Honan Chapter 36, 37, 38, 39, 43, 44, 45, 46, 47 PHARM:
A patient with Bell's palsy asks the nurse why she has to wear an eye shield at night. What would be the nurse's best response?
"A patient with Bell's palsy needs an eye shield at night to prevent injury to the eye."
A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?
"Although AIDS is an immune deficiency, your child's condition is different from AIDS."
The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed?
"I will be sure to eat lots of fresh fruits and vegetables every day."
There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency.
"Your immune system was most likely affected by an underlying disease process."
A patient who suffers from allergies to grass and mold is getting ready to cut grass. Prior to cutting grass, he takes cetirizine (Zyrtec). When will the patient expect the medication to reach maximum effects?
1 hour
Cerebral edema peaks at which time point after intracranial surgery?
24 hours
A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
3
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?
4:00 pm
The maximum intensity of histamine occurs within which time frame after contact with an antigen?
5 - 10 minutes
SATA 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 nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?
AIDS
A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?
Administering ordered analgesics and monitoring their effects
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following?
Anticoagulant therapy
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?
Assess the client for medication allergies.
What intervention is a priority when treating a client with HIV/AIDS?
Assessing fluid and electrolyte balance
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
Kaposi sarcoma (KS) is diagnosed through
Biopsy
SATA Where are Alpha1-receptors found?
Blood vessels The iris Urinary bladder
SATA Which of the following is a common cancer that metastasizes to the spinal cord?
Breast Prostate Lung
At which of the following spinal cord injury levels does the patient have full head and neck control?
C5
The nurse intervenes to assist the client with fibromyalgia to cope with which symptoms?
Chronic fatigue, generalized muscle aching, and stiffness
A patient with Crohn's disease is given a corticosteroid to decrease inflammation. Which of the following effects will occur with the use of corticosteroids?
Decreased antibody production
A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to:
Depression
Which is a sympathetic effect of the nervous system?
Dilated pupils
A patient is diagnosed with Alzheimer's disease. The nurse should anticipate administering which of the following medications?
Donepezil (Aricept)
The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client?
Explaining hospice care and services
A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?
Fever and change in urine clarity
Which term refers to an incomplete antigen?
Hapten
Which is a primary chemical mediator of hypersensitivity?
Histamine
A 44-year-old man has come to the clinic with an asthma exacerbation. He tells the nurse that his father and brother also suffer from asthma, as does his 15-year-old son. The nurse explains that this is an allergic response based on a genetic predisposition. The specific allergen initiated by this immunological mechanism is usually mediated by:
Immunoglobulin E
An 80-year-old man has been diagnosed with early-stage Alzheimer's disease and has begun treatment with donepezil (Aricept). When providing health education to the patient and his wife, the nurse should identify what goal of treatment?
Improvement of cognition and function
A patient is administered atropine to increase the heart rate. What is the action of atropine?
It blocks the parasympathetic vagal stimulation.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?
Keeping the client in one position to decrease bleeding
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?
Lioresal (Baclofen)
A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact her bone marrow is unable to produce a sufficient amount of what?
Lymphocytes
Which term describes the fibrous connective tissues that cover the brain and spinal cord?
Meninges
Which is the most common cause of spinal cord injury (SCI)?
Motor vehicle crashes
A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand?
Neutrophils
A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke?
Noncontrast computed tomography
Which of the following is the initial diagnostic in suspected stroke?
Noncontrast computed tomography (CT)
What severe complication does the nurse monitor for in a patient with ataxia-telangiectasia?
Overwhelming infection
During a neurological assessment examination, the nurse assesses a patient for tactile agnosia. The nurse places a familiar door key in the patient's hand and asks him to identify the object with his eyes closed. The nurse documents his inability to identify the object and notes the affected area of the brain. Which of the following is the most likely affected area of the brain?
Parietal lobe
A nurse knows that more than 50% of clients with CVID develop the following disorder.
Pernicious anemia
A patient, diagnosed with cancer of the lung, has just been told that she has metastases to the brain. The family should be aware that the neurologic signs and symptoms of metastatic brain disease are most often what?
Personality changes
A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect?
Pneumocystis jiroveci
What is the function of the thymus gland?
Programs T lymphocytes to become regulator or effector T cells.
SATA A nurse is developing a teaching plan for a client with an immunodeficiency. What would the nurse need to emphasize?
Prophylactic medication regimens Ways to manage stress Maintenance of a well-balanced diet
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?
Provide thickened commercial beverages and fortified cooked cereals.
Which condition is associated with impaired immunity relating to the aging client?
Renal function decreases
Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy?
Respiratory or urinary system infections
A military nurse is part of a team reviewing the appropriate response to chemical weapons attacks, including sarin, tabun, and soman. When reviewing the physiology of a response to such drugs, the nurse should identify what goal of treatment?
Restore anticholinesterase function.
The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following?
Serum, which depletes the body's store of immunoglobulins
The nurse working in the emergency department is asked to explain allergy testing to a client who experienced an allergic reaction to an unknown allergen. Which test indicates the quantity of allergen necessary to evoke an allergic reaction?
Serum-specific IgE test
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?
Smoking
SATA A patient with a recent diagnosis of HIV infection has expressed to the nurse that he is motivated to learn as much about his disease as possible. The patient has heard and read about the role of the different T cells, but is unclear of their roles in the immune response. Which of the following roles of T cells should the nurse identify? Select all that apply.
Stimulating the immune system Secreting cytokines Directly attacking antigens Activating other T cells
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma
Which disorder is characterized by a butterfly-shaped rash across the bridge of the nose and cheeks?
Systemic lupus erythematous (SLE)
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.
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6
The nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
Tachypnea and restlessness
A client taking fosamprenavir reports "getting fat." What is the nurse's best action?
Teach the client about medication side effects.
The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?
The client grasps the affected arm at the wrist and raises it.
A 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. What is the most important factor related to the client's assessment?
The client's use of other drugs
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
The day the patient has the stroke
A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder?
The immune system recognizes one's own tissues as "foreign."
A patient with a suspected brain tumor has been scheduled for a positron emission tomography (PET) scan. The nurse should explain to the patient that this test is being performed to assess:
The metabolic activity taking place in the patient's brain
The nurse is teaching a client who has been diagnosed with Hashimoto's thyroiditis. Which statement correctly describes the process of autoimmunity?
The normal protective immune response attacks the body, damaging tissues.
Muscarinic and nicotinic receptors are part of what system?
The parasympathetic nervous system
A client is scheduled to have a prick test to determine what specific allergens are creating problems for the client. What should the nurse inform the client is involved with the testing?
The skin will be scratched, and applying a small amount of the liquid test antigen to the scratch, usually on the back.
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Transient ischemic attack
Nursing students are reviewing information about Parkinson's disease in preparation for class the next day. The students demonstrate understanding of the material when they identify which of the following as a cardinal sign of this disorder?
Tremor Rigidity Bradykinesia Postural instability
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
Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy?
Use ophthalmic lubricant and protect the eye.
What test will the nurse assess to determine the client's response to antiretroviral therapy?
Viral load
The nurse explains to a client that immunotherapy initally starts with injections at which interval?
Weekly
A client is recovering from an attack of gout. What will the nurse include in the client teaching?
Weight loss will reduce uric acid levels and reduce stress on joints.
A client was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. What would not be a part of teaching plan for this condition?
applications of ice
Which of the following medications is administered for ingestion of clitocybe mushrooms?
atropine sulfate
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness.
SATA The nurse is reviewing the client's medications. What antihistamines are contraindicated for a client with narrow-angle glaucoma? Select all that apply.
diphenhydramine loratadine cetirizine brompheniramine
A patient has been diagnosed with chronic obstructive pulmonary disease. The patient is to be administered tiotropium bromide (Spiriva HandiHaler). The patient's creatinine level is 25. What is the patient at risk for developing?
drug toxicity
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:
dysfunction in the brain stem.
The nurse is working with a client with allergic rhinitis. What medication does the nurse anticipate will be prescribed to treat the allergic rhinitis?
fexofenadine
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
immediately
Bone density testing in clients with post-polio syndrome has demonstrated
low bone mass and osteoporosis.
A client is being admitted to a rehabilitation hospital as a result of the tetraplegia caused a stroke. The client's condition is stable, and after admission the client will begin physical and psychological therapy. An important part of nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention?
maintain sufficient integument capillary pressure
A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms
may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphoterici
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:
neutrophils and monocytes.
A nurse has developed a latex allergy and now uses latex-free purple gloves to avoid a hypersensitivity response. What in this nurse's reaction to latex differs from all other types of hypersensitivity responses?
no antibody production
The nurse is teaching a client about contact dermatitis. What type of contact dermatitis requires light exposure in addition to allergen contact?
photoallergic
The nurse is teaching a client about allergic rhinitis and its triggers. What is the most common trigger for the respiratory allergic response?
plant pollen
SATA When muscarinic receptors are stimulated, what happens physiologically in the body?
pupil constriction Increased secretions Increased bladder contraction
A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?
suction the airway
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
supine position with the head slightly elevated.
In its attempt to suppress allergic responses, the body releases several chemicals which have a role in mediating physical reactions. Epinephrine, which interferes with vasoactive chemical release from mast cells, is instrumental in suppressing which type of hypersensitivity response?
type I
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
Which of the following procedures involves a surgical fusion of the joint?
Arthrodesis
The initial sign of increasing intracranial pressure (ICP) includes
decreased level of consciousness.
The nurse tells the client that if exposure to an allergen occurs around 8:00 AM, then the client should expect a mild or moderate reaction by what time?
10:00 AM
A patient has atony of the smooth muscle of the gastrointestinal tract. Which type of medication may be administered to increase smooth muscle strength?
Cholinergic drugs
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?
"Have you experienced any viral infections in the last month?"
A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?
"A secondary headache is associated with an organic cause, such as a brain tumor."
When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction?
"Avoid sharing such articles as toothbrushes and razors."
To evaluate a client's cerebellar function, a nurse should ask:
"Do you have any problems with balance?"
A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?
"I am trying to quit smoking and have a patch on."
When do most perinatal HIV infections occur?
After exposure during delivery
Which of the following cell types are involved in humoral immunity?
B lymphocytes
A patient has been receiving bethanechol (Urecholine) for 1 week. One hour after the dose is administered, he develops sweating, flushing, abdominal cramps, and nausea. What is the rationale for the development of these symptoms?
Cholinergic overdose
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state?
Confusion
The nurse's medication reconciliation performed on a patient who is newly admitted to the hospital reveals that he regularly takes infliximab (Remicade), a humanized IgG monoclonal antibody. The nurse is justified in suspecting that this patient may have a history of which of the following?
