Chapter 17 Iggy Practice Questions, Chapter 18 Iggy Practice Questions 3-2, IGGY Ch.37 Care of Patients with Shock - Textbook, Chapter 19 Iggy Practice questions, Care of Patients with Problems with HIV Disease Ch 19 (Elsevier), IGGY Ch.19 - Care of...

A nurse is educating an immunocompromised patient about preventing infection. Which should the patient report to the health care provider immediately? 1 Foul-smelling or cloudy urine 2 Missing a dose of prescribed drugs 3 An intermittent cough without sputum 4 Temperature greater than 98°F

1 The patient should report to the physician immediately if there is foul-smelling or cloudy urine, because this may indicate infection. The patient should take all prescribed drugs but does not need to call the physician if he or she misses a dose; rather, he or she can read the drug's instructions that describe when to take the next dose. A persistent cough with or without sputum indicates an infection, but an intermittent cough does not. The patient only needs to contact the physician if his or her is about 100°F.

In human immunodeficiency virus (HIV) infections, more virus particles are created when the virus enters which type of host cell? 1 CD4+ T-cell 2 CD8+ T-cell 3 Natural killer T-cell 4 Gamma delta T-cell

1 To infect the host, HIV must first enter the bloodstream and then "hijack" certain cells, especially the CD4+ T-cell, also known as the CD4+ cell, helper/inducer T-cell, or T4-cell. This cell directs immunity and regulates the activity of all immune system cells. When HIV enters a CD4+ T-cell, it can then create more virus particles. CD8+ T-cells, natural killer T-cells, and gamma delta T-cells are other immune cells but are not involved directly in the replication of HIV.

What class of drugs for human immunodeficiency virus (HIV) infection prevents viral binding? 1 Entry inhibitors 2 Protease inhibitors 3 Integrase inhibitors 4 Nucleoside reverse transcriptase inhibitors (NRTIs)

1 Viral binding to the CD4 receptor and to either of the co-receptors is needed for the HIV virus to enter the cell. Entry inhibitors prevent the interaction needed for entry of HIV into the CD4+ T-cell. New virus particles are made in the form of one long protein strand that is clipped by the enzyme HIV protease into smaller functional pieces. Protease inhibitors work here to inhibit HIV protease. HIV then uses its enzyme integrase to get its DNA into the nucleus of the host's CD4+ T-cell and insert it into the host's DNA. Integrase inhibitors prevent viral DNA from integrating into the host's DNA. NRTIs prevent viral replication by reducing how well reverse transcriptase can convert HIV genetic material into human genetic material.

How often should the patient taking tenofovir/emtricitabine for pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) be tested for HIV? 1 Every three months 2 Every 12 months 3 Once before beginning PrEP 4 After each contact that puts the patient at risk for infection

1 Every three months The patient taking tenofovir/emtricitabine for PrEP for HIV should be tested for HIV every three months. Every 12 months is longer than recommended. The patient should be tested once before beginning PrEP, but the patient must continue getting screened. After each contact that carries a risk of infection is more than necessary.

Abnormal functioning of which body system is responsible for the signs and symptoms of human immunodeficiency virus (HIV) disease? 1 Immune 2 Respiratory 3 Cardiovascular 4 Gastrointestinal

1 Immune system Abnormal functioning of the immune system is responsible for the signs and symptoms of HIV disease. Signs and symptoms may occur in the respiratory, cardiovascular, and gastrointestinal symptoms, but abnormal functioning of the immune system is the underlying mechanism.

The nurse has been exposed to the blood of a patient who is human immunodeficiency virus (HIV) positive. What is the window of opportunity to begin postexposure prophylaxis (PEP) for the best possible outcome in preventing HIV infection? 1 Two hours 2 72 hours 3 Two weeks 4 One month

1 Two hours Once the exposure has been discovered, PEP with combination antiretroviral therapy (cART) within two hours of the exposure has the best possible outcome in preventing HIV infection. The window of opportunity for best outcome closes when prophylaxis is started after 72 hours. The professional receiving prophylaxis must return for complete electrolytes, creatinine, and blood counts two weeks after starting cART and periodic HIV testing at one, three, and six months.

Which gastrointestinal (GI) signs and symptoms may occur in a patient with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1 Nausea 2 Diarrhea 3 Dementia 4 Confusion 5 Lymphadenopathy 6 Hypergammaglobulinemia

1, 2 Nausea and diarrhea are GI signs and symptoms that may occur in a patient with AIDS. Dementia and confusion are central nervous system signs and symptoms. Lymphadenopathy and hypergammaglobulinemia are immunologic signs.

What disease- and treatment-related endocrine complications may occur in human immunodeficiency virus (HIV)-positive men? Select all that apply. 1 Lipoatrophy 2 Lipodystrophy 3 Decreased energy 4 Adrenal insufficiency 5 Increased testosterone

1, 2, ,3, 4 Disease- and treatment-related endocrine complications that may occur in HIV-positive men include lipoatrophy, lipodystrophy, decreased energy, adrenal insufficiency, and decreased, not increased, testosterone.

immunodeficiency virus (HIV) testing process? Select all that apply. 1 Counseling 2 Interpretation 3 Confidentiality 4 Written consent 5 Health insurance coverage

1, 2, 3 HIV testing requires counseling, interpretation, and confidentiality. Written consent and health insurance coverage are not required.

Some adults develop an acute infection within four weeks of first being infected with human immunodeficiency virus (HIV). What symptoms may indicate this acute HIV infection? Select all that apply. 1 Fever 2 Night sweats 3 Memory loss 4 Muscle aches 5 Purplish lesions

1, 2, 4 Some adults develop an acute infection within four weeks of first being infected with HIV. Symptoms are similar to those seen with any virus and include fever, night sweats, and muscle aches. Memory loss is a central nervous system symptom that may occur with acquired immunodeficiency syndrome (AIDS). Purplish lesions are a sign of Kaposi sarcoma that may occur with AIDS.

Which are common means of human immunodeficiency virus (HIV) transmission? Select all that apply. 1 Sexual 2 Casual 3 Perinatal 4 Household 5 Parenteral 6 Workplace

1, 3, 5 Common means of HIV transmission include sexual (genital, anal, or oral sexual contact with exposure of mucous membranes to infected semen or vaginal secretions); perinatal (from the placenta, from contact with maternal blood and body fluids during birth or from breast milk from an infected mother to child); and parenteral (sharing of needles or equipment contaminated with infected blood or receiving contaminated blood products). HIV is not transmitted by casual contact in the home, school, or workplace. Sharing household utensils, towels and linens, and toilet facilities does not transmit HIV.

Higher incidences of which conditions occur among pregnant women with human immunodeficiency virus (HIV)? Select all that apply. 1 Preterm delivery 2 Shoulder dystocia 3 Gestational diabetes 4 Vertical transmission 5 Low-birth-weight infants

1, 4, 5 The effect of HIV on pregnancy outcomes includes higher incidences of premature delivery, vertical transmission of the disease from the mother to the infant, and low-birth-weight infants. HIV in pregnancy is not associated with a higher risk of shoulder dystocia or gestational diabetes.

