Immune
In teaching a female client who is HIV-positive about pregnancy and the human immunodeficiency virus (HIV), the nurse would know more teaching is necessary when the client says:
"I'll need to have a C-section if I become pregnant and have a baby."
The parents of a 5-month-old infant diagnosed with humoral IgA deficiency question the nurse about why the infant was not diagnosed sooner. Which response by the nurse most appropriate?
"Maternal antibodies crossed the placenta and that prevented infections until now." --lgA does not have specific treatment and is usually found when evaluating another illness and is associated with allergies.
The nurse is providing dietary interventions for a 12-year-old child with a shellfish allergy. Which response by the parent most concerns the nurse?
"My child will likely outgrow this."
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."
The young girl has been diagnosed with juvenile idiopathic arthritis (JIA) and has been prescribed methotrexate. Which statements by the child's parent indicates that adequate learning has occurred? Select all that apply.
"Swimming sounds like a good exercise for her." "A warm bath before bed might help her sleep better." "We'll need to bring her back in for some lab tests after she starts methotrexate."
A client with a new diagnosis of human immunodeficiency virus (HIV) tells the nurse, "I did not think drinks, dinner, and great sex would lead to a life-threatening disease." Which of the following is a therapeutic response by the nurse?
"This sounds distressing for you. What questions do you have?"
The nurse is caring for an infant exposed to HIV. The polymerase chain reaction (PCR) test was negative at birth. The nurse tells the mother that the child will most likely be tested again at what age?
4-7 weeks
Which client will the nurse assess first after receiving shift report?
A client with human immunodeficiency virus (HIV) whose temperature is 102.2°F (39°C)
After undergoing testing, a client comes to a physician's office for a follow-up appointment. During the appointment, the physician informs the client that she has systemic lupus erythematosus (SLE) . Which resource might be helpful for a nurse to recommend to this client?
A support group for clients with SLE
The nurse is reviewing the medical history of a 4-year-old child. What would the nurse identify as potentially indicative of a primary immunodeficiency? Select all that apply.
Acute otitis media, one episode every 3 to 4 weeks over the past year. Recurrent deep abscess of the thigh Oral candidiasis (thrush), persistent over the past 6 to 7 months
The parents of a 3-month-old infant report concerns the infant is irritable, feeds poorly, and has a rash. The nurse notes weeping, crusty lesions on the infant's cheeks and neck. Which action by the nurse is most appropriate?
Contact the health care provider to request treatment.
The laboratory results of a child with juvenile arthritis are being evaluated. Which are consistent with this condition? Select all that apply.
Hemoglobin 9.3 mg/dLErythrocyte sedimentation rate elevated
When describing anaphylaxis to a group of parents whose children have experienced anaphylaxis from insect stings, the nurse integrates knowledge that this response is related to which immunoglobulin?
IgE
Nursing students demonstrate correct understanding when they identify which immunoglobin as occurring most frequently in plasma and the major one to be synthesized during secondary response?
IgG
When teaching about primary and secondary humoral responses, what should the nurse identify as the immunoglobin that is first to appear in the serum?
IgM
Which of the following treatments are common to both systemic lupus erythematosus and juvenile idiopathic arthritis? Select all that apply.
NSAID corticosteridos
The nursing instructor is describing the events of anaphylaxis. Place the assessment findings in the order that they would occur from first to last.
Nausea, vomiting, diarrhea Urticaria, angioedema Bronchospasm Hypoxia Seizures
An infant born to a mother who was HIV positive was tested at birth and found to be negative. The infant is scheduled for follow-up testing. Which test would the nurse expect to be performed?
PCR test
A 6-month-old boy has been admitted to the hospital with severe bloody diarrhea. The nurse notes petechiae and eczema with signs of secondary infection. As the nurse documents the boy's history, the parents report easy bruising and prolonged bleeding after circumcision. Based on these findings, the nurse suspects a diagnosis of which of the following?
Wiskott-Aldrich syndrome
The nurse is caring for a child with HIV currently taking zidovudine. Which statement by the parent would be the most concerning?
Zidovudine decreases the chance my child will transmit HIV to others.
