patient in pursed-lip breathing.

The nurse is educating the family of a patient in the late stages of amyotrophic lateral sclerosis (ALS). Which information is most important for the nurse to include?

Cognitive and mental capacities will most likely remain intact throughout the disease progression.

The nurse is caring for a patient who underwent a laryngectomy. Which need should the nurse address first?

Communication method

Which action(s) may help to reduce the risk of transmitting a common cold? (Select all that apply.)

Cover the mouth and nose when sneezing. Wash the hands frequently. Turn the head to the crook of the arm when coughing.

The nurse is teaching a patient who underwent a laryngectomy. Which statement describes the correct technique for warming inspired air during cold weather?

Cover the stoma with a scarf.

The nurse is caring for a patient with suspected bacterial pneumonia. Which finding supports the potential diagnosis?

Interstitial inflammation

The nurse is performing a neurologic assessment on a newly admitted patient with a head injury. Which sign best indicates that the patient may have experienced a brainstem injury?

Decerebrate posturing

The nurse is caring for an older adult patient who was admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness. The nurse most carefully monitors the patient for which change?

Decreasing level of consciousness (LOC)

The nurse is assessing an 80-year-old patient. The nurse correctly attributes the slowed knee jerk reflex with which age-related change?

Degeneration of myelin sheath

The nurse is preparing a presentation that highlights the benefits of annual influenza vaccination. The nurse correctly targets which groups? (Select all that apply.)

Diabetics who are over 50 years old. Pregnant women. Home health aides. CNAs who work in long-term care facilities.

The nurse is caring for a patient admitted with a transient ischemic attack (TIA). A carotid ultrasound reveals a 40% obstruction. The nurse anticipates that the treatment will likely consist of which factor(s)? (Select all that apply.)

Diet modification Lifestyle alteration Aspirin for antiplatelet aggregation

The nurse is caring for a patient with myasthenia gravis. The patient asks the nurse if she can return to her normal job as a data entry specialist. Which symptom would most affect the patient's ability to perform her job?

Diplopia

Through which method(s) can influenza spread? (Select all that apply.

Direct contact Indirect contact Droplets

The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which assessment finding indicates a potential complication and requires the nurse's immediate attention?

Distended neck veins

The nurse is caring for a stroke patient who is experiencing homonymous hemianopsia. The patient asks if he is going to have any limitations when discharged from the hospital. The nurse anticipates the patient will be restricted from what activity?

Driving a vehicle

The nurse is caring for an adult patient with a history of seizures. In the event of a seizure, the nurse should document which information? (Select all that apply.)

Duration of seizure Location of initiation of seizure Description of movements Presence of incontinence

The nurse is preparing a care plan for a person with late-stage Parkinson disease. The nurse should plan interventions to address which problem(s)? (Select all that apply.)

Dysphagia Immobility Insomnia Urinary incontinence

The nurse is preparing to administer the influenza immunization to four patients. Allergy to which substance should cause the nurse to question giving the immunization?

Eggs

Following a craniotomy to relieve increased intracranial pressure (ICP), which implementation should the nurse implement?

Elevate the head of the bed 20 to 30 degrees.

The nurse is caring for a patient with a spinal cord injury who develops autonomic dysreflexia (AD). Which action is most important for the nurse to take first?

Elevate the head of the bed.

After assessing a patient, the nurse suspects that the patient has an abscessed tooth. Which assessment finding confirms that the immune system is fighting the abscess?

Enlarged cervical lymph node

Which factor(s) is/are most likely a potential cause(s) of multiple sclerosis (MS)?

Environmental factors and genetic predisposition

After an influenza immunization, the patient complains of shortness of breath, breaks out in hives, and begins to twitch. Which ordered medication should the nurse give first?

Epinephrine injection

The FOUR (Full Outline of UnResponsiveness) tool is based on the assessment of which components? (Select all that apply.)

Eye response Motor response Brainstem response Respiratory function

When collecting data from a patient suspected of having an immune deficiency, which factor(s) should be included? (Select all that apply.)

Family history of immune disorders Age Alcohol use Exposure to HIV

Which drug therapy is indicated for an acute severe attack of multiple sclerosis (MS)?

