RESTORATIVE IMMUNE TEST

The type of immunity achieved through the administration of vaccine is called: 1. active immunity 2. passive immunity 3. titer 4. vaccine

1. Active Immunity Rationale: Active Immunity occurs when the patient has received the vaccine. Passive immunity is achieved by directly administering antibodies to a patient. A titer is a measurement of the amount of antibody produced after a vaccine.

The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1.Client's temperature 2.Expiration date on the bag 3.Time of last dressing change 4.Tightness of tubing connections

1. Client's temperature Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change.

The nurse caring for the patient in isolation wears latex gloves. Which is an important consideration? 1. First assess the patient for potential latex allergy. 2. Vinyl gloves actually provide higher barrier protection than latex 3. The cost of latex gloves is significantly higher than that of synthetic gloves. 4. Latex gloves are so reliable as barriers that hand hygiene is not required.

1. First assess the patient for potential latex allergy.

The nurse would question an order for immunostimulant therapy if the patient had which of following conditions? (Select all that apply) 1. Pregnancy 2. Renal disease 3. Infection 4. Liver disease 5. Metastatic cancer

1. Pregnancy 2. Renal disease 4. Liver disease 5. Metastatic cancer Rationale: Pregnancy, renal or liver disease, and metastatic cancer are contraindications to the use of immunostimulant drugs. Infection, immunodeficiency disease, and cancer are indications for use of these drugs

A 24-year-old is admitted to a medical unit with the diagnosis of hepatitis A and placed in contact precautions. What is the primary goal of this action? 1. To prevent transmission of infectious microorganisms 2. To control the environment of the patient 3. To protect the patient from infectious microorganisms 4. To protect only the family

1. To prevent transmission of infectious microorganisms

A client with human immunodeficiency virus is taking nevirapine (Viramune). The nurse should monitor for which side/adverse effects of the medication? Select all that apply. 1.Rash 2.Hepatotoxicity 3.Hyperglycemia 4.Peripheral neuropathy 5.Reduced bone mineral density

1.Rash 2.Hepatotoxicity Rationale: Nevirapine (Viramune) is a nonnucleoside reverse transcriptase inhibitor that is used to treat HIV infection. It is used in combination with other antiretroviral medications to treat HIV. Adverse effects include rash, Stevens-Johnson syndrome, hepatitis, and increased transaminase levels. Hyperglycemia, peripheral neuropathy, and reduced bone density are not side/adverse effects of this medication.

The patient asks the nurse how his skin will be sterilized before his surgery. What is the best response by the nurse? 1. "We will use alcohol to sterilize your skin." 2. "It is not possible to sterilize skin, but we will use an antimicrobial solution to eliminate most microorganisms." 3. "There are a series of steps used in sterilizing your skin to prevent you from getting an infection." 4. "We will use Betadine solution to sterilize your skin."

2. "It is not possible to sterilize skin, but we will use an antimicrobial solution to eliminate most microorganisms."

A patient with severe crippling rheumatoid arthritis is confined to bed for extended periods. An erythematous area over the coccyx that has the potential to become an open lesion is noted. The nurse is correct in reporting this area to the health care provider as having the potential to become what? 1. An inflammatory ulcer 2. A pressure ulcer 3. A stasis ulcer 4. An arterial ulcer

2. A pressure ulcer

A patient isolated for pulmonary tuberculosis seems to be angry. The nurse recognizes this is a normal response to the isolation. What action by the nurse is most appropriate? 1. Provide a dark, quiet room to calm the patient .2. Explain isolation procedures and provide meaningful stimulation. 3. Reduce the level of precautions to keep the patient from becoming angry. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

2. Explain isolation procedures and provide meaningful stimulation.

A 45-year-old man is admitted to the hospital with cellulitis of the right foot. Three days later, he develops bacterial pneumonia. How is this type of infection classified? 1. Acute primary 2. Health care-associated 3. Interstitial 4. Mycoplasmic

2. Health care-associated

The nurse should monitor a transplant patient for the major adverse effect of cyclosproine (Neoral, Sandimmune) therapy by assessing which lab test? 1. CBC 2. Serum creatinine 3. Liver enzymes 4. Electrolytes

2. Serum creatinine Rationale: 75% of patients on cyclosporine experience decreased renal output because of physiological changes in the kidneys, such as micro calcification and interstitial fibrosis. The serum creatinine test is a good indicator of renal fucntion

The nurse is supervising a new UAP providing hygiene care to a patient. Which action by the UAP requires the nurse to provide additional instruction regarding hygiene care? (Select all that apply.) 1. The UAP performs hand hygiene before providing care. 2. The UAP holds the clean linens against the uniform. 3. The UAP places soiled linens on the floor. 4. The UAP places clean linens on the patient's overbed table. 5. The UAP places soiled linens in a linen bag for transport.

2. The UAP holds the clean linens against the uniform.

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include in the plan of care regarding this medication? Select all that apply. 1.Restrict fluid intake. 2.Instruct the client to avoid alcohol. 3.Monitor hepatic and liver function studies. 4.Administer the medication with an antacid. 5.Instruct the client to avoid exposure to the sun. 6.Administer the medication on an empty stomach.

2.Instruct the client to avoid alcohol. 3.Monitor hepatic and liver function studies. 5.Instruct the client to avoid exposure to the sun. Rationale: Ketoconazole is an antifungal medication. It is administered with food (not on an empty stomach), and antacids are avoided for 2 hours after taking the medication to ensure absorption. The medication is hepatotoxic, and the nurse monitors liver function studies. The client is instructed to avoid exposure to the sun because the medication increases photosensitivity. The client is also instructed to avoid alcohol. There is no reason for the client to restrict fluid intake. In fact, this could be harmful to the client.

The nurse is speaking with a patient about the need to prevent infection. The nurse recognizes that the patient understands proper hand hygiene when she makes what statement? 1. "The water I wash my hands with should be as hot as I can tolerate to kill all of the germs on my skin." 2. "If there isn't time to completely wash my hands, it will be all right to rinse them quickly in warm water." 3. "After washing my hands with soap for at least 15 seconds, I will rinse them thoroughly under running water." 4. "I will put soap into a basin of warm water, lather my hands for 15 seconds, and then rinse them in the basin."