Crohns disease
Which of the following is the most frequent route of exposure to a latex allergy?
Cutaneous
A client with an allergic disorder calls the nurse and asks what treatment is available for allergic disorders. The nurse explains to the client that there is more than one treatment available. What treatments would the nurse tell the client about?
Desensitization
A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority?
Disturbed body image related to loss of fat in the face and arms
The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available?
Equipment to maintain infection control precautions
Which medication classification is known to inhibit prostaglandin synthesis or release?
Nonsteroidal anti-inflammatory drugs (in large doses)
Which of the following is a late symptom of spinal cord compression?
Paralysis
Which lobe of the brain is responsible for spatial relationships?
Parietal
Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident?
Prevention of joint contractures
Which of the following is the first-line therapy for myasthenia gravis (MG)?
Pyridostigmine bromide (Mestinon)
The nurse administers a drug that stimulates beta2 receptors. What type of health condition would this drug treat?
Respiratory disease
A patient with Parkinson's disease has been prescribed rasagiline. When educating this patient on this medication, which herbal supplement has the potential to produce hyperpyrexia and death with rasagiline?
St Johns wort
A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function?
Surgical removal of the appendix
A patient has been discharged from the hospital after a kidney transplant. Which of the following nursing interventions is the first line of defense against the immunosuppressed patient developing an infection?
Teach the patient the importance of personal hygeine
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tensilon test
A patient's recent diagnostic workup has resulted in a diagnosis of a glioma, and a treatment plan is being promptly created by the multidisciplinary care team. The patient's oncologist has recommended chemotherapy, which is to be administered by the intrathecal route. The nurse should understand that the rationale for choosing this administration route involves which of the following considerations?
The drug will bypass the blood-brain barrier.
A patient has been diagnosed with migraines after experiencing headaches of increasing severity. When providing health education to this patient about her new diagnosis, what should the nurse convey?
The etiology of migraines is thought to have a genetic component.
A 14-year-old boy was brought to the emergency department (ED) by his father after suffering an apparent concussion during a game. Assessment in the ED confirmed the father's suspicion, and the boy is being discharged home in his father's care. What health education should the nurse provide to the boy's father?
The father should awaken his son every 2 hours during the night.
A patient is receiving immunosuppressant therapy and is preparing for discharge. For which of the following should the patient be educated?
The importance of keeping the home clean
SATA The nurse is completing the physical assessment of a patient suspected of a neurologic disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient?
The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling
Which statement accurately reflects current stem cell research?
The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.
Sirolimus and cyclosporine are being used to prevent renal transplant rejection in an adult patient. What principle should guide the nurse's administration of these two drugs?
The two drugs should be given at least 4 hours apart.
Which is a major manifestation of Wiskott-Aldrich syndrome?
Thrombocytopenia
The nursing is assessing a client who has been diagnosed with a pituitary adenoma, but has not yet started treatment. The client reports having increased heart rate, hand tremors, difficulty sleeping, weight loss and hyperthermia. The nurse anticipates the client will require blood work to assess for overproduction of which hormone?
Thyroid-stimulating hormone
The nurse is seeing a client who is suspected of having a glioblastoma multiforme tumor. The nurse anticipates the client will require which diagnostic test to confirm the client has this form of brain tumor?
Tissue biopsy
SATA A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure?
Turn the client to the side. Provide verbal reassurance.
The body makes norepinephrine by using what from the diet?
Tyrosine
A nurse has been administering seasonal influenza vaccinations to the residents of a long-term care facility. One resident has refused the vaccinations, stating that he believes the vaccination to be a cause of influenza infection rather than a protection against it. The nurse's response to this resident should encompass which of the following facts about vaccination?
Vaccination prompts the body to produce antibodies against influenza.
A second-generation H1 receptor antagonist antihistamine formulated as a nasal spray for topical use is
azelastine (Astelin).
What does the body require in order to produce acetylcholine?
choline from diet
A patient is being admitted to the floor following a motor vehicle accident. Because of the stressful nature of the event, the nurse anticipates the patient will continue to have a sympathetic stress reaction during the postoperative period. When monitoring the patients serum electrolytes, what will the nurse closely monitor?
decreased potassium
Lower motor neuron lesions cause
flaccid muscles.
SATA What types of cells are the primary targets of the healthy immune system? Select all that apply.
infectious cells foreign cells cancerous cells
A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:
is not responding to stimuli.
Osteoarthritis is known as a disease that
is the most common and frequently disabling of joint disorders
The nurse is completing a health history with a client in a clinic. What assessment finding best correlates with a diagnosis of osteoarthritis
joint stiffness that decreases with activity
The nurse is assessing a client with a history of ankylosing spondylitis. What will the nurse most commonly assess?
low back pain
A middle-aged patient describes her headaches as "utterly debilitating" and tells the nurse, "It's hard to explain, but I just know when one is coming, and I'm never wrong." This patient's statement suggests that she has what diagnosis?
migraines
A patient is suspected of having myositis. The nurse prepares the patient for what procedure that will confirm the diagnosis?
muscle bx
SATA The nurse administers a drug that stimulates the nicotinic receptors. What assessment findings would indicate effectiveness of the drug?
muscle contractions Release of norepinephrine from the adrenal medulla Signs and symptoms of a stress reaction
The nurse is teaching a client about histamine release during an anaphylactic reaction. What does histamine release in anaphylaxis cause?
nasal congestion
A transplant nurse is aware of the need to closely monitor a patient's serum levels of cyclosporine. In order to do this, the nurse should ensure that blood is drawn at what time?
2 hours after a dose
While taking the health history of a newly admitted client, the nurse reviews general lifestyle behaviors. What strategies would have a positive effect on the immune system?
Biofeedback, relaxation, and hypnosis
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?
Bleeding
A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?
"It will get better and worse again."
Following an extensive diagnostic workup, a 40-year-old woman's complaints of fatigue and muscle pain have been attributed to systemic lupus erythematosus (SLE).When performing health education with this patient, what should the nurse emphasize?
"It's important to limit your exposure to sunlight and to use a good sunscreen."
The nursing instructor is going over laboratory results for patients with HIV/AIDS. The instructor tells the students that, upon interpretation of a patient's laboratory results, the nurse should recognize that a patient with HIV is considered to have AIDS when the CD4 T-lymphocyte cell count drops below what level?
200 cells/mm3 of blood
A patient in his 40s is considering immunotherapy as a treatment for his longstanding allergic rhinitis, a problem which is taking an increasing toll on his quality of life. The nurse at the allergy clinic should ensure that the patient knows that allergy control by this method usually requires treatment for how long?
3 - 5 years
The nurse is preparing to administer the recommended dose of intravenous gamma-globulin for a 60-kg male patient. How many grams will the nurse administer?
30g
SATA The patient is undergoing chronic stress and has a prolonged sympathetic response. What type of drug could this patient receive to reduce the sympathetic response?
A drug that reduces sympathetic response A drug that increases parasympathetic response A drug that reduces central nervous system (CNS) response
The nurse administers a drug to treat hypertension that causes vasodilation of blood vessels. What is the drug stimulating?
Beta 1 receptors
A patient is diagnosed with a paralytic ileus. Which of the following medications will be administered to treat a paralytic ileus?
Bethanechol (Urecholine)
SATA The nurse at a long-term care facility is assessing a new resident's current medication regimen, and the resident states that she often takes an OTC remedy when she experiences a migraine. She has brought the bottle with her, and the nurse notes it to be Anacin Advanced Headache Formula. The nurse should document that the patient takes which drugs?
Acetaminophen Aspirin Caffeine
Myasthenia gravis occurs when antibodies attack which receptor sites?
Acetylcholine
A patient is scheduled to receive one unit of packed red blood cells. The patient states that she has had an allergic reaction to a transfusion in the past. What class of medication will assist in preventing a reaction to the packed red blood cell transfusion?
Antihistamines
While taking the health history of a newly admitted client, the nurse asks for a list of the client's current medications. Which of the following medication classifications would place the client at risk for impaired immune function?
Antimetabolites
A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise?
Avoid fibrous foods, lactose, fat, and caffeine
A nurse comes to the employee health center for evaluation and is diagnosed with allergic contact dermatitis related to latex. What manifestation would the nurse most likely exhibit?
Blistering
An unlicensed care provider administered Benadryl to an elderly resident who has been suffering from seasonal pollen allergies. Which of the following assessment findings should prompt the nurse at the facility to suspect that the resident is experiencing anticholinergic effects of this drug?
Blurry vision
Neurons that use acetylcholine as its neurotransmitter are what type of neurons?
Cholinergenic
While the nurse is making initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?
Cluster
The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?
Cranial nerve XII
What is another name for the parasympathetic nervous system?
Craniosacral system
Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?
Creutzfeldt-Jakob disease
The presence of crystals in synovial fluid obtained from arthrocentesis is indicative of
Gout
A patient has received a bone marrow transplant. What will occur if the patient receives inadequate immunosuppression after the transplant?
Graft vs host disease
A client is diagnosed with a brain angioma. When teaching the client about the risks associated with this type of brain tumor, the nurse would educate about signs and symptoms associated with which condition?
Hemorrhagic stroke
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?
Herniation
A nurse is taking the health history of a newly admitted client and asks for a list of the client's current medications. Which medication classification would NOT place the client at risk for impaired immune function?
Inotropics
The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?
Insertion of a nasogastric (NG) tube
A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. What instruction should the nurse give to the client to minimize injury?
Install safety devices in the home.
The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?
Intradermal
What is the only known risk factor for brain tumors?
Ionizing radiation
After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action?
Jabs the autoinjector into the outer thigh at a 90-degree angle
SATA The nurse is performing a physical assessment for a patient at the clinic and palpates enlarged inguinal lymph nodes on the left. What should the nurse document? (Select all that apply.)
Location Size Consistency Reports of tenderness
An emergency department nurse has just received a call from EMS that they are transporting a 17-year-old male who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
Motor vehicle accidents
A nurse was administering a scheduled subcutaneous dose of heparin to a patient who has HIV when the needle penetrated the nurse's thumb. What prophylactic action should the nurse first take?
Perform a thorough wash of the injury site with soap and water.
The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?
Placing food on the affected side of the mouth
A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis?
Poor
Primary gout is often caused by an inherited disorder in which type of metabolism?
Purine
A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?
Restrict fluids before surgery
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness
A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?
Severe lower back pain
Nursing students have learned that removal of specific organs may place the patient at risk for impaired immune function. The students are taught that it is important, while taking the patient's health history, to ask the patient if he or she had surgical removal of what organ that may lead to impairment of the immune system?