Intravenous (IV) methylprednisolone

The nurse is assessing a patient on intravenous (IV) phenytoin (Dilantin). Which assessment finding is most concerning to the nurse?

Irregular apical pulse

The nurse is caring for a patient with Huntington chorea. Which symptom(s) is/are characteristic manifestation(s) of this disease? (Select all that apply.)

Fidgeting Restlessness Constant movement Dementia

The nurse is caring for a patient with suspected sinusitis. Which assessment finding supports this diagnosis?

Generalized pain in the upper teeth.

Which physical signs indicate labored breathing? (Select all that apply.)

Grunting on expiration Elevating shoulders and ribs on inspiration Tensing neck and shoulder muscles Substernal retraction

During assessment of the patient diagnosed with systemic lupus erythematosus (SLE), which sign(s) and symptom(s) would the nurse expect to find? (Select all that apply.)

Hair loss Mouth sores Fatigue Rashes

Which position is best for an unconscious patient with a right-sided closed head injury?

Head of bed 20 to 30 degrees

A patient presents to the health clinic with low back pain that radiates into the buttocks and below the knee. The nurse suspects which condition?

Herniated disk

When feeding a patient with dysphagia with a left-sided hemiplegia, how should the nurse position the patient?

High fowler

The nurse is assessing an older adult with a family tendency of developing laryngeal cancer. The nurse should ask the patient about which risk factors? (Select all that apply.)

History of smoking Alcohol abuse Exposure to asbestos Occupational exposure to wood dust

A patient has been exposed to an allergen resulting in a hypersensitivity reaction. The nurse correctly recognizes that which immunoglobulin has been triggered?

IgE

The nurse is reviewing laboratory results of a patient who had surgery 2 days ago. The nurse notes that the C-reactive protein is elevated. What potential problem does this finding indicate?

Impending infection

The nurse is caring for a patient immediately postoperative after a left pneumonectomy. How should the nurse position the patient?

In a left side-lying position

After using a nasal cannula delivery system at 3 L/min, a patient with chronic airflow limitation (CAL) changes to a simple face mask. The nasal equipment oxygen was set at 3 L/min. How should the nurse adjust the oxygen flow for the new delivery system?

Increase it to 6 L.

After an older adult falls, the nurse suspects the development of a subdural hematoma based on which finding(s)? (Select all that apply.)

Increasing irritability Complaint of a dull headache Frequent "nodding off" in chair during the day

The nurse performs a reflex test on a newly admitted adult patient. The nurse runs a tongue blade along the sole of the foot and the patient responds with the great toe bending backward (upward) and the smaller toes fanning outward. These findings cause the nurse to suspect that the patient may have experienced which problem(s)? (Select all that apply.)

Injury to the central nervous system (CNS) that resulted in an abnormality in the motor control pathways leading from the cerebral cortex Influence of chemical substances

The nurse is aware that unlike dogs, humans do not contract such diseases as distemper. Which type of immunity explains this protection?

Innate immunity

The nurse is caring for a patient experiencing epistaxis. What action should the nurse take first?

Instruct the patient to sit forward and pinch the nose below the bone.

While performing an assessment, the nurse auscultates a coarse low-pitched sonorous rattling in the left lower lobe. Based on the presence of this adventitious lung sound, which action should the nurse take next?

Instruct the patient to turn, cough, and deep-breathe.

The student nurse is planning care for a patient with a recent spinal cord injury. Which intervention indicates that the student nurse requires further instruction regarding appropriate care for this patient?

Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 hours.

The nurse is aware that absence (petit mal) seizures are difficult to detect for which reason(s)? (Select all that apply.)

Lack of an aura Appearance as a brief moment of absentmindedness Absence of patient memory of the event Absence of postictal signs

In assessing the patient with a significant right intracerebral hemorrhage, the nurse anticipates that the patient will demonstrate which signs?

Left-sided hemiplegia with dilated right pupil

The nurse instructs a person taking phenytoin (Dilantin) that periodic blood tests will be necessary. The nurse explains that the laboratory checks will monitor for which potential medication-induced change?