3. "After washing my hands with soap for at least 15 seconds, I will rinse them thoroughly under running water."

The nurse is assigned to represent the unit on the infection prevention and control committee. The committee is discussing the CDC's hand hygiene recommendations for implementation in the hospital. Which statement demonstrates an understanding of the CDC's recommendation? 1. Health care providers will wear gloves at all times when providing patient care. 2. Disinfecting hands after glove removal is not necessary. 3. Alcohol-based hand cleaner is effective on hands that are not visibly soiled with blood and body fluids. 4. It is necessary to remove waterless alcohol-based hand cleaner with paper towels to remove pathogens from hands.

3. Alcohol-based hand cleaner is effective on hands that are not visibly soiled with blood and body fluids.

The nurse is working in a clinical medical area with a census of 15. Each patient has a different illness. When planning care, the nurse recognizes which of the following as the most important action to provide protection to each patient from health care-associated infections? 1. Wearing a gown 2. Placing each patient in isolation 3. Hand hygiene 4. Wearing gloves

3. Hand hygiene

The nurse is caring for a postrenal transplant client taking cyclosporine (Sandimmune). The nurse notes an increase in one of the client's vital signs, and the client is complaining of a headache. Which is the vital sign that is most likely increased? 1.Pulse 2.Respirations 3.Blood pressure 4.Temperature

3.Blood pressure Rationale: Hypertension can occur in a client taking cyclosporine (Sandimmune), and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitoring most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.

Amikacin (Amikin) is prescribed for a client with a bacterial infection. The client should be instructed to contact the health care provider (HCP) immediately if which occurs? 1.Nausea 2.Lethargy 3.Hearing loss 4.Muscle aches

3.Hearing loss Rationale: Amikacin (Amikin) is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the HCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the HCP immediately if nausea occurs. If nausea persists or results in vomiting, the HCP should be notified.

The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the health care provider if which significantly elevated result is noted? 1.Serum protein 2.Blood glucose 3.Serum amylase 4.Serum creatinine

3.Serum amylase Rationale: Didanosine (Videx) can cause pancreatitis. A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet. The nurse should check the latest result of which laboratory study while the client is taking this medication? 1.CD4+ cell count 2.Serum albumin 3.Serum creatinine 4.Lymphocyte count

3.Serum creatinine Rationale: Foscarnet is toxic to the kidneys. Serum creatinine is monitored before therapy, two to three times per week during induction therapy and at least weekly during maintenance therapy. Foscarnet may also cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels are also measured with the same frequency.

The nursing instructor is discussing the chain of infection to a group of student nurses. What is the most important information about identifying the chain of infection for the health care provider? 1. Understanding of the chain of infection allows for tests to be performed to assess resistance to communicable diseases. 2. Recognition of the chain of infection provides information about which patients will most benefit from isolation precautions. 3. The need for antibiotic therapy can be determined by assessing the chain of infection. 4. Determination of points at which the infection can be stopped or prevented can be made by identifying the chain of infection.

4. Determination of points at which the infection can be stopped or prevented can be made by identifying the chain of infection.

A 5-year-old child is due for prekindergarten immunizations. After interviewing her mother, which of the following response may indicate a possible contraindication for giving this preschooler a live vaccine (e.g MMR) at this visit and would require further exploration by the nurse? 1. Her cousin has the flu 2. The mother has just finished her series of hepatitis B vaccines 3. Her arm got really sore after her last tetanus shot 4. They are caring for her grandmother who has just finished her second chemotherapy treatment for breast cancer.

4. They are caring for her grandmother who has just finished her second chemotherapy treatment for breast cancer. Rationale: Live vaccines may be contraindicated when patients present an exposure risk of the infections agent to immuno compromised patients such as those on chemotherapy or immunsuprressant therapy. The patient's cousin having the flu is not a potential contraindication, assuming the cousin has a normal and active immune system. the mother would not be at risk since she has received recent vaccinations, assessment of her immune system would have been completed at that time. Soreness of the injected arm is a potential (mild) adverse effects of immunizations and can be managed symptomatically

A 64-year-old patient with terminal cancer is too weak to perform her own perineal care. The student nurse includes bathing which areas as part of perineal care? 1. Back and buttocks 2. Eyes, ears, and nose 3. Upper torso and thighs 4. Upper thighs, genitalia, and anal area

4. Upper thighs, genitalia, and anal area

A 55 year old female patient is receiving cyclosporine (Neoral, Sandimmune) after a heart transplant. The patient exhibits a white blood cell count of 12,000 cells/mm3, a sore throat, fatigue, and a low-grade fever. The nurse suspects: 1. transplant rejection 2. heart failure 3. dehydration 4. infection

4. infection Rationale: Due to immune system suppression by the medication, infections are common

The client with acquired immunodeficiency syndrome has begun therapy with zidovudine (Retrovir). The nurse should carefully monitor which laboratory result during treatment with this medication? 1.Blood culture 2.Blood glucose level 3.Blood urea nitrogen 4.Complete blood count

4.Complete blood count Rationale: A common side/adverse effect of therapy with zidovudine is leukopenia and anemia. The nurse monitors the complete blood count results for these changes. Options 1, 2, and 3 are unrelated to the use of this medication.

The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine isethionate (Pentam 300). The client develops a temperature of 101° F. The nurse should do further monitoring of the client, knowing that this sign would most likely indicate which? 1.The dose of the medication is too low. 2.The client is experiencing toxic effects of the medication. 3.The client has developed inadequacy of thermoregulation. 4.This is the result of another infection caused by the leukopenic effects of the medication.

4.This is the result of another infection caused by the leukopenic effects of the medication. Rationale: Frequent side/adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

Which cells are stimulated by the presence of antibodies in a type I hypersensitivity reaction? A) Mast cells B) Macrophages C) B lymphocytes D) T lymphocytes

A) Mast cells During a type I hypersensitivity reaction, the presence of IgE stimulates mast cell degranulation.

