TEST 3
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurse's priority for care?
Protect the patient's airway.
A patient was tested for HIV using enzyme immunoassay results were positive. nurse should expect the primary care provider to order what test to confirm the EIA test results?
The Western blot test detects antibodies to HIV and is used to confirm the EIA test results.
A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patient's CD4+ T-cell membranes. This process characterizes what phase in the HIV
cleavage
A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate adverse effects of this drug?
"I have this ringing in my ears that just won't go away."
A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a priority nursing intervention for this patient?
Teaching about symptom management
A patient with systemic lupus erythematosus is preparing for discharge. nurse knows that the patient has understood health education when the patient makes what statement?
"I'll make sure to monitor my body temperature on a regular basis."
An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurse's best response?
"It's possible that your baby could contract HIV, either before, during, or after delivery."
nurse is providing health education to the parents of a toddler who has been diagnosed with food allergies. nurse teach this family about the child's health problem?
"Many children outgrow their food allergies in a few years if they avoid the offending foods."
The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse?
"OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
The teen asks the nurse what she can do keep from getting HIV. What would be the nurse's best response?
"Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV."
A patient with SLE asks the nurse why she has to come to the office so often for "check-ups." What would be the nurse's best response?
"Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working."
A nurse has asked the nurse educator if there is any way to predict the severity of a patient's anaphylactic reaction. What would be the nurse's best response?
"The faster the onset of symptoms, the more severe the reaction."
Patient teaching regarding infection prevention for the patient with an immunodeficiency includes which of the following guidelines?
All foods must be cooked to avoid food-borne illness. The patient should avoid contact with individuals who have recently been ill or vaccinated.
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently
"coughed up some blood." What is the nurse's most appropriate action? Place the patient on respiratory isolation and inform the physician.
Which of the following individuals would be the most appropriate candidate for immunotherapy?
A patient with severe allergies to grass and tree pollen
A nurse knows of several patients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which patient?
A pregnant woman at 30 weeks' gestation
assessment of an HIV-positive patient whose CD4+ count has fallen, nurse carefully assesses for signs and symptoms related to opportunistic infections. most common life-threatening infection?
AIDS is Pneumocystis pneumonia , caused by P. jiroveci (formerly carinii). Other infections may involve Salmonella, Mycobacterium tuberculosis, and Clostridium difficile.
A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in
AIDS patients by increasing body fat stores? Megestrol
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?
Addressing possible barriers to adherence
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis,
nurse is explaining that patients with primary immunodeficiencies are living longer than in past decades because of advances in medical treatment. This increased longevity is
Advances in medical treatment have meant that patients with primary immunodeficiencies live longer, thus increasing their overall risk of developing cancer.
A nurse is educating a patient with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make?
Alcohol and red meat can precipitate an acute exacerbation of gout.
The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction?
Anaphylactic reaction after a bee sting Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by IgE antibodies and requires previous exposure to the specific antigen.
patient is admitted for the treatment of a primary immunodeficiency and intravenous immunoglobulin is ordered. the nurse monitor for as a potential adverse effects
Anaphylaxis include hypotension, flank pain, chills, and tightness in chest, terminating with a slightly elevated body temperature and anaphylactic reaction.
A patient with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the patient about this treatment?
Ans: The patient will remain in the clinic to be monitored for 30 minutes following the injection.
He says he never knew what was wrong but his mother had him undergo "blood testing" as a child. Based on these statements, what health problem should the nurse suspect?
X-linked agammaglobulinemia
A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis.
Arthrocentesis involves needle aspiration of synovial fluid.
A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?
Assess for signs and symptoms of anaphylaxis.
nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus . What would the nurse expect to observe on inspection?
Butterfly rash An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks occurs in SLE.
A nurse is providing care for a patient who has a recent diagnosis of giant cell arteritis What aspect of physical assessment should the nurse prioritize?
Careful attention should be directed toward assessing the head for changes in vision, headaches, and jaw claudication.
A nurse is aware of the need to assess patients' risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
Computed tomography with contrast solution
nurse caring for a patient who has an immunosuppressive disorder knows that continual monitoring the primary rationale behind the need for continual monitoring?