Liver damage

The nurse is caring for a 20-year-old patient who recently underwent a tonsillectomy. The patient is fully awake and clearing his throat frequently but denies pain. Which action is most important for the nurse to take first?

Look in the patient's mouth.

A patient is admitted to the hospital to rule out the possibility of bacterial meningitis. Which test will be most helpful in diagnosing this condition?

Lumbar puncture for cerebrospinal fluid (CSF) analysis and culture

The nurse is caring for a patient with bacterial meningitis. What interventions should the nurse include in the plan of care?

Maintain a quiet environment with minimal stimulation.

The nurse outlines nutritional needs for the patient with multiple sclerosis (MS). Which dietary instruction(s) is/are most important for the nurse to emphasize? (Select all that apply.)

Maintain fluid intake of at 1500 mL each day. Include intake of high-fiber foods in the diet Add supplemental calcium and vitamin D to the diet.

Which mechanisms are ways in which antibodies can protect the body by either destroying or inactivating a particular antigen? (Select all that apply.)

Mechanically harming the antigen Activating the complement system Releasing chemicals that alter the environment of the antigen

Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse?

Meningitis

The nurse is assisting a patient with agnosia after a CVA. Which intervention is most appropriate?

Moving the patient's hand with a toothbrush in repetitive motion to brush teeth.

MOPP and ABVD therapy for the treatment of Hodgkin disease are treatment protocols that use which combination of factors?

Multiple medications given concurrently

The nurse is assessing a patient's lymph nodes. Which finding would alert the nurse to the possibility of the patient having non-Hodgkin's lymphoma (NHL)?

Noncontiguous enlarged lymph nodes.

The nurse interprets the physician's finding of a grade of 2/5 on the Achilles tendon to mean what has occurred?

Normal response for the first and second sacral nerves

The nurse is caring for a patient with a head injury. Over a time span of 30 minutes, the nurse observes the following vital signs changes: temperature from 97° to 98° F; pulse from 86 to 78 beats/min; respirations from 18 to 14 breaths/min; and blood pressure from 140/86 to 150/82. Which action is most important for the nurse to take?

Notify the physician immediately.

The nurse is aware that the patient is in respiratory failure when the blood gas findings contain which values?

PaO2 46 mm Hg; PaCO2 52 mm Hg

The nurse is preparing to write a care plan for the patient with fibromyalgia. Which problem/nursing diagnosis best addresses this disorder?

Pain, Chronic

Which statements about passive immunity are true? (Select all that apply.)

Passive immunity prevents further tissue damage. Passive immunity provides temporary immunity from the disease.

The young father tells the industrial nurse at work that he is afraid he will give his 2-week-old baby his cold. The nurse can assure him that the baby is protected by which type of immunity?

Passive natural immunity

While performing an assessment, the nurse taps a patient's knee and observes that the quadriceps muscle reflexively contracts. How should the nurse document this finding?

Patellar reflex 2/5

The home health nurse is making an initial call on a newly diagnosed tuberculosis (TB) patient. The patient lives with his wife and child. Which infection control instructions should the nurse include in the teaching plan? (Select all that apply.)

Place contaminated tissues in sealable plastic bag. Take medications exactly as directed. Wash hands frequently. Wear a mask when in crowds.

Which nursing intervention best encourages self-feeding in a patient with right-sided paralysis after a CVA?

Place finger foods on the left side of the plate.

To help prevent aspiration while feeding a patient who has a right-sided paralysis, the nurse should implement which intervention(s)? (Select all that apply.)

Place the patient in high Fowler position. Instruct the patient to tilt the head and neck forward. Place food in the left side of the mouth. Avoid mixing foods with different textures

The nurse is writing the care plan for a cerebrovascular accident (CVA) patient who has partial left-sided paralysis and is experiencing ataxia. Which intervention is most beneficial for this patient?

Place the patient's call light on the right side of the patient and remind her to call for assistance before getting up.

Which organism(s) are common causative agents for sinusitis? (Select all that apply.)

Pneumococci Haemophilus influenzae Streptococci

When caring for a patient with acquired immune deficiency syndrome (AIDS), the nurse is aware that this patient is most at risk for developing which type of pneumonia?

