Week 2 (30)

14)The nurse is educating a client about allergy management at home. What client statements indicate no further teaching is required? Select all that apply.

* "I have pull shades on all of my windows."*"I bought a wooden chair for my living room."

24)A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?

* "I understand your concern. The blood is screened very carefully for different viruses as well as HIV."

23)A client requires a blood transfusion for anemia and informs the nurse that he refuses because he doesn't want to contract acquired immune deficiency syndrome (AIDS). What is the best response by the nurse?

* "The blood is screened very carefully; the risk is approximately 1 in 2,000,000.

25)A client with acquired immunodeficiency syndrome is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?

* Listen and show interest as the client expresses feelings.

7)Lymphoid tissues, which perform a function within the immune response, are found throughout the body. While the thymus gland, tonsils and adenoids, spleen, and lymph nodes are lymphoid tissues, where else in the body can lymphoid tissues be found? Select all that apply.

* intestines,*lungs

11)The nurse is teaching a client about a recent order for loratadine to help with seasonal allergies. What client statements indicate no further teaching is required? Select all that apply.

*"Taking my medication on an empty stomach is a must."* "Sucking on ice chips will help if my mouth is dry."* "Being careful driving is important after taking the medication."*"It is recommended that I buy a humidifier for my bedroom."

18)A 17-year-old girl with spina bifida is helping her mother prepare for her younger brother's birthday party. After blowing up a balloon, the girl develops erythema and itching around her mouth. This is likely due to which of the following?

*A latex allergy

4)A nurse has given a child's scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following?

*Active acquired immunity

15)A client is experiencing severe anaphylactic shock. What actions should the nurse take first? Select all that apply.

*Administer diphenhydramine.*Ask the client if they are lightheaded.*Give intravenous fluids.*Prepare for insertion of an endotracheal tube.

19)The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?

*Airway obstruction

10)A client has not responded to chemotherapy and radiation therapy. What option may be available for treatment for this client?

*Aldesleukin

13)A client is experiencing an acute hemolytic reaction. What actions should the nurse take? Select all that apply.

*Check for low back pain.*Assess for anxiety and mental status changes.*Notify the health care provider.

21)Other than abstinence, what is the only proven method of decreasing the risk of sexual transmission of HIV infection?

*Consistent and correct use of condoms

2)All the following items are related to cancer. Which does not affect the immune system?

*Diagnostic tests for cancer

16)A nurse is providing information on food allergies to a group of teachers. What food items would the nurse inform the teachers are common allergens?

*Eggs and nuts

30)A client with AIDS is having a recurrence of 10 to 12 loose stools a day. What medication may help this client with controlling the chronic diarrhea?

*Octreotide

5)The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

*Palpation of the client's lymph nodes

26)A nurse is completing a nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.

*Serum albumin level,*Weight history,*Body mass index,*Blood urea nitrogen (BUN) level

9)A patient with a recent diagnosis of HIV infection has expressed to the nurse that he is motivated to learn as much about his disease as possible. The patient has heard and read about the role of the different T cells, but is unclear of their roles in the immune response. Which of the following roles of T cells should the nurse identify? Select all that apply.

*Stimulating the immune system,*Secreting cytokines,*Directly attacking antigens,*Activating other T cells

29)A client's current antiretroviral regimen includes enfuvirtide (T-20). What dietary counseling will the nurse provide based on the client's medication regimen?

*Take this medication without regard to meals.

28)The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? Select all that apply.

*The CD4 count is the major indicator of immune function and guides therapy.*Antiretroviral therapy targets different stages of the HIV life cycle.

8)An older client doesn't understand why advancing age increases susceptibility to illness. What will be included in the nurse's explanation? Select all that apply.

*The body's number of T-cell lymphocytes decreases with age,*The amount of antibody produced in response to most foreign antigens decreases with age.

1)Why would it be important for the nurse to question the client about sexual practices, history of substance abuse, and his lifestyle during the interview process?

*To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS)

22)A client who is HIV/AIDS positive has orders for laboratory tests to be performed. What precautions should the nurse observe whenever there is a risk of exposure to the blood and body fluids of an infected client?

*Transport the specimens of body fluids in leak-proof containers.

3)A nurse has been administering seasonal influenza vaccinations to the residents of a long-term care facility. One resident has refused the vaccinations, stating that he believes the vaccination to be a cause of influenza infection rather than a protection against it. The nurse's response to this resident should encompass which of the following facts about vaccination?

*Vaccination prompts the body to produce antibodies against influenza.

6)The nurse is reviewing the client's medications. What antihistamines are contraindicated for a client with narrow-angle glaucoma? Select all that apply.

*diphenhydramine,*loratadine,*cetirizine,*brompheniramine

12)The nurse is conducting an assessment on a client that has acute irritant contact dermatitis. What signs and symptoms would the nurse expect to see upon assessment? Select all that apply.

*edema*redness

20)Client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What action is of primary importance upon admission?

*maintain airway

17)A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action?

*maintaining an open airway

27)It is important for a nurse to refer an HIV-positive client to support groups and resources because:

*support groups and resources provide information about new HIV drug development and clinical drug trials to clients.