Continual monitoring of the patient's condition is critical, so that early signs of impending infection may be detected and treated before they seriously compromise the patient's status.
nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment?
Current medication regimen Identification of patient's support system Immune system function History of sexual practices
A patient is receiving a transfusion of packed RBCs. Shortly after initiation of the transfusion, patient begins to exhibit signs and symptoms of a transfusion reaction.
Cytotoxic type II A type II hypersensitivity reaction resulting in red blood cell destruction is associated with blood transfusions.
nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. nurse should prioritize which of the following interventions?
Educational programs that focus on control and prevention
nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care?
Decreased coordination is likely to constitute a risk for falls.
Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic findings?
Decreased platelets
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown.
nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodeficiency disease . medication should the nurse administer prior
Diphenhydramine and acetaminophen are administered 30 minutes prior to an IVIG infusion
A patient with a diagnosis of primary immunodeficiency informs the nurse that he has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the patient's vital signs are within reference ranges, what action should the nurse take? Teach the patient deep breathing and coughing exercises.
Dyspnea and cough are among the many signs and symptoms that may suggest infection in an immunocompromised patient.
A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow?
Emergency equipment should be readily available.
nurse is caring for a patient who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis?
Encouraging the patient and family to be active partners in the management of the immunodeficiency is the key to successful outcomes and a favorable prognosis.
A nurse is caring for a patient who is suspected of having giant cell arteritis What laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply.
Erythrocyte sedimentation rate, C-reactive protein
A nurse is assessing a patient with rheumatoid arthritis. The patient expresses his intent to pursue complementary and alternative therapies. What fact should underlie the nurse's response to the patient?
Evidence shows minimal benefits from most CAM therapies.
A patient with polymyositisis experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action?
Facilitate referrals to occupational and physical therapy
patient diagnosed with systemic lupus erythematosus has been admitted . Which of the following nursing diagnoses is the most plausible inclusion in the plan of care?
Fatigue Related to Anemia
nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient?
Fatigue Related to Pain.Fibromyalgia is characterized by fatigue, generalized muscle aching, and stiffness.
Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV?
Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 2% of the population but 61% of the new infections.
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same patient.
patient who has received a heart transplant is taking cyclosporine, animmunosuppressant. What should the nurse emphasize during health education about infection prevention?
Hand hygiene is imperative in infection control. A well-balanced diet is important, but for most patients this is secondary to hygiene as an infection-control measure.
nurse is planning the care of a patient who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. the most important component of infection control in the care of this patient?
Hand hygiene is usually considered the most important aspect of infection control.
nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
In prioritizing care, the pneumonia would be assessed first by the nurse. Tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority.
A patient with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient?
Identifying the offending agent, if possible
The nurse is caring for a patient with an immunodeficiency who has experienced sudden malaise. The nurse's colleague states, "I'm pretty sure that it's not an infection, because the most recent blood work looks fine." What principle should guide the nurse's response to the colleague? Immunodeficient patients will usually exhibit subtle and atypical signs of infection.
Immunodeficient patients often lack the typical objective and subjective signs and symptoms of infection.
A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin?
Immunoglobulin E
A patient who has AIDS has been admitted for the treatment of Kaposi's sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?
Impaired Skin Integrity Related to Kaposi's Sarcoma
A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education?
Importance of personal hygiene
The nurse is creating a care plan for a patient suffering from allergic rhinitis. Which of the following outcomes should the nurse identify?
Improved coping with lifestyle modifications
What assessment finding is most consistent with the clinical presentation of RA? Joint stiffness, especially in the morning
In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning. Joints are typically swollen, not atrophied,
patient's primary immunodeficiency disease is characterized by the inability of white blood cells to initiate an inflammatory response to infectious organisms. What is the diagnosis?
In one rare type of phagocytic disorder, hyperimmunoglobulinemia E syndrome , white blood cells cannot initiate an inflammatory response to infectious organisms.
A patient with SLE has come to the clinic for a routine check-up. When auscultating the patient's apical heart rate, the nurse notes the presence of a distinct "scratching" sound. What is the nurse's most appropriate action?
Inform the primary care provider that a friction rub may be present.
A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following?