Desensitization therapy improves allergies by which of the following mechanisms? A) Producing antibodies that prevent the allergen from binding to IgE B) Decreasing the amount of IgE in the body C) Decreasing the amount of antigen in the bloodstream D) Decreasing the responsiveness of the bronchi and blood vessels to histamine

A) Producing antibodies that prevent the allergen from binding to IgE Desensitization therapy works by producing blocking antibodies that prevent the allergen from binding to IgE.

Graves' disease is an autoimmune disease caused by autoantibodies that: A) stimulate the production of thyroid hormone. B) block the effects of thyroid hormone. C) destroy the thyroid gland. D) destroy cells that normally respond to thyroid hormone.

A) stimulate the production of thyroid hormone. Hyperthyroidism in Graves' disease is caused by the production of autoantibodies that mimic the effects of thyroid-stimulating hormone.

Autoimmunity can result from all of the following hypersensitivities except: A) type I. B) type II. C) type III. D) type IV.

A) type I. Type I hypersensitivities result in mast cell degranulation, and problems are caused by the effects of histamine and other inflammatory mediators. In type II, III, and IV reactions, the body begins to recognize self-antigen as foreign.

1. A nurse is planning care for a dient who has a platelet count of 10,000/mm Which of the following interventions should the nurse include in the plan of care? A. Apply prolonged pressure to puncture site after blood sampling. B. Administer epoetin alfa as prescribed C. Place the client in a private room D. Have the client use an oral topical anesthetic before meals

A. Apply prolonged pressure to puncture site after blood sampling.

A nurse is providing information about a new prescription for corticosteroid cream to a client who hasmild psoriasis. Which of the following should the nurse include in the information? (Select all that apply.) A. Apply an occlusive dressing after application. B. Apply three to four times per day. C. Wear gloves after application to lesions on the hands. D. Avoid applying in skin folds.E. Use medication continuously over a period of several months.

A. CORRECT: An occlusive dressing can enhance the efficacy of the topical corticosteroid on the exposed lesions. C. CORRECT: Gloves worn after the medication can enhance the efficacy of the topical corticosteroid on the exposed lesions of the hands. D. CORRECT: Corticosteroid cream applied to lesions in skin folds increases the risk of yeast infections.

A nurse is assessing a client who has seborrheic keratosis on the forehead and nose. Which of thefollowing manifestations should the nurse expect to find? (Select all that apply.) A. Waxy appearance of the lesions B. Black, rough lesions C. Pruritus of the lesions D. Purplish skin stain around the lesion E. Wart like surface of the lesions

A. CORRECT: Seborrheic keratosis lesions appear waxy in texture. B. CORRECT: Seborrheic keratoses are tan, brown, or black lesions that are rough and become irritated due to friction. E. CORRECT: A wart like surface of the lesions is common for seborrheic keratosis, and the lesions are removed for cosmetic reasons.

A nurse is caring for a client who has breast cancer and asks why she is receiving a combination therapy of cyclophosphamide, methotrexate, and fluorouracil. The appropriate response by the nurse is that combination chemotherapy is used to do which of the following? (Select all that apply.) A. Decrease medication resistance. B. Attack cancer cells at different stages of cell growth. C. Block chemotherapy agent from entering healthy cells. D. Stimulate immune system. E. Decrease injury to normal body cells.

A. Decrease medication resistance. B. Attack cancer cells at different stages of cell growth. E. Decrease injury to normal body cells.

A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the clients indicates an understanding of the teaching? A. I will need to take methotrexate even if I am in remission B. I'm thankful that this type of lupus only efects skin C. Each day I should apply a sunblock with a sun protection factor of 15 D. A mild fever is common with SLE and usually does not require medical intervention

A. I will need to take methotrexate even if I am in remission SLE is an autoimmune disorder characterized by accerbations and remissions

2. A nurse is reinforcing teaching for a client about maintaining a diet that can prevent certain cancers.The nurse should inform the client that the intake of which of the following can be beneficial? (Select allthat apply.) A. Low saturated fats B. Fiber C. Red meats D. Simple carbohydrates E. Fish

A. Low saturated fats B. Fiber E. Fish

A nurse is teaching a client who has Raynaud's disease. Which of the follwing pieces of the information should the nurse including in the teaching? A. Protect against the cold by wearing layers of clothing B. Begin an exercise program of 2-mile walks once per week C. Increase vitamin A in the diet D. Elevated the hands above heart level when resting

A. Protect against the cold by wearing layers of clothing Clients who have Raynaud's disease are prone to attacks during cold weather

A nurse is preparing to administer cyclophosphamide IV to a client who has Hodgkin's disease. Which of the following medications should the nurse expect to administer concurrently with the chemotherapy to prevent an adverse effect of cyclophosphamide? A. Uroprotectant agent, such as mensa (Mesnex) B. Opiod, such as morphine C. Loop diuretic, such as furosemide (Lasix) D. H1 receptor antagonist, such as diphenhydramine (Benadryl)

A. Uroprotectant agent, such as mensa (Mesnex)

The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

ANS 1. Protecting the client from infection Rationale: The client with immune deficiency has inadequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection.

Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply. 1. Use non-latex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Do not puncture rubber stoppers with needles. 5. Keep a latex-safe supply cart available in the client's area. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

ANS: 1. Use non-latex gloves. 2. Use medications from glass ampules. 5. Keep a latex-safe supply cart available in the client's area. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure. Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use non-latex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with a rubber stopper that requires puncture with a needle. It is not necessary to place the client in a private room.

A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous? 1. Weight gain 2. Subnormal temperature 3. Elevated red blood cell count 4. Rash on the face across the bridge of the nose and on the cheeks

ANS: 4. Rash on the face across the bridge of the nose and on the cheeks Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

Which action will the nurse include in the plan of care for a 33-year-old patient with a new diagnosis of rheumatoid arthritis? a. Instruct the patient to purchase a soft mattress. b. Suggest that the patient take a nap in the afternoon c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

ANS: B Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress. When stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve the flexibility and strength of the affected joints, and the patient's overall endurance.

