Exam 3 practice questions (adult 2)

Along with other criteria, a diagnosis of AIDS is made when an HIV-infected client has A. a CD4+ cell count of < 200 cells/mm3 B. an increasing amount of HIV in the blood C. persistent generalized lymphadenopathy D.oral hairy leukoplakia

a CD4+ cell count of <200

contact with antigen through infection

active natural immunity

Collaborative care of a client with mild to moderate ascites includes: A. Oral fluid restrictions B. Low carbohydrate, low protein diet C. Albumin and Diuretics D. Activity level: out of bed as tolerated

albumin & diuretics

A client with cirrhosis is being transported to the Emergency Department (ED) via ambulance for "some type of bleeding." In preparing to care for this client, the nurse is most concerned about the possibilty of: A. Bleeding esophageal varices B. A clogged peritoneovenous shunt C. Melena and hematemesis D. Low hemoglobin & hematocrit levels

bleeding esophageal varices

Identify which hypersensitivity reaction is Type II: cytotoxic a. Cellular lysis or phagocytosis through complement activation following antibody antigen binding on cell surfaces. b. Antigen links with specific IgE antibodies bound to mast cells or basophils releasing chemical mediators c. T lymphocyte attack on antigens or release of lymhokines attract macrophages that cause tissue damage d. Antigens combined with IgG and IgM too small to be removed from by mononuclear phagocytic system deposit in tissue and cause fixation of complement

cellular lysis or phagocytosis through complement activation following antibody antigen binding on cell surfaces

During the assessment of a client with obstructive jaundice, the nurse would expect to find: A. A bilirubin level 2x the normal level B. Steatorrhea C. Clay-colored stools D. Clear yellow urine

clay-colored stools

Type IV: delayed hypersensitivity

contact dermatitis, transplant rejection

active artificial immunity

immunization with antigen

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis jiroveci pneumonia. Which nursing diagnosis has the highest priority for this client? A. Impaired gas exchange B. Impaired oral mucous membranes C. Unbalanced nutrition, less than body requirements D. Activity intolerance

impaired gas exchange

The nurse is aware that patients with Hepatitis B infection are susceptible to developing: A. Hepatitis D B. HIV/AIDS C. Liver carcinoma D. Hepatitis A

liver carcinoma

A priority nursing measure while the patient has a Senstaken-Blakemore tube in place is to A. monitor serum ammonia levels. B. monitor the client's airway. C. measure the abdomen. D. place the patient flat in bed.

monitor the client's airway

A patient is suspected of having systemic lupus erythematosus (SLE). The patient also has accompanying platelet count of 60,000/mm3. What precautions does the nurse need to include in the plan of care? a. Not allowing visitors or staff with infections to have direct contact b. Removing clutter and objects that could contribute to a fall c. Checking for a positive Homan's sign or calf tenderness d. Encouraging foods like green leafy vegetables

removing clutter & objects that could contribute to a fall

IgE

responsible for allergic reactions

Type III: immune complex mediated

rheumatoid arthritis, good pastures syndrome, SLE, glomerulonephritis

A priority nursing diagnosis for a client with altered mental status due to AIDS encephalopathy is A. risk for injury. B. imbalanced nutrition, less than body requirements. C. risk for infection. D. disturbed body image.

risk for injury

The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client most concerns the nurse? A. "I'm very constipated today and have been straining during bowel movements." B. "I can't button my pants anymore because my stomach is so swollen." C. "When I sleep, I have to sit in a recliner so that I can breathe more easily." D. "I forgot to take my dose of Aldactone (sprinolactone) this morning."

"I can't button my pants anymore because my stomach is so swollen."

A nursing assistant asks the nurse if respiratory isolation is needed for a client with Pneumocystis jiroveci (PCP) pneumonia. What is the nurse's best response? A. "This type of pneumonia is an opportunistic infection, so the staff is not at risk." B. "You should wear a mask and a gown to provide care." C. "Yes, please institute respiratory isolation because this is very contagious." D. "You are not at risk for this infection if you have had a vaccination."

"this type of pneumonia is an opportunistic infection, so the staff is not at risk"

A client who has engaged in needle-sharing activities has developed a flu-like infection and presents to a clinic for testing. An HIV antibody test is negative. Which statement should the nurse include in teaching the client prior to her leaving the clinic? A. "You are fortunate not to have contracted HIV from an infected needle." B. "You must be repeatedly exposed to HIV before becoming infected, next time you might not be so lucky." C. "You may be in the acute infection phase of the HIV infection, and should come back for testing within 4-6 weeks." D. "The HIV antibody test is negative because you have the influenza virus."