Spleen
A young woman who is 14 weeks pregnant has sought care because she has been experiencing migraine headaches with increasing severity and frequency in recent months. She states, "My headaches used to be something I could live with, but now they're affecting every other part of my life." The patient has conducted online research and requested a prescription for ergotamine. How will this patient's current health status affect the clinician's response to this request?
The patient cannot safely take ergotamine until she has weaned her infant
A middle-aged woman has scheduled an appointment with her nurse practitioner because she has been experiencing intractable muscle weakness in recent weeks. Which of the following characteristics of the patient's weakness should cause the nurse to suspect a neurological etiology?
The weakness is primarily on the left side of the patient's body.
The parents of a child with contact dermatitis are asking questions about the reaction within the immune system. What description regarding contact dermatitis as a type IV hypersensitivity reaction is accurate?
a delayed-type hypersensitivity that is mediated by T cells
Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including
a low-fat, low-cholesterol diet and increased exercise.
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:
a positive edrophonium (Tensilon) test.
A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?
acute
A client is being placed on a purine-restricted diet. What foods will the nurse include in the client's diet plan?
dairy products
A patient has been administered atropine for sinus bradycardia. Which of the following symptoms is noted with large doses of atropine?
flushing
Neurotransmitters are small molecules that exert their actions through specific proteins, called receptors, embedded in the postsynaptic membrane. Where are neurotransmitters synthesized?
in the axon terminal
A diet plan is developed for a client with gouty arthritis. What should the nurse advise the client to limit the intake of?
organ meats
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?
osteoporosis
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?
severe headache
Which are characteristics of autonomic dysreflexia?
severe hypertension, slow heart rate, pounding headache, sweating
The nurse is teaching a client with osteoarthritis about the disease. What is the most important client focus for disease management?
strategies for remaining active
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?
take daily weights
A patient with long-standing Parkinson's disease has been prescribed entacapone (Comtan). The patient asks the nurse to describe exactly how this medication works. Which of the following responses is most appropriate?
"Entacapone inhibits COMT so that dopamine is active for a longer time."
When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask?
"Have you ever received a blood transfusion?"
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following
"Have you experienced any viral infections in the last month?"
The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?
"I can apply powder under the liner to help with sweating."
The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed?
"I can take my child to the beach, as long as we play in the sand rather than swim in the water."
A patient is instructed to take diphenhydramine (Benadryl) after an allergic reaction. Which of the following statements by the patient indicates successful teaching concerning the safe and effective use of diphenhydramine?
"I should not drive my car after taking this medication."
The physician has ordered scopolamine transdermally for motion sickness. Which of the following statements by the patient indicates an understanding of the medication's administration guideline?
"I will change the patch every 3 days."
A patient with a long-standing history of seasonal allergies has sought care during the spring and been advised to take a second-generation antihistamine. Which of the patient's following statements suggests a need for the nurse to perform health education?
"I'm really hoping that these pills will cure my allergies before summer starts."
A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?
"If I notice tingling in my lips or mouth, gargling may help the symptoms."
A clinic nurse has been charged with the responsibility of teaching avoidance strategies to an adult patient who has allergic rhinitis. What measure should the nurse recommend to this patient?
"If possible, make sure that no one smokes tobacco in your home."
A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?
"It is a hyperimmune response to something in the environment that is usually harmless."
A nurse is conducting health education with a man who has Alzheimer's disease and his daughter, who is his primary caregiver. The man has been deemed to be a good candidate for treatment with donepezil (Aricept) and will soon begin taking this medication. What teaching point should the nurse convey?
"It's important to take this medication at bedtime."
The nurse is teaching a woman who has Parkinson's disease about the dietary implications of her upcoming treatment with levodopa/carbidopa. What should the nurse teach this patient?
"It's important to take this medication on a full stomach so that it doesn't make you nauseous."
A patient has been treated for migraines on an ongoing basis and the care provider has just prescribed sumatriptan. Which of the following is the priority intervention for patient education?
"Make sure that you stop taking ergotamine before you get this prescription filled."
A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?
"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."
A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?
"My finger joints are oddly shaped."
A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
A patient with myasthenia gravis is administered pyridostigmine (Mestinon) for the first time. She asks the nurse the reason why she has been changed to this medication. Which of the following is the nurse's best response?
"Pyridostigmine (Mestinon) will allow you to awaken with the ability to swallow."
A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse?
"The full benefit of the medication may take up to 2 weeks to be achieved."
A client with a malignant glioma is scheduled for surgery. The client demonstrates a need for additional teaching about the surgery when he states which of the following?
"The surgeon will be able to remove all of the tumor."
A patient is administered mycophenolate (CellCept) to prevent rejection of his transplanted heart. It is recommended that he have a CBC drawn weekly. He asks the nurse the reason for the weekly CBC. Which of the following is the nurse's best response?
"The weekly CBC assesses for the development of infection."
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?
"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
The nurse is providing health education to a client recently diagnosed with a brain tumor. During the appointment, the client states, "I'm really worried that I will have a seizure while I am at work or with my kids. Should I be concerned about this?" How should the nurse respond?
"There is a risk for seizures in people who have this diagnosis. What have you already discussed with your primary health care provider regarding management of seizures?"
A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?
"There is a strong familial tendency."
A 64-year-old woman has been admitted to the neurological unit after being diagnosed with a brain tumor. The woman is slated for neurosurgery the following day, and the woman's daughter has come to the hospital from out of state. After visiting her mother for the first time since she was diagnosed, the daughter is distraught and tells the nurse, "My mother has always been one of the kindest, most considerate people, and I don't remember her ever being so abrasive." How should the nurse best respond to the daughter's statement?
"Those personality changes are probably a result of the tumor's effect on her brain."
A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response?
"Treatment aims at keeping you independent as long as possible."
A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which statement?
"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling."
A patient has been newly diagnosed with AIDS. The patient is a 32-year-old mother of two young children. When the nurse is performing the patient's initial assessment, the patient expresses fear of dying. How should the nurse best respond to the patient?
"What concerns you most about death?"
The nurse is performing a detailed mental status assessment of an older adult patient who has a diagnosis of mild Alzheimer's disease. What assessment most accurately gauges the patient's abstract reasoning?
"What would you do if you found a stamped envelope on the street?"
A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?
"You may experience progressive deterioration in all voluntary muscles."
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
"You must avoid coughing, sneezing, and blowing your nose."
A nurse in a long-term care facility has a longstanding relationship with a female resident whose osteoarthritis has become more severe in recent months. To facilitate the resident's continued engagement in activities and to promote her mobility, the nurse has begun implementing motivational interviewing (MI). The resident has stopped attending the quilting circle, stating, "I still enjoy quilting, but my knuckles are so painful lately." What response by the nurse best exemplifies MI?
"You say you'd like to keep quilting but it's painful. What ideas do you have for reducing your pain?"
An 80-year-old patient has been prescribed an anticholinergic agent for treatment of Parkinson-related symptoms. What patient education should be provided?
"avoid high environmental temps"
A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.
0.5
A patient with a neurological disorder is being assessed by the nurse. The nurse assesses the patient's biceps reflex as diminished. The nurse would be correct in documenting this response as what?
1+
A client with a history of anaphylactic reactions to insect stings has just been stung by a wasp. Place the steps in the correct order that the client will follow for self-administration of an EpiPen. Use all options.
1. Remove the gray safety-release cap 2. Inject the black tip into the outer thigh 3. Massage the injection area 4. Call the emergency medical response number (911)
The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of:
15
The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF?
15 to 20 mL/100 g/min
The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?
15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:
190 mm Hg/120 mm Hg
A patient comes to the clinic with pruritus and nasal congestion after eating shrimp for lunch. The nurse is aware that the patient may be having an anaphylactic reaction to the shrimp. These symptoms typically occur within how many hours after exposure?
2 hours
The nurse is preparing to infuse gamma-globulin intravenously (IV). When administering this drug, the nurse knows the speed of the infusion should not exceed what rate?
3mL/min
The nurse is caring for a client experiencing an anaphylactic reaction. The nurse prepares for the maximum intensity of histamine response to occur within which time frame?
5 - 10 minutes
The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?
5.4
A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time?
6 Weeks
As part of the assessment process for a patient suspected of having gout, the nurse evaluated his serum uric acid levels. Select the value that is considered above the saturation point for crystal formation.
6.8 mg/dL
The nurse is aware that in an ischemic stroke there is an area of low CBF around the infracted area (penumbra region). This area cannot be saved if tissue plasminogen activator (tPA) is administered at a CBF level of:
8 mL/100 g/min
SATA The nurse is providing education to a client who is being discharged with an outpatient treatment plan that includes taking a chemotherapeutic agent. What instructions should the nurse include?
> The client should ensure no one else handles the medication. > The client should seek emergency care if he or she develops a fever. > Hair loss should be expected when taking the medication.
What are the characteristis of a B-cell deficiency, such as common variable immune deficiency (CVID)? Select all that apply.
> There is a disappearance of germinal centers from lymphatic tissue. > There is complete lack of antibody production. > Disease onset occurs most often in the second decade of life.
A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?
A cell-mediated response
Antihistamines are used to treat nasal congestion. Which of the following patients should not be administered an antihistamine?
A male patient with prostatic hypertrophy
A 10-year-old boy has been brought to the emergency department (ED) by ambulance in apparent anaphylaxis after accidentally eating a snack bar that contained peanuts. The ED nurse should be aware that this patient's signs and symptoms are attributable to:
A massive release of histamine
A nurse knows that a patient exhibiting seizurelike movements localized to one side of the body most likely has what type of tumor?
A motor cortex tumor
A 30-year-old primiparous woman has been admitted in early labor. The obstetrical nurse has read on the patient's prenatal record that she has a history of seizures. The nurse should understand that seizures most often occur as a result of:
Abnormal activity in the cerebral cortex
SATA Which signs are considered cardinal signs of brain death? .
Absence of brainstem reflexes Apnea Coma
Which of the following neurotransmitters are deficient in myasthenia gravis?
Acetylcholine
Which of these is a neurotransmitter?
Acetylcholine (ACh)
After the effector cell has been stimulated by acetylcholine (ACh), what enzyme stops this stimulation and allows the effector membrane to repolarize?
Acetylcholinesterase
A nurse is working in a pediatric clinic. After giving a hepatitis B immunization to an infant, the parent asks what kind of protection this provides for the child. What is the nurse's best response?
Active acquired immunity, which lasts many years or a lifetime
A nurse at a small, rural nursing station that lacks the services of a physical therapist is responsible for planning the care of a local resident who has rheumatoid arthritis. When planning a regimen of physical activity for this patient, what principle should underlie the nurse's choice of interventions?
Active range-of-motion (ROM) exercises can reduce joint stiffness.