After the nurse has taught a 28-year-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. "I am going to join a soccer team to get more exercise." b. "I will need to stop drinking so much coffee and soda." c. "I will call the doctor every time my symptoms get worse." d. "I should avoid using over-the-counter medications for pain."

ANS: B Dietitians frequently suggest that patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently, rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management.

Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels

ANS: C C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids

A patient with rheumatoid arthritis being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

A 71-year-old patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of? a. sertraline (Zoloft). b. famotidine (Pepcid). c. oxycodone (Roxicodone). d. hydrochlorothiazide (HydroDIURIL).

ANS: D Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

A nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse understands that which problem is a priority for the client? 1. Infection 2. Inability to cope 3. Lack of information about the disease 4. Feeling uncomfortable about body changes

ANS:1. Infection Rationale: The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority problem is infection.

A client calls the office of his primary care health care provider and tells the nurse that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction, because the client's neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to: 1. Advise the client to soak the site in hydrogen peroxide. 2. Ask the client if he ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency room. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

ANS:2. Ask the client if he ever sustained a bee sting in the past. Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice

A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which of the following descriptions of this condition? 1. The presence of tiny red vesicles 2. An autoimmune disease that causes blistering in the epidermis 3. The presence of skin vesicles found along the nerve caused by a virus 4. The presence of red, raised papules and large plaques covered by silvery scales

ANS:2. An autoimmune disease that causes blistering in the epidermis Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters.

The client is diagnosed with stage I of Lyme disease. The nurse assesses the client for which characteristic of this stage? 1. Arthralgias 2. Flu-like symptoms 3. Enlarged and inflamed joints 4. Signs of neurological disorders

ANS:2. Flu-like symptoms Rationale: The hallmark of stage I is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bullseye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Neurological deficits occur in stage II. Arthralgias and joint enlargements are most likely to occur in stage III.

A client who is prescribed zidovudine (Retrovir) has been diagnosed with severe neutropenia. The nurse anticipates which intervention will be implemented? 1. The medication dose will be reduced. 2. The medication will be temporarily discontinued. 3. Prednisone will be added to the medication regimen. 4. Epoetin alfa (Epogen) will be added to the medication regimen.

ANS:2. The medication will be temporarily discontinued. Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or neutropenia develops, treatment should be interrupted until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

A nurse is assigned to care for a client who returned home from the emergency department following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should: 1. Contact the health care provider (HCP). 2. Cover the crutch pads with cloth. 3. Call the local medical supply store, and ask for a cane to be delivered. 4. Tell the client that the crutches must be removed immediately from the house.

ANS:2. Cover the crutch pads with cloth. Rationale: The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 4 is inappropriate and may alarm the client. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may not be appropriate, considering this client's injury. No reason exists to contact the HCP at this time.

A client with acquired immunodeficiency syndrome (AIDS) is taking zidovudine (Retrovir) 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. Which of the following would the nurse anticipate to be prescribed for the client? 1. Reduction in the medication dosage 2. Discontinuation of the medication 3. The administration of prednisone concurrent with the therapy 4. Administration of epoetin alfa (Epogen)

ANS:2. Discontinuation of the medication Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate in the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wearing a gown and gloves to change the bed linens and gloves only for the bath

ANS:2. Wearing a gown and gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

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 of the following? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions on the skin

ANS:3. Punch biopsy of the cutaneous lesions Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is: 1. A local rash that occurs as a result of allergy 2. A disease caused by overexposure to sunlight 3. An inflammatory disease of collagen contained in connective tissue 4. A disease caused by the continuous release of histamine in the body

ANS:3. An inflammatory disease of collagen contained in connective tissue Rationale: SLE is an inflammatory disease of collagen contained in connective tissue.

The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed? 1. Antibiotic 2. Antidiarrheal 3. Corticosteroid 4. Opioid analgesic

ANS:3. Corticosteroid Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. The incorrect options are not standard components of medication therapy for this disorder.

A female 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 of the following nursing actions is appropriate? 1. Refer the client for a blood test immediately. 2. Inform the client that there is not a test available for Lyme disease. 3. Tell the client that testing is not necessary unless arthralgia develops. 4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

ANS:4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable. Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years.

A client with human immunodeficiency virus (HIV) who has contracted tuberculosis (TB) asks the nurse how long the medication therapy lasts. The nurse responds that the duration of therapy would likely be for at least: 1. 6 total months and at least 1 month after cultures convert to negative 2. 6 total months and at least 3 months after cultures convert to negative 3. 9 total months and at least 3 months after cultures convert to negative 4. 9 total months and at least 6 months after cultures convert to negative

ANS:4. 9 total months and at least 6 months after cultures convert to negative Rationale: The client with tuberculosis who is coinfected with HIV requires that antitubercular therapy last longer than usual. The prescription is usually for a total of 9 months and at least 6 months after sputum cultures convert to negative.

The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that immunization provides which of the following? 1. Protection from all diseases 2. Innate immunity from disease 3. Natural immunity from disease 4. Acquired immunity from disease

ANS:4. Acquired immunity from disease Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases.

A client who is human immunodeficiency virus (HIV) positive has had a Mantoux skin test. The results show a 7-mm area of induration. The nurse evaluates that this result is: 1. Negative 2. Borderline 3. Uncertain 4. Positive

ANS:4. Positive Rationale: The client with HIV is considered to have positive results on Mantoux skin testing with an area of 5 mm of induration or greater. The client without HIV is positive with induration greater than 10 or 15 mm if the client is at low risk. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is also possible for the client infected with HIV to have false negative readings because of the immunosuppression factor.

Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma? 1. A kidney transplant client 2. A male with a history of same-sex partners 3. A client receiving antineoplastic medications 4. An individual working in an environment where exposure to asbestos exists

ANS:4. An individual working in an environment where exposure to asbestos exists Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It is seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma.

What should the nurse do because of the increasing strength of the dose in the injections for immunotherapy? a. Observe the patient for at least 20 minutes after administration b. Take the vital signs every 10 minutes for an hour c. Have the patient lie down quietly for an hour d. Place a warm compress on the area to speed its absorption

ANSWER A Observe the patient for at least 20 minutes after administration The patient should be observed for 20 minutes after the increased dose of the allergen. If anaphylaxis is going to occur, it will do so within that time frame.

