MS2 Ch 19
The nurse is contributing to the teaching plan for a patient diagnosed with Hashimotos thyroiditis who has progressed to hypothyroidism with a goiter. Which self-care instructions should the nurse recommend? (Select all that apply.) a. Eat a soft diet. b. Increase activity slowly. c. Eat more foods high in iodine. d. Keep home at a cool temperature. e. Eat a high-carbohydrate, high-protein diet. f. During low-energy periods, use anti-embolism stockings.
a, b, f
The nurse is reinforcing teaching about potential triggers with a patient experiencing allergic rhinitis. What should the nurse include in the teaching? (Select all that apply.) a. Dust b. Penicillin c. Ragweed d. Pet dander e. Topical lotion f. Oral multivitamin
a, c, d
The nurse is assisting in the care of a patient with ankylosing spondylitis. What should the nurse expect to find in the patients collaborative plan of care? (Select all that apply.) a. Physical therapy daily b. Sitz baths three times daily c. Tylenol #3 every 4 hours prn pain d. Administer Remicade as prescribed e. Activity as tolerated; up with assistance
a, c, d, e
A patient is diagnosed with urticaria. For which type of hypersensitivity reaction should the nurse plan care for this patient? a. Type I b. Type II c. Type III d. Type IV
a
A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins the patient reports low back pain and a headache. Which action should the nurse take first? a. Stop the blood infusion. b. Notify the physician STAT. c. Start the new 0.9% normal saline infusion. d. Prepare a new 0.9% normal saline infusion.
a
A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient? a. Wear Medic-Alert identification. b. Stay indoors as much as possible. c. Wear insect repellent when outdoors. d. Take corticosteroids before going outdoors.
a
The nurse is assisting in the planning of care for a patient with chronic serum sickness. Which action should be a priority for this patient? a. Assessing for a decrease in urine output b. Administration of immunosuppressive medications c. Closely monitoring the patient during the transfusion of blood products d. Discussing with the patient and significant other the need for genetic counseling
a
The nurse is caring for a patient at risk for infection. Which immunoglobulin should the nurse consider as being the cause of this patients infection risk? a. IgA b. IgE c. IgG d. IgM
a
The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops? a. Hives b. Retinal hemorrhage c. Jugular vein distention d. Pallor around the sting sites
a
The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient? a. Assist with ambulation. b. Teach good hand hygiene. c. Avoid intramuscular injections. d. Obtain manual blood pressures.
a
The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness? a. A patient who receives intravenous (IV) penicillin for an infection b. A patient who has a transfusion with packed red blood cells (RBCs) c. A patient who is given cryoprecipitate and factor IX after an abdominal injury d. A patient given steroids and immunosuppressant therapy after organ transplantation
a
The nurse is reinforcing teaching provided to a patient with Hashimotos thyroiditis. What should the nurse explain as occurring initially in this health problem? a. Thyroid hormone production increases. b. Thyroid hormone production decreases. c. Thyroid-stimulating hormone production increases. d. Thyroid-stimulating hormone production decreases.
a
The nurse is participating in a teaching plan to address Risk for Impaired Skin Integrity for a patient with contact dermatitis. Which information should the nurse recommend be included in this plan? (Select all that apply.) a. Keep fingernails short. b. Take baths with an oatmeal solution. c. Use oil-in-water lubricants for skin dryness. d. Rub affected area roughly, but do not scratch. e. Avoid washing affected area with brown soap. f. Use cool washcloths over affected area to ease itching.
