RN- NCLEX QUESTIONS IMMUNITY
indirect Coombs' test
To detect maternal antibodies against fetal Rh-positive factor
myelomeningocele
latex allergy Cross-reactions to food items such as bananas, kiwi, chestnuts, and avocados also occur.
A client with neutropenia has an absolute neutrophil count (ANC) of 900 (0.9 X 109/L). What is the client's risk of infection?
moderate risk Explanation: A client is at moderate risk when the ANC is less than 1,000 (1 × 109/L). The ANC decreases proportionately to the increased risk for infection. Normal risk for infection is when the ANC is 1,500 (1.5 × 109/L) or greater. High risk for infection is when the ANC is less than 500 (0.5 × 109/L). An ANC of 100 (0.1 × 109/L) or less is life threatening.
The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative?
"Just as I get over a virus, it seems that I get another." this is the Correct to this question Explanation: Immune deficiencies make it harder for the body to fight infection. With a low resistance, the client is susceptible to obtaining more circulating viruses. Having morning stuffiness and a sore throat is indicative of sinus congestion. Having a leg sore is indicative of cardiovascular insufficiency or diabetes. Sneezing with watery eyes is indicates seasonal allergies.
Passive immunity
-occurs from antibody transmission and occurs rapidly but it's temporary. -may be transferred by mother to neonate.
Which is the best nursing response to make when a client asks why their blood glucose is higher on days when they sleep less? a) "Cortisol levels remain high when you sleep less, since cortisol is inhibited during sleep." b) "You are probably eating more when you sleep less. This is making your blood glucose higher than usual." c) "You are more active when you sleep less, so your blood glucose will be higher." d) "Your body is producing cortisol for the extra energy you need when you sleep less."
a) "Cortisol levels remain high when you sleep less, since cortisol is inhibited during sleep." Explanation: Cortisol is decreased during sleep, and also decreases blood glucose levels. Less sleep means that cortisol continues to be produced, and blood glucose levels are high. The other statements are incorrect.
Choice Multiple question - Select all answer choices that apply. A 4-year-old child with suspected leukemia is admitted to the hospital for diagnosis and treatment. Which tests aid in diagnosing leukemia? Select all that apply. a) Bone marrow aspiration and analysis b) Complete blood count c) Quantitative hemoglobin studies d) Lumbar puncture e) Chest radiography
a) Bone marrow aspiration and analysis b) Complete blood count d) Lumbar puncture Bone marrow aspiration and analysis are necessary to confirm leukemia. The bone marrow of a child with leukemia is characterized by hypercellularity, lack of fat globules, and blast cells (immature white cells). Complete blood counts show thrombocytopenia and neutropenia in clients with leukemia. Lumbar puncture is performed to detect meningeal involvement. Quantitative hemoglobin studies are used to diagnose thalassemia. Chest radiography verifies the presence of a mediastinal mass in those with suspected Hodgkin's disease.
A mother brings her 4-month-old infant to the clinic for a wellness checkup. Which immunizations should the infant receive? a) DTaP, IPV, Hib, hepatitis B, and pneumococcal conjugate vaccine (PCV) b) Haemophilus influenzae type B (Hib), rotavirus, DTaP, and IPV c) DTaP, hepatitis B, Hib, and varicella d) Diphtheria, tetanus toxoids, and acellular pertussis (DTaP), inactivated polio virus (IPV), rotavirus, and measles-mumps-rubella (MMR)
a) DTaP, IPV, Hib, hepatitis B, and pneumococcal conjugate vaccine (PCV) Explanation: DTaP, IPV, Hib, hepatitis B, and PCV are administered at ages 2 and 4 months. The MMR vaccine is typically administered at age 12 to 15 months. Rotavirus vaccine is no longer recommended because of the associated risk of intussusception. The varicella vaccine is commonly administered between ages 12 and 18 months
Choice Multiple question - Select all answer choices that apply. A 42-year-old client comes to the clinic and is diagnosed with shingles. Which findings confirm this diagnosis? Select all that apply. a) Fever b) Malaise c) Severe, deep pain around the thorax d) Diarrhea e) Red, nodular skin lesions around the thorax
a) Fever b) Malaise c) Severe, deep pain around the thorax e) Red, nodular skin lesions around the thorax Shingles, also called herpes zoster, is an acute unilateral and segmental inflammation of the dorsal root ganglia. It is caused by infection with the herpes virus varicella-zoster, the same virus that causes chickenpox. It commonly causes severe, deep pain along a peripheral nerve on the trunk of the body and red, nodular skin lesions. Fever and malaise typically accompany these findings. Diarrhea does not commonly occur with shingles.
An 11-year-old child contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear? a) Gown, gloves, mask, and eye goggles or eye shield b) Gown, gloves, and mask c) Gloves d) Gown and gloves
a) Gown, gloves, mask, and eye goggles or eye shield The transmission of SARS isn't fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any health care worker providing care for a person with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.