A nurse is planning care for a client who has a platelet count of 10,000/mm^3. Which of the following interventions should the nurse include in the plan of care? A. Apply prolonged pressure to the puncture site after blood sampling B. Administer epoetin alfa as perscribed C. Place the clientin a private room D. Have the client use an oral topical anesthetic before meals

ANSWER A Implement bleeding procautions for the client who has thrombocytopenia

What is the substance released by the T cells that stimulates the lymphocytes to attack an inflammation? a. Lymphokine b. Epinephrine c. B cells d. Histamine

ANSWER A Lymphokine Lymphokines help attract macrophages to the site of the inflammation.

A patient is admitted with a secondary immunodeficiency from chemotherapy. The nursing plan of care should include provisions for: a. infection control. b. supporting self-care. c. nutritional education. d. maintaining high fluid intake.

ANSWER A. infection control. Immune deficient persons are at risk for infection and need to be protected aggressively for contagion.

The patient who had an asthma-like reaction to a desensitization shot was medicated with a subcutaneous injection of epinephrine. What effect should the nurse assure the anxious patient this will have? a. Cause vasodilation b. Produce bronchodilation c. Cause productive coughing d. Reduction of pulse rate

ANSWER B Produce bronchodilation The drug epinephrine is given in the case of anaphylaxis because it is a quick-acting drug that produces bronchodilation and vasoconstriction, which relieves respiratory distress. The drug can be ordered to be repeated every 20 minutes. The patient may experience an increase in heart rate.

What is the major negative effect of cell-mediated immunity? a. Depression of bone marrow b. Rejection of transplanted tissue c. Activation of the T cells d. Stimulation of the B cells

ANSWER B Rejection of transplanted tissue Cell-mediated immunity has the negative effect of rejection of transplanted tissue. Activation of T cells and stimulation of B cells are the positive basis of the cell-mediated immunity.

Immediately after the nurse administers an intradermal injection of a suspected antigen during allergy testing, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially? a. Elevate the arm above the shoulder b. Administer subcutaneous epinephrine c. Apply a warm compress to area d. Apply a local anti-inflammatory cream to the site

ANSWER B Administer subcutaneous epinephrine Injection of subcutaneous epinephrine should be given at the first sign of allergy.

What is B-cell proliferation dependent on? a. Presence of NK (natural killer) cells b. Complement system c. Antigen stimulation d. Lymphokines

ANSWER C Antigen stimulation Antigen stimulation is the sole focus of B-cell proliferation.

A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, what should the patient receive? a. Larger doses each week b. Higher concentrations each week c. Increased amounts and concentrations in 6-week cycles d. The same amount and concentration each visit

ANSWER C Increased amounts and concentrations in 6-week cycles Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better effect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period.

The nurse takes into consideration that when the antigen and antibody react, the complement system is activated which: a. toughens the cell wall. b. generates more T cells. c. attracts phagocytes. d. makes the antigen resistant.

ANSWER C attracts phagocytes. The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes.

Because the older adult has decreased production of saliva and gastric secretions, they are at risk for: a. mouth ulcers. b. fissures in corners of the mouth. C. gastrointestinal infections. d. bloating.

ANSWER C gastrointestinal infections. Deficient saliva and gastric secretions make the older adult prone to gastrointestinal infections.

How does normal aging change the immune system? a. Depresses bone marrow b. T cells become hyperactive c. B cells show deficiencies in activity d. Increase in the size of the thymus

ANSWER C. B cells show deficiencies in activity Normal aging causes deficiencies in both B and T cell activation, but the bone marrow is essentially uncompromised. The thymus decreases in size.

What is the etiology of autoimmune diseases based on? a. Reaction to a "superantigen" b. Immune system producing no antibodies at all c. T cells destroying B cells d. B and T cells producing autoantibodies

ANSWER D B and T cells producing auto antibodies Autoimmune disorders are failures of the tolerance to "self." B and T cells produce auto antibodies that can cause pathophysiologic tissue damage. Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish "self" protein from "foreign" protein.

The nurse explains that when the patient received tetanus antitoxin with the antibodies in it, the patient received a ___________ type of immunity. a. Active natural b. Passive natural c. Active artificial d. Passive artificial

ANSWER D Passive artificial When a person receives an inoculation of antibodies from another source, as with tetanus antitoxin, it is considered a passive artificial immunity.

Which person is most at risk for a hypersensitivity reaction? a. 26-year-old receiving his second desensitization injection b. 35-year-old starting back on birth control tablets c. The 52-year-old started on a new series of Pyridium for cystitis d. The 84-year-old receiving penicillin for an annually recurring respiratory infection

ANSWER D The 84-year-old receiving penicillin for an annually recurring respiratory infection The 84-year-old with the deteriorated immune system is a prime candidate for a delayed hypersensitivity reaction.

A patient who works in a plant nursery and has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment? a. "I need to think about a change in my occupation." b. "I will learn to administer epinephrine so that I will be prepared if I am stung again." c. "I should wear a Medic-Alert bracelet indicating my allergy to insect stings." d. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."

ANSWER D. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings." The nurse's responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance doses of corticosteroids because this was a short, rapid reaction.

What would the nurse recommend for a 94-year-old home health patient with deteriorated cell-mediated immunity? a. Avoiding the influenza vaccine b. Getting pneumonia vaccine c. Having skin tests for all antigens d. Taking large doses of beta-carotene

ANSWER: B Getting pneumonia vaccine As the older adult loses some of the cell-mediated immunity, especially against pneumonia and influenza, it is recommended that they acquire the immunization.

A nurse is planning care for a client who is undergoing chemotherapy and is on neutropenic precautions. Which of the following interventions should be included in the plan of care? (Select all that apply) A. Encourage a high fiber diet B. Eliminate standing water in the room C. Have the client wear a mask when leaving the room D. Have the client-specific equipment remain in the room E. Eliminate raw foods from the clients diet.