A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect:
Acute attacks with full recovery or residual deficit upon recovery.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
Administer atropine to control the side effects of edrophonium.
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the prioritynursing intervention?
Administer corticosteroids as ordered.
After receiving a dose of penicillin, a client develops dyspnea and hypotension and the nurse suspects the client is experiencing anaphylactic shock. What is the nurse's first action?
Administer epinephrine, as ordered.
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?
Administer medications at exact intervals ordered.
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
Administering a stool softener as ordered
SATA The nurse is teaching a class about the autonomic nervous system for critical care nurses. What statements, if made by the nurse during the class, are accurate?
Adrenergic receptors respond to norepinephrine. Adrenergic receptors are part of the sympathetic nervous system. Cholinergic receptors are part of the parasympathetic nervous system. Cholinergic and adrenergic receptors are part of the autonomic nervous system.
Which term refers to the failure to recognize familiar objects perceived by the senses?
Agnosia
A nurse is managing the care of a client who has gout. Which medication would be prescribed as the drug of choice to prevent tophi formation and promote tophi regression?
Allopurinol
When caring for a patient who has had a hemorrhagic stroke, close monitoring of vital signs and neurological status is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke?
Alteration in LOC
A patient has been diagnosed with an allergy to peanuts. What is a priority for this patient to carry at all times?
An EpiPen
A health care provider orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?
An above-normal anti-deoxyribonucleic acid (DNA) test
A middle-aged woman suffers from debilitating seasonal allergies and has sought care because over-the-counter remedies do not adequately relieve her symptoms. The clinician's understanding of the patient's problem should include the fact that hypersensitivity is a result of what pathophysiological process?
An exaggerated, inappropriate response to an antigen
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
An intracerebral hematoma
A mother has come to the emergency department (ED) with her 2-year-old who appears to be having a hypersensitivity reaction. The ED nurse knows that a hypersensitivity reaction may be characterized by an immediate reaction beginning within minutes of exposure to an antigen. What condition is an example of such a reaction?
Anaphylactic reaction immediately following a bee sting
A 33-year-old man who is in healthy physical condition has been admitted to the emergency room with unilateral weakness and slurred speech. A computed tomography (CT) scan of the man's head reveals a hemorrhagic stroke despite the fact that the man is in good health with no history of hypertension, thromboembolism, or drug use. What type of brain tumor has the potential to cause this man's health problem?
Angioma
Which term refers to fixation or immobility of a joint?
Ankylosis
Which medication classification should be avoided in the treatment of brain tumors?
Anticoagulants
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?
Apply an eye patch to the right eye.
A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring?
Applying thigh-high elastic stockings
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia
A male patient's symptomatic HIV has progressed to AIDS, and the patient is now unable to independently perform most of his activities of daily living. To prevent skin breakdown, what action should the nurse take?
Arrange for a pressure-reducing mattress.
A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?
Artificially acquired active immunity
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?
Ask the client if he has trouble breathing.
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is
Aspirin
What is the priority intervention for a client who has been admitted repeatedly with attacks of gout?
Assess diet and activity at home
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
SATA Which interventions would be recommended for a client with dysphagia?
Assist the client with meals. Test the gag reflex before offering food or fluids. Allow ample time to eat.
The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care?
Assist with chest physiotherapy every 2 to 4 hours.
A client has sustained a head injury to the parietal lobe and cannot identify a familiar object by touch. The nurse knows that this deficit is
Astereognosis
Which of the following, if left untreated, can lead to an ischemic stroke?
Atrial fibrillation
A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses. As part of the presentation, the nurse is planning to describe the events that occur once HIV enters the host cell. What would the nurse describe as the first step?
Attachment
A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?
Auditory
A nurse on a medical unit is caring for a patient who has experienced a recent exacerbation of HIV. The nurse is being vigilant in assessments and preventative measures related to the common complications of HIV infection. What assessment addresses the most common opportunistic infection related to HIV?
Auscultating the patient's lungs and monitoring oxygen saturation and respiratory rate
A client has been having joint pain and swelling in the left foot and is diagnosed with rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and the client has significant joint destruction. What type of disease is this considered?
Autoimmune
A 33-year-old female patient with a recent history of visual disturbances and dysphagia has just been diagnosed with myasthenia gravis. The nurse should recognize that this patient's health problem is ultimately attributable to what pathophysiological process?
Autoimmune destruction of acetylcholine receptors
A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?
Autonomic dysreflexia
The nurse teaches the client diagnosed with Huntington disease that it is transmitted as which type of genetic disorder?
Autosomal dominant
The nurse is teaching a client after a medication allergic reaction has occurred. What is the mostimportant action for the nurse to teach the client to take to prevent anaphylaxis?
Avoid potential allergens.
The nurse is caring for a client who was diagnosed with a glioma 5 months ago. Today, the client was brought to the emergency department by his caregiver because he collapsed at home. The nurse suspects late signs of rising intracranial pressure (ICP) when which blood pressure and pulse readings are noted?
BP = 175/45 mm Hg; HR = 42 bpm
Extensive diagnostic testing has resulted in a patient's diagnosis of a benign brain tumor. When providing care for this patient, the nurse should be cognizant of which of the following characteristics of benign brain tumors?
Benign brain tumors can slowly grow into an area of vital brain function.
What helps to prevent overstimulation of effector sites on nerve membranes?
Beta 1 receptors
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
Body temperature
SATA A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad?
Bradycardia Bradypnea Hypertension
A neurological nurse is conducting a scheduled assessment of a patient who is receiving care on the unit. The nurse is aware of the need to conduct a vigilant assessment of the patient's level of consciousness (LOC). How should the nurse best gauge a patient's LOC?
By assessing according to the Glasgow Coma Scale (GCS)
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?
CN I
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?
CN II
The nursing student learns that the hypothalamus serves what purpose?
Causes the secretion of adrenocorticotropic hormone (ACTH)
A patient with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. What is the immune response that predominates in this situation?
Cellular
A client comes to the clinic for evaluation because of complaints of dizzinesss and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?
Cerebellum
In which location are most brain angiomas located?
Cerebellum
The nurse is caring for a client who has been hospitalized for investigation of a sudden change in gait due to loss of balance and coordination. A magnetic resonance imaging scan reveals the client has a brain tumor. On or close to which brain structure is the tumor most likely situated?
Cerebellum
SATA Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following is cause of a secondary injury associated with brain injury?
Cerebral edema Ischemia Infection Seizures Hyperthermia
The nurse is caring for a client who underwent surgery to remove a spinal cord tumor. When conducting the postoperative assessment, the nurse notes the presence of a bulge at the surgical site. The nurse suspects the client is experiencing what complication from the surgery?
Cerebrospinal fluid leakage
Which is the earliest sign of increasing intracranial pressure?
Change in level of consciousness
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?
Check the equipment.
Magnetic resonance imaging has confirmed a diagnosis of glioblastoma multiforme (GBM) in a 56-year-old male patient. The nurse who is planning this patient's care should prioritize which of the following nursing actions?
Choosing psychosocial interventions that are relevant to the patient's poor prognosis
The nurse is teaching a client about the characteristics of osteoarthritis. How will the nurse determine the client teaching was successful?
Clients may develop Heberden nodes
A 33-year-old man with AIDS is being treated for cytomegalovirus retinitis and has been prescribed ganciclovir. The nurse who is participating in this patient's care should recognize that this treatment necessitates which of the following assessments?
Close monitoring of the patient's WBC differential
A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke?
Cocaine use
A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test?
Coffee
A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as
Coma
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?
Compliance with the prescribed medication regimen
A 66-year-old woman with a recent history of headaches and agitation has been found to have a meningioma. The neurological nurse should understand that the symptoms of this woman's tumor are attributable to what pathophysiological process?
Compression of brain tissue
SATA A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify?
Confusion Sudden numbness Visual disturbances
A man with a neurogenic bladder secondary to a spinal tumor has been taking bethanechol. The patient has illuminated his call light, and the nurse has found him anxious, diaphoretic, and visibly flushed. Following a safety assessment, what action should the nurse take?
Contact the physician as the patient may be experiencing a cholinergic crisis.
The nurse in an allergy clinic is assessing a new patient. The nurse is aware that histamine plays an important role in the immune response and that the effects of histamine can manifest in assessment findings. What response can occur as a result of histamine release?
Contraction of bronchial smooth muscle
A patient is having an allergic reaction to mold. The patient describes chest tightness and difficulty breathing. Which of the following body effects is occurring?
Contraction of smooth muscle in the bronchi
A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?
Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.
There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.
Cranial nerve II
Which microorganism is known to cause retinitis in people with HIV/AIDS?
Cytomegalovirus
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.
Cytotoxic T cell
An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated?
Cytotoxic T cells
A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?
Decerebrate
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?
Decerebrate
A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following?
Decerebrate positioning implying severe dysfunction and brain pathology
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?
Decerebrate posturing and loss of corneal reflex
SATA Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition?
Decreased muscle mass Increased sensitivity to heat and cold Reduced papillary responses
If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?
Decreased muscle tone
An adult patient has questioned whether fexofenadine (Allegra) would be preferable to the first-generation H1 receptor antagonists that he has long taken in the treatment of his environmental allergies. When describing the benefits of second-generation drugs such as Allegra, the nurse should cite what advantage?
Decreased sedation
The nurse is discharging home a patient who suffered a stroke. The patient has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to the home health nurse because the hospital nurse is aware that the most common patient response to a change in body image is what?
Depression
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
All the following items are related to cancer. Which does not affect the immune system?
Diagnostic tests for cancer
The nurse is performing an admission assessment on a patient with AIDS. When assessing the patient's gastrointestinal (GI) system what is most likely to be the priority nursing diagnosis?
Diarrhea
A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke?
Difficulty speaking
A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used?
Digestive enzymes destroy its protein structure.
The nurse is preparing to administer a medication that has an affinity for H1 receptors. Which medication would the nurse administer?
Diphenhydramine
An adult patient has complained to the nurse that she has been experiencing a dry mouth and urinary retention after several nights of taking an OTC sleep aid. The nurse should suspect that this medication contains what antihistamine?
Diphenhydramine (Benadryl)
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
Diplopia and ptosis
A client calls the clinic and asks the nurse if using oxymetazoline nasal spray would be alright to relieve the nasal congestion he is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications?
Do not overuse the medication as rebound congestion can occur.
When assessing the skin of a client with allergic contact dermatitis, the nurse would most likley expect to find irritation at which area?
Dorsal aspect of the hand
The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease?
Drugs administered may cause a wide variety of adverse effects.
A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has?
