course point
The nurse educator, who is teaching a class on sexually transmitted infections, recognizes that teaching has been effective when students indicate which statement is true about the difference between colonization and infection?
"Colonization becomes infection when the host and organism interact."
The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction?
"I will not salt my food; instead I'll use salt substitute."
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?
Cerebral edema
The nurse is caring for a client with genital herpes experiencing a reoccurrence. Which nursing diagnosis would be the priority?
Impaired Skin Integrity
nociceptive pain
Physiological: tissue injury
A client reports nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucous membranes as pale and dry. The client has sunken eyes with the following vital signs: pulse 122 and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which is the priority nursing intervention?
Request an order from the physician for IV rehydration therapy.
The nurse understands that which statement is true about tolerance and addiction?
Although clients may need increasing levels of opioids, they are not addicted.
Critical care pain observation tool (CPOT)
Facial expression body movement compliance with ventilator or vocalization muscle tension
Face, Legs, Activity, Cry, Consolability (FLACC)
Facial expression leg movement activity crying consolability
T-cells can be either regulator T cells or effector T cells. Regulator T cells are made up of helper and suppressor cells. What function are helper T-cells important in?
Fighting infections
A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
Foul-smelling discharge from the penis
Adverse effects of non-opioid analgesic
AcetaminopHen: Hempato-toxicity NSAIDS: IbupRoFen: Renal Failure/disease/gastric ulcer Increased bleeding time
Activation of a natural immunity response is enhanced by physical and chemical barriers. Which of the following is a physical barrier, which the nurse knows can be altered by illness, nutrition, or lifestyle?
Cilia of the respiratory tract
A client is diagnosed with scabies in a long-term care facility. Which type of client care precautions would the nurse institute?
Contact
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?
Extracellular fluid volume deficit
The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?
Hypocalcemia
A client is recovering from abdominal surgery and sleeping. The client had received an opioid medication 3 hours ago. The client's son requests pain medication for the client, stating "I do not want her to wake up in pain." The first nursing action is
Instruct the son about lack of client consent.
A 34-year-old client is diagnosed with chronic hepatitis C. Testing reveals that the client is a candidate for treatment. The nurse anticipates that which therapy could be used to treat the client's condition?
Interferon
A high school football player hurts his foot while playing a game. The client complains of intense pain with muscle spasms and swelling of the toe. Which pain assessment tool will the nurse most likely use to assess the client's pain level?
Numeric Rating Scale (NRS)
A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant?
Provide oral care every 2-3 hours.
Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis?
Sodium bicarbonate
Types of adjuvant analgesics
Local anesthetics: Lidocaine 5% patch anticonvulsants: gabapentin, pregabalin antidepressants: TCA's, Desipramine & Nortriptyline SNRIs: duloxetine, venlafaxine ketamine: dissociative anesthetic agent
A client has been admitted with primary syphilis. Which signs or symptoms should the nurse expect to see with this diagnosis?
A painless genital ulcer that appeared about 3 weeks after unprotected sex
Which adverse effect should the nurse closely monitor in a client who takes immunosuppressive drugs?
Respiratory or urinary system infections
Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?
Risk for impaired gas exchange
Which condition is a heightened response that occurs after exposure to a noxious stimulus?
Sensitization
How often should women diagnosed with human papillomavirus (HPV) have Pap smears?
Yearly
Adverse effects of opioid analgesic agents
respiratory depression sedation nausea & vomitting constipation pruritis
Acute pain
results of tissue damage surgery or trauma Break through of chronic pain become acute
Acute pain assessment
wounds, burns, broken bones
Analgesic Agents: Non-opioid
Acetaminophen & NSAIDS ibuprophen, naproxen, celecoxib
The nurse is obtaining data regarding the medication that the client is taking on a regular basis. The client states he is taking duloxetine, an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving?
Adjuvant drug therapy
Pain Assessment in advanced dementia scale (PAINAD)
Advanced dementia breathing negative vocalization facial expression body language & consolability
Which of the following is accurate regarding acquired immunity? Select all that apply.
An immunologic response acquired during life but not present at birth Usually develops as a result of exposure to an antigen through immunization Can develop by contracting a disease
A client is diagnosed with rheumatoid arthritis. When teaching the client and family about rheumatoid arthritis, the nurse should provide which information?
Autoimmune disorders include connective tissue (collagen) disorders.
A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease?
Azithromycin (Zithromax)
At 39 weeks' gestation, a pregnant client visits the physician for a scheduled prenatal checkup. The physician determines that the fetus has developed an infection in utero and sends the client for an emergency cesarean delivery. The client is very concerned about the health of her unborn child. Based on knowledge of the immune system, the delivery room nurse explains about which immunoglobulin that will be increased in the fetus at the time of birth and will be actively fighting the infection?
IgG
Which of the following is a center for immune cell proliferation?
Lymph nodes
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?
Metabolic acidosis
An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?
Naturally acquired active immunity
The nurse is seeing a client in the community health clinic who reports finding "sores" in the mouth. On assessment, the nurse notes the lesions appear flat, flesh colored and papillary. What should the nurse do next?
Obtain a health history that includes inquiring about sexual health practices
A client is reporting her pain as "8" on a 0-to-10 pain intensity scale. Then, the client states the pain is "3." Before the nurse leaves the room, the client states her pain is "6." The best action of the nurse is to
Obtain a pain scale with faces for the client to measure her pain.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
Serum sodium level of 124 mEq/L
Painless chancres or ulcerated lesions are associated with which systemic disease?
Syphilis
A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following?
The client's immune system cannot mount a response to the skin test.
A client who has undergone extensive fracture repair continues to request opioid pain medication with increasing frequency. The initial surgeries occurred more than 2 months ago, and the nurse is concerned about the repeated requests. What does the nurse suspect to be the cause of the client's frequent appeals for pain medication?
Tolerance
A 38-year-old client has begun to suffer from rheumatoid arthritis and is being assessed for disorders of the immune system. The client works as an aide at a facility that cares for children infected with AIDS. Which is the most important factor related to the client's assessment?
Use of other drugs
A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?
Weight
Early signs of hypervolemia include
increased breathing effort and weight gain.
According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment?
location, onset, alleviating factors, and aggravating factors
A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance?
metabolic alkalosis
How to assess pain
onset, provoking, palliative, quality, radiation, timing, severity Subjective: given from patient Objective: self observed and results reassess
Oncotic pressure refers to the
osmotic pressure exerted by proteins.
Neuropathic pain
pathophysiological: damage to peripheral / central nervous system
A client's potassium level is elevated. The nurse is reviewing the ECG tracing. Identify the area on the tracing where the nurse would expect to see peaks.
peaked T waves with a narrow base, shortened QT interval; and ST-segment depression
A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected?
Assess for ataxia using the finger-to-nose test and heel-to-shin test
Analgesic Agents: Opioids
MU agnoist morphine, fentanyl, oxycodone, hydromorphone
T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do?
T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person.
A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection?
Through the mucous membranes of the throat
Chronic pain assessment
arthritis or degenerative
Analgesic agents: Agoinist antagonist
buprenorphine, nalbuphine, butorphanol
An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking properly. When assessing the client for dehydration, the nurse would expect to find:
tachycardia
A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about?
the limits on dose and frequency that are programmed into the PCA
Chronic pain
time limited of life time Cancer, peripheral neuropathy, back pain, osteoarthritis