ANSWER: B,C,D and E B= Neutropenic precautions include the client not having ptted plants C = Neutropenic precautions include having a clietn wear a mask D = Neutropenic precautions include needing the clients own equipment to be only used by him to prevent HRI's E = Neutropenia precautions include a diet that doesnt consist of raw fruit.

An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurse's first intervention? a. Apply cool compresses to urticaria b. Provide oxygen per non-rebreathing mask c. Cover patient with a warm blanket d. Prepare for venipuncture for the delivery of IV medication

ANSWER: B. Provide oxygen per non-rebreathing mask Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the patient may have to be intubated. Covering the patient with a warm blanket is not wrong, but not an initial intervention.

Which of the following is an example of immunocompetence? a. A child that is immune to measles because of an inoculation b. A person who has seasonal allergies every fall c. When the symptoms of a common cold disappear in 1 day d. A neonate having a natural immunity from maternal antibodies

ANSWER: C When the symptoms of a common cold disappear in 1 day Immunocompetence is demonstrated by the immune system responding appropriately to a foreign stimulus and the body's integrity is maintained as with cold symptoms that resolve with residual illness.

A nurse is assessing a 66 year old client during a routine physical examination. This is the clients first clinical visit, and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization the client replies " I am not sure, but its been at least 5 years since I've had any immunizations." Which of the following responses should the nurse provide? A. In case you had the immunization before, we can't give you another one B. You'll need a series of 3 injections C. This immunization is unsafe for people over the age of 65 years old D. Lets go ahead and give you this immunization

ANSWER: D Let's go ahead and give you this immunization. The Centers for Disease Control and Prevention recommend this immunization for people who are 65 years of age and older. If the client did recieve this vaccine more thatn 5 years ago, the nurse should administer nother because the client is over 65.

What is the focus of primary prevention?

Address the needs of health clients to promote health and prevent disease.

What is the focus of tertiary prevention?

Aims to prevent long term consequences of a chronic illness or disability and to support optimal functioning.

Which individual is least at risk for the development of Kaposi's sarcoma?

An individual working in an environment where exposure to asbestos exists

A 33-year-old client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is her neighbor's son. What action should the nurse take to protect the client's right to privacy? 1. Inform the nurse director she's violating the client's right to privacy and ask her to return the chart. 2. Remind the nurse director not to share the client's medical information with anyone because of his HIV status. 3. Report the incident to the medical director. 4. Ask the nurse director if she has permission to read the client 's chart, and if she does not, tell her she needs to obtain it before further reading.

Answer 1: RATIONALES: Under the Health Insurance Portability and Accountability Act (HIPAA), personal health information may not be used for purposes not related to health care. The nurse director found reading the chart isn't providing health care to the client and, therefore, doesn't require access to the chart. The nurse should confront the nurse director and ask her to return the client's chart. The director shouldn't have access to this client's healthcare information regardless of his HIV status. If she doesn't comply with the nurse's request, the nurse should report the incident to her nurse manager, so the infraction can be reported through the proper channels. The staff nurse shouldn't report the incident to the medical director. Option 4 doesn't protect client confidentiality.

A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do? 1. Continue with the bath and tell the client not to worry. 2. Ask the physician to obtain a psychiatric consultation. 3. Listen and show interest as the client expresses feelings. 4. State that these friends' behavior shows that they aren't true friends.

Answer: 3 RATIONALES: The nurse should listen actively and nonjudgmentally as the client expresses feelings. Telling the client not to worry would provide false reassurance. A psychiatric consultation would be appropriate only after further assessment. Stating that the client's friends aren't true friends would discount the client's feelings.

Which of the following features is characteristic of a type IV hypersensitivity? A) Antibody-dependent cell-mediated toxicity B) Delayed response C) Usually life-threatening D) Mediated by the complement system

B) Delayed response A key feature of type IV hypersensitivities is that manifestations of the reactions are usually delayed by 24 to 72 hours.

What is the effect of H1 receptors for histamine on smooth muscle tissue? A) Bronchodilation B) Endothelial cell retraction C) Prolonged vasoconstriction D) All of the above

B) Endothelial cell retraction Binding histamine to H1 receptors on endothelial cells results in increased capillary permeability from endothelial cell retraction.

A child who has a history of many allergies, recurrent respiratory tract infections, and chronic yeast infections of the gastrointestinal tract may have an underlying immune disease called: A) severe combined immunodeficiency. B) IgA deficiency. C) Bruton agammaglobulinemia. D) autoimmunity.

B) IgA deficiency. IgA deficiency results in recurrent infections of the mucosal membranes. The systems most commonly afflicted are the respiratory and gastrointestinal linings.

Which of the following hypersensitivity reactions involves the formation of antibodies against tissue-specific antigen? A) Type I B) Type II C) Type III D) Type IV

B) Type II Type II hypersensitivity reactions involve the formation of antibodies that attack the body's own tissues.

Hyperacute allograft rejection is caused by: A) cytokines and growth factors produced by trauma to vascular endothelial cells. B) preformed antibodies that react immediately with the graft. C) Tc and NK cell destruction of the graft. D) production of antibodies to the new graft by B lymphocytes.

B) preformed antibodies that react immediately with the graft. Hyperacute rejection is an immediate reaction to the graft caused by the presence of preformed antibodies to the transplanted tissue. In most cases these antibodies are present from previous transplantation or transfusion.

2. A nurse at a health fair is reviewing possible warning signs of cancer that a client should watch for.Which of the following information should the nurse include in this review? (Select all that apply.) A. Presence of a fever of 102° F (38.9° C) for more than 48 hr B. A sore that does not heal C. Difficulty swallowing D. Presence of unusual discharge E. Weight gain of 4 lb (1.8 kg) in 2 weeks

B. A sore that does not heal C. Difficulty swallowing D. Presence of unusual discharge

A nurse is teaching a client who has breast cancer about tamoxifen (Nolvadex). Which of the following adverse effects of tamoxifen should the nurse discuss with the client? A. Irregular heart beat B. Abnormal uterine bleeding C. Yellow sclera dark-colored urine D. Difficulty Swallowing

B. Abnormal uterine bleeding

A nurse is teaching a client who has a history of psoriasis about photochemotherapy and ultravioletlight (PUVA) treatments. Which of the following should the nurse include in the teaching? A. Apply coal tar before each treatment. B. Administer a psoralen medication before the treatment. C. Use this treatment every evening. D. Remove the scales gently following each treatment.