What laboratory changes are most likely in a patient whose immune system is being overwhelmed by human immunodeficiency virus (HIV)? 1 CD4+ T-cell counts and viral numbers fall 2 CD4+ T-cell counts fall, viral numbers rise 3 CD4+ T-cell counts rise, viral numbers fall 4 CD4+ T-cell counts and viral numbers rise

2 In early HIV infection before the disease is evident, the immune system can still attack and destroy most of the newly created virus particles. However, with time, the number of HIV particles overwhelms the immune system. Gradually CD4+ T-cell counts fall, viral numbers (viral load) rise, and without treatment, the patient eventually dies of opportunistic infection or cancer. Laboratory findings in a patient whose immune system is being overwhelmed by HIV would not show both CD4+ T-cell counts and viral numbers falling, CD4+ T-cell counts rising while viral numbers fall, or both CD4+ T-cell counts and viral numbers rising.

What class of drugs for human immunodeficiency virus (HIV) infection prevents new virus particles from splitting into functional pieces? 1 Entry inhibitors 2 Protease inhibitors 3 Integrase inhibitors 4 Nucleoside reverse transcriptase inhibitors (NRTIs)

2 New virus particles are made in the form of one long protein strand that is clipped by the enzyme HIV protease into smaller functional pieces. Protease inhibitors work here to inhibit HIV protease. Viral binding to the CD4 receptor and to either of the co-receptors is needed for the HIV virus to enter the cell. Entry inhibitors prevent the interaction needed for entry of HIV into the CD4+ T-cell. HIV then uses its enzyme integrase to get its DNA into the nucleus of the host's CD4+ T-cell and insert it into the host';s DNA. Integrase inhibitors prevent viral DNA from integrating into the host's DNA. NRTIs prevent viral replication by reducing how well reverse transcriptase can convert HIV genetic material into human genetic material.

How does the assessment of the financial resources of the patient with AIDS help the nurse? 1 It helps in assessing the neurologic status of the patient. 2 It helps in assessing the nutritional status of the patient. 3 It helps in assessing the cardiovascular status of the patient. 4 It helps in assessing the gastrointestinal status of the patient.

2 The financial resources of an AIDS patient may give the nurse insight into the patient's food intake, weight loss or gain, general condition of skin, and overall nutritional status of the patient. Cognitive changes, motor changes, and sensory disturbances are part of the assessment of the neurologic status of the patient. The cardiovascular status is assessed via the heart, veins, and arteries. The gastrointestinal status is assessed through the mouth and oropharynx, presence of dysphagia, presence of abdominal pain, or the presence of nausea, vomiting, diarrhea, or constipation.

According to the Centers for Disease Control and Prevention (CDC) classifications, what stage of human immunodeficiency virus (HIV) is marked by CD4+ T-cell count greater than 500 cells/mm 3 (0.5 × 109/L) or 29% or greater? 1 Stage 0 2 Stage 1 3 Stage 2 4 Stage 3

2 Stage 1 Stage 1 CDC Case Definition describes a patient with CD4+ T-cell count greater than 500 cells/mm 3 (0.5 × 109 /L) or 29% or greater. An adult at this stage has no AIDS-defining illnesses. Stage 0 CDC Case Definition describes a patient who develops a first positive HIV test result within six months after a negative HIV test result. Changing the patient';s status to stage 1, 2, or 3 does not occur until six months have elapsed since the stage 0 designation, even when CD4+ T-cell counts decrease or an AIDS-defining condition is present. Stage 2 CDC Case Definition describes a patient with CD4+ T-cell count between 200-499 cells/mm 3 (0.2-0.449 × 109/L) or 14-28%. An adult at this stage has no AIDS-defining illnesses. Stage 3 CDC Case Definition describes any patient with CD4+ T-cell count less than 200 cells/mm 3 (0.2 × 109/L) or less than 14%. An adult who has higher CD4+ T-cell counts or percentages but who also has an AIDS-defining illness meets the Stage 3 CDC Case Definition.

In patients with human immunodeficiency virus (HIV), which type of laboratory test measures the patient's response to the virus rather than parts of the virus? 1 Stool testing 2 Skin biopsies 3 Antibody testing 4 Viral load testing

3 Antibody tests are used to measure the patient's response to the virus (the antigen) rather than parts of the virus. Stool testing and skin biopsies test for opportunistic infections. Viral load testing directly measures the actual amount of HIV viral RNA particles present in the blood.

Patients with low CD4+ T-cell counts are at risk for what conditions caused by organisms that are present as part of the body's microbiome and usually kept in check by normal immunity? 1 Primary infections 2 Secondary infections 3 Opportunistic infections 4 AIDS-defining conditions

3 As the CD4+ T-cell level drops, the patient is at an increased risk for bacterial, fungal, and viral infections, as well as opportunistic cancers. Opportunistic infections are those caused by organisms that are present as part of the body's microbiome and usually are kept in check by normal immunity. These infections are not known as primary infections or secondary infections. Many opportunistic infections are also acquired immunodeficiency syndrome (AIDS)-defining conditions, but AIDS-defining conditions are not necessarily opportunistic infections.

What class of drugs for human immunodeficiency virus (HIV) infection prevents the virus from inserting its DNA into the host's DNA? 1 Entry inhibitors 2 Protease inhibitors 3 Integrase inhibitors 4 Nucleoside reverse transcriptase inhibitors (NRTIs)

3 HIV uses its enzyme integrase to get its DNA into the nucleus of the host's CD4+ T-cell and insert it into the host';s DNA. Integrase inhibitors prevent viral DNA from integrating into the host's DNA. Viral binding to the CD4 receptor and to either of the co-receptors is needed for the HIV virus to enter the cell. Entry inhibitors prevent the interaction needed for entry of HIV into the CD4+ T-cell. New virus particles are made in the form of one long protein strand that is clipped by the enzyme HIV protease into smaller functional pieces. Protease inhibitors work here to inhibit HIV protease. NRTIs prevent viral replication by reducing how well reverse transcriptase can convert HIV genetic material into human genetic material.

In North America, the highest rates of new human immunodeficiency virus (HIV) infections occur among which population? 1 Women 2 Men who have sex with men 3 African American and Hispanic adults 4 Adults who have used injection drugs

3 In North America, the highest rates of new HIV infections occur among African American and Hispanic adults. Women, men who have sex with men, and adults who have used injection drugs have lower rates of infection.

What defines the concept known as treatment as prevention (TAP) of human immunodeficiency virus (HIV)? 1 Written consent for including HIV screening as part of routine testing is not required. 2 The use of HIV-specific antiretroviral drugs in an HIV-uninfected adult serves the purpose of preventing HIV infection. 3 The use of combination antiretroviral therapy (cART) reduces the viral load to undetectable levels, thereby reducing the risk of HIV transmission. 4 Expanded screening recommendations include a one-time screen for all adults ages 15-65, annual screening of those at heightened risk, routine prenatal screening, and frequent testing in adults with repeated high-risk exposures.

3 Once an adult is placed on cART, reducing the viral load to undetectable levels significantly reduces the risk that HIV will be transmitted, a concept known as TAP. TAP is not defined by a lack of written consent for routine testing, the use of HIV-specific antiretroviral drugs in an HIV-uninfected adult to prevent HIV infection, or expanded screening recommendations.

Which term describes infections caused by organisms that are present as part of the body's microbiome and usually are kept in check by normal immunity but may cause infection in patients with acquired immunodeficiency syndrome (AIDS)? 1 Viral infections 2 Co-occurring infections 3 Opportunistic infections 4 Sexually transmitted infections

3 Opportunistic infections are infections caused by organisms that are present as part of the body's microbiome and usually are kept in check by normal immunity but may cause infection in patients with AIDS. Opportunistic infections may be viral infections, as well as fungal, bacterial, and protozoal infections and malignancies. Co-occurring infections is a more general term to describe infections that occur simultaneously. Opportunistic infections may be sexually transmitted but are not necessarily transmitted this way.

According to the Centers for Disease Control and Prevention (CDC) classifications, what stage of human immunodeficiency virus (HIV) is marked by CD4+ T-cell count between 200-499 cells/mm 3 (0.2-0.449 × 109/L) or 14-28%? 1 Stage 0 2 Stage 1 3 Stage 2 4 Stage 3

3 Stage 2 CDC Case Definition describes a patient with CD4+ T-cell count between 200-499 cells/mm 3 (0.2-0.449 × 109/L) or 14-28%. An adult at this stage has no AIDS-defining illnesses. Stage 0 CDC Case Definition describes a patient who develops a first positive HIV test result within six months after a negative HIV test result. Stage 1 CDC Case Definition describes a patient with CD4+ T-cell count greater than 500 cells/mm 3 (0.5 × 109 /L) or 29% or greater. An adult at this stage has no AIDS-defining illnesses. Stage 3 CDC Case Definition describes any patient with CD4+ T-cell count less than 200 cells/mm 3 (0.2 × 109/L) or less than 14%. An adult who has higher CD4+ T-cell counts or percentages but who also has an AIDS-defining illness meets the Stage 3 CDC Case Definition.

Which features of the human immunodeficiency virus (HIV) virus assist the viral particle in finding a host? 1 RNA and lipid bilayer 2 P17 matrix and p24 capsid 3 Gp41 and gp120 docking proteins 4 Reverse transcriptase and integrase enzymes

3 Viral particle features include an outer envelope with special "docking proteins," known as gp41 and gp120, which assist in finding a host. The RNA and lipid bilayer, p17 matrix and p24 capsid, and reverse transcriptase and integrase enzymes are other features of the HIV viral particle that do not assist in finding a host.

The number of CD4+ T-cells is reduced in human immunodeficiency virus (HIV) disease. How many CD4+ T-cells are usually present in a cubic millimeter (mm 3) of a healthy adult's blood? 1 200-499 2 500-799 3 800-1000 4 More than 1000

3 800-1000 A healthy adult usually has 800-1000 CD4+T-cells/mm 3. A patient with 200-499 CD4+T-cells/mm 3 meets the criteria for stage 2 of the Centers for Disease Control and Prevention (CDC) Case Definition of HIV disease. A patient with greater than 500 CD4+T-cells/mm 3 meets the criteria for stage 1 CDC Case Definition of HIV disease. More than 1000 CD4+T-cells/mm 3 may be present in a healthy adult but are not typical.

Which sexual act carries the highest risk for the transmission of human immunodeficiency virus (HIV)? 1 Kissing 2 Oral sex 3 Anal sex 4 Vaginal sex

3 Anal sex Sexual acts or practices that permit infected seminal fluid to come into contact with mucous membranes or nonintact skin carry the highest risk for sexual transmission of HIV. The practice with the highest risk is anal intercourse with the penis and seminal fluid of an infected adult coming into contact with the mucous membranes of the uninfected partner's rectum. Anal intercourse allows seminal fluid to make contact with the rectal mucous membranes and also tears the mucous membranes, making infection more likely. Kissing is considered low risk for transmission unless obvious blood is present. Oral sex and vaginal sex are risky sexual acts for the transmission of HIV but less so than anal sex.

What phase of the human immunodeficiency virus (HIV) life cycle involves separating from the infected cell's membrane to search for another CD4+ T-cell to infect? 1 Virion 2 Fusion 3 Budding 4 Uncoating

3 Budding The budding phase of the HIV life cycle involves separating from the infected cell's membrane to search for another CD4+ T-cell to infect. Virion, fusion, and uncoating phases occur earlier in the HIV life cycle.

When the human immunodeficiency virus (HIV) virus enters the patient's CD4+ T-cell, what is the new role served by the immune cell? 1 Antigen 2 Antibody 3 HIV factory 4 Natural killer cell

3 HIV factory Effects of HIV infection are related to the new genetic instructions that now direct CD4+ T-cells to change their role in immune system defenses. The new role is to be an "HIV factory," making up to 10 billion new viral particles daily. The CD4+ cell does not become an antigen, antibody, or natural killer cell.

Which central nervous system (CNS) signs and symptoms may occur in a patient with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1 Nausea 2 Diarrhea 3 Dementia 4 Confusion 5 Lymphadenopathy 6 Hypergammaglobulinemia

3, 4 Dementia and confusion are CNS signs and symptoms that may occur in a patient with AIDS. Nausea and diarrhea are gastrointestinal signs and symptoms. Lymphadenopathy and hypergammaglobulinemia are immunologic signs.

To prevent infection in the patient with human immunodeficiency virus (HIV), the nurse should educate the patient to avoid which foods? Select all that apply. 1 Salty foods 2 Cooked fruits 3 Raw vegetables 4 Undercooked meat 5 Pepper and paprika

3, 4, 5 To prevent infection, the patient with HIV should avoid eating raw vegetables, undercooked meats, and pepper and paprika. Salty foods and cooked fruits do not have a high risk of causing infection.

Which factor distinguishes a diagnosis of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS)? 1 Viral load 2 Course of treatment 3 Duration of infection 4 Number of CD4+ T-cells

4 Everyone who has AIDS has an HIV infection, but not everyone who has HIV has AIDS. The distinction is the number of CD4+ T-cells and whether any opportunistic infections have occurred. Viral load, course of treatment, and duration of infection are not distinguishing factors between HIV and AIDS diagnoses.

What is true regarding the risk of human immunodeficiency virus (HIV) transmission from patients receiving combination antiretroviral therapy (cART)? 1 The patient's viral load is low, so there is no risk of transmission. 2 The patient is no longer HIV positive, so there is no risk of transmission. 3 The patient's viral load and risk of transmission remain high, although other signs and symptoms may decrease. 4 The patient's viral load may drop to undetectable levels, but there is still a risk of transmission.

4 In patients receiving cART, the patient's viral load may drop to undetectable levels, but there is still a risk of transmission. It is not true that there is no risk of transmission. The patient remains HIV positive. Viral load and risk of transmission are likely to be reduced with cART.

What class of drugs for human immunodeficiency virus (HIV) infection reduces how well HIV genetic material can be converted into human genetic material? 1 Entry inhibitors 2 Protease inhibitors 3 Integrase inhibitors 4 Nucleoside reverse transcriptase inhibitors (NRTIs)

4 NRTIs prevent viral replication by reducing how well reverse transcriptase can convert HIV genetic material into human genetic material. Viral binding to the CD4 receptor and to either of the co-receptors is needed for the HIV virus to enter the cell. Entry inhibitors prevent the interaction needed for entry of HIV into the CD4+ T-cell. New virus particles are made in the form of one long protein strand that is clipped by the enzyme HIV protease into smaller functional pieces. Protease inhibitors work here to inhibit HIV protease. HIV uses its enzyme integrase to get its DNA into the nucleus of the host's CD4+ T-cell and insert it into the host's DNA. Integrase inhibitors prevent viral DNA from integrating into the host's DNA.

According to the Centers for Disease Control and Prevention (CDC) classifications, what stage of human immunodeficiency virus (HIV) is marked by CD4+ T-cell count less than 200 cells/mm 3 (0.2 × 109/L) or less than 14%? 1 Stage 0 2 Stage 1 3 Stage 2 4 Stage 3

4 Stage 3 CDC Case Definition describes any patient with CD4+ T-cell count less than 200 cells/mm 3 (0.2 × 109/L) or less than 14%. An adult who has higher CD4+ T-cell counts or percentages but who also has an AIDS-defining illness meets the Stage 3 CDC Case Definition. Stage 0 CDC Case Definition describes a patient who develops a first positive HIV test result within six months after a negative HIV test result. Stage 1 CDC Case Definition describes a patient with CD4+ T-cell count greater than 500 cells/mm 3 (0.5 × 109 /L) or 29% or greater. An adult at this stage has no AIDS-defining illnesses. Stage 2 CDC Case Definition describes a patient with CD4+ T-cell count between 200-499 cells/mm 3 (0.2-0.449 × 109/L) or 14-28%. An adult at this stage has no AIDS-defining illnesses.

Which features of the human immunodeficiency virus (HIV) virus convert HIV's RNA into DNA and insert it into the host's DNA? 1 RNA and lipid bilayer 2 P17 matrix and p24 capsid 3 Gp41 and gp120 docking proteins 4 Reverse transcriptase and integrase enzymes

4 The HIV enzyme reverse transcriptase converts HIV's RNA into DNA, which makes the viral genetic material the same as human DNA. HIV then uses its enzyme integrase to get its DNA into the nucleus of the host's. The RNA and lipid bilayer, p17 matrix and p24 capsid, and gp41 and gp120 docking proteins are other features of the HIV viral particle that do not convert HIV's RNA into DNA and insert it into the host's DNA.

Consensual and nonconsensual sexual exposures involving insertive and receptive types of sex with oral, vaginal, or anal contact are considered which type of exposure to human immunodeficiency virus (HIV)? 1 Perinatal 2 Parenteral 3 Occupational 4 Non-occupational

4 Non-occupational Consensual and nonconsensual sexual exposures involving insertive and receptive types of sex with oral, vaginal, or anal contact are considered non-occupational exposure. Perinatal exposure involves transmission from the mother to the infant. Parenteral transmission may occur from occupational or non-occupational exposure as a result of injection drug use. Occupational exposure is defined as contact between blood, tissue, or selected body fluids from a patient who is positive for HIV and the blood, broken skin, or mucous membranes of a health care professional.

Occupational exposure of the health care worker's broken skin or mucous membranes to which body fluids from a patient with human immunodeficiency virus (HIV)-positive status requires postexposure prophylaxis? Select all that apply. 1 Feces 2 Saliva 3 Vomit 4 Breast milk 5 Amniotic fluid

4, 5 Occupational exposure is defined as contact between blood, tissue, or selected body fluids, including breast milk and amniotic fluid, from a patient who is positive for HIV and the blood, broken skin, or mucous membranes of a health care professional. Bodily substances not considered infectious for HIV unless obviously bloody include feces, saliva, and vomit.

Which immunologic signs and symptoms may occur in a patient with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1 Nausea 2 Diarrhea 3 Dementia 4 Confusion 5 Lymphadenopathy 6 Hypergammaglobulinemia

5, 6 Lymphadenopathy and hypergammaglobulinemia are immunologic signs that may occur in a patient with AIDS. Nausea and diarrhea are gastrointestinal signs and symptoms. Dementia and confusion are central nervous system signs and symptoms.

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. "Be sure you get enough sleep at night." b. "Eat plenty of high-protein, high-iron foods." c. "Notify your provider at once if you get a fever." d. "Weigh yourself every day on the same scale."

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. "Be sure you get enough sleep at night." b. "Eat plenty of high-protein, high-iron foods." c. "Notify your provider at once if you get a fever." d. "Weigh yourself every day on the same scale."

What is an example of natural passive immunity a. a mother passing breast milk to an infant b. vaccine c. used on present disease such as rabies d. the body fighting an antigen that was picked up

A. natural- comes from another organism passive- the antigens are given directly to you vaccine is not correct because it is an active artificial rabies is not correct because it is passive artificial antigen is not correct because it is active natural

18. A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4° F (39.1° C) b. Client with Bruton's agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

ANS: A A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client. DIF: Applying/Application REF: 338 KEY: HIV/AIDS| immune disorders| prioritizing| fever| infection| white blood cell count MSC: IntegratedProcess:NursingProcess:Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

3. The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands "HIV+" d. Wearing a mask within 3 feet of the client

ANS: A According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact. DIF: Remembering/Knowledge REF: 332 KEY: HIV/AIDS| infection control| Standard Precautions| immune disorders MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

ANS: A All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

ANS: A All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

2. The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse

ANS: A Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus. DIF: Understanding/Comprehension REF: 330 KEY: HIV/AIDS| safer sex| infection| immune disorders MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6° F (36.4° C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.

ANS: A Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.

ANS: A Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with the health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

ANS: A Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

ANS: A Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept.

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. "I always wear long sleeves, pants, and a hat when outdoors." b. "I try not to use cosmetics that contain any type of sunblock." c. "Since I tend to sweat a lot, I use a lot of baby powder." d. "Since I can't be exposed to the sun, I have been using a tanning bed."

ANS: A Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden's nodules. What assessment technique is correct? a. Inspect the client's distal finger joints. b. Palpate the client's abdomen for tenderness. c. Palpate the client's upper body lymph nodes. d. Perform range of motion on the client's wrists.

ANS: A Herberden's nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the client's distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists.

A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis

ANS: A Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate? a. "Drink 1 to 2 liters of water each day." b. "Have 10 to 12 ounces of juice a day." c. "Liver is a good source of iron." d. "Never eat hard cheeses or sardines."

ANS: A Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this recommendation is not clear. Clients with gout should not eat organ meats or fish with bones, such as sardines.

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3

ANS: A Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.

A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. "It increases the elimination of T lymphocytes from circulation." b. "It inhibits cytokine production in most lymphocytes." c. "It prevents DNA synthesis, stopping cell division in activated lymphocytes." d. "It prevents the activation of the lymphocytes responsible for rejection."

ANS: A Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.

A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes

ANS: A Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started "acting up," especially both hips and knees. What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Baker's cysts. b. Inspect the client's feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

ANS: A Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker's cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.

A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. "Avoid large crowds and people who are ill." b. "Check over-the-counter meds for acetaminophen." c. "Take this medicine exactly as prescribed." d. "You have a higher risk of developing cancer."

ANS: A Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils

ANS: A The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.

5. A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result What action by the nurse is most important? a. Assess the client's sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

ANS: A The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the client's sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate. DIF: Applying/Application REF: 336 KEY: HIV/AIDS| safer sexual practices| nursing assessment| immune disorders MSC: IntegratedProcess:NursingProcess:Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

14. A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client's partner is listed as the emergency contact, but the client's mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

ANS: A The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve. DIF: Applying/Application REF: 336 KEY: HIV/AIDS| autonomy| advocacy| referrals| LGBTQ MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the client's leg.

ANS: A The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

15. A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.'

ANS: A The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms. DIF: Applying/Application REF: 339 KEY: HIV/AIDS| immune disorder| antiretrovirals| HAART MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the client's culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

ANS: A The nurse needs a more thorough understanding of the client's culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.

13. A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the "AIDS guy" and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the unit's nursing management. d. Tell the client that other staff members are talking about him or her.

ANS: A The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything. DIF: Applying/Application REF: 344 KEY: HIV/AIDS| communication| advocacy| caring| patient-centered care MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

ANS: A This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

1. The nurse is caring for a client diagnosed with human immune deficiency virus. The client's CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

ANS: A This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease. DIF: Applying/Application REF: 328 KEY: HIV/AIDS| safer sex| immune disorders MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

12. A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

ANS: A This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know. DIF: Applying/Application REF: 343 KEY: HIV/AIDS| nursing assessment| psychosocial response| support| caring MSC: IntegratedProcess:Caring NOT: Client Needs Category: Psychosocial Integrity

A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include? a. "Avoid large crowds or people who are ill." b. "Stay upright for 1 hour after taking this drug." c. "This drug may cause your hair to fall out." d. "You may double the dose if pain is severe."

ANS: A This drug has a Food and Drug Administration black box warning about opportunistic or other serious infections. Teach the client to avoid large crowds and people who are ill. The other instructions do not pertain to golimumab.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotic as ordered. b. Assess the client's white blood cell count. c. Instruct the client to shower the night before. d. Monitor the client's temperature postoperatively.

ANS: A To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

19. An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. "Truvada does not reduce the need for safe sex practices." b. "This drug has been taken off the market due to increases in cancer." c. "Truvada reduces the number of HIV tests you will need." d. "This drug is only used for postexposure prophylaxis."

ANS: A Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis. DIF: Understanding/Comprehension REF: 332 KEY: HIV/AIDS| immune disorders| vaccinations| patient education MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse is caring for a client with systemic sclerosis. The client's facial skin is very taut, limiting the client's ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate? a. Dentist b. Massage therapist c. Occupational therapy d. Physical therapy

ANS: A With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells

ANS: A, B, C The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.) a. Allow the client uninterrupted rest time. b. Assess the client's usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill.

ANS: A, B, C, D Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the client's usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.

MULTIPLE RESPONSE 1. A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

ANS: A, B, C, D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease. DIF: Remembering/Knowledge REF: 327 KEY: HIV/AIDS| immune disorders| inflammation MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes

ANS: A, B, C, D Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding. DIF: Analyzing/Analysis REF: 332 KEY: HIV/AIDS| infection control| culture| patient-centered care MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Psychosocial Integrity

2. Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

ANS: A, B, D A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics. DIF: Remembering/Knowledge REF: 328 KEY: HIV/AIDS| immune disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

ANS: A, B, D Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.) a. Acupuncture b. Stretching c. Supplements d. Tai chi e. Vigorous aerobics

ANS: A, B, D There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

ANS: A, B, D, E Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." c. "Pregnancy and breast-feeding are not affected by MTX." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."

ANS: A, B, D, E MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization

ANS: A, B, D, E The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash - Systemic lupus erythematosus (SLE) b. Esophageal dysmotility - Systemic sclerosis c. Excess uric acid excretion - Gout d. Footdrop and paresthesias - Osteoarthritis e. Vasculitis causing organ damage - Rheumatoid arthritis

ANS: A, B, E A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis.

7. A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess the client's mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the client's abdomen.

ANS: A, C, D Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client's mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure. DIF: Applying/Application REF: 334 KEY: HIV/AIDS| nursing assessment| informed consent| NPO| endoscopy MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.

ANS: A, C, D, E Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply an abduction pillow to the client's legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.

ANS: A, C, E The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurse's responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.

4. A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL 3 d. Platelet count: 80,000/mm e. Serum sodium: 120 mEq/L

ANS: A, D, E The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal. DIF: Analyzing/Analysis REF: 340 KEY: HIV/AIDS| laboratory values| antibiotics| immune disorders MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth

ANS: A, D, E The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

16. A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

ANS: B Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the client's mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment. DIF: Applying/Application REF: 334 KEY: HIV/AIDS| nursing assessment| fluids and electrolytes MSC: IntegratedProcess:NursingProcess:Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

ANS: B Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this client's viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed. DIF: Applying/Application REF: 338 KEY: HIV/AIDS| nursing assessment| immune disorders| medications MSC: IntegratedProcess:NursingProcess:Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

ANS: B All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. "Are you compliant with following the diabetic diet?" b. "Have you been taking glucosamine supplements?" c. "How much exercise do you really get each week?" d. "You're still taking your diabetic medication, right?"

ANS: B All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. "Compliant" is a word associated with negative images, and the client may deny being "noncompliant." Asking how much exercise the client "really" gets is accusatory. Asking if the client takes his or her medications "right?" is patronizing.

A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

ANS: B During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

ANS: B Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.

ANS: B SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

ANS: B The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling

ANS: B The recipient's immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

ANS: B This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the client's red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The client's white blood cell count is normal, so avoiding infection is not the priority.

10. A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management? a. "Infusions will be scheduled every 3 to 4 weeks." b. "Treatment is aimed at treating specific infections." c. "Unfortunately, there is no effective treatment." d. "You will need many immunoglobulin A infusions."

ANS: B Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate. DIF: Understanding/Comprehension REF: 345 KEY: Immune disorders| patient education MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

ANS: B, C RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched? (Select all that apply.) a. Allopurinol (Zyloprim) - Acute gout b. Colchicine (Colcrys) - Acute gout c. Febuxostat (Uloric) - Chronic gout d. Indomethacin (Indocin) - Acute gout e. Probenecid (Benemid) - Chronic gout

ANS: B, C, D, E Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and probenecid. Allopurinol is used for chronic gout.

A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

ANS: B, C, D, E Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.

6. A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

ANS: B, C, D, E The UAP can assist the client with getting out of bed, obtain a bedside commode for the client's use, cleanse the client's perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status. DIF: Applying/Application REF: 341 KEY: HIV/AIDS| delegation| hygiene| elimination| patient safety| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Felty's syndrome c. Joint deformity d. Low-grade fever e. Weight loss

ANS: B, C, E Late manifestations of RA include Felty's syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

5. A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.

ANS: B, C, E The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used. DIF: Applying/Application REF: 341 KEY: HIV/AIDS| delegation| unlicensed assistive personnel (UAP)| oral care MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance

ANS: C The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.

A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. Blood urea nitrogen (BUN) of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr

ANS: C A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower siderail on the affected side. d. Remind the client to do quad-setting exercises.

ANS: C Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best? a. "A little sedation will help you get some rest." b. "Depression often accompanies fibromyalgia." c. "This drug works in the brain to decrease pain." d. "You will have more energy after taking this drug."

ANS: C Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.

17. A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. "Gabapentin can be used as an antidepressant too." b. "I have no idea why you should be taking this drug." c. "This drug helps treat the pain from nerve irritation." d. "You are at risk for seizures due to fungal infections."

ANS: C Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client. DIF: Understanding/Comprehension REF: 341 KEY: HIV/AIDS| neuropathic pain| tricyclic antidepressants| pain| pharmacologic pain management MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

ANS: C Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. "Inflammatory" is not a type of immunity.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

ANS: C Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

ANS: C Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

4. A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

ANS: C Since this client's CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case. DIF: Applying/Application REF: 334 KEY: HIV/AIDS| Transmission-Based Precautions| infection control| immune disorders MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? a. "I can bend down to pick something up." b. "I no longer need to do my exercises." c. "I will not sit with my legs crossed." d. "I won't wash my incision to keep it dry."

ANS: C There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the client's pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the client's bladder or perform a bladder scan.

ANS: C With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.

The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Collaborate with a registered dietitian for appropriate foods. b. Inspect the skin and note any areas of ulceration. c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating.

ANS: C, D, E The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynaud's phenomenon. The UAP can adjust the room temperature for the client's comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.

9. A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

ANS: D All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital. DIF: Applying/Application REF: 342 KEY: HIV/AIDS| wound care| dressings| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important? a. Administering pain medication before transport b. Answering any last-minute questions by the client c. Ensuring the family has directions to the facility d. Providing a verbal hand-off report to the facility

ANS: D As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

ANS: D Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.

An older adult has a mild temperature, night sweats, and productive cough. The client's tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).

ANS: D Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the client's TB test could be a false negative.

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal

ANS: D For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the client's hands. d. Use an abduction pillow.

ANS: D Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the client's mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the client's white blood cell count. b. Culture any drainage from the wound. c. Monitor the client's temperature every 4 hours. d. Use aseptic technique for dressing changes.

ANS: D Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren's syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity

ANS: D Sjögren's syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjögren's syndrome.

The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells

ANS: D Suppressor T cells help prevent hypersensitivity to one's own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.

8. A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

ANS: D The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients. DIF: Evaluating/Synthesis REF: 341 KEY: HIV/AIDS| malnutrition| nutrition MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the client's oxygen during activity . d. Pace activities, allowing for adequate rest.

ANS: D This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client's activity. DIF: Applying/Application REF: 340 KEY: HIV/AIDS| immune disorders| rest and sleep| fatigue MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)

ANS: D Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels.

11. An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.

ANS: D Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client. DIF: Applying/Application REF: 334 KEY: HIV/AIDS| infection control| Standard Precautions MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A client has a possible connective tissue disease and the nurse is reviewing the client's laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all that apply.) a. Elevated antinuclear antibody (ANA) - Normal value; no connective tissue disease b. Elevated sedimentation rate - Rheumatoid arthritis c. Lowered albumin - Indicative only of nutritional deficit d. Positive human leukocyte antigen B27 (HLA-B27) - Reiter's syndrome or ankylosing spondylitis e. Positive rheumatoid factor - Possible kidney disease

ANS: D, E The HLA-B27 is diagnostic for Reiter's syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.

the patient is receiving his immunization before traveling abroad. An expected outcome for this patient is the development of which type of immunity? a. natural active b. artificial active c. natural passive d. artificial passive

B. artificial active immunity is the type of immunity acquired through vaccination. In natural active immunity, an antigen enters the body without human assistance and the body makes antibodies against that antigen. Natural passive immunity is acquired when antibodies are passed from mother to fetus. In artificial passive immunity, injected antibodies are expected to inactivate an antigen

a client has a white blood cell change in which the number of suppressor t cells is way below normal and asks the nurse which type of health problems could be expected as a result of this deficiency. What is the nurses best response? a. "you will need to receive booster vaccinations more than others because your ability to make antibodies is reduced" b. "try to avoid crowds and people who are ill because you are now more susceptible to bacteria and viral infections " c. "you will be more prone to allergic reactions when exposed to allergens or drugs" d. "Your risk for cancer development is increased"

C.

p. 753, Safe and Effective Care Environment Which clinical manifestation in a client alerts the nurse to the probability of septic shock instead of hypovolemic shock? A. Hypotension B. Pale, clammy skin C. Decreased urine output D. Oozing of blood at the IV site

D Rationale: The manifestations of hypotension, pale and clammy skin, and decreased urine output are associated with any type of shock, including hypovolemic shock and septic shock. Sepsis and septic shock, however, are associated with disseminated intravascular coagulation, which consumes clotting factors and leaves the client at high risk for hemorrhage. One of the earliest manifestations of septic shock is bleeding from any area of nonintact skin, including IV insertion sites.

The nurse is caring for a patient who recently had a first positive human immunodeficiency virus (HIV) test result within six months after a negative HIV test result. According to the Centers for Disease Control and Prevention (CDC) classifications, when should the patient's status be changed from stage 0 to stage 1, 2, or 3? 1 When 12 months have elapsed 2 When CD4+ T-cell counts decrease 3 When an acquired immunodeficiency syndrome (AIDS)-defining condition is present 4 When six months have elapsed and the conditions for another stage are met

The nurse is caring for a patient who recently had a first positive human immunodeficiency virus (HIV) test result within six months after a negative HIV test result. According to the Centers for Disease Control and Prevention (CDC) classifications, when should the patient's status be changed from stage 0 to stage 1, 2, or 3? 1 When 12 months have elapsed 2 When CD4+ T-cell counts decrease 3 When an acquired immunodeficiency syndrome (AIDS)-defining condition is present 4 When six months have elapsed and the conditions for another stage are met

Question 17 of 21 In discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? a. "Have you had sex with men or women or both?" b. "I hope you use condoms to protect your partners." c. "You must tell me all of your partners' names, so I can let them know about possibly having AIDS." d. "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know."

a "Have you had sex with men or women or both?" The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate. "I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. Asking for information in the name of the public health department is not straightforward, and the tone of this entire statement is judgmental.

Question 15 of 21 A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? a. "With this treatment, I probably cannot spread this virus to others." b. "This treatment does not kill the virus." c. "This medication prevents the virus from replicating in my body." d. "Research has shown the effectiveness of this therapy if I do not forget to take any doses."

a "With this treatment, I probably cannot spread this virus to others." HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids. HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance.

Question 20 of 21 A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? a. Fluconazole (Diflucan) b. Trimethoprim/sulfamethoxazole (Bactrim) c. Rifampin (Rifadin) d. Acyclovir (Zovirax)

a Fluconazole (Diflucan) Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. Rifampin (Rifadin) is used for treatment of tuberculosis. Acyclovir (Zovirax) is an antiviral agent.

Question 21 of 21 Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)? a. The dietary worker hands the disposable meal trays to the LPN assigned to the client. b. The social worker encourages the client to verbalize about stressors at home. c. A member of the housekeeping staff thoroughly cleans and disinfects the hallways near the client's room. d. The health care provider orders vital signs, including temperature, every 8 hours.

a The dietary worker hands the disposable meal trays to the LPN assigned to the client. The dietary worker giving the meal tray to the LPN limits the number of health care personnel entering the room, thus reducing the risk for infection. Verbalizing stressors does not reduce the risk for infection. Cleaning of bathrooms, not hallways, at least once daily by housekeeping staff reduces risk for infection. Vital signs, including temperature, should be taken every 4 hours to detect potential infection, but this does not reduce the risk for infection.

Question 16 of 21 Which interventions does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)-related dementia? Select all that apply. a. Change the decorations in the home according to the season. b. Put the bed close to the window. c. Write out detailed instructions, and have the client read them over before performing a task. d. Ask the client what time he or she prefers to shower or bathe. e. Mark off the days of the calendar, leaving open the current date.

a, b, d, e Change the decorations in the home according to the season., Put the bed close to the window., Ask the client what time he or she prefers to shower or bathe., Mark off the days of the calendar, leaving open the current date. Changing decorations according to the season and using a calendar to mark off the days will help to keep the client oriented. Keeping the bed close to the window may help keep the client oriented. The client should be included in planning the daily schedule. Directions should be short and uncomplicated.

Question 4 of 21 Which factors are possible transmission routes for human immune deficiency virus (HIV)? Select all that apply. a. Breast-feeding b. Anal intercourse c. Mosquito bites d. Toileting facilities e. Oral sex

a, b, e Breast-feeding, Anal intercourse, Oral sex HIV can be transmitted via breast milk from an infected mother to the child. Anal intercourse not only allows seminal fluid to make contact with the mucous membranes of the rectum, but it also tears the mucous membranes, making infection more likely. Oral sexual contact exposes the mucous membranes to infected semen or vaginal secretions. HIV is not spread by mosquito bites or by other insects. HIV is not transmitted by casual contact, and sharing toilet facilities does not allow transmission of HIV.

Question 2 of 21 The nurse presents a seminar on human immune deficiency virus (HIV) testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention regarding HIV testing? Select all that apply. a. "I am 78 years old, and I was treated and cured of syphilis many years ago." b. "In 1986, I received a transfusion of platelets." c. "Seven years ago, I was released from a penitentiary." d. "I used to smoke marijuana 30 years ago, but I have not done any drugs since that time." e. "At 68, I am going to get married for the fourth time."

a, c, e "I am 78 years old, and I was treated and cured of syphilis many years ago.", "Seven years ago, I was released from a penitentiary.", "At 68, I am going to get married for the fourth time." People who have had a sexually transmitted disease should be tested. People who are in or have been in correctional institutions such as jails or prisons and people who are planning to get married should be tested for HIV. HIV testing is recommended for clients who received a blood transfusion between 1978 and 1985. People who have used injectable drugs (not marijuana) should be tested.

Review Questions - NCLEX® Examination - Chapter 37 Question 7 of 26 Which clients are at immediate risk for hypovolemic shock? Select all that apply. a. Unrestrained client in motor vehicle accident b. Construction worker c. Athlete d. Surgical intensive care client e. 85-year-old with gastrointestinal virus

a, d, e The client who is unrestrained in a motor vehicle accident is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock; a gastrointestinal virus results in fluid losses. Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock; they may be at risk for dehydration.

Review Questions - NCLEX® Examination - Chapter 37 Question 11 of 26 A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. a. Ask family members to stay with the client. b. Call the health care provider. c. Increase IV and oxygen rates. d. Remain with the client. e. Reassure the client that everything is being done for him or her.

a, d, e Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client's psychosocial integrity.

Question 14 of 21 When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? a. "Condoms should be used when lesions are present on the penis." b. "Always position the condom with a space at the tip of an erect penis." c. "Make sure it fits loosely to allow for penile erection." d. "Use adequate lubrication, such as petroleum jelly."

b "Always position the condom with a space at the tip of an erect penis." Positioning the condom with a space at the tip of the erect penis allows for the collection of semen at the tip of the condom. Condoms must be used by HIV-infected people at all times for sexual activity, with or without the presence of lesions. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. Lubricants should be water-based only.

Question 12 of 21 A client diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The client asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? a. "This will not make any difference in the viral load." b. "Blood concentrations will be decreased, which will lead to increased viral replication." c. "If only one dose of medication is missed, this will not make a difference." d. "This will cause an increase in opportunistic infections."

b "Blood concentrations will be decreased, which will lead to increased viral replication." When doses are missed, blood concentrations become lower than what is needed for inhibition of viral replication (often called the inhibitory concentration). When this concentration is too low, the organism can replicate and produce new organisms that are resistant to the drugs being used. Therefore, it is critical to ensure that highly active antiretroviral therapy (HAART) doses are not missed, delayed, or administered in lower-than-prescribed dosages in the inpatient setting. Teach clients the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART.

Question 8 of 21 The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery by his family? a. "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" b. "Is there somewhere private in the home where we can go and talk?" c. "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick." d. "It is your duty to protect your family members from getting AIDS."

b "Is there somewhere private in the home where we can go and talk?" A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. The client has a right to privacy and can make the decision whether to post handwashing signs; caution signs invade the client's right to privacy. Protection from infection is important, but stating that the family members should know about the disease is not respectful of the client's right to privacy. The nurse suggesting that it is the client's responsibility to protect his or her family from getting AIDS is an intimidating statement. It is the client's right to make the decision whether to inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently.

Question 19 of 21 Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? a. "I told family members they need to wash their hands when they enter and leave the room." b. "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." c. "Yes, I understand the reasons why I have to wear gloves when I bathe the client." d. "The client's spouse told me she got HIV from a blood transfusion."

b "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse. Instruction on handwashing to family members or friends is not a breach of confidentiality. Understanding the reasons for wearing gloves recognizes Standard Precautions in direct care and is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.

Question 13 of 21 A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the client? a. Clean toothbrushes once a week. b. Bathe daily using an antimicrobial soap. c. Eat salad at least once a day. d. Wash dishes in cool water.

b Bathe daily using an antimicrobial soap. Bathing daily and using an antimicrobial soap will help decrease the risk for opportunistic infections by reducing the number of bacteria found on the skin. Toothbrushes should be cleaned daily through the dishwasher or by rinsing in liquid laundry bleach. Salads and raw fruits and vegetables could be contaminated and should be avoided. Dishes should be washed in hot, soapy water or in a dishwasher.

Question 5 of 21 The nurse is assigned to care for four clients. Which client does the nurse assess first? a. Client with human immune deficiency virus (HIV) and Kaposi's sarcoma who has increased swelling of a sarcoma lesion on the right arm b. Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature c. Client who has been admitted to receive a monthly dose of serum immune globulin to treat Bruton's agammaglobulinemia d. Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count

b Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature The temperature elevation of the client with a history of liver transplantation indicates that infection may be occurring; the client is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated. Information regarding the HIV-positive client with Kaposi's sarcoma and the client with Bruton's agammaglobulinemia indicates that these clients' physiologic statuses are relatively stable. It is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count.

Review Questions - NCLEX® Examination - Chapter 37 Question 12 of 26 Which laboratory result is seen in late sepsis? a. Decreased serum lactate b. Decreased segmented neutrophil count c. Increased numbers of monocytes d. Increased platelet count

b Decreased segmented neutrophil count A decreased segmented neutrophil count is indicative of late sepsis. Serum lactate is increased in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis; late in sepsis, platelets may decrease due to consumptive coagulopathy.

Question 1 of 21 Which factor relates most directly to a diagnosis of primary immune deficiency? a. History of viral infection b. Full-term infant surfactant deficiency c. Contact with anthrax toxin d. Corticosteroid therapy

b Full-term infant surfactant deficiency Genetic mutation causes surfactant deficiency; this is a primary immune deficiency. Viral infection can cause a secondary immune deficiency. Anthrax and medical therapy are examples of a secondary immune deficiency.

Review Questions - NCLEX® Examination - Chapter 37 Question 19 of 26 How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? a. PaCO2 58 mm Hg b. Lactate 9.0 mmol/L c. Partial thromboplastin time 64 seconds d. Potassium 2.8 mEq/L

b Lactate 9.0 mmol/L Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid. Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis; this value is decreased and is not consistent with septic shock.

Review Questions - NCLEX® Examination - Chapter 37 Question 6 of 26 Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? a. Localized erythema and edema b. Low-grade fever and mild hypotension c. Low oxygen saturation rate and decreased cognition d. Reduced urinary output and increased respiratory rate

b Low-grade fever and mild hypotension Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and increased respiratory rate indicate severe sepsis.

Review Questions - NCLEX® Examination - Chapter 37 Question 9 of 26 A postoperative client is admitted to the intensive care unit with hypovolemic shock. Which nursing action does the nurse delegate to an experienced nursing assistant? a. Obtain vital signs every 15 minutes. b. Measure hourly urine output. c. Check oxygen saturation. d. Assess level of alertness.

b Measure hourly urine output. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

Question 3 of 21 A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? a. Collaborate with the client to select foods that are high in calories. b. Provide oral care to the client before meals to enhance appetite. c. Assess the perianal area every 8 hours for signs of skin breakdown. d. Discuss the need to avoid foods that are spicy or irritating.

b Provide oral care to the client before meals to enhance appetite. Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants. Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice; these actions should be done by licensed staff.

Question 7 of 21 The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority? a. Administer antibiotics as prescribed. b. Transfuse ordered packed red blood cells. c. Teach pursed-lip breathing. d. Encourage increased fluid intake.

b Transfuse ordered packed red blood cells. Packed red blood cells increase hemoglobin molecules; this increases sites at which oxygen can attach and improves gas exchange. Antibiotics treat infection; they do not improve oxygenation. Mouth breathing does not improve oxygenation related to anemia. Fluid intake does not have an effect on improving oxygenation.

Question 18 of 21 The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address? a. "When I injected heroin, I was exposed to HIV." b. "I don't understand how the antiretroviral drugs work." c. "I remember to take my antiretroviral drugs almost every day." d. "My sex drive is weaker than it used to be since I started taking my antiretroviral medications."

c "I remember to take my antiretroviral drugs almost every day." Because inconsistent use of antiretroviral medications can lead to unsuccessful therapy and the development of drug-resistant HIV strains, it is important that clients take these drugs consistently. The nurse should immediately assess the reasons why the client does not take the medications daily and then should implement a plan to improve adherence. The nurse should assess whether the client is still injecting drugs and should make certain the client understands the risks for infection with another strain of HIV or other bloodborne pathogens and the risk for spreading HIV, but this does not need to be addressed immediately. The nurse must provide further education about how the medications work and assess how the lack of knowledge or decreased libido influences compliance, but this does not need to be addressed immediately.

Question 6 of 21 The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? a. "I need to know my HIV status, so I must get tested before caring for any clients." b. "Putting on a gown and gloves will cover up the itchy sores on my elbows." c. "Washing my hands and putting on a gown and gloves is what I must do before starting care." d. "I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client's genitals."

c "Washing my hands and putting on a gown and gloves is what I must do before starting care." Standard Precautions include whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes. Knowing HIV status is important for preventing transmission of HIV, but is not a Standard Precaution. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of a gown and gloves. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.

Question 11 of 21 A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first? a. Obtain a 12-lead electrocardiogram (ECG). b. Call for a portable chest x-ray. c. Obtain blood cultures from two sites. d. Give cefazolin (Kefzol) 500 mg IV.

c Obtain blood cultures from two sites. Antibiotics should be given as soon as possible to immunocompromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic. A 12-lead ECG can be obtained and calling for a portable chest x-ray can be done after other priority requests have been carried out.

Review Questions - NCLEX® Examination - Chapter 37 Question 8 of 26 Which problem places a client at highest risk for sepsis? a. Pernicious anemia b. Pericarditis c. Post kidney transplant d. Client owns an iguana

c Post kidney transplant The post-kidney transplant client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a very high risk for infection, sepsis, and death.

Question 9 of 21 In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? a. Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma b. Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency c. Potential for infection transmission related to recurring opportunistic infections d. High risk for inadequate nutrition related to acquired secondary immune deficiency and Candida albicans

c Potential for infection transmission related to recurring opportunistic infections Protecting the client from further opportunistic infection such as Candida albicans is a priority. Loss of social contact is not a priority problem with an opportunistic infection. Mouth sores would be the secondary concern because Candida albicans causes the mouth sores. Nutrition will be affected because of Candida albicans; however, it is not a priority.

Review Questions - NCLEX® Examination - Chapter 37 Question 25 of 26 What typical sign/symptom indicates the early stage of septic shock? a. Pallor and cool skin b. Blood pressure 84/50 mm Hg c. Tachypnea and tachycardia d. Respiratory acidosis

c Tachypnea and tachycardia Signs of systemic inflammatory response syndrome, which precedes sepsis, include rapid respiratory rate, leukocytosis, and tachycardia. In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis occurs early in shock because of an increased respiratory rate.

Review Questions - NCLEX® Examination - Chapter 37 Question 1 of 26 When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? a. Obtain IV access and hang prescribed fluid infusions. b. Apply the automatic blood pressure cuff. c. Assess level of consciousness and pupil reaction to light. d. Check the airway and respiratory status.

d Check the airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.

Question 10 of 21 A client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? a. Therapeutic highly active antiretroviral therapy (HAART) level b. Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot c. Positive Papanicolaou (Pap) test d. Improved CD4+ T-cell count and reduced viral load

d Improved CD4+ T-cell count and reduced viral load Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication. Therapeutic HAART level is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. ELISA and Western blot, if positive, indicate that the client is HIV positive (a fact already known for this client) and do not indicate response to prescribed medication. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication.

Review Questions - NCLEX® Examination - Chapter 37 Question 21 of 26 The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? a. Hypotension b. Bradypnea c. Heart blocks d. Tachycardia

d Tachycardia Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.