Choice Multiple question - Select all answer choices that apply. A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis (RA). Which medical facts about RA are essential in developing a plan of care? Select all that apply. a) The client experiences stiff, swollen joints bilaterally. b) The client may not exercise once the disease is diagnosed. c) Onset is acute and usually occurs between ages 20 and 40. d) Erythrocyte sedimentation rate (ESR) is elevated, and x-rays show erosions and decalcification of involved joints. e) The first-line treatment is gold salts and methotrexate. f) Inflamed cartilage triggers complement activation, which stimulates the release of additional inflammatory mediators.
a) The client experiences stiff, swollen joints bilaterally. d) Erythrocyte sedimentation rate (ESR) is elevated, and x-rays show erosions and decalcification of involved joints. f) Inflamed cartilage triggers complement activation, which stimulates the release of additional inflammatory mediators. Explanation: RA is a chronic disorder where individuals experience stiff, swollen joints due to a severe inflammatory reaction. Elevated ESR and x-ray evidence of bony destruction are indicative of severe involvement. RA starts insidiously, with fatigue, persistent low-grade fever, anorexia, and vague skeletal symptoms, usually in middle age between the ages 35 and 50 years. Maintaining the ROM by a prescribed exercise program is essential, but clients must rest between activities. Salicylates and nonsteroidal anti-inflammatory drugs are considered the first-line treatments.
After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which information? a) antibodies coating the neonate's red blood cells b) degree of anemia in the neonate c) initial bilirubin level d) antigens coating the neonate's red blood cells
a) antibodies coating the neonate's red blood cells A direct Coombs test is done on umbilical cord blood to detect antibodies coating the neonate's red blood cells. Hematocrit is used to detect anemia. A direct Coombs does not measure bilirubin but may help explain the underlying cause of increased bilirubin levels. Antigens on the neonate's red blood cells are proteins that help determine the neonate's blood type.
Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report: a) sore throat. b) increased urine output. c) painful, excessive menstruation. d) constipation.
a) sore throat. The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider (HCP) signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.
A nurse practicing in a nurse-managed clinic suspects that an 8-year-old child's chronic sinusitis and upper respiratory tract infections may result from allergies. She orders an immunoglobulin assay. Which immunoglobulin would the nurse expect to find elevated? a) Immunoglobulin M b) Immunoglobulin E c) Immunoglobulin D d) Immunoglobulin G
b) Immunoglobulin E The nurse would expect elevated immunoglobulin (Ig) E levels because IgE is predominantly found in saliva and tears as well as intestinal and bronchial secretions and, therefore, may be found in allergic disorders. IgD's physiologic function is unknown and constitutes only 1% of the total number of circulating immunoglobulins. IgG is elevated in the presence of viral and bacterial infections. IgM is the first antibody activated after an antigen enters the body, and is especially effective against gram-negative organisms.
A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Which snacks have the greatest probability of stimulating autoimmunity? a) Applesause and dried apricots b) Potato chips and chocolate milk shakes c) Raisins and carrot sticks d) Fruit salad and mineral water
b) Potato chips and chocolate milk shakes A diet containing excessive fat, such as that found in potato chips and milk shakes, seems to contribute to autoimmunity — overreaction of the body against constituents of its own tissues. Raisins, carrot sticks, fruit, mineral water, applesauce, and dried apricots are snacks containing adequate amounts of vitamin A, zinc, and carotene, which are beneficial for the body.
A nurse is caring for a client with the following laboratory values: white blood cell count (WBC) 4,500/mm3, neutrophils 15%, and bands 1%. Based on the client's absolute neutrophil count (ANC), the nurse knows that the clients risk for infection is: a) No increased risk b) Significant risk c) low risk d) intermediate risk
b) Significant risk In practical clinical terms, a normal ANC is 1.5 or higher; a "safe" ANC is 500-1500; a low ANC is less than 500. A safe ANC means that the patient's activities do not need to be restricted (on the basis of the ANC).
An infant is to receive the diphtheria, tetanus, and acellular pertussis (DTaP) and inactivated polio vaccine (IPV) immunizations. The child is recovering from a cold and is afebrile. The child's sibling has cancer and is receiving chemotherapy. Which action is most appropriate? a) Postpone both immunizations until the sibling is in remission. b) Withhold both immunizations until the infant is well. c) Administer the DTaP and IPV immunizations. d) Give the DTaP and withhold the IPV.
c) Administer the DTaP and IPV immunizations. At this time, the infant can be given the vaccines. The fact that the child's sibling is immunosuppressed because of chemotherapy is not a reason to withhold the vaccines. The fact that the child has a cold is not grounds for delaying the immunizations. However, if the child had a high fever, the immunizations would be delayed.