Pneumocystis jiroveci

The nurse is assessing muscle strength in a fully conscious patient as part of a neurologic assessment. Which technique should the nurse employ?

Press down on the patient's extended arms one at a time while the patient attempts to raise the arm.

The nurse is caring for a patient with advanced emphysema. Which signs are manifestations of this disorder? (Select all that apply.)

Productive cough Dyspnea Barrel chest Cyanotic skin tone

A patient with an immune deficiency disorder has been admitted to the medical unit due to a current infection and weight loss of 12% of his body weight. Which nutritional intervention is most appropriate for this patient?

Protein

The caregiver of a patient with Parkinson disease is concerned with the patient's recent weight loss. The home health nurse should suggest which modification to help the caregiver enhance the patient's nutrition?

Provide six mini-meals throughout the day.

The nurse is assessing a patient with suspected myasthenia gravis. The nurse is aware that which assessment finding supports this diagnosis?

Ptosis

Which scenario explains how a patient can be protected by passive artificial immunity?

Receiving an injection with immune globulin

The loss of neurons in the autonomic nervous system (ANS) of the older adult will cause the older adult to take longer to complete which action(s)? (Select all that apply.)

Recuperate from an illness Apply brakes to stop a car

Most of the inspired oxygen is carried to the tissues via which component of the body?

Red blood cells

The nurse is educating a patient about his cluster headaches. The nurse includes information that cluster headaches may be accompanied by which signs or symptoms? (Select all that apply.)

Reddened conjunctiva Nasal congestion Ptosis Sensitivity to touch

The nurse is teaching about changes in the immune system that result from the aging process. Which change should the nurse include?

Reduced ciliary action

The nurse is caring for a patient with suspected Hodgkin's lymphoma (HL). For confirmation of this diagnosis, the nurse understands that the patient's blood work would reveal which type of abnormal cell?

Reed-Sternberg (R-S) cells

Which statement(s) provide examples of ways in which individuals may be proactive in reducing neurologic injuries? (Select all that apply.)

Refusing to start the car until all seat belts are buckled. Requiring children to wear bike helmets. Reminding swimmers to test water depth before diving. Encouraging use of hard hats at industrial sites. Discouraging recreational drug use.

Which type of multiple sclerosis (MS) is the most common?

Relapsing-remitting

A patient is admitted to the medical unit with an acute illness accompanied by a fever for the last 3 days. What will likely be the patient's respiratory response?

Respiratory alkalosis

The home health nurse is educating a 60-year-old patient with emphysema with a nutritional deficit. Which instructions should the nurse include in the teaching plan to address this problem? (Select all that apply.)

Rest before eating. Avoiding gas-producing foods. Eat four to six small meals instead of three large meals. Take small bites and chew slowly.

The patient with a right-sided paralysis from a stroke becomes frustrated when attempting to self-feed. He throws the spoon at the nurse and begins to cry. What nursing action(s) is/are most appropriate at this time? (Select all that apply.)

Retrieve the spoon and sit quietly for a few seconds. Touch the patient and inquire if he would rather have a high-protein milkshake for his meal. Remind the patient that such behavior is not acceptable. Add an intervention to the NCP for increased support with self-feeding.

The nurse is planning care for a patient with Parkinson disease. Which problem statement/nursing diagnosis is most appropriate for the patient experiencing bradykinesia?

Risk for falls

Which problem statement/nursing diagnosis is most appropriate for a person with Parkinson disease?

Risk for falls related to unsteady gait.

The home health nurse is caring for a patient with multiple sclerosis (MS) who complains of severe fatigue. What activity should the nurse suggest to diminish the effects of fatigue?

Scheduling rest periods during the day

The patient reports intense intermittent headaches over the last 6 months that are preceded by specific symptoms. What symptom is the patient most likely experiencing?

Scotoma

The nurse is caring for an immune compromised patient. The patient displays a low-grade fever and complains of a burning and shooting pain, along with itching and tingling, that progresses from the clavicle to the scapula. The nurse suspects that the patient will undergo evaluation for which infection?

Shingles

Which factors predominantly determine probable diagnosis of multiple sclerosis (MS)?

Signs and symptoms assessed and reported by the patient

To enhance more erect posture in the patient with Parkinson disease, the nurse should encourage the patient to practice which activity?