Dysfunction of the vagus nerve
A client with Parkinson's disease has been receiving levodopa as treatment for the past 7 years. The client comes to the facility for an evaluation and the nurse observes facial grimacing, head bobbing, and smacking movements. The nurse interprets these findings as which of the following?
Dyskinesia
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?
Dyskinesia
The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding?
Dysphonia
A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?
Dyspnea, bronchospasm, and/or laryngeal edema.
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?
Ecchymosis over the mastoid
A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?
Edrophonium (Tensilon)
The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find?
Elevated erythrocyte sedimentation rate
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?
Elevating the head of the bed to 30 degrees
A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?
Engulfment and digestion of bacteria and foreign material
Which neurotransmitter inhibits pain transmission?
Enkephalin
A client is suspected of having an immune system disorder. The health care provider wants to perform a diagnostic test to confirm the diagnosis. What test should the nurse prepare the client for?
Enzyme-linked immunosorbent assay
A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?
Enzyme-linked immunosorbent assay (ELISA)
A teenage boy is undergoing allergy testing and has had blood work drawn as part of the diagnostic workup. When reviewing the patient's laboratory results, the nurse should pay particular attention to the levels of what white blood cell (WBC) component?
Eosinophils
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?
Establishing eye contact
The client with a brain tumor may be at increased risk for aspiration. What does the nurse determine is the most important nursing intervention?
Evaluation of gag reflex and ability to swallow
A patient is being treated in hospital for St. Louis encephalitis. When planning this patient's care, the nurse should be aware that this specific variant of encephalitis creates a potential for what nursing diagnosis?
Excess fluid volume
SATA Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS?
Eye opening Verbal response Motor response
The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?
Facial distortion and pain
A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
Facial erythema, pericarditis, pleuritis, fever, and weight loss
A hospital patient is complaining of nausea and vomiting that has failed to respond to first-line antiemetics. Which of the following medications may be administered for the treatment of nausea and vomiting?
First-generation antihistamine agent: hydroxyzine (Vistaril)
A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?
Flaccidity
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?
Flat, except for logrolling as needed
A middle-aged patient has not achieved adequate symptom relief of migraines with first- line therapies, and the clinician is considering the use of frovatriptan (Frova). The patient's concurrent use of what medication would contraindicate the safe use of frovatriptan?
Fluoxetine (Prozac)
SATA A patient had a lumbar puncture 3 days ago in the outpatient clinic and calls the nurse with complaints of a throbbing headache. What can the nurse educate the patient to do for relief of the discomfort?
Force fluids (unless contraindicated). Get plenty of bed rest. Take some over-the-counter analgesics.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?
Form words that are understandable or comprehend spoken words
From which direction should a nurse approach a client who is blind in the right eye?
From the left side of the client
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
Which lobe of the brain is responsible for concentration and abstract thought?
Frontal
SATA The nurse is conducting a neurological assessment with a client who has increased intracranial pressure secondary to growth of brain tumor mass. What assessment tools can the nurse use to determine the client's neurological status?
Glascow coma scale (GCS) Mini mental status examination (MMSE)
What is the most common type of brain neoplasm?
Glioma
The nurse is reviewing the medical record of a client who is positive for human immunodeficiency virus (HIV). The nurse notes that the client is classified as HIV asymptomatic based on which CD4+ T lymphocyte count?
Greater than 500/mm3
A 37-year-old mother of three has just been diagnosed with a grade I meningioma. As part of patient education, the nurse tells the patient that:
Growth is slow and symptoms are caused by compression rather than tissue invasion.
The victim of a motor vehicle accident has been admitted with massive trauma, including traumatic brain injury. Emergency treatment of increased intracranial pressure (ICP) has failed to resolve the problem, and monitoring reveals the ominous presence of Cushing's triad. What assessment findings would be consistent with this clinical phenomenon?
HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute
A patient has developed symptoms of rigidity and bradykinesia. Which of the following medications has been linked to secondary parkinsonism?
Haloperidol
A client who has been diagnosed with osteoarthritis asks if he or she will eventually begin to notice deformities in the hands and fingers as the condition progresses. Which concept should the nurse include in the response?
Hand and finger deformities are associated with the development of rheumatoid arthritis.
The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?
Has a weight gain of 5 pounds
A patient is receiving omalizumab (Xolair) to treat allergic asthma, which is not relieved by inhaled corticosteroids. Which nursing intervention is appropriate with each dose administration of omalizumab?
Have episode available during administration
A patient diagnosed with a pituitary adenoma has arrived on the oncology unit. Based upon the nurse's initial assessment, the patient is most likely to exhibit:
Headache
Which condition is an early manifestation of HIV encephalopathy?
Headache
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
Headache and nuchal rigidity
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?
Helicopod
A client is admitted to undergo lumbar laminectomy for treatment of a herniated disk. Which action should the nurse take first to promote comfort preoperatively?
Help the client assume a more comfortable position.
A client is diagnosed with a brain angioma. When providing care to this client, the nurse would be especially vigilant in monitoring for signs and symptoms of which of the following?
Hemorrhagic stroke
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
Heparin sodium
A 66-year-old man who originally sought care because of increasing pain in his great toe has subsequently been diagnosed with gout. In addition to pharmacological interventions, what dietary regimen should the nurse recommend to this patient?
High fluid intake and low protein intake
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?
High in protein and low in carbohydrate
Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?
Histamine
Which disturbance results in loss of half of the visual field?
Homonymous hemianopsia
Which terms refers to blindness in the right or left half of the visual field in both eyes?
Homonymous hemianopsia
A patient is suffering from urinary urgency and frequency. Which of the following medications will assist in treating the patient's symptoms of urinary frequency?
Hyoscyamine (Anaspaz)
SATA The nurse administers a medication that stimulates the parasympathetic nervous system (PNS). What manifestations would indicate the medication is working?
Hyperactive bowel sounds Increased saliva production Constricted pupils
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:
Hypertension
A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse would include which of the following as a causative agent in gout?
Hyperuricemia
A patient is hospitalized with a severe case of gout. The patient has gross swelling of the large toe and rates pain a 10 out of 10. With a diagnosis of gout, what should the laboratory results reveal?
Hyperuricemia
Which term means a lack of one or more of the five immunoglobulins?
Hypogammaglobulinemia
The staff educator is orientating a nurse new to the neurological ICU when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What sign or symptom is consistent with this diagnosis?
Hypotension
Which of the following areas of the brain are responsible for temperature regulation?
Hypothalamus
A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not include when teaching the client and family information about managing the disease?
If you have problems with a medication, you may stop it until your next physician visit.
What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction?
IgE
The nurse is teaching a group of health care workers about latex allergies. What reaction will the nurse teach the workers to be most concerned about with laryngeal edema?
IgE-mediated hypersensitivity
Which immunoglobulin assumes a major role in bloodborne and tissue infections?
IgG
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?
Immunosuppressive agents
A middle-aged man has presented for care to a nurse practitioner because his seasonal allergies are detracting from his quality of life. What should the nurse teach this patient about allergic rhinitis?
Immunotherapy may have the potential to provide long-term relief from symptoms.
A patient is administered edrophonium (Tensilon) to confirm the diagnosis of myasthenia gravis. What effect will the edrophonium (Tensilon) have 30 minutes after the medication administration, which will confirm the diagnosis?
Improved breathing
The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority?
Include client in planning of care and setting of goals.
The nurse assesses that the patient is having a sympathetic response when noting what manifestations?
Increase in blood pressure, bronchodilation, and decreased bowel sounds
A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of:
Increased ICP
A young woman who lives alone comes home at night to find a man in her apartment. What body responses would be expected for the young woman?
Increased blood pressure (BP), increased heart rate, and pupil dilation
The nurse administers a drug that stimulates the parasympathetic nervous system. What physiological response would indicate the drug is working?
Increased gastrointestinal (GI) motility
A nurse assesses a patient who has been diagnosed with having a pituitary adenoma that is pressing on the third ventricle. The nurse looks for the associated sign/symptom. What is that sign/symptom?
Increased intracranial pressure
A patient has been admitted to the intensive care unit (ICU) for the treatment of bacterial meningitis. The ICU nurse is aware of the need for aggressive treatment and vigilant nursing care because meningitis has the potential to cause what sequela?
Increased intracranial pressure (ICP)
Following a successful kidney transplant in 1999, a 59-year-old woman has presented to the clinic for one of her regularly scheduled follow-up appointments. The nurse at the clinic should assess the patient in the knowledge that long-term use of antirejection drugs has been associated with
Increased risk of malignancy
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care?
Ineffective airway clearance related to altered LOC
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?
Ineffective airway clearance related to brain injury
Mrs. Gonzaga is a 60-year-old woman who first began having headaches during the onset of menopause and who has subsequently been diagnosed with migraines. She tearfully explains to the nurse how her husband downplays her health condition and tells her that she needs to "just push through a headache." She describes how her migraines have limited her ability to provide childcare for her young grandchildren and explains that she is unable to keep up her garden. The nurse should identify what nursing diagnosis when planning Mrs. Gonzaga's care?
Ineffective role performance related to migraine headaches
A patient has had rheumatoid arthritis for over 10 years, and the health care provider has now ordered cyclophosphamide (Cytoxan) for treatment of the disease. The nurse must be alert to what side effects of this medication when administering an immunosuppressant?
Infection
A patient in the clinic states, "My boyfriend told me he went to the clinic and was treated for gonorrhea." While testing for the sexually transmitted infection (STI), what else should be done for this patient?
Inform the patient that it would be beneficial to test for HIV.
A patient who lives with migraines has been prescribed naproxen. The nurse should recognize that this drug achieves a therapeutic effect through which of the following means?
Inhibiting the synthesis of COX-1 and COX-2
A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?
Initiate isolation precautions.
The nurse is assessing a client who was brought to the emergency department due to a severe headache with sudden onset, lowered level of consciousness and slurred, non-sensical speech. The client completed chemotherapy and radiation treatment for a glioma-type brain tumor 6 months ago. The client has been taking low molecular weight heparin since completing treatment. The nurse should be prepared to provide care for which possible problem?
Intracerebral hemorrhage
A patient with myasthenia gravis is experiencing rhinorrhea. Which of the following medications should not be administered to the patient?
Ipratropium (Atrovent)
A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?
It allows for stabilization of the cervical spine along with early ambulation.
What is the function of cerebrospinal fluid (CSF)?
It cushions the brain and spinal cord.
A patient has been suffering from repeated sinus infections and is diagnosed with allergic rhinitis. The patient is prescribed a first-generation H1 receptor antagonist. What is one of the effects of this medication?
It decreases capillary permeability.
Which points should be included in the medication teaching plan for a client taking adalimumab?
It is important to monitor for injection site reactions.