In a client infected with human immunodeficiency virus (HIV) has a low CD4 level. What interventions should the nurse implement as a result of this finding? a) Request human granulocyte colony-stimulating factor to improve WBC production. b) Provide antibiotics as per order. c) Place the client in reverse isolation. d) Increase nutritional protein with each meal.
c) Place the client in reverse isolation. CD4+ levels in the blood of an individual with HIV infection determine the extent of damage to the individual's immune system. The test indicates the individual's risk of an opportunistic infection, but does not identify specific infections. Viral loads and resistance to specific antigens are determined using other diagnostic tests. Because of the client's risk, isolation is recommended
Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for: a) intra-abdominal instillation of methylprednisolone sodium succinate. b) bone marrow transplant. c) removal of the transplanted kidney. d) high-dose I.V. cyclosporine therapy.
c) removal of the transplanted kidney. Hyperacute rejection isn't treatable; the only way to stop this reaction is to remove the transplanted organ or tissue. Although cyclosporine is used to treat acute transplant rejection, it doesn't halt hyperacute rejection. Bone marrow transplant isn't effective against hyperacute rejection of a kidney transplant. Methylprednisolone sodium succinate may be given I.V. to treat acute organ rejection, but it's ineffective against hyperacute rejection.
A 12-month-old child is seen in the neighborhood clinic for a regular checkup. Which statement by the child's mother about the influenza vaccine reflects the need for more teaching? a) "The first time a child receives the influenza vaccine, a second dose is recommended in 1 month." b) "Yearly influenza vaccinations are recommended to begin as early as 6 months of age." c) "My child is too young to receive the live attenuated intranasal vaccine." d) "The Haemophilus influenzae vaccine my child has already received helps protect against some forms of the flu."
d) "The Haemophilus influenzae vaccine my child has already received helps protect against some forms of the flu." Haemophilus influenzae is a bacteria that can cause severe disease in children younger than age 5 years, but it does not cause influenza. Yearly vaccination for influenza is recommended to begin at 6 months. The live vaccine is not recommended for children younger than 2 years or with respiratory disease. A second vaccine 4 weeks after the first is recommended the first time a child younger than 9 years receives the flu vaccine.
The nurse is assigning a room for a client admitted with hepatitis A. Which of the following diagnoses would be an appropriate roommate for this client? a) Pneumonia b) Varicella c) Postoperative hip arthroplasty d) Congestive heart failure
d) Congestive heart failure The nurse is assigning rooms for the new admissions of the following clients. The nurse needs to determine the need for specific standard and transmission-based precautions. It would be appropriate for a hepatitis A and congestive heart failure client to share a room, as neither requires isolation. The varicella is airborne isolation and must be in a private negative airflow room. Postoperative clients should not be in a room with a medical client with a communicable infection.
When teaching the mother of a child diagnosed with phenylketonuria (PKU) about its transmission, the nurse should use knowledge of which factor as the basis for the discussion? a) chromosome translocation b) x-linked recessive gene c) chromosome deletion d) autosomal recessive gene
d) autosomal recessive gene PKU is caused by an inborn error of metabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine. A form of Down syndrome, trisomy 21, is an example of a disorder caused by chromosomal translocation. Cri du chat is an example of a disorder caused by chromosomal deletion. Hemophilia A is an example of a disorder caused by an X-linked recessive gene
Active immunity
results from direct exposure of an antigen by immunization or disease exposure.
Choice Multiple question - Select all answer choices that apply. After teaching the parents of a child with celiac disease about diet, the nurse understands the teaching has been effective if the parents state that which foods should be avoided? Select all that apply. a) soy milk b) corn tortillas c) hot dog buns d) bologna on rye sandwich e) white rice
• hot dog buns • bologna on rye sandwich Explanation: Children with celiac disease should avoid foods containing the protein gluten, which is found in wheat, oats, rye, and barley grains. Hot dog buns, unless otherwise labeled, contain wheat.
The nurse is discussing treatment options with the parents of a child who has been newly diagnosed with leukemia. Which of the following is the most appropriate information for the nurse to give the parents about treatment options? a) "Chemotherapy has the greatest potential to cure the cancer." b) "Bone marrow transplant is the quickest treatment option." c) "There are numerous alternative therapies that are highly effective." d) "Immunotherapy has fewer side effects than traditional therapies."
a) "Chemotherapy has the greatest potential to cure the cancer." Chemotherapy is the treatment of choice for leukemia. Other options may eventually be considered, but initially a course of chemotherapy is the expected treatment modality.
A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated? a) IgE b) IgG c) IgA d) IgB
a) IgE Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates the complement system. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.
A parent of a child with acute post-streptococcal glomerulonephritis (APSCN) asks how streptococcal infection caused the child to have a kidney problem. What is the nurse's best response? a) "The streptococcal infection spread through the bloodstream to your child's kidneys." b) "By-products of immune complexes that fought the infection are depositing in the kidneys." c) "The strep infection weakened your child's immune system, making him susceptible to a secondary infection." d) "Your child made excessive antibodies to fight the infection that are now attacking the kidneys."
b) "By-products of immune complexes that fought the infection are depositing in the kidneys." Explanation: APSGN is an immune complex disease. Large antigen-antibody complexes are formed that deposit in the glomerular capillary loops leading to obstruction. APSGN is considered an autoimmune disorder, not an infection. Antibodies do not attack the kidneys in this disorder.