B. CORRECT: PUVA treatment involves the administration of a medication, such as a psoralen, toenhance photosensitivity.

A nurse is caring for a client who is being treated with interferon alfa-2b for malignant melanoma. Forwhich of the following adverse effects should the nurse monitor? (Select all that apply.) A. Tinnitus B. Muscle aches C. Peripheral neuropathy D. Bone loss E. Depression

B. Muscle aches C. Peripheral neuropathy E. Depression

3.) A nurse is planning care for a client who is undergoing chemotherapy and is on neutropenic precautions Which of the following interventions should be included in the plan of care? (Select all that apply) A. Encourage a high-fiber diet B. Remove plants from the room C. Have the client wear a mask when leaving the room. D. Have client-specific equipment remain in the room. E. Eliminate raw foods from the client's diet

B. Remove plants from the room C. Have the client wear a mask when leaving the room. D. Have client-specific equipment remain in the room. E. Eliminate raw foods from the client's diet

A nurse is conducting dietary teaching for a client who has AIDS. Which of the following instructions should the nurse include in the teaching? A. Discard leftovers after 8 hours B. Use a separate cutting board for poultry C. Thaw frozen foods at room temperature D. Store cold foods at 10*c (50*F) or less

B. Use a separate cutting board for poultry

When the maternal immune system becomes sensitized against antigens expressed by the fetus, what type of immune reaction occurs? A) Autoimmune B) Anaphylaxis C) Alloimmune D) Allergic

C) Alloimmune Alloimmune responses involve reactions against the tissue of another individual. In this case, the mother produces antibodies against fetal red blood cells.

HIV inserts its genetic material by binding to the _____ on the helper T cell. A) gp 120 receptor B) CD8 receptor C) CD4 receptor D) phospholipids

C) CD4 receptor HIV inserts its genetic material by binding to the CD4 receptor on the helper T cell.

Manifestations of the autoimmune disease SLE include: A) wheezing, eczema, and itching. B) pulmonary edema, leg swelling, and vein distention. C) arthritic joint pain, pleuritic chest pain, and rash. D) nasal polyps, headache, and rhinorrhea.

C) arthritic joint pain, pleuritic chest pain, and rash. Arthritic joint pain, pleuritic chest pain, and rashes are the most common symptoms of SLE.

The microorganism that causes acquired immunodeficiency syndrome (AIDS) is a: A) gram-negative bacterium. B) gram-positive bacterium. C) retrovirus. D) protozoan.

C) retrovirus. AIDS is caused by a retrovirus that contains only viral RNA.

Type IV hypersensitivities, such as poison ivy reactions, are initiated by: A) B cells that release IgD 24 to 48 hours after exposure. B) the release of neutrophil chemotactic factor. C) the stimulation of cytotoxic T cells. D) the release of large quantities of IgE.

C) the stimulation of cytotoxic T cells. Type IV hypersensitivities are mediated by Tc cells.

Raynaud phenomenon is an example of a: A) type I hypersensitivity. B) type II hypersensitivity. C) type III hypersensitivity. D) type IV hypersensitivity.

C) type III hypersensitivity. Raynaud phenomenon involves immune complex deposition in blood vessels, joints, or kidneys and is therefore characterized as a type III hypersensitivity.

4.) A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? A "Your nausea will lessen with each course of chemotherapy" B. "Hot food is better tolerated due to the aroma." C. "Try eating several small meals throughout the day" D."Increase your intake of red meat as tolerated"

C. "Try eating several small meals throughout the day"

A nurse in a clinic is assessing a client who was diagnosed with Mononucleosis 2 weeks ago. Which of the following finding should the nurse report to the provider? A. Headache and Fatigue B. Swollen lymph nodes in the neck C. Abdominal pain in the left upper quadrant D. Fever and sore throat

C. Abdominal pain in the left upper quadrant With mononeucliosis there is an enlarged spleen that can rupture causing the pain in the area. The client should refrain from engagging in strenuous activity until the enarged spleen is resolved.

A nurse is providing teaching for a client who is scheduled for a Papanicolaou (Pap) test. The nurse should instruct the client that she is being tested for which of the following?

Cervical Cancer

nurse is working with an assistive personnel (AP) who is assigned to bathe a client with herpes zoster. The AP asks the nurse is herpes zoster is contagious. Which of the following responses should the nurse make? A. Adults receive natural immunity to herpes zoster from casual exposure to children who have had chickenpox B. Herpes Zoster is not ocntagious to individuals who recieved an MMR vaccine as an infant C. A client who has herpes Zoster is not contagious if blisters are present on the skin D. Herpes Zoster is not contagious to people who have ahd chickenpox

D Herpes Zoster is not contagious to people who have had chickenpox

Type I hypersensitivity is mediated by which of the following antibodies? A) IgG B) IgD C) IgM D) IgE

D) IgE Large amounts of IgE are produced during type I hypersensitivity reactions.

A positive tuberculin skin test for detecting the presence of tuberculosis is indicative of which type of hypersensitivity reaction? A) Type I B) Type II C) Type III D) Type IV

D) Type IV Because this reaction takes 24 to 72 hours to appear, it is a classic example of a type IV hypersensitivity reaction.

In type II hypersensitivity, tissue injury is caused by: A) autoantibody activation of complement and subsequent destruction of target cells. B) autoantibody stimulation of NK cells that destroy target cells. C) autoantibody opsonization of target cells and subsequent phagocytosis. D) all of the above.

D) all of the above. Type II hypersensitivities involve the production of autoantibodies that target the body's own tissues in all three ways.

The most severe type I hypersensitivity response is: A) eczema. B) allergic rhinitis. C) serous otitis. D) anaphylaxis.