A nurse in surgical daycare is completing a preoperative assessment of a woman who will undergo hip arthroplasty. The nurse has questioned the woman about her daily use of gabapentin (Neurontin), and the woman has stated that she takes this drug to treat her migraines. What role does this drug play in migraine treatment?
It prevents migraines from occurring.
The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury?
It results from inadequate delivery of nutrients and oxygen to the cells.
A patient with myasthenia gravis is administered neostigmine (Prostigmin). How does this drug produce its therapeutic effect?
It stimulates the parasympathetic nervous system.
A patient is scheduled for a hemithyroidectomy. She has been prescribed an anticholinergic agent prior to surgery. Why is it important to administer the anticholinergic agent in the preoperative phase?
It will decrease respiratory secretions.
A public health nurse is participating in a health promotion workshop and is teaching a group of high school students how to respond if a person suffers an apparent spinal cord injury. The nurse should instruct participants to:
Keep the victim's head in a neutral position at all times.
The nurse is providing postoperative care for a client who just underwent surgery to remove a metastatic intramedullary tumor. On postoperative day 3, the client states, "I am really looking forward to going running again, it had become too difficult because of the loss of feeling in my feet." Which should the nurse address in the client's care plan?
Knowledge deficit
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?
Lack of deep tendon reflexes
Which of the following antiseizure medication has been found to be effective for post-stroke pain?
Lamotrigine (Lamictal)
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
Lateral recumbent, with chin resting on flexed knees
A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury?
Left frontoparietal region
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?
Lethargy and stupor
The nurse is caring for a patient with Parkinson's disease and is preparing to administer medication. What does the nurse administer to the patient that is considered the most effective drug currently given for the tremor of Parkinson's?
Levodopa
A patient is being treated for Parkinson's disease and has been prescribed both levodopa (L-dopa) and carbidopa (Lodosyn). Why is this course of combination treatment most effective?
Levodopa restores dopamine and carbidopa decreases peripheral breakdown of levodopa.
The admission assessment form on a neurological unit requires the admitting nurse to assess each patient's superficial reflexes. To assess a patient's corneal reflex, the nurse should:
Lightly touch the patient's sclera with some wisps of cotton.
Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?
Liquids
A patient with osteoarthritis is taking up to 4 grams of acetaminophen daily. The nurse knows to obtain periodic:
Liver enzyme results.
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?
Look for signs of increased intracranial pressure
A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?
Lymphocyte
A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:
Lymphocytes migrate to areas of the lymph node
The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents?
Macrophages
A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client?
Magnetic resonance imaging
A 13-year-old patient is admitted to the pediatric unit with a suspected brain tumor. The nurse should understand that which diagnostic test is the most helpful in the diagnosis of brain tumors?
Magnetic resonance imaging (MRI)
The diagnosis of multiple sclerosis is based on which test?
Magnetic resonance imaging (MRI)
Which diagnostic is most commonly used for spinal cord compression?
Magnetic resonance imaging (MRI)
Which of the following is accurate regarding a hemorrhagic stroke?
Main presenting symptom is an "exploding headache."
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?
Maintain cerebral perfusion pressure from 50 to 70 mm Hg
A client with degenerative joint disease asks the nurse for suggestions to avoid unusual stress on the joints. Which suggestion would be most appropriate?
Maintain good posture.
An older adult patient has been brought to the emergency department (ED) after being found unconscious by a neighbor. What action should be the ED nurse's highest priority in the care of this patient?
Maintain the patency of the patient's airway.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?
Maintaining a patent airway
A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?
Maintains a patent airway
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?
Maintenance of a patent airway
The nurse explains to the client with projectile vomiting and severe headache that a medication is being prescribed to reduced edema surrounding the brain and lessen these symptoms. What medication is the nurse preparing to administer?
Mannitol
SATA A client with common variable immunodeficiency disease (CVID) has an order for an IVIG infusion. What actions should the nurse perform before beginning the infusion?.
Measure the client's height and weight. Premedicate with acetaminophen and diphenhydramine. Assess baseline vital signs. Assess for history of migraine headaches.
SATA A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply.
Milk Eggs Shrimp
A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
Monitor your body temperature
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?
Monitoring is needed as rapid neurologic deterioration may occur.
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?
Monro-Kellie
A nurse helps a patient recently diagnosed with a pituitary adenoma understand that:
Most tumors produce too much of one or more hormones.
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
Moving the head and chin toward the chest
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?
Multiple sclerosis
Central nervous system drugs bind to receptors embedded in the cell membranes of neurons. Cholinergic receptors have been classified as what?
Muscarinic
When the nurse administers a drug that stimulates the nicotinic receptors, what manifestation would indicate the drug is working?
Muscle contraction
SATA The nurse administers a parasympathetic stimulator that only stimulates nicotinic receptors. What effects would the nurse expect to assess?
Muscle contraction Signs and symptoms of a stress reaction Release of epinephrine from adrenal medulla
When administering anticholinesterase drugs, what assessment finding would indicate the patient is experiencing a toxic effect of the medication?
Muscle weakness
A patient who suffers from Parkinson's disease is being treated with levodopa/carbidopa. Which of the following disorders will result in the discontinuation of this drug based on a disease-related contraindication?
Narrow-angle glaucoma
The physician orders benztropine mesylate (Cogentin). What disease process would contraindicate the administration of this anticholinergic medication?
Narrow-angle glaucoma
A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?
Natural immunity
The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?
Natural killer cells
A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?
Naturally acquired active immunity
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
Which type of immunity becomes active as a result of infection by a specific microorganism?
Naturally acquired active immunity
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?
Neglect of the left side
A patient is administered cyclosporine (Sandimmune, Neoral) to prevent rejection of a kidney transplant. Which of the following is a major adverse effect of cyclosporine?
Nephrotoxicity
SATA Following recent changes in memory and personality, a 72-year-old man is undergoing neurological testing to rule out Alzheimer's disease. The nurse is aware that this disease is characterized by what pathophysiological phenomena?
Neurofibrillary tangles Arteriovenous malformations (AVMs)
A client is receiving ganciclovir as part of the treatment for cytomegalovirus retinitis. What would the nurse monitor the results of the client's laboratory tests for?
Neutropenia
Students are reviewing information from the Centers for Disease Control and Prevention (CDC) for a class presentation about preventing the transmission of HIV. Which of the following would the students be least likely to include in their presentation?
Nonlatex lambskin condoms are highly effective in preventing HIV infection.
A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client?
Nonsteroidal anti-inflammatory drugs
SATA A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations?
Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia
A nurse is caring for a patient newly diagnosed with osteoarthritis (OA). The patient asks the nurse what causes OA. What would the nurse tell the patient is a well-recognized risk factor for osteoarthritis?
Obesity
The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?
Observe for any signs of behavioral changes.
A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?
Occipital
A patient is brought to the emergency room following a motor vehicle accident in which she sustained a head trauma. The patient is complaining of blindness in her left eye. The nurse would be correct in suspecting that this sensory deficit is related to damage in what cerebral lobe?
Occipital
A 77-year-old female patient who is recovering in the hospital from a total knee replacement has rung her call bell and told the nurse that she needs pain medication. When assessing the patient's pain, what principle should the nurse bear in mind?
Older adults tend to have a blunted pain sensation, so complaints should be followed-up promptly.
A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"?
Only use the nasal spray for 3 to 4 days once every 12 hours.
Which of the following is the most likely indication for the use of immunosuppressant agents?
Organ transplantation
Which of the following is a hallmark of spinal metastases?
Pain
A client seeks care for lower back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk?
Pain radiating down the posterior thigh
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
Paresthesia
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:
Parkinson's disease.
A 60-year-old male patient has developed a tremor of the right hand with a pill-rolling motion. Upon interviewing the patient, he states he sustained several head injuries playing football. Based on this information, what do you suspect the patient is suffering from?
Parkinsons disease
A patient in the intensive care unit has a diagnosis of immune thrombocytopenia (ITP) and has been treated with an infusion of intravenous immunoglobulin (IVIG). The therapeutic effects of IVIG are an example of:
Passive acquired immunity
Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment?
Past substance abuse
A surgical nurse is careful to include an assessment question addressing latex allergies for each patient who is admitted to the surgical day care unit. This nurse should be aware that which of the following patients tend to have an increased risk of latex allergies?
Patients who have undergone multiple surgeries and medical procedures
A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a storm door. The fall resulted in a 6 cm laceration of the right antecubital. The nurse caring for this patient knows that the site of the injury will have an invasion of what?
Phagocytic cells
What intervention is a priority for a client diagnosed with osteoarthritis?
Physical therapy and exercise
An anatomy and physiology instructor scratches chalk across the blackboard causing a screeching sound. Several students get a feeling like their hair is standing on end. This response is part of the sympathetic stress reaction and is called what?
Piloerection
The nurse educator is teaching nursing students about various types of brain tumors. The instructor recognizes that teaching has been effective when students correctly identify a client whose lab work indicates excessively high levels of thyroid stimulating hormone would most likely be diagnosed with which type of tumor?
Pituitary adenoma
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
Pituitary carcinoma
A patient has had an ischemic stroke and has been admitted to the unit. The nurse knows the importance of the principles of body alignment and correct positioning to stroke victims. How should the nurse position the patient to prevent joint deformities?
Place a pillow in the axilla when there is limited external rotation.
An adult male patient is postoperative day 2 following a kidney transplant, and his regimen of antirejection drugs began just prior to surgery. What nursing action should be integrated into this patient's plan of care?
Place the patient in a single, positive-pressure room.
A patient is treated for a neurologic dysfunction affecting facial expressions. The affected cranial nerve originates in the:
Pons
SATA After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke?
Poor abstract reasoning Decreased attention span Short- and long-term memory loss
After assessing a client who is in postoperative recovery from surgery to resect a brain tumor, the nurse notes the client is at risk for aspiration. Which nursing intervention should be included in the client's postoperative care plan?
Position client side lying with head of bed elevated to 30 degrees
A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?
Position the client flat for at least 3 hours.
A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck, and he tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection?
Positive Kernig's sign
A health care provider needs help in identifying the precise location of a brain tumor. To measure brain activity, as well as to determine structure, the nurse expects the health care provider to order which of the following tests?
Positron-emission tomography (PET)
The parents of a 3-year-old boy have just been informed that allergy testing suggests their son has multiple food allergies. When providing health education for this family, what subject should the nurse prioritize?
Possible sources of food allergens and strategies for avoiding offending foods
A 36-year-old woman has been experiencing debilitating pain and fatigue for several months and has sought care on numerous occasions from several different care providers. She is now being assessed for fibromyalgia. The patient tells the clinic nurse that it is an incredible relief to have a possible diagnosis, stating, "I felt for so long that absolutely no one was taking me seriously." The nurse should recognize that this statement represents an improvement in which of the following nursing diagnoses?