Which of the following clients are at an increased risk of developing Kaposi's sarcoma skin lesions? Select all that apply. a) Client status post a liver transplant b) Client with acquired immunodeficiency syndrome (AIDS) c) Client with type 1 diabetes mellitus d) Female client of European ancestry e) Male client of Mediterranean/Jewish ancestry
b) • Client with acquired immunodeficiency syndrome (AIDS) a) • Client status post a liver transplant e) • Male client of Mediterranean/Jewish ancestry Explanation: Clients with a compromised immune system (such as transplant clients or those with AIDS) are at an increased risk of developing Kaposi's sarcoma. Kaposi's sarcoma is also more prevalent among males of Mediterranean or Jewish ancestry, although in a less severe form. Clients with type 1 diabetes mellitus or females of European ancestry are not at an increased risk.
The nurse is caring for a 2-year-old child with cancer. The parents have been told that the child will need an allogeneic bone marrow transplant and want to know what this means. What is the best response by the nurse? a) "The donor for this type of transplant must have the same DNA as your child." b) "This type of transplant uses the child's own stem cells for the procedure." c) "A donor is determined after testing for similar human leukocyte antigens." d) "The donor bone marrow can be accepted from anyone who volunteers."
c) "A donor is determined after testing for similar human leukocyte antigens." Explanation: An allogeneic transplant is one in which the donor and the recipient are related or unrelated but share similar human leukocyte antigens (HLA).
A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? a) "I won't go to see my nephew right after he gets his vaccines." b) "I stopped smoking last year; this year I'll quit drinking alcohol." c) "I won't go to see my sister while she has a cold." d) "I can eat whatever I want as long as it's low in fat."
d) "I can eat whatever I want as long as it's low in fat." The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client.
The mother of a child with newly diagnosed Duchenne's muscular dystrophy asks how her child developed the disease. The nurse gives a response incorporating which statement about its transmission? a) "It is a disorder usually carried by females and transmitted to male children." b) "It is a disorder primarily transmitted by males in the family." c) "It is an autosomal recessive genetic disorder." d) "It is a genetic disorder carried by males and transmitted to male children
a) "It is a disorder usually carried by females and transmitted to male children." The gene for Duchenne's muscular dystrophy is carried by women and transmitted to their male children. It involves an X-linked inheritance pattern. About one-third of new cases involve mutations.
A healthy 2-month-old infant is being seen in the local clinic for a well-child checkup and initial immunizations. When analyzing the pediatric record, which immunizations would the nurse anticipate administering at this appointment? Select all that apply. a) IPV (inactivated polio vaccine) b) Hib (Haemophilus influenzae vaccine) c) Varicella (chickenpox) vaccine d) PCV (pneumococcal vaccine) e) DTaP (diphtheria, tetanus, and acellular pertussis) f) MMR (measles, mumps, and rubella)
a) IPV (inactivated polio vaccine) b) Hib (Haemophilus influenzae vaccine) d) PCV (pneumococcal vaccine) e) DTaP (diphtheria, tetanus, and acellular pertussis) At age 2 months, the American Academy of Pediatrics and Public Health Agency in Canada recommends the administration of DTaP, IPV, (Hep B in the United States), Hib, Rotavirus vaccine, and PCV. The MMR and varicella immunizations would be administered at 12 to 15 months.
The nurse is caring for a client newly diagnosed with human immunodeficiency virus (HIV) obtained from unprotected sex. The nurse is in the room when the client is explaining the disease to another person. Which statement by the client would the nurse clarify? Select all that apply. a) "I will have this for the rest of my life." b) "The disease can also be spread by body fluids." c) "I am afraid that I will give this disease to my nephew." d) "I could pass this on to a baby before I give birth." e) "My sexual practices will have to change." f) "Medications can cure the disease."
c) "I am afraid that I will give this disease to my nephew." f) "Medications can cure the disease." Human immunodeficiency virus (HIV) is a sexually transmitted infection. Casual contact such as that with a family member will not spread the disease.Unfortunately, at this time, there is no cure for the disease. The client is correct in stating that sexual practices will have to change to prevent further spread of the disease, the disease can be spread by body fluids and can also be passed on to a fetus.
A preschooler with a history of repaired lumbar myelomeningocele is in the emergency department with wheezing and skin rash. Which question should the nurse ask the parent first? a) "What are you doing to treat your child's skin rash?" b) "Who brought your child to the emergency department?" c) "Is your child taking any medications?" d) "Is your child allergic to bananas or any other food?"
d) "Is your child allergic to bananas or any other food?" Children with myelomeningocele are at high risk for development of latex allergy because of repeated exposure to latex products during surgery and bladder catheterizations. Cross-reactions to food items such as bananas, kiwi, chestnuts, and avocados also occur. These allergic reactions vary in severity ranging from mild (such as sneezing) to severe anaphylaxis. While the child could have allergies to medications that caused the wheezing, latex and food allergies are more common. Asking about the skin rash is not a priority when a child is wheezing. Who brought the child to the emergency department is irrelevant at this time.