Increased uric acid levels Gout is caused by hyperuricemia (increased serum uric acid).
A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the patient to do?
Keep her hands well-moisturized at all times.
nurse is planning the care of a patient with AIDS who is admitted to the unit with Pneumocystis pneumonia . Which nursing diagnosis has the highest priority
Ineffective Airway Clearance is the priority nursing diagnosis for the patient with Pneumocystis pneumonia . Airway and breathing take top priority
A 6-month-old infant has been diagnosed with X-linked agammaglobulinemia and the parents do not understand why their baby did not develop an infection during the first months of life. The nurse should describe what phenomenon?
Infants with X-linked agammaglobulinemia usually become symptomatic after the natural loss of maternally transmitted immunoglobulins (passive acquired immunity), which occurs at about 5 to 6 months of age.
patient has a diagnosis of rheumatoid arthritis and the provider has now prescribed cyclophosphamide (Cytoxan). nurse's assessments should address what potential adverse effect?
Infection.When administering immunosuppressives such as Cytoxan, the nurse should be alert to manifestations of bone marrow suppression and infection.
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
Keep the patient's bed linens free of wrinkles.
5-year-old boy has been diagnosed with a severe food allergy. What is important parameter to address when educating the parents of this child about his allergy and care?
Wear a medical identification bracelet.
A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. What topics should the nurse address during health education?
Managing Raynaud's-type symptoms, Smoking cessation, The importance of vigilant skin care
A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurse's choice of educational interventions?
Many older adults do not see themselves as being at risk for HIV infection.
nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following?
Methotrexate Rheumatrex Now it is recommended that treatment with the non-biologic DMARDs begin within 3 months of disease onset.
A nurse is caring for a patient who has allergic rhinitis. What intervention would be most likely to help the patient meet the goal of improved breathing pattern?
Modify the environment to reduce the severity of allergic symptoms.
A patient is learning about his new diagnosis of asthma with the asthma nurse. What medication has the ability to prevent the onset of acute asthma exacerbations?
Montelukast Singulair
patient's current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors . dietary counseling will the nurse provide based on the patient's medication regimen?
NRTIs exist, but all of them may be safely taken without regard to meals. Protein, fluid, and sodium restrictions play no role in
patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?
Obtain a stool culture to identify possible pathogens
A patient has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The nurse should be aware of what aspects of PMR?
PMR has an association with the genetic marker HLA-DR4, Immunoglobulin deposits occur in PMR, PMR occurs predominately in Caucasians
A patient with Wiskott-Aldrich syndrome is admitted to the medical unit. The nurse caring for the patient should prioritize which of the following? Protective isolation
Patients with Wiskott-Aldrich syndrome are at a grave risk for infection; infection prevention is a priority aspect of nursing care.
patient who has a diagnosis of paroxysmal nocturnal hemoglobinuria. When planning this patient's care, nurse should recognize patient's heightened risk of what complications.
Patients with paroxysmal nocturnal hemoglobinuriahave a high incidence of life-threatening venous thrombosis, which occurs most commonly in the abdominal and cerebral veins.
A patient has been admitted with a phagocytic cell disorder and the nurse is reviewing the most common health problems that accompany these disorders.
Patients with phagocytic cell disorders experience recurrent cutaneous abscesses, chronic eczema, bronchitis, pneumonia, chronic otitis media, and sinusitis.
A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
Perianal region and oral mucosa
nurse is caring for a patient who has an immunodeficiency. What assessment finding should prompt nurse to consider that the patient is developing an infection?
Persistent diarrhea is among the varied signs and symptoms that may suggest infection in an immunocompromised patient.
The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what?
Positive test results indicate that antibodies to the AIDS virus are present in the blood.
A nurse's plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals?
Preserve and increase range of motion while limiting joint stress .
nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency
Primary immunodeficiency diseases are genetic in origin and result from intrinsic defects in the cells of the immune system.
nurse has created a plan of care for an immunodeficient patient, specifying that care providers take the patient's pulse and respiratory rate for a full minute.
Pulse rate and respiratory rate should be counted for a full minute, because subtle changes can signal deterioration in the patient's clinical status.
decreased mobility is ultimately the result of an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. patient has been diagnosed with
RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane
The nurse is preparing to care for a patient who has scleroderma. The nurse refers to resources that describe CREST syndrome. the following is a component of CREST syndrome?