Powerlessness
Which intervention is the single most important aspect for the client at risk for anaphylaxis?
Prevention
The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function?
Previous organ transplantation
The nurse cares for a client with Huntington disease. What intervention is a priority for safe care?
Protecting the client from falls
SATA The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement?
Provide a dimly lit environment. Elevate the head of bed 30 degrees. Administer docusate per order
Which set of symptoms characterize Korsakoff syndrome?
Psychosis, disorientation, delirium, insomnia, and hallucinations
The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?
Rapid, jerky, involuntary movements
A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?
Rebound hypotension
SATA The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache?
Red wine Menstruation Exposure to flashing light
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?
Related to impaired balance
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?
Renal
The nurse administers an injection to a client with AIDS. When finished, the nurse attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse
Report the incident to the supervisor.
A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration
A child is experiencing severe flu-like symptoms with nausea and vomiting and is admitted to the hospital. Which disorder in children will contraindicate the administration of promethazine?
Reye's syndrome
The nursing educator is talking with a group of recent nursing graduates about common diagnoses on the unit. What diffuse connective tissue disease would the instructor tell the group is caused by an autoimmune reaction that results in phagocytosis, producing enzymes within the joint that break down collagen and cause edema?
Rheumatoid arthritis (RA)
The nurse is completing the intake assessment of a client new to the allergy clinic. The client states that he was taking nose drops six times a day to relieve his nasal congestion. The nasal congestion increased, causing him to increase his usage of the nasal spray to eight times a day. But again the congestion worsened. The nurse communicates to the health care provider that the client experienced
Rhinitis medicamentosa
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:
Right-sided paralysis.
A client is diagnosed with amyotrophic lateral sclerosis (ALS) in the early stages. Which medication would the nurse most likely expect to be prescribed as treatment?
Riluzole
A gerontological nurse has encouraged a group of caregivers who work with older adults to avoid administering first-generation H1 receptor antagonists to these patients. The nurse's cautionary message is an acknowledgment of what possible nursing diagnosis?
Risk for falls related to sedation
The nurse is planning the care of an 8-year-old boy who has been diagnosed with atopic dermatitis. In the boy's plan of nursing care, what nursing diagnosis should the nurse prioritize?
Risk for impaired skin integrity related to atopic dermatitis
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?
Risk for injury related to neurologic deficit
SATA The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client?
Safe exercise Medication dosages and side effects Assistive devices
Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues?
Scleroderma
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
Seizure was 1 minute in duration including tonic-clonic activity.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Semi Fowlers
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration?
Semisolid food with thick liquids
A patient with a history of allergies comes to the clinic for an evaluation. The following laboratory test findings are recorded in a patient's medical record:Total serum IgE levels: 2.8 mg/mLWhite blood cell count: 5,100/cu mmEosinophil count: 4%Erythrocyte sedimentation rate: 20 mm/hThe nurse identifies which result as suggesting an allergic reaction?
Serum IgE level
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:
Severe TBI
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
Shivering
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?
Smoking
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
Spasticity
A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's:
Speech
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
Speeds nerve impulse transmission
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?
Stool specimen for ova and parasites
Thirty minutes after the nurse begins an intravenous immunoglobulin (IVIG) infusion, the client reports itching at the site and a lump in the throat. Which action should the nurse take first?
Stop the infusion.
A nurse is teaching a community group about healthy lifestyles. A participant asks about how to maintain a healthy immune system. The nurse informs the group that which factor will positively affect the immune system?
Strong family and community connections
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?
Suction machine with catheters
A nurse is providing care to a client recently diagnosed with a brain tumor. When planning this client's care, the nurse anticipates which therapy as providing the best outcome for the client?
Surgery
The nurse is gathering objective data for a client at the clinic complaining of arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as?
Swan neck deformity
The nurse knows to follow the CDC's guidelines for Standard Precautions while caring for patients regardless of known or unknown infectious status. The nurse is aware that barrier protection is not necessary for which body fluid?
Sweat
The nurse accompanies the physician into the patients room and remains after the patient is told he has cancer and it is likely to be terminal. The patients respirations become rapid and deep, pupils dilate, and measurement of vital signs indicates the patients heart rate and blood pressure are elevated. What type of response is the nurse assessing?
Sympathetic nervous system (SNS) response
The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction?
Symptoms are localized to the area of exposure, usually the back of the hands.
The nurse is providing discharge instructions for a client who was admitted to the oncology unit due to dehydration and anorexia after chemotherapy treatment. What information should the nurse provide to the client to promote improve the client's nutritional intake at home?
Take prescribed pain medication prior to commencing a meal
A client is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication?
Take the medication with food to avoid stomach upset.
An older adult patient with a diagnosis of moderate Alzheimer's disease will soon return home with her husband. How can the nurse best facilitate the safe and effective administration of donepezil in the home setting?
Teach the patient's husband to administer the medication in a timely and safe manner.
The nurse in the oncology outpatient clinic receives a phone call from a family member of a client who was diagnosed with a metastatic spinal cord tumor. The family member informs the nurse that the client has been reporting increased back pain in the region of the tumor and dizziness. How should the nurse respond?
Tell the family member to get the client to hospital for emergency assessment
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concer
Temperature increase from 98.0°F to 99.6°F
The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
The client has cerebral spinal fluid (CSF) leaking from the ear.
The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm3, and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse?
The client has converted from HIV infection to AIDS.
A patient experiences debilitating migraines on a frequent basis and has had oral prochlorperazine (Compazine) added as an adjuvant medication to abortive therapy. When teaching the patient to take this drug safely in the home setting, the nurse should emphasize what teaching point?
The importance of taking the pill whole and not crushing or splitting it
What statement correctly explains the nerve impulse transmission?
The impulse travels from the central nervous system (CNS) to the preganglionic neuron to the ganglia to the postganglionic neuron to the neuroeffector cells.
A patient who is well-known to the clinic asked if it would safe for him to take Excedrin Extra Strength for the treatment of a severe headache. The nurse is well aware of this patient's medical history and should advise against using this medication based on what aspect of his current health status?
The patient has a diagnosis of liver cirrhosis.
A patient has been placed on tacrolimus, and the route will be changed from IV to oral prior to discharge home from the hospital. How will this change in administration route affect the patient's plan of care?
The patient's dose of tacrolimus will have to be increased.
A nurse has administered a scheduled dose of naproxen to a hospital patient who has been taking the drug for several weeks. What assessment finding should cause the nurse to suspect that the patient is experiencing adverse effects of this drug treatment?
The patient's stool tests positive for occult blood.
A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA?
The woman's stroke has a hemorrhagic etiology.
The nurse is seeing the mother of a client who states, "I'm so relieved because my son's doctor told me his brain tumor is benign." The nurse knows what is true about benign brain tumors?
They can affect vital functioning.
The central nervous system (CNS) cells, where the impulses for the sympathetic nervous system (SNS) originate, are located where?
Thoracic and lumbar sections of the spinal cord
Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage?
Tophi
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
Traction with weights and pulleys
A patient has been administered chlorpromazine (Thorazine) for many years to treat his psychotic disorder. He has recently developed extrapyramidal symptoms related to long- term administration of this drug. Which of the following medications can be administered to assist in relieving these symptoms?
Trihexyphenidyl (Trihexy)
A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection?
Trimethoprim-sulfamethoxazole
A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?
Type 1
A patient is being administered epinephrine for the treatment of anaphylaxis. This patient is experiencing what type of hypersensitivity reaction?
Type 1
A patient is diagnosed with allergic rhinitis. What type of hypersensitivity reaction is causing allergic rhinitis?
Type 1
SATA The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern?
Unequal pupils Pinpoint pupils Absence of pupillary response
A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan?
Use a topical skin moisturizer daily.
A nurse who works on a busy medical unit has been experiencing dry, itchy, reddened hands that she believes are a result of the frequent hand-washing that her job requires. What should the nurse's colleague recommend for the relief of this problem?
Use of a different type of soap
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain?
V
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve:
VIII
A patient has been brought to the emergency department (ED) with signs and symptoms of a stroke and a stat computed tomography (CT) head scan has been ordered. The ED nurse should know that the image that results from CT indicates distinguishing differences based on which of the following variables?
Variations in tissue density
The nurse is performing stroke risk screenings at a hospital open house. Identification of high-risk individuals is the goal of the screenings. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at highest risk for a stroke?
White man, age 60 with history of uncontrolled hypertension
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
Widened pulse pressure
The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?
X
A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?
XIII
An adult male patient is being administered immunosuppressant agents on a long-term basis. Which of the following assessments should be made routinely with the use of long-term immunosuppressant therapy?
Yearly skin assessment
A 40-year-old woman has received a diagnosis of myasthenia gravis (MG) and is scheduled to begin treatment with oral neostigmine in her home. When providing relevant health education, the nurse should emphasize that successful control of MG symptoms will primarily depend on
adhering strictly to the prescribed administration schedule.
A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include
adrenal suppression.
A nurse is assessing a client with possible osteoarthritis. What is the most significant risk factor for primary osteoarthritis?
age
A patient is to be administered antithymocyte globulin (ATG) to treat renal transplant rejection. What skin test should be assessed prior to the administration of the first dose of medication?
allergy to horse serum
The nurse administers a drug that causes vasoconstriction, contracted piloerection muscles, pupil dilation, closure of salivary sphincter, and male sexual emission. What receptor is this drug stimulating?
alpha 1 receptors
Which allergic reaction is potentially life threatening?
angioedema
The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as
angioneurotic edema.
An elderly patient is given diphenhydramine (Benadryl) for allergic response to mold. The nurse should consequently assess the patient for
anticholinergic effects.
A nurse is teaching a patient how to take Imitrex in the home setting in order to maximize therapeutic benefit while reducing the risk of adverse effects. The nurse should teach the patient to take Imitrex
as soon as the earliest symptoms of migraine are sensed
A client with rheumatoid arthritis tells the nurse about experiencing mild tinnitus, gastric intolerance, and rectal bleeding. What medication does the nurse suspect is causing these side effects?
aspirin
A patient who is being treated for myasthenia gravis is receiving neostigmine, and her pulse drops to 50 after the administration. Which medication should be administered to treat the bradycardia?
atropine
A client has begun sensitivity testing to determine the allergen which caused an anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more sensitive to allergens?
back
A patient is experiencing allergy symptoms after being exposed to environmental dust. This reaction involves the action of histamine, which is released by what cells?
basophils
The nurse administers a drug to the patient whose heart rate is bradycardic aimed at increasing heart rate and myocardial activity. What adrenergic receptor is this drug stimulating?
beta 1
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?
body temperature
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:
body temperature control.