When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information? a) The vaccine prevents a future fetus from developing congenital anomalies. b) The client should avoid contact with children diagnosed with rubella. c) The injection will provide immunity against the chickenpox. d) Pregnancy should be avoided for 4 weeks after the immunization.
d) Pregnancy should be avoided for 4 weeks after the immunization. After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 4 weeks to prevent the possibility of the vaccine's teratogenic effects to the fetus. The vaccine does not protect a future fetus from infection. Rather it protects the woman from developing the infection if exposed during pregnancy and subsequently causing harm to the fetus. The vaccine will provide immunity to rubella, also known as German measles. The injection immunizes the client against the 3-day or German measles, not chickenpox.
When discussing plans for genetic counseling with the parents of a fetus with Down syndrome, which function should the nurse include as the primary role of the genetic team when working with a family? a) Prepare the parents psychologically for the birth of a child with disabilities. b) Prescribe birth control or abortion measures for the parents as needed. c) Report the findings of chromosome analysis of the amniotic cells. d) Provide parents with information about the risks of birth defects.
d) Provide parents with information about the risks of birth defects. Explanation: The primary aim of genetic counseling is to inform clients of birth defect risks and the nature of the disorder to help the family understand and adjust to the disorder. Reporting results of chromosome analysis of amniotic cells is a secondary role of the team. Preparing a couple psychologically for the birth of a child with a disability is a secondary role. Although suggestions may be offered, the decision about birth control methods should be left to the couple.
Choice Multiple question - Select all answer choices that apply. The nurse is planning care for a client with human immunodeficiency virus (HIV). Which statement by the nurse indicates understanding of HIV transmission? Select all that apply. a) "I will wear a gown, mask, and gloves with all client contact." b) "I don't need to wear any personal protective equipment due to decreased risk of occupational exposure." c) "I will wear a mask if the client has a cough caused by an upper respiratory infection." d) "I will wear a mask, gown, and gloves when splashing bodily fluids is likely." e) "I will wash my hands after client care."
e) "I will wash my hands after client care." d) "I will wear a mask, gown, and gloves when splashing bodily fluids is likely." Standard precautions include wearing gloves for any known or anticipated contact with blood, body fluids, tissue, mucous membranes, and nonintact skin. If the task or procedure may result in splashing or splattering of blood or body fluids to the face, the nurse should wear a mask and goggles or face shield. If the task or procedure may result in splashing or splattering of blood or body fluids, the nurse should wear a fluid-resistant gown or apron. The nurse should wash hands before and after client care and after removing gloves. A gown, mask, and gloves are not necessary for all client care unless contact with bodily fluids, tissue, mucous membranes, and nonintact skin is expected. Nurses have an increased, not decreased, risk of occupational exposure to blood-borne pathogens. HIV is not transmitted in sputum unless blood is present.
The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative?
this answer is incorrect but was shown as the correct answer on prep U "I sneeze and have watery eyes throughout the spring and summer." Explanation: Immune deficiencies make it harder for the body to fight infection. With a low resistance, the client is susceptible to obtaining more circulating viruses. Having morning stuffiness and a sore throat is indicative of sinus congestion. Having a leg sore is indicative of cardiovascular insufficiency or diabetes. Sneezing with watery eyes is indicates seasonal allergies.
A child with Down syndrome has an upper respiratory infection (URI). Which of the following is the nurse's best action? Select all that apply. a) Restricting visitation of sick siblings b) Providing fluids that the child likes c) Administering oxygen d) Consulting a speech therapist e) Ensuring that child is as active as possible
• Providing fluids that the child likes • Restricting visitation of sick siblings • Ensuring that child is as active as possible Explanation: A child with Down syndrome has deficits in the immune system and increased mucus viscosity, which contribute to URI. Providing fluids the child likes will increase the chance the child will drink the fluid and help with hydration. Sick siblings should not visit, as the child has deficits in the immune system. Increasing activity as much as possible will help the URI to resolve. Speech therapy and oxygen are not routinely needed for a child with Down syndrome who has URI.
Choice Multiple question - Select all answer choices that apply. The nurse is caring for a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which information would be included in a teaching plan that focuses on home care? Select all that apply. a) Keep exercise to a minimal level. b) Avoid over-the-counter (OTC) medications unless approved by the physician. c) Avoid exposure to sunlight. d) Take rest periods as needed. e) Report development of a butterfly rash on the face.
a) Keep exercise to a minimal level. b) Avoid over-the-counter (OTC) medications unless approved by the physician. c) Avoid exposure to sunlight. d) Take rest periods as needed. Explanation: The client who suffers from SLE has a tendency toward photosensitivity; therefore, the client would avoid exposure to sunlight. The client would also be advised to keep exercise to a minimum, to avoid OTC medications unless directed by the physician, and to rest as needed. Because the butterfly rash associated with lupus is an initial sign, the client would already have the rash and would not be reporting its development after discharge.
The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following? a) Reed-Sternberg cells. b) Duchenne's cells. c) Tay-Sachs cells. d) Sarcoidosis cells.
a) Reed-Sternberg cells. A definitive diagnosis of Hodgkin's disease is made if Reed-Sternberg cells are found in the histologic examination of the excisional lymph node biopsy. Tay-Sachs disease is an inherited disease carried by an autosomal recessive gene. Sarcoidosis is an inflammatory granulomatous disease. Duchenne's disease is a type of muscular disorder.