Raynaud's phenomenon The "R" in CREST stands for Raynaud's phenomenon.
A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, what management technique should the nurse emphasize?
Restrict consumption of foods high in purines. Although severe dietary restriction is not necessary, the nurse should encourage the patient to restrict consumption of foods high in purines, especially organ meats.
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patient's care, what nursing diagnosis should be prioritized?
Risk for Impaired Gas Exchange Related to Airway Obstruction
woman was diagnosed with Raynaud's phenomenon because of a progressive worsening of her symptoms patient states that many of her skin surfaces are "stiff, like the skin is being stretched from all directions."
Scleroderma starts insidiously with Raynaud's phenomenon and swelling in the hands.the skin and the subcutaneous tissues become increasingly hard and rigid
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment?
Serum albumin level Weight history Body mass index Blood urea nitrogen (BUN) level
patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should further assess the patient for the adverse effects of what medications?
Stomatitis is an adverse effect that is associated with gold therapy.
The nurse's assessment reveals that the patient's submandibular lymph nodes are swollen, a finding that represents a change from the previous day.
Swollen lymph nodes are suggestive of infection and warrant prompt medical assessment and treatment.
A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?
Teach the patient guided imagery.
nurse is admitting a patient with an immunodeficiency to the medical unit. planning the care of this patient, nurse should assess for what common sign of immunodeficiency?
The cardinal symptoms of immunodeficiency include chronic or recurrent severe infections, infections caused by unusual organisms or organisms that are normal body flora,
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to squeeze out air.
A patient's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patient's drug regimen.
The drug should be used for as short a time as possible.
A nurse at an allergy clinic is providing education for a patient starting immunotherapy for the treatment of allergies. What education should the nurse prioritize?
The importance of keeping appointments for desensitization procedures
A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is a priority for health education?
The need for the parents to carry an epinephrine pen
The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient?
The nurse can help the patient verbalize feelings and identify resources for support. The nurse should respond with an open-ended question
IVIG has been ordered for patient with an immunodeficiency. Which of the following actions should the nurse perform before administering this blood product?
The nurse should obtain height and weight before treatment to verify accurate dosing. IVIG can be administered through a peripheral line.
nurse has admitted a patient diagnosed with severe combined immunodeficiency disease to the unit. patient's orders include IVIG. How will the patient's dose of IVIG be determined?
The optimal dosage of IVIG is determined by the patient's response. In most instances, an IV dose of 200 to 800 mg/kg of body weight is administered
A patient is in the primary infection stage of HIV. What is true of this patient's current health status?
The patient is infected with HIV but lacks HIV-specific antibodies.
nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurse's teaching?
The patient must be made aware that all health-related instructions are lifelong. Immunizations may be contraindicated and infection usually requires inpatient treatment.
nurse is preparing to discharge a patient with an immunodeficiency. preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize?
The patient who is to receive IVIG at home will need information about adverse reactions and their management.
A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patient's care, what goal should the nurse include?
The patient will express satisfaction with her ability to perform ADLs.
A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor?
The patient's body mass index is 34 obese.
nurse is performing a visit to the home of a patient who has rheumatoid arthritis. On what aspect of the patient's health should the nurse focus most closely during the visit?
The patient's functional status
patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test?
The safest way the test can be facilitated is to have a portable x-ray machine in the patient's room.
A patient's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patient's immune response.
This physiologic state is known as which of the following? viral set point
parents of a 1-month-old infant bring their child to the pediatrician with symptoms of congestive heart failure.infant is ultimately diagnosed with DiGeorge syndrome. What will prolong this infant's survival?
Transplantation of fetal thymus, postnatal thymus, or human leukocyte antigen matched bone marrow has been used for permanent reconstitution of T-cell immunity in infants with DiGeorge syndrome.
A patient has sought care, stating that she developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?
Type I Urticaria hives is a type I hypersensitive allergic reaction
A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient.
What is the nurse's best response? AIDS is commonly transmitted by contact with blood and body fluids.