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?
brain tumor
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?
cardio embolic
A nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
cerebral angiography
A patient with Parkinson's disease is being treated with rasagiline (Azilect). This medication inhibits the metabolism of dopamine by monoamine oxidase. Which of the following foods should the patient be instructed to avoid?
cheddar cheese and polish sausage
A middle-aged female patient has been admitted to the outpatient treatment unit of the hospital for an edrophonium (Tensilon) test. Shortly after the administration of the medication, the patient reports that her muscle strength is significantly weaker than before the test. The nurse who is participating in the test should recognize that this finding is suggestive of what diagnosis?
cholinergic crises
The nurse is reviewing the medication administration record of the client. Which medication would lead the nurse to suspect that the client is suffering from an acute attack of gout?
colchicine
While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?
concussion
The control systems of the body act in many ways to maintain homeostasis. These homeostatic control systems regulate the functions of the cell, integrate the functions of different organ systems, and do what else?
control vital functions
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at
controlling seizures and increased intracranial pressure.
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will:
convert glycogen to glucose for immediate use.
When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as
decerebrate.
When there is stimulation of the sympathetic nervous system (SNS), blood is diverted away from the gastrointestinal (GI) tract. What might the nurse assess that would indicate this diversion of blood flow to the GI tract?
decreased bowel sounds
If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit
decreased muscle tone.
The nurse is gathering a health history for a client with osteoarthritis. What clinical manifestation will the nurse expect to find?
early morning stiffness
A client is being treated for hyperuricemia. Part of the treatment strategy is for the client to avoid contributing factors whenever possible. Which activities might bring on an acute attack?
eating organ meats and sardines
An acoustic neuroma is a benign tumor of which cranial nerve?
eight
A woman is admitted to the emergency department with a diagnosis of sinus bradycardia. The patient has been prescribed atropine 0.5 mg IV. How often can atropine be administered?
every 3 to 5 minutes
The nurse is reviewing various medications with a client that can be used to treat allergic disorders. What medication will the nurse identify as an intranasal corticosteroid?
fluticasone
A client comes to the clinic and reports pain in the right great toe which is worse at night. Assessment reveals tophi. What does the nurse suspect?
gouty arthritis
A patient is ordered to receive cyclosporine intravenously, and the nurse has explained the need for frequent blood work. This blood work is required because cyclosporine
has a narrow therapeutic range
The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following?
heartbeat to decrease
A patient is administered methotrexate for the treatment of severe rheumatoid arthritis. Administration of this drug should be performed with particular care because of the associated high risk of
hepatotoxicity
A nurse is working in a dermatology clinic with clients who have allergies. What is the most important chemical mediator involved in the allergic response?
histamine
A patient is stung by a bee. What is the chemical mediator released in immune and inflammatory response to the bee sting?
histamine
The nurse administers a medication that stimulates the muscarinic receptors. What types of manifestations will the nurse assess in this patient that indicate the drug is working?
increased activity of bowel sounds
The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care?
increased fatigue
Which immunity type becomes active as a result of infection by a specific microorganism?
naturally acquired active immunity
A 71-year-old woman has experienced a sharp decline in her mobility and quality of life due to severe rheumatoid arthritis. As a result, her care provider has recently prescribed abatacept (Orencia). This fusion protein inhibitor will achieve a therapeutic effect by what means?
preventing the activation of T cells
The nurse teaches the client that corticosteroids will be used to treat his brain tumor to
reduce cerebral edema.
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to
refrain from eating or drinking for now.
A young man has been diagnosed with migraines, and the nurse is teaching him about abortive therapy. The primary goal of this form of therapy will be to
relieve the symptoms of the patient's migraines.
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for
renal complications related to acyclovir therapy.
A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, the nurse would anticipate a delayed reaction in:
response due to interrupted impulses from the central nervous system
The sympathetic nervous system (SNS) is associated with a fight-or-flight reaction. What reaction is the parasympathetic nervous system is associated?
rest and digest
A patient is to begin treatment for rheumatoid arthritis with infliximab (Remicade). What potential risk should the nurse identify as being associated with this drug?
risk for infection
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:
she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube
A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because
shivering in hypothermia can increase ICP.
An accidental overdose of neostigmine has prompted the emergency administration of atropine. When assessing the patient, the emergency department nurse should take into account that this intervention will not relieve the effects of neostigmine on
skeletal muscle
During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:
support the joint where the tendon is being tested.
The client asks the nurse about types of exercise that do not stress the joints. What exercise will the nurse include in the teaching plan?
t'ai chi
A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wartlike lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding?
testing the client for the presence of HIV
The lower the client's viral load,
the longer the survival time.
A 77-year-old male patient with Parkinson's disease will soon begin treatment with levodopa, carbidopa, and entacapone (Stalevo). Prior to starting this course of treatment, the nurse must ensure that
the patient has completed an anticholinergic challenge in a clinical setting.
A patient has been taking cephalexin (Keflex) for an upper respiratory infection. On the seventh day of treatment, the patient develops myalgia and fever. What reaction is the patient likely having?
the patient has serum sickness
The client asks the nurse how to determine a cause for rhinitis. What diagnostic test will the nurse explain to the client that will identify the cause of rhinitis?
total serum IgE test
A woman in her 40s has been living with migraines for many years, and these have only just been identified as being linked to her menstrual cycles. Estradiol has been prescribed, which the nurse will administer
transcutaneously.
A client diagnosed with AIDS develops pneumocystis pneumonia (PCP). When planning the care for the client, which medication would the nurse anticipate being prescribed?
trimethoprim-sulfamethoxazole (TMP-SMZ)
A client comes to the clinic complaining of a rash on the arms, chest and upper thighs. Inspection reveals pink, raised lesions of varying sizes and shapes. The client reports that the lesions are "quite itchy and uncomfortable." The client's medication history is unremarkable. The nurse would document these lesions as:
urticaria
A client with a neurologic impairment reports having problems with constipation. Which foods might the nurse recommend?
vegetables
The balance between the amount of HIV in the body and the immune response is the
viral set point.
The term used to define the amount of virus in the body after the initial immune response subsides is
viral set point.
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client
vomits
During a 12-month well-baby visit, a mother reports that the baby has been breastfed since birth and has never been ill. The mother is trying to convince her sister, who is currently pregnant, to breastfeed also and asks the nurse about the benefits of breastfeeding. The nurse explains the immune benefits of breastfeeding and provides the mother with pamphlets. The nurse determines the mother understands the teaching based on which statement?
"Breastfeeding is beneficial because the dominant antibody IgA in breast milk acts by functioning as an antigen receptor in the mucosal membranes."
A nurse is explaining treatment options to a client diagnosed with an immune dysfunction. Which statement by the client accurately reflects the teaching about current stem cell research?
"Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, and clinical trials using stem cells are underway in clients with a variety of disorders with an autoimmune component."
A client is informed that his white blood cell count is low and that he is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse?
"White blood cells are produced in the bone marrow."
While monitoring the patient's eosinophil level, the nurse suspects a definite allergic disorder when seeing an eosinophil value of what percentage of the total leukocyte count?
15% to 40%
A nurse is aware of the important role that interferons (IFNs) perform in the normal function of the immune system. As well, the nurse has provided care for patients who have benefited from interferon therapy. IFN therapy is most likely to be effective in the treatment of which of the following patients?
A 68-year-old woman who is being treated for chronic myeloid leukemia (CML)
A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of his last tetanus shot, which he tells the nurse was more than 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what?
An antibody
A client has breast cancer. The nurse is concerned about a compromised immune system in this client for which reason?
Antineoplastic drug therapy
A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?
Assure the client that this is a normal reaction
Which assessment should be completed if immune dysfunction is suspected in the neurosensory system?
Ataxia
An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response?
B lymphocytes produce antibodies that are specific to the pathogen.
During an allergic reaction, histamine is released in about 15 minutes. The patient usually takes an antihistamine that has an affinity for bronchiolar smooth muscle cells (an H2 receptor). Which of the following is most likely the drug described?
Benadryl
A nurse is caring for a client undergoing evaluation for possible immune system disorders. Which intervention will best help support the client throughout the diagnostic process?
Educate the client about the diagnostic procedures and answer their questions about the possible diagnosis
A nurse on a medical unit is providing care for a patient who has been admitted because of the simultaneous development of several complications of AIDS. For the past several days, the patient has been experiencing six to eight watery bowel movements each day. The nurse should consequently assess the patient's:
Electrolyte levels
A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells?
Epoetin alfa (Epogen)
A nurse is teaching a health education class to a group of young adults and perceives that misinformation exists about the signs, symptoms, and trajectory of HIV infection. The nurse should inform participants that the first symptoms of HIV exposure include
Fever, headache, and malaise
The nurse practitioner explains to the patient scheduled for the RAST that the test will measure allergen-specific __________.
Ig E
When the body is in contact with an allergen, this lymphocyte, located in the respiratory and intestinal mucosa, triggers the release of histamine. Choose that lymphocyte.
Ig E
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
An elderly client is diagnosed with a respiratory infection. While reviewing age-related changes in the immune system, what would the nurse identify as having contributed to this client's infection?
Impaired ciliary action from exposure to environmental toxins
A woman who has experienced severe seasonal allergies in recent years has been referred for allergy skin testing. The nurse at the allergy clinic should be aware of the need to take precautions against the patient's risk of which of the following nursing diagnoses?
Impaired gas exchange
The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?
Lymphoid tissues
A client with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this client?
Meticulous infection control precautions
A client has a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected?
Protein electrophoresis
A client comes to the clinic and informs the nurse that he feels as though he has allergies. What laboratory test results will be a positive indicator for an allergic disorder?
Radioallergosorbent blood test (RAST) of 3
The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (HIV). Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications?
Side effects of drug therapy
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
The client appears mildly ill, listless, and disheveled.
The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis?
The injection area swells if the client has developed antibodies against the antigen.
A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have?
The nurse ensures a written consent is obtained prior to testing.
An older adult client, who leads a sedentary lifestyle, and a younger client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. The nurse knows that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?
The older client because of age
A client has undergone a kidney transplant. The nurse is concerned about a compromised immune system in this client for which reason?
Use of anti-rejection drugs
A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test?
Western blot assay
Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that:
filter bacteria from tissue fluid.
The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?
interferons
SATA A client has recently been diagnosed with rheumatoid arthritis, and is also receiving further testing for disorders of the immune system. The client works as an aide at a facility caring for children infected with AIDS. Which factors will hold significant implications during the client's assessment? Select all that apply.
work environment history of immunizations and allergies use of other drugs