An 8-year-old child has been admitted to the oncology unit with a suspected diagnosis of acute lymphoblastic leukemia. The nurse is obtaining a health history from the parents. During the interview, the parents ask the nurse if any of the factors discussed would make their child more at risk for this type of leukemia. What information about potential risk factors is correct for the nurse to share with the parents? a) The diagnosis of Down's syndrome at birth b) A diet that includes a large proportion of dairy products c) A weight that is above the limit for the child's age d) The X-rays that the child had at age 6 for a broken leg
a) The diagnosis of Down's syndrome at birth Explanation: Children with Down's syndrome and other genetic conditions have an increased risk of developing acute lymphoblastic leukemia. Prenatal exposure to X-rays is actually a higher concern than postnatal exposure with respect to increasing the risk of developing ALL. The exception would be postnatal exposure to high doses of therapeutic radiation used as a treatment modality, which was not indicated here. Diet would have little impact on risk factors at this stage in the child's life.
Choice Multiple question - Select all answer choices that apply. A school nurse is gathering registration data for a child entering first grade. Which immunizations would the school nurse verify that the child has had? Select all that apply. a) Varicella vaccine. b) Diphtheria-tetanus-pertussis series. c) H. influenzae type b series. d) Oral polio series. e) Pneumonia vaccine. f) Influenza vaccine.
a) Varicella vaccine. b) Diphtheria-tetanus-pertussis series. c) H. influenzae type b series. Explanation: The exact immunization schedule differs between the United States and Canadian provinces but there are many similarities. Diphtheria-tetanus-pertussis series, H. influenzae type b series, varicella, and inactivated (not oral) polio series are the immunizations that the child would receive before entering first grade. The oral polio vaccine was discontinued; the safer IPV is now used. Pneumonia vaccine is not required or routinely given to children.
Choice Multiple question - Select all answer choices that apply. The nurse is teaching the parents of a 5-year-old child about commonly expected adverse effects of the diphtheria, tetanus, and pertussis; inactivated polio; and measles, mumps, and rubella vaccines. What possible effects should be included? Select all that apply. a) rash b) redness at the injection site c) anorexia d) diarrhea e) prolonged crying f) fever of 103° F (39.5° C)
a) rash b) redness at the injection site c) anorexia Common adverse effects associated with these vaccines include redness, swelling, soreness at the injection site, low-grade fever, anorexia, malaise, and fussiness; rash may also occur 7 to 10 days after the measles, mumps, and rubella vaccine. A fever of 103° F (39.5° C) is a high-grade fever and not usually seen following immunization administration. Prolonged crying and diarrhea are not associated with these immunizations.
A nurse is evaluating the parents' comprehension of their child's diagnosis of celiac disease. Which of the following statements indicates a need for further teaching? a) "Celiac disease is an autoimmune disease with symptoms that vary by person." b) "Possible complications of the disease include vitamin deficiency and various neurological manifestations." c) "Our child must maintain these dietary restrictions for life." d) "We will need to bring our child in for regular blood work to monitor the disease."
d) "We will need to bring our child in for regular blood work to monitor the disease." Teaching is effective if the parents say that their child must maintain the dietary restrictions for life, because the child needs to avoid recurrence of the disease's clinical manifestations. Celiac disease is an autoimmune disorder that can cause vitamin deficiencies and neurological manifestations. The symptoms can vary from person to person. However, regular lab work is not needed.
Choice Multiple question - Select all answer choices that apply. Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive? Select all that apply. a) Varicella b) Pneumonia c) Hepatitis B d) Pertussis e) Influenza
b) Pneumonia d) Pertussis e) Influenza Clients with COPD are more susceptible to respiratory infections, so they should be encouraged to receive the influenza, pneumococcal, and pertussis vaccines. Clients with COPD are not at high risk for varicella or hepatitis B.
A 34-year-old multigravida at 36 weeks' gestation in active labor has been diagnosed with Rh sensitization. The fetus is in a frank breech presentation. The client's membranes rupture spontaneously, and the nurse documents the color of the fluid as yellowish. This color indicates: a) amniotic fluid embolism. b) oligohydramnios. c) Rh sensitization. d) abnormal presentation.
c) Rh sensitization. Amniotic fluid is normally clear. Yellowish fluid indicates Rh sensitization. The yellowish color is related to fetal anemia and bilirubin in the amniotic fluid. In an abnormal presentation, in this case a breech presentation, it is not uncommon for the amniotic fluid to be green in color owing to meconium expelled by the fetus. Amniotic fluid embolism is not related to the fluid color. This condition, a medical emergency, may occur naturally after a difficult labor or from hyperstimulation of the uterus. Oligohydramnios refers to a markedly decreased volume of amniotic fluid. It has no association with the color of the fluid.