Which client is most likely to develop systemic lupus erythematosus (SLE)?
a 27 yo black female more common in women , more common in blacks
The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What information about the client is most important to communicate to the health care provider?
a 3kg weight gain over 2 days
A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safe sex practices for persons with HIV is accurate?
a latex condom with spermicide provides the best protection against HIV transmission
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?
administer epinephrine
Which nursing intervention is priority when caring for a child with HIV?
administering prescribed medications
The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms SLE?
an above normal DNA test
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution?
anaphylactic reaction
A nurse is monitoring a client who developed facial edema after receiving a medication by tablet. What should the nurse do next?
assess for SOB
A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?
autoimmune disorders include connective tissue disorders
A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:
autonomy
The nurse is developing a teaching plan for the client with aplastic anemia. Which is most important to include in the plan?
avoid exposure to others with acute infections
When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?
avoid sharing articles such as toothbrushes and razors
The nurse is providing teaching for the parents of a child with a latex allergy. The nurse tells the client to avoid which food?
bananas
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
benadryl
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
bilateral hearing loss
A child is diagnosed with severe combined immunodeficiency syndrome. Which of the following would the nurse expect to find when reviewing the child's history and physical examination?
chronic diarrhea
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. What should the nurse do first?
discontinue the transfusion
The nurse is caring for a 6-month-old boy with Wiskott-Aldrich syndrome. The nurse teaches the parents which of the following:
do not insert anything in the rectum
The nurse is monitoring the labs of a child admitted for an exacerbation of juvenile pauciarticular arthritis. Which lab result does the nurse expect to be elevated?
erythrocyte sedimentation rate (ESR)
The couple with the lowest risk of having a child with sickle cell anemia disease is the one in which the
father is HbA and mother is HbS
The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education?
humoral immunity is generally functional at birth. cellullar immunity is functional at birth. over time humoral immunity develops
Which immunoglobulin is specific to an allergic response?
lgE
After teaching a class of nursing students about acquired immunodeficiency, the instructor determines that the teaching was effective when the students identify which of the following as a contributing factor? Select all that apply.
malnutrition immunosuppressive drugs cancer
The nurse is teaching a client about preventing toxic shock syndrome (TSS). Which action is a risk factor for toxic shock syndrome?
only tampons at night
The nurse is teaching a female client about taking folic acid supplements for folic acid deficiency anemia. What information should be included in the teaching plan?
oral contraceptive use, pregnancy, and lactation increase daily requirements
What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
osteoporosis
The physician prescribes didanosine (ddI [Videx]), 200 mg by mouth every 12 hours, for a client with acquired immunodeficiency syndrome (AIDS) who is intolerant to zidovudine (azidothymidine, AZT [Retrovir]). Which condition in the client's history warrants cautious use of this drug?
peripheral neuropathy
The nurse is preparing to administer intravenous immunoglobulin (IVIG) for a child who has not had an IVIG infusion in over 10 weeks. The nurse knows to first:
premedicate with acetaminophen or diphenhydramine
The nurse is planning a program for community members that focus on the 2020 National Health Goals for allergies and immunologic functioning. What content should the nurse include in this program? Select all that apply.
promote safe sex discourage IV substance use discuss role of sexual relations encourage parents to discuss the air quality in schools
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
reduced sneezing
The nurse is administering the drug cyclophosphamide to a child who has severe systemic lupus erythematosus (SLE). What body system is the nurse most concerned about regarding adverse effects of this drug immediately after administration?
renal
A client with severe arthritis has been receiving maintenance therapy of prednisone 10 mg/day for the past 6 weeks. The nurse should instruct the client to immediately report which symptom?
respiratory infection
Which nursing problems could be associated with a child with primary immunodeficiency? Select all that apply.
risk for infection altered skin integrity delayed growth and development
A 4-year-old child is receiving monthly IgG transfusions for hypergammaglobulinemia. In assessing the child's current health status, the nurse will ask about several aspects of care, including which of the following? Select all that apply.
sleep disturbances frequency of recent illnesses participation in activities vacation plans nutritional intake