D) anaphylaxis. Anaphylaxis involves severe bronchoconstriction and hypotension, which can be life-threatening.

3. A nurse is reinforcing preoperative teaching with a client who will undergo a shave biopsy for suspectedcancer. Which of the following statements by the client indicates understanding of the procedure? A. "A test of my bone marrow will be performed." B. "A lymph node will be removed." C. "A needle will be inserted into the mass." D. "A small skin sample will be obtained."

D. "A small skin sample will be obtained."

1. A nurse is evaluating a client's understanding about the risk for cancer. Which of the following clientstatements indicates the need for further teaching? A. "I see a dermatologist regularly for the mole on my thigh." B. "I take Milk of Magnesia for occasional constipation." C. "I tan using an indoor tanning lotion instead of laying out in the sun." D. "I used to smoke but switched to chewing tobacco 3 years ago."

D. "I used to smoke but switched to chewing tobacco 3 years ago."

A nurse is preparing to administer leucovorin to a client who has cancer and is receiving chemotherapy with methotrexate (Trexall). Which of the following responses is appropriate when the client asks why leucovorin is being given? A. "Leucovorin reduces the risk of a transfusion reaction from methotrexate." B. "Leucovorin increases platelet production and prevents bleeding." C. "Leucovorin potentiates the cytotoxic effects of methotrexate." D. "Leucovorin protects healthy cells from methotrexate's toxic effects."

D. "Leucovorin protects healthy cells from methotrexate's toxic effects."

A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care? A. Rinse the mouth with chlorhexidine solution every 2 hours B. Limit fluid intake with meals C. Provide oral care hygiene with a firm bristled toothbrush after each meal D. Avoid Salty Foods

D. Avoid Salty Foods Stomatitis can cause ulcers in the mouth. Foods that are spicy, acidic or salty can cause irritation or damage to the oral mucousa

A nurse is reviewing the laboratory data of a client who reports manifestations suggesting systemic lupus erythematosus (SLE). The nurse should expect an increase in which the following parameters for a client who has SLE? A. Platelet Count B. RBC Count C. Hct D. Erythrocyte Sedimentation Rate (ESR)

D. Erythrocyte Sedimentation Rate (ESR)

A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following pieces of information should the nurse include in the teaching? A. Wear nylon socks with shoes B. Wear flip flops instead of going barefoot when outside C. Apply moisterizer cream between your toes D. Wash your feet daily using luke warm water and soap

D. Wash your feet daily using luke warm water and soap A diabetic should keep their feet clean and free of dirt whic can cause infection.

A nurse in the emergency department is assessing a newly admitted client. Which of the following places is the client at increased risk for contracting hepatitis B?

Engaging in unprotected sexual intercourse(Hep B is transmitted by sexual contact)

The nurse outlines for a patient who has asthma attacks from pollen that the process from exposure to symptoms follows a systematic sequence. Place the physiologic responses of an allergic asthma attack in sequence. (Separate letters by a comma and space as follows: A, B, C, D) a. Release of histamine b. Edema c. Vasodilation d. Activation of mast cells e. Bronchospasm f. Exposure to pollen

F, D, A, C, B, E The mast cells in the lungs are activated by the exposure to pollen. Histamine is released causing vasodilation, edema, and bronchospasm for the asthmatic.

What is the focus of secondary prevention?

Focus on identifying illness, providing treatment, and conducting activities to help prevent a worsening health status.

Which of the following body substances causes increased gastric secretions, dilation of capillaries, and constriction of the bronchial smooth muscle?

Histamine

A nurse is providing education for the parent of a child about administration guidelines for the human papilloma virus (HPV) vaccine. Which of the following information should the nurse include?

Three doses should be given starting at age 11 or 12.-second dose 1-2 months after-3rd dose be given 6 months after -1st dose-can be given up to age 26

Which of the following are diseases which result from one's own immune system attacking the body? (Select all that apply.) a. Lupus erythematosus b. Glomerulonephritis c. Polio d. Rheumatoid arthritis e. Thrombocytopenic purpura f. Osteoarthritis

a. Lupus erythematosus b. Glomerulonephritis d. Rheumatoid arthritis e. Thrombocytopenic purpura Autoimmune diseases such as systemic lupus erythematosus, glomerulonephritis, myasthenia gravis, thrombocytopenic purpura, rheumatoid arthritis, and Guillain-Barré syndrome are treated with plasmapheresis.

Which of the following provide the body with innate immunity? (Select all that apply.) a. Skin and mucous membranes b. Lungsc. Heart d. Tears and saliva e. Natural intestinal and vaginal flora f. Stomach acid

a. Skin and mucous membranes d. Tears and saliva e. Natural intestinal and vaginal flora f. Stomach acid The innate immune system is composed of the skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissues, and secretions provide biochemical and physical barriers to disease.

To provide examples of an active acquired immunity, the nurse uses the example of a person who has acquired immunity from measles because that person has had: (Select all that apply.) a. Chickenpox and mumps b. Measles c. An extremely healthy immune system d. An inoculation against measles e. Maternal antibodies against measles

b. Measles d. An inoculation against measles Active or acquired or adaptive immunity occurs from having had disease or having had an immunization against that specific disease.

The nurse outlines the functions of the immune system as those actions which: (Select all that apply.) a. Prevention of hemorrhage b. Protection of the body's internal environment c. Maintenance of hemoglobin level d. Maintenance of homeostasis by removing damaged cells e. Destruction of growth of abnormal cells

b. Protection of the body's internal environment d. Maintenance of homeostasis by removing damaged cells e. Destruction of growth of abnormal cells The three main functions of the immune system are to protect the body's internal environment by destroying antigens and pathogens, maintenance of homeostasis by removing damaged cells, and the destruction of abnormal growth in the body.

a nurse is in-servicing a group of clients in the community on early detection for colorectal cancer; the nurse knows that the american cancer society recommends that men and women beginning at age 50 are at average risk and should have flexible sigmoidoscopy every

five years

Placental transfer of IgG from mother to fetus during pregnancy is an example of what type of immunity?

naturally acquired passive immunity