Antenatal laboratory testing revealed a negative rubella antibody for a client admitted to the postpartum unit. Which action takes priority for this client during early puerperium? a) Rubella counseling and immunization with adult measles-mumps-rubella (MMR) vaccine b) Rubella counseling and immunization with Rho(D) immune gobulin vaccine c) Rubella counseling and immunization with live rubella virus vaccine d) Rubella counseling and instruction to obtain live rubella virus vaccine during her first postpartum examination
c) Rubella counseling and immunization with live rubella virus vaccine Explanation: A client who contracts rubella during pregnancy is at risk for delivering a fetus with severe congenital defects. Therefore, the client should receive rubella counseling and immunization with the live rubella virus vaccine before discharge. Immunization should take place as soon as possible before the client becomes pregnant again. The client should be advised to avoid pregnancy for 3 months after immunization. Rho(D) immune gobulin is administered to clients who are Rh-negative and come in contact with Rh-positive blood from an Rh-positive fetus.
The client with idiopathic thrombocytopenic purpura (ITP) asks the nurse why it is necessary to take steroids. The nurse should base the response on which information? a) Steroids increase phagocytosis and increase the life of platelets. b) Steroids neutralize the antigens and prolong the life of platelets. c) Steroids alter the spleen's recognition of platelets and increase the life of platelets. d) Steroids destroy the antibodies and prolong the life of platelets.
c) Steroids alter the spleen's recognition of platelets and increase the life of platelets. ITP is treated with steroids to suppress the splenic macrophages from phagocytizing the antibody-coated platelets, which are recognized as foreign bodies, so that the platelets live longer. The steroids also suppress the binding of the autoimmune antibody to the platelet surface. Steroids do not destroy the antibodies on the platelets, neutralize antigens, or increase phagocytosis.
Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: A client is experiencing an allergic response. The nurse should perform the actions in which order from first to last? All options must be used. 1 Activate the rapid response team. 2 Assess the airway and breathing pattern. 3 Notify the health care provider (HCP). 4 Assess for urticaria.
1) Assess the airway and breathing pattern. 2) Assess for urticaria. 3) Activate the rapid response team. 4) Notify the health care provider (HCP). Explanation: If a client is experiencing an allergic response, the nurse's initial (1st) action is to assess the client for signs/symptoms of anaphylaxis, first checking the airway, breathing pattern, and vital signs, with particular attention to signs of increasing edema and respiratory distress. (2nd) The nurse should then assess for other indications of anaphylaxis, such as urticaria, feelings of impending doom or fright, weakness, sweating (because a severe systemic response to an allergen can result in massive vasodilation), increased capillary permeability, decreased perfusion, decreased venous return, and subsequent decreased cardiac output. (3rd) The nurse should call the rapid response team and (4th) then notify the HCP.
Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: During a school party a child with a known food allergy has an itchy throat, is wheezing, and reports not feeling "quite right." The nurse should do the following in what order from first to last? All options must be used. 1 Assess vital signs. 2 Position to facilitate breathing. 3 Send someone to activate the Emergency Management Systems (EMS). 4 Administer the child's epinephrine. 5 Notify the parents.
1) Send someone to activate the Emergency Management Systems (EMS). 2) Administer the child's epinephrine. 3) Position to facilitate breathing. 4) Assess vital signs. 5) Notify the parents. Explanation: The child is exhibiting signs of anaphylaxis. The principles of emergency management involve activating EMS when an emergency is first realized. The nurse then follows the priorities of Circulation, Airway, Breathing (C, A, B). The epinephrine should then be given to reduce airway constriction and prevent cardiovascular collapse. The child should be assisted into the most comfortable position to facilitate breathing, usually with the head elevated. Then the nurse can take the child's vital signs to assess the effectiveness of the treatment. Lastly, the nurse should notify the family.
When developing a teaching plan for the parent of an asthmatic child concerning measures to reduce allergic triggers, which suggestion should the nurse include? a) Keep the humidity in the home between 50% and 60%. b) Have the child sleep in the bottom bunk bed. c) Use a scented room deodorizer to keep the room fresh. d) Vacuum the carpet once or twice a week.
a) Keep the humidity in the home between 50% and 60%. Explanation: To help reduce allergic triggers in the home, the nurse should recommend that the humidity level be kept between 50% and 60%. Doing so keeps the air moist and comfortable for breathing. When air is dry, the risk for respiratory infections increases. Too high a level of humidity increases the risk for mold growth. Typically, the child with asthma should sleep in the top bunk bed to minimize the risk of exposure to dust mites. The risk of exposure to dust mites increases when the child sleeps in the bottom bunk bed because dust mites fall from the top bed, settling in the bottom bed. Scented sprays should be avoided because they may trigger an asthmatic episode. Ideally, carpeting should be avoided in the home if the child has asthma. However, if it is present, carpeting in the child's room should be vacuumed often, possibly daily, to remove dust mites and dust particles.