A patient was prescribed an antibiotic for treatment of sinusitis. patient has now stopped, stating she developed a rash shortly after taking the first dose of the drug.
What is the nurse's most appropriate response? Refer the woman to her primary care provider to have the medication changed.
A nurse is planning the care of a patient who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia.
What nursing diagnosis is most likely to apply to this woman's care needs? Ineffective Role Performance Related to Pain
The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms.
What risk nursing diagnosis should the nurse include in the patient's care plan? Risk for Disturbed Body Image Related to Skin Lesions
patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it.
What would be the nurse's best response?"I can only imagine how you feel. Would you like to talk about it?"
nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold?
When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS.
A patient is diagnosed with giant cell arteritis and is placed on corticosteroids. A concern for this patient is that he will stop taking the medication as soon as he starts to feel better.
Why must the nurse emphasize the need for continued adherence to the prescribed medication? To avoid complications such as blindness
nurse is preparing to administer IVIG to a patient who has an immunodeficiency. What nursing guideline should the nurse apply?The nurse should administer pretreatment
acetaminophen and diphenhydramine as prescribed 30 minutes before the start of the infusion. patient should be weighed prior and IV infusion rate should not exceed 200 ml/Hr
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patient's discharge. In the event of an
anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site? Thigh
A hospital nurse has experienced percutaneous exposure to an HIV-positive patient's blood as a result of a needlestick injury. The nurse has informed the supervisor
and identified the patient. What action should the nurse take next? Report to the emergency department or employee health department.
A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses anger
and irritation when her call bell isn't answered immediately. "You seem like you're feeling angry. Is that something that we could talk about?"
An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/μL, and the nurse recognizes the patient's increased risk for Mycobacterium
avium complex (MAC disease). The nurse should anticipate the administration of what drug? Azithromycin
The nurse is admitting a patient to the unit with a diagnosis of ataxia-telangiectasia. The nurse's assessment should reflect the patient's increased risk for what complication?
cancer Frequent causes of death in patients with ataxia-telangiectasiaare chronic pulmonary disease and malignancy.
A child is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are
common allergens? Eggs and wheat seafood lobster, legumes peanuts, peas, beans, licorice, seeds sesame, cottonseed, caraway, mustard, flaxseed, sunflower seeds),
The nurse in an allergy clinic is educating a new patient about the pathology of the patient's health problem. What response should the nurse describe as a possible
consequence of histamine release?Contraction of bronchial smooth muscle
An adolescent patient's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient
consequently faces an increased risk of what health problem? Asthma
A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond?
nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach, emphasizing the need to communicate with care providers.
She states that she is frustrated by her chronic nasal congestion, anosmia inability to smell inability to concentrate. nurse should identify which of the following nursing
diagnoses? Ineffective Individual Coping with Chronicity of Condition and Need for Environmental Modification
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patient's plan of care. The presence of what chronic health problem would most likely prompt this
diagnosis? Spina bifida Patients with spina bifida are at a particularly high risk for developing a latex allergy.
A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed
diagnostic workup that reveals a phagocytic disorder.This patient faces an increased risk of what complication? Patients with phagocytic cell disorders develop severe neutropenia.
immunodeficiency is admitted to the unit with an acute episode of upper airway edema. This is the fifth time in the past 3 months that the patient has had such as episode. nurse caring
for this patient, you know that the patient may have a deficiency of what?C1esterase inhibitor which opposes the release of inflammatory mediators.
A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the patient appears to have lost some of her ability to
function since her last office visit. Which of the following is the most appropriate action?Arrange for the patient to be assessed in her home environment.
The nurse is applying standard precautions in the care of a patient who has an immunodeficiency. What are key elements of standard precautions? Select all that apply.
include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions.)
nurse is caring for a patient with a phagocytic cell disorder. The patient states, "My specialist says that I will likely be cured after I get my treatment tomorrow." To what treatment
is patient most likely referring? Hematopoietic stem cell transplantation another form of cell therapy, has proven to be a successful curative modality.
nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, motor functions. nurse recognizes that these symptoms are most
likely related to the onset of what complication?HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, motor functions.