Sleep in the prone position.

The student nurse is researching relapsing-progressive forms of multiple sclerosis (MS). What characteristic(s) is/are typical of this form of the disease? (Select all that apply.)

Steadily worsens Clear, acute relapses

Which condition(s) may cause seizures? (Select all that apply.)

Stroke Cerebral tumor Hyperpyrexia Epilepsy Metabolic toxicity

Which substance decreases the surface tension of the alveolar walls?

Surfactant

When teaching a patient about esophageal speech, which technique should the nurse instruct the patient to use first?

Swallow air and force it back up through the esophagus.

The nurse explains to a patient with a painful toe that the pain is related to the inflammatory response. What process causes this discomfort?

Swelling, which compresses nerves

The home health nurse is planning an exercise program for a patient with multiple sclerosis (MS). Which exercise would be most beneficial for this patient?

Swimming

The nurse is caring for a patient who has a tracheostomy with a one-way valve box. The nurse explains to the CNA that this valve allows the patient to carry out which function?

Talking

The emergency room nurse is assessing a newly admitted patient with a head injury. The nurse observes clear drainage from the nose. Which action should the nurse perform first?

Test the fluid with a Dextrostix.

A student nurse questions the nurse about the difference between a quadriplegic and a tetraplegic patient. Which statement correctly describes tetraplegia?

Tetraplegia is the newer term for the old term quadriplegia.

When creating a visual aid to show the mechanics of inhaling, the nurse correctly illustrates which scenario?

The diaphragm moves downward.

The nurse is assisting the physician with the insertion of a new tracheostomy tube. The physician asks for the obturator. The nurse correctly hands the physician which device?

The guide for the tracheostomy tube to be inserted

The nurse is caring for a patient during the immediate postoperative period following a rhinoplasty. Which finding is most concerning to the nurse?

The nurse notices the patient is swallowing frequently.

The nurse is performing deep tracheal suctioning of a patient with a respiratory disorder. Which action demonstrates appropriate technique?

The nurse suctions the patient for 10 to 15 seconds.

Why is the older adult more at risk for a cranial bleed following a head injury?

The older adult's brain is smaller, which allows for more movement inside the cranium.

The nurse is evaluating the patient to determine if adequate learning has occurred regarding care of lower back pain. Which activities indicate that the patient adequately understands the nurse's teaching? (Select all that apply.)

The patient bends the knees, with the back straight, and crouches to lift an item off the floor. The patient uses a lumbar pillow or roll when sitting for long periods. The patient performs proper back exercises twice a day. The patient maintains proper body weight.

The nurse is educating an asthma patient about proper use of the peak flowmeter. The nurse determines that the patient needs further teaching when observing which action?

The patient breathes deeply through the mouthpiece.

The 75-year-old patient presents to the emergency department with shortness of breath, fatigue, and a dry cough. When information leads the nurse to suspect that this patient should undergo workup for histoplasmosis?

The patient lives on a farm and raises chickens.

Which behavior causes the nurse to report a positive Romberg test?

The patient sways from side to side.

The home care nurse is visiting a patient in the late stages of amyotrophic lateral sclerosis (ALS). Which example indicates that the patient accepts the grief associated with the condition and prognosis?

The patient talks with his family about his desires for his funeral.

Techniques of testing for possible allergy include which of the following? (Select all that apply.)

The scratch test Drinking diluted solution of antigen Intradermal injection Adhesive patches

The nurse differentiates the humoral response from the cell-mediated response. Which statement about cell-mediated response is true?

The sensitized lymphocytes attack the cell for which they were sensitized.

The nurse differentiates the sympathetic from the parasympathetic nervous systems. Which statement about the sympathetic system is accurate?

The sympathetic system provides energy for "fight or flight" in stressful situations.

The radical neck resection removes a large amount of tissue on the same side as the lesion. Which statement(s) about the tissue removed is/are correct? (Select all that apply.)

The tissue includes all muscle, lymph nodes, and soft tissue from the lower edge of the mandible to the top of the clavicle. The tissue includes all muscle, lymph nodes, and soft tissue from the top of the trapezius to the midline. The tissue includes all muscle, lymph nodes, and soft tissue from the lower edge of the eye socket to the bottom of the maxilla, including the zygomatic arch.