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching and there is a rise in the client's temperature. The nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction with a blood transfusion? a) Type II (cytolytic, cytotoxic) hypersensitivity reaction b) Type IV (cell-mediated, delayed) hypersensitivity reaction c) Type I (immediate, anaphylactic) hypersensitivity reaction d) Type III (immune complex) hypersensitivity reaction
a) Type II (cytolytic, cytotoxic) hypersensitivity reaction ABO (blood type) incompatibility, such as from an incompatible blood transfusion, is a type II hypersensitivity reaction. Transfusions of more than 100 ml of incompatible blood can cause severe and permanent renal damage, circulatory shock, and even death. Drug-induced hemolytic anemia is another example of a type II reaction. A type I hypersensitivity reaction occurs in anaphylaxis, atopic diseases, and skin reactions. A type III hypersensitivity reaction occurs in Arthus reaction, serum sickness, systemic lupus erythematosus, and acute glomerulonephritis. A type IV hypersensitivity reaction occurs in tuberculosis, contact dermatitis, and transplant rejection.
A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin (RHIG) injection for what reason? a) to provide active antibody protection for this pregnancy b) to prevent Rh-positive sensitization with the next pregnancy c) to decrease the amount of Rh-negative sensitization for the next pregnancy d) to destroy fetal Rh-positive cells during the next pregnancy
b) to prevent Rh-positive sensitization with the next pregnancy The purpose of the RhoGAM is to provide passive antibody immunity and prevent Rh-positive sensitization with the next pregnancy. It should be given within 72 hours after birth of an Rh-positive neonate. Clients who are Rh-negative and conceive an Rh-negative fetus do not need antibody protection. Rh-positive cells contribute to sensitization, not Rh-negative cells. The RhoGAM does not cross the placenta and destroy fetal Rh-positive cells.
The nurse is caring for a client being discharged following kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use? a) Administer medication following breakfast daily. b) Sprinkle the contents of the capsule on food. c) Contact the health care provider at first signs of an infection. d) Administer the medication with an antacid to prevent stomach upset.
c) Contact the health care provider at first signs of an infection. Mofetil is an organ rejection medication that diminishes the body's ability to identify and eliminate pathogens (immunosuppressant). Identifying symptoms of infection at an early state is helpful in treating the infection. This medication is administered on an empty stomach. Typically, capsules would not be opened dispensing medication at one time. Antacids may decrease the absorption of the medication
A 2-month-old infant hasn't received any immunizations. Which immunizations should the nurse prepare to administer? a) Polio (IPV), DTaP, MMR b) Varicella, Haemophilus influenzae type b (HIB), IPV, and DTaP c) HIB, DTaP, HepB, IPV, and pneumococcal conjugate vaccine (PCV) d) Measles, mumps, rubella (MMR); diphtheria, tetanus toxoids, and acellular pertussis (DTaP); and hepatitis B (HepB)
c) HIB, DTaP, HepB, IPV, and pneumococcal conjugate vaccine (PCV) The current immunizations recommended for a 2-month-old who hasn't received any immunizations are HIB, DTaP, HepB, PCV, and IPV. The first immunizations for MMR and varicella are recommended when a child is age 12 months.
A nurse practicing in a nurse-managed clinic suspects that an 8-year-old child's chronic sinusitis and upper respiratory tract infections may result from allergies. Which laboratory test would the nurse most likely order? Select all that apply. a) Metabolic panel b) Rheumatoid factor c) Immunoglobulin assay (IgE) d) Liver function studies e) Complete blood count
c) Immunoglobulin assay (IgE) e) Complete blood count The nurse would order a complete blood count, which may indicate elevate white blood cells and eosinophils, as well as an immunoglobulin assay to look specifically for IgE elevations. Rheumatoid factor would be ordered for rheumatic disorders and Sjögren's syndrome; metabolic panel and liver function studies would not provide information about allergies.
When explaining the long-term toxic effects of cancer treatments on the immune system, what should the nurse tell the client? a) Long-term immunologic effects have been studied only in clients with breast and lung cancer. b) Clients with persistent immunologic abnormalities after treatment are at a much greater risk for infection than clients with a history of splenectomy. c) The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment. d) The helper T cells recover more rapidly than the suppressor T cells, which results in positive helper cell balance that can last 5 years.
c) The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment. Explanation: Studies of long-term immunologic effects in clients treated for leukemia, Hodgkin's disease, and breast cancer reveal that combination treatments of chemotherapy and radiation can cause overall bone marrow suppression, decreased leukocyte counts, and profound immunosuppression. Persistent and severe immunologic impairment may follow radiation and chemotherapy (especially multiagent therapy). There is no evidence of greater risk of infection in clients with persistent immunologic abnormalities. Suppressor T cells recover more rapidly than the helper T cells.
Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which condition? a) an antibody response to Rh-negative blood b) development of a future Rh-positive fetus c) development of Rh-positive antibodies d) a future pregnancy resulting in abortion
c) development of Rh-positive antibodies Rh sensitization can be prevented by Rho(D) immune globulin, which clears the maternal circulation of Rh-positive cells before sensitization can occur, thereby blocking maternal antibody production to Rh-positive cells. Administration of this drug will not prevent future Rh-positive fetuses, nor will it prevent future abortions. An antibody response will not occur to Rh-negative cells. Rh-negative mothers do not develop sensitivities if the fetus is also Rh negative.