A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patient's gastrointestinal system and analyzing the data, what is most
likely to be the priority nursing diagnosis?Diarrhea is a problem in 50% to 60% of all AIDS patients.
An office worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the
office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? Anaphylactic (type 1)
A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the
management of the patient's diarrhea? Sandostatin octreotide is a man made protein
home health nurse is assessing a patient who is immunosuppressed following a liver transplant. What is the most essential teaching for this patient and the family?
must be informed of the need for continuous monitoring for subtle changes in the patient's physical health status and of the importance of seeking immediate health care if changes are detected.
A patient has just been told by his physician that he has scleroderma. The physician tells the patient that he is going to order some tests to assess for systemic involvement. The
nurse knows that priority systems to be assessed include what?GI Assessment of systemic involvement with scleroderma attention to gastrointestinal, pulmonary, renal, and cardiac systems. Liver,
home health nurse will soon begin administering IVIG to a new patient on a regular basis. What teaching should the nurse provide to the patient?
patient who is to receive IVIG at home will need information about the expected benefits and outcomes of the treatment as well as expected adverse reactions and their management.
A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the
patient's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Foods, Medications, Insect stings,latex
nurse is working with the team to care for a patient who has recently been diagnosed with severe combined immunodeficiency disease . What treatment is likely of most benefit to this
patient?Treatment options for SCID include stem cell and bone marrow transplantation, but HSCT is the definitive therapy for the disease and
A nurse is providing health education regarding self-care to a patient with an immunodeficiency. What teaching point should the nurse emphasize?
patients develop oral manifestations and need education about promoting good dental hygiene to diminish the oral discomfort and complications that frequently result in inadequate nutritional intake.
A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will
present with what alteration in laboratory values? Increased eosinophils
A patient diagnosed with common variable immune deficiency has been admitted to the acute medicine unit. When reviewing this patient's laboratory findings, the nurse should
prioritize what values? patient diagnosed with CVID often develops pernicious anemia; the patient's hemoglobin and vitamin B12 levels would be used to assess for complications
Family members of an immunocompromised patient have asked the nurse why antibiotics are not being given to the patient in order to prevent infection.the nurse best respond
prophylactic drug treatment effectively prevents some bacterial and fungal infections, it must be used with caution because it has been implicated in the emergence of resistant organisms.
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young I used to take antihistamines, but they always
put me to sleep." How should the nurse best respond "The newer antihistamines are different than in years past, and cause less sedation."
child has been transported to the ED after a severe allergic reaction. The ED nurse is evaluating the patient's respiratory status. How should the nurse evaluate the patient's
respiratory status?Assess breath sounds, Measure the child's oxygen saturation by oximeter, Monitor the child's respiratory pattern, Assess the child's respiratory rate
A nurse is providing care for a patient who has a rheumatic disorder. The nurse's comprehensive assessment includes the patient's mood, behavior, LOC, and neurologic
status. What is this patient's most likely diagnosis? Systemic lupus erythematosus (SLE)
patient diagnosed with rheumatoid arthritis patient tells the nurse that she has not been taking her medication because she usually cannot remove the childproof medication lids.
the nurse best facilitate the patient's adherence to her medication regimen?Encourage her to have pharmacy replace the tops with alternatives that are easier to open.
A patient who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should
the nurse implement? The patient's test should be cancelled until he is off his corticosteroids.
After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy,
the nurse should promote what action?Removing the cat from the family's home
A patient's decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies
the patient's health problem? The patient's body has mistakenly identified a normal constituent of the body as foreign. Type II reactions, or cytotoxic hypersensitivity,
nurse's plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. nursing intervention best addresses this risk?
thorough mouth care has the potential to prevent or limit the severity of this infection.
A patient with diagnosis of common variable immunodeficiency begins to develop thick, sticky, tenacious sputum. The patient has a history of episodes of pneumonia at least one
time per year for the last 10 years. What does the nurse suspect the patient is developing? bronchiectasis and pulmonary failure.
A nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatoid arthritis. The patient has been prescribed antimalarials for
treatment, so the nurse knows to teach the patient to self-monitor for what adverse effect? Visual changes
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having
trouble breathing. What should the nurse suspect? Anaphylaxis due to a latex allergy