The nurse is caring for a patient on a mechanical ventilator that it is set on assist-control mode. Which statement(s) accurately describe this function? (Select all that apply.)

The ventilator delivers a set tidal volume. The ventilator delivers a set number of breaths if the patient's rate falls.

The nurse is caring for a patient with a closed-chest drainage system with chest tubes. Which observation confirms that the system is intact and working?

The water level in the water-seal chamber fluctuates.

The nurse describes a concussion as a closed head injury in which:

There is amnesia related to the incident.

The nurse uses a visual aid to demonstrate how a coup-contrecoup injures the brain. Which information should the nurse include? (Select all that apply.)

These injuries cause the brain to move forward to strike the anterior interior skull. These injuries cause the brain to strike the bony area opposite of the site of impact.

The nurse clarifies that when interstitial edema occurs in the lung tissue, it inhibits ventilation by causing which problem(s)? (Select all that apply.)

Thickening alveolar membranes Alveoli filling with fluid Gas failing to diffuse across membrane

The patient with a suspected subdural hematoma is on an intravenous (IV) drip of mannitol infusing at 50 mL/hr. The nurse explains that the slow infusion rate is essential for what purpose?

To avoid fluid overload.

What is the purpose of treatment with amantadine (Symmetrel)?

To lessen the severity of type A flu symptoms if taken within 48 hours of exposure.

What is the purpose of mucus?

To trap particles and bacteria.

The nurse is caring for a patient with a complete transection of the cord at C7. The patient asks the nurse what functions he will be able to perform. The nurse responds that the patient will most likely be able to perform which activities? (Select all that apply.)

Transferring himself Dressing himself Using a wheelchair with standard hand rims Feeding himself

The nurse is assessing a patient with Parkinson disease. Which statement likely characterizes this patient's tremors?

Tremors decrease with voluntary movement.

When turning the patient who is in Crutchfield tongs traction, the nurse should employ which technique?

Turn the patient as a unit by log rolling.

The home health nurse assesses the patient with Parkinson disease who just started taking carbidopa-levodopa. The nurse should be alert for which side effect(s)? (Select all that apply.)

Urinary retention Diaphoresis Orthostatic hypotension

The school nurse is instructing a group of high school sophomores in safe sex practices. Which practice(s) should the nurse include in her teaching? (Select all that apply.)

Use a condom. Practice abstinence. Avoid unprotected orogenital sex.

The nurse is caring for a patient with spastic paralysis. Which technique is most appropriate for the nurse to use when moving the patient?

Use the palms of hands to support the joints.

The nurse is working in a trauma unit and is accidentally stuck with an IV needle following venipuncture of the patient. What is the nurse's first action?

Wash the punctured area with soap and water.

The home care nurse is caring for a patient with a severe immune deficiency disorder. What information about infection prevention is most important for the nurse to include in the teaching plan?

Wash your hands frequently.

Which manifestation(s) are age-related changes that alter the respiratory system? (Select all that apply.)

Weakened cough Kyphosis Decrease in body fluid Muscle weakness

The home health nurse is teaching the HIV-positive patient and his family members about infection control in the home. Which action indicates that the nurse's teaching has been successful?

Wearing gloves during household chores

The nurse is caring for a 30-year-old American Indian female who is taking Rifater, a drug containing rifampin, isoniazid, and pyrazinamide. The patient asks how long she will have to take the medication. Which response explains when the patient may discontinue the medication?

When three consecutive sputum cultures are negative

The nurse is performing discharge teaching for a patient who underwent a microlaryngoscopy with laser removal of polyps. Which instruction(s) should the nurse include? (Select all that apply.)

You can return to work in 3 days. Observe 2 days of voice rest.

The industrial nurse should teach all middle-aged employees to receive a tetanus booster how often?

every 10 years

Bladder training begins with scheduling the patient's toileting in what time increment?

every 2 hours

The outpatient clinic nurse is collecting a health history on a 78-year-old patient who has a history of emphysema. Which annual immunization is most important for the patient to receive?

influenza