a, b, c, f
A patient with an autoimmune disorder asks, What might cause my body to do this to itself? What should the nurse state as reasons for the body to have lost the ability to recognize self? (Select all that apply.) a. Drugs b. Hormones c. Vaccinations d. Viral infections e. Bacterial infections
a, b, d
The nurse is contributing to a staff education program about nursing care for hypersensitivity reactions. Which should the nurse include as examples of type I hypersensitivity reactions? (Select all that apply.) a. Anaphylaxis b. Angioedema c. Serum sickness d. Allergic rhinitis e. Contact dermatitis f. Hypogammaglobulinemia
a, b, d
The nurse applies clean white cotton socks over the hands of a patient with contact dermatitis. What should the nurse explain to the patient about the purposes of this intervention? (Select all that apply.) a. Cotton allows air movement. b. White cotton has no dye in the material. c. White cotton prevents the wounds from spreading. d. The cotton will absorb the drainage from the wounds. e. Scratching is less during sleep when the area is covered.
a, b, e
The nurse is contributing to the plan of care for a patient with systemic lupus erythematosus (SLE). Which interventions should the nurse recommend for this patient? (Select all that apply.) a. Eat a balanced diet. b. Report foamy urine to physician. c. Take cool showers or baths to relieve joint stiffness. d. Avoid naps and obtain a minimum of 6 hours of sleep. e. Exercise when pain and inflammation in joints is increased. f. Use a daily personal schedule to plan activities to reduce fatigue.
a, b, f
A patient is diagnosed with hypogammaglobulinemia. Which of immune cell should the nurse realize is defective in this disorder? a. T cells b. B cells c. Mast cells d. Plasma cells
b
A patient is suspected as having a blood transfusion reaction. Which laboratory test should the nurse expect to be done to confirm this diagnosis? a. Skin testing b. Direct Coombs test c. White blood cell count d. C-reactive protein level
b
A patient who developed hemolytic anemia related to the administration of penicillin asks for an explanation of this condition. What is the most appropriate response by the nurse? a. The red blood cells are being produced inappropriately. b. An antigenantibody reaction is causing destruction of red blood cells. c. An allergy to penicillin is destroying your platelets for unknown reasons. d. Allergens are invading the bone marrow and interfering with red blood cell production.
b
The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease? a. Gardening outdoors on dry, windy days b. Wearing a mask when mowing the lawn c. Driving the car with the windows open during high pollen counts d. Taking frequent walks outside in spring when the weather is warm
b
The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how the disease process occurred. What should the nurse explain to the mother? a. It rarely occurs in males. b. It occurs after exposure to pesticides. c. It is because the infant was premature. d. There are no known causes for this disorder.
d
The nurse is caring for a patient who has had a portion of stomach removed. Which manifestations should the nurse expect to determine if the patient has a vitamin B12 deficiency? a. Fever, malaise, muscle soreness, and diarrhea b. Numbness and tingling, weakness, and glossitis c. Urticaria, angioedema, anorexia, pruritus, and blistered lesions d. Frequent infections, fever, malaise, vertigo, and lymphadenopathy
b
The nurse is caring for a patient with a severe allergic reaction. Which medication and route should the nurse anticipate being ordered for this patient? a. Intramuscular morphine b. Subcutaneous epinephrine c. IV diphenhydramine d. Oral diphenhydramine (Benadryl)
b
The nurse is collecting data from a patient with skin eruptions. What should the nurse recall to differentiate urticaria from angioedema? a. It is less pruritic. b. It lasts a shorter period of time. c. It includes mucous membrane edema. d. It causes more widespread skin lesions.
b
The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms? a. Installing a hot air heater b. Cover heating ducts with filters c. Installing wall-to-wall carpeting d. Using heavy draperies on sunny windows
b
The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus. Which adverse effect should the nurse encourage the patient to report when taking this medication? a. Tarry stools b. Vision changes c. Any weight gain d. Changes in joint movement
b
The nurse is reinforcing teaching provided to a patient with pernicious anemia. Which patient statement indicates that teaching has been effective? a. I can miss a month or two of injections if I am feeling better. b. I will need to take vitamin B12 injections for the rest of my life. c. I will take the vitamin B12 injections until my strength returns. d. I can take a vitamin B12 injection when I feel tired or fatigued.
b
The nurse is reviewing data collected on several patients. Which patient should the nurse identify as being most likely to exhibit signs and symptoms of systemic lupus erythematosus? a. A 16-year-old Caucasian man b. A 20-year-old Hispanic woman c. A 45-year-old Caucasian woman d. A 42-year-old Asian American man
b
A patient with lupus erythematosis is prescribed a corticosteroid. What side effects of this medication should the nurse review with the patient? (Select all that apply.) a. Tinnitus b. Facial hair c. Moon face d. Mood changes e. Increased weight f. Rash and pruritus
b, c, d, e
The nurse is experiencing severe skin blisters after wearing latex gloves at work. Which treatment should the nurse expect to be prescribed by the health care provider for these skin lesions? (Select all that apply.) a. Oral antibiotics b. Topic drying agent c. Oral antihistamines d. Topical corticosteroid e. Topical immunomodulators
b, c, d, e
The nurse is assisting in an educational seminar on common allergens. What should the nurse include as the most common irritant causing contact dermatitis? (Select all that apply.) a. Bleach b. Rubber c. Fire ants d. Poison ivy e. Poison oak
b, d, e
A patient is being started on a blood transfusion. For how many minutes should the nurse stay with the patient during this transfusion? a. 5 b. 10 c. 15 d. 20
c
A patient is experiencing an episode of urticaria. Which intervention should the nurse recommend to include in the teaching plan to assist the patient in controlling the symptoms of urticaria? a. Avoiding tub baths b. Taking one aspirin daily c. Using relaxation techniques d. Drinking decaffeinated coffee
c
A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take? a. Verify the patients kidney function. b. Verify the patients hematocrit level. c. Verify blood type of the patient and donor. d. Verify the patients admitting medical diagnosis.
c
The nurse has been caring for a patient with pernicious anemia. Which finding should indicate to the nurse that treatment has been successful? a. Decreased folic acid level and an increase in enlarged RBCs b. A decrease in intrinsic factor and increased vitamin B12 excreted in the urine c. An increase in vitamin B12 levels and decrease in number of enlarged RBCs d. A decrease in hydrochloric acid levels in gastric secretion and decrease in production of RBCs
c
The nurse is caring for a patient with a severe allergic reaction. Which medication should the nurse anticipate being administered to control the itching? a. Morphine b. Epinephrine c. Diphenhydramine (Benadryl) d. Hydrocortisone sodium succinate (Solu-Cortef)
c
The nurse is caring for a patient with severe ankylosing spondylitis. What nursing action would be most appropriate? a. Provide tepid tub soaks. b. Encourage a high-fiber diet. c. Provide activity every 2 hours. d. Administer narcotic analgesics.
c
The nurse recommends the diagnosis Disturbed Body Image for a patient with systemic lupus erythematosus. What would be an appropriate long-term outcome for this patient? a. Engages in diversional activities b. Uses normal coping mechanisms c. Returns to previous social involvement d. Verbalizes feelings about body changes
c
A patient comes into the emergency department with a fear of developing poison ivy after falling while walking through a wooded area earlier in the day. What should the nurse instruct the patient to do if exposure to poison ivy occurs again? a. Flood the area with cold water. b. Wrap the area with a thick towel. c. Cover the area with cotton gauze. d. Wash the area with brown soap or any soap.
d
The nurse is caring for a patient who had a kidney transplant 5 days ago. The patient had been very outgoing and jovial, but this morning the patient is very quiet and refusing breakfast, and ambulation. What would be the most appropriate nursing action at this time? a. Notify the physician for laboratory orders. b. Notify the social worker for discharge follow-up care. c. Inform the patient that kidney rejection signs are appearing. d. Spend extra time with the patient, allowing verbalization of feelings.
d
The nurse notes that a patient has an elevated lactate dehydrogenase, fragmented RBCs seen on microscopic examination, and low RBC count, hematocrit (Hct), and hemoglobin (Hgb) levels. For which health problem should the nurse consider planning care for this patient? a. Serum sickness b. Pernicious anemia c. Hemolytic transfusion reaction d. Idiopathic autoimmune hemolytic anemia
d