"you may be in the acute infection phase of the HIV infection, & should come back for testing within 4-6 weeks"

The nurse is working with a client at a public health clinic. The client says to the nurse, "The doctor said that my CD4+ count is 450. Is that good?" What is the nurse's best response? A. "Your count is very low and you actually now have AIDS." B. "Your count is a bit low and you are susceptible to infection." C. "Your count is normal because your medications are working well." D. "Your count is high so you can cut back on your medication."

"your count is a bit low & you are susceptible to infection"

The nurse is assessing a patient with acute pancreatitis and notes ecchymosis and bluish spots around his umbilicus. The nurse would document this finding as? a. Grey-Turner's sign b. Spider angioma c. Cullen's sign d. Umbilical hemorrhage

Cullen's sign

Identify which hypersensitivity reaction is a Type IV: delayed hypersensitivity a. Cellular lysis or phagocytosis through complement activation following antibody antigen binding on cell surfaces. b. Antigen links with specific IgE antibodies bound to mast cells or basophils releasing chemical mediators c. T lymphocyte attack on antigens or release of lymhokines attract macrophages that cause tissue damage d. Antigens combined with IgG and IgM too small to be removed from by mononuclear phagocytic system deposit in tissue and cause fixation of complement

T lymphocyte attack on antigens or release of lymphokines attract macrophages that cause tissue damage

The nurse informs the patient with a bacterial pneumonia that the most important factor in antibiotic treatment is A. antibiotics should have been used to prevent pneumonia. B. all of the supplied antibiotics should be taken even when symptoms have resolved. C. enough antibiotics for 2 days' treatment should be reserved in case symptoms recur. D. patients should request antibiotics for upper respiratory infections to prevent development of streptococcal-related diseases.

all of the supplied antibiotics should be taken even when symptoms have resolved

Which of these instructions would be appropriate for a person with Hepatitis A? A. Take any over-the-counter (OTC) medication for fever B. Don't cook for others until four days after the onset of jaundice C. Limit alcohol intake to one drink per day D. All persons in close contact should receive the immunoglobulin

all persons in close contact should receive the immunoglobulin

Which of the following laboratory results should the nurse report to the primary care provider regarding a patient who has had alcoholic cirrhosis for several years? A. INR 1.8 B. Bilirubin 1.2 mg/dL C. Ammonia 176 mg/dL D. Albumin 3.5 g/dL

ammonia 176 mg/dl

IgG

antibodies against ABO antigens, assists in B lymphocyte differentiation, passed to neonate in the colostrum, predominant in secondary immune response

Identify which hypersensitivity reaction is a Type I: IgE medicated reaction a. Cellular lysis or phagocytosis through complement activation following antibody antigen binding on cell surfaces. b. Antigen links with specific IgE antibodies bound to mast cells or basophils releasing chemical mediators c. T lymphocyte attack on antigens or release of lymhokines attract macrophages that cause tissue damage d. Antigens combined with IgG and IgM too small to be removed from by mononuclear phagocytic system deposit in tissue and cause fixation of complement

antigen links with specific IgE antibodies bound to mast cells or basophils releasing chemical mediators

Identify which hypersensitivity reaction is Type III: immune complex mediated a. Cellular lysis or phagocytosis through complement activation following antibody antigen binding on cell surfaces. b. Antigen links with specific IgE antibodies bound to mast cells or basophils releasing chemical mediators c. T lymphocyte attack on antigens or release of lymhokines attract macrophages that cause tissue damage d. Antigens combined with IgG and IgM too small to be removed from by mononuclear phagocytic system deposit in tissue and cause fixation of complement

antigens combined with IgG & IgM too small to be removed from by mononuclear phagocytic system deposit in tissue & cause fixation of complement

IgA

assist in parasitic infections

Which of the following nursing actions included in the plan of care for a patient with cirrhosis can the RN delegate to nursing assistive personnel? A. Assessing the patient for jaundice B. Measuring abdominal girth C. Palpating the abdomen for a "fluid wave" D. Assisting the patient in choosing the diet

assisting the patient in choosing the diet

Type I: IgE medicated reactions

asthma, angioedema, allergic rhinitis, anaphylactic shock, atopic dermatitis

The nurse is caring for a patient who is receiving antiretroviral therapy (ART) for treatment of AIDS. Which assessment best indicates that the patient's condition is improving? A. Decreased viral load B. Increased drug resistance C. Decreased CD4+ T-cell count D. Increased aminotransferase levels

decreased viral load

Ten years after infection with the virus, an HIV-infected client has a CD4+ cell count of 800/µl and an undetectable viral load. What is the priority nursing intervention at this time? A. Monitor for symptoms of AIDS. B. Teach about the effects of antiretroviral agents. C. Encourage adequate nutrition, exercise, and sleep. D. Discuss likelihood of increased opportunistic infections.

encourage adequate nutrition, exercise, & sleep

Which of the following is the highest priority assessment finding in a patient with cirrhosis? A. Cullen's sign B. Fetor hepaticus C. Asterixis D. Hematemesis

hematemesis

A diagnosis of AIDS can be made for a patient with HIV with A. a CD4+ T-cell count <500/µL. B. a WBC count <3000/µL (3 × 109/L). C. development of oral candidiasis (thrush). D. onset of Pneumocystis jiroveci pneumonia.

onset of pneumocystis jiroveci pneumonia

maternal immunoglobulins in neonate

passive natural immunity

The nurse working in an HIV testing and treatment clinic plans teaching about antiretroviral therapy for a A. patient who tested positive for HIV 3 years ago and has developed tuberculosis. B. male health care worker who is HIV negative but has unprotected sex with men. C. patient who was infected with HIV 10 years ago and has a CD4+ T-cell count of 650/μL. D. patient with persistent generalized lymphadenopathy who was exposed to HIV 2 years previously.

patient who tested positive for HIV 3 years ago & has developed tuberculosis

passive artificial immunity

polled gammaglobulins

IgM

predominant in primary immune response

The nurse caring for a patient with Hepatitis B is planning care. The nursing diagnosis "Imbalanced Nutrition: Less than Body Requirements" is used. Which intervention should integrate in her plan of care? a. Provide a high-calorie diet b. Discuss the use of total parenteral nutrition (TPN) c. Instruct the patient to decrease sodium intake d. Encourage the patient to increase fluid intake

provide a high-calorie diet

A client with cholelithiasis will be having an endoscopic retrograde cholangiopancreatography (ERCP) done to crush the stones mechanically. Following this procedure, the nurse on the surgical unit will pay particular attention to assessing the client for: A. Sudden onset of severe LUQ pain B. Abdominal discomfort relieved by vomiting C. An anaphylactic reaction to contrast medium D. High fever, hypertension, bradycardia

sudden onset of severe LUQ pain

A patient received IM penicillin which of the signs and symptoms indicate that the patient is having an anaphylactic reaction (select all that apply): a. Bradycardia b. Tachycardia c. Hypotension d. Hypertension e. Laryngeal spasm

tachycardia, hypotension, laryngeal spasm

The nurse would expect a male client with hematologic problems related to cirrhosis to have: A. A white blood cell count (WBC) of 25,000 B. A hemoglobin of 14 grams/dL C. Thrombocytopenia D. Decreased GGT, AST, ALT levels

thrombocytopenia

Type II: cytotoxic

transfusion reaction

A 25 year old client with newly diagnosed Hepatitis C is being discharged from the hospital after an appendectomy. The teaching plan would include: A. Use condoms for sexual intercourse B. Schedule your hepatitis C vaccination within six months C. Expect some nausea and vomiting this week D. Avoid the use of multivitamins

use condoms for sexual intercourse

A client has had two positive enzyme-linked immunosorbent assay (ELISA) tests for HIV antibodies. The nurse expects the physician to order which of the following tests to confirm the ELISA test results? A. An additional ELISA test B. Viral load test C. Western blot test D. CD4/CD8 ratio

western blot test

Management of acute pancreatitis includes a. surgery to remove the inflamed pancreas b. administration of IV toradol for pain relief c. NG suction to keep the stomach empty d. replacement of pancreatic enzymes with meals

NG suction to keep the stomach empty

Which nursing action will be most useful in assisting a 21-year-old college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? A. Give the client detailed information about possible medication side effects. B. Remind the client of the importance of taking the medications as scheduled. C. Encourage the client to join a support group for students who are HIV positive. D. Check the client's class schedule to help decide when the ART should be taken.

Remind the client of the importance of taking the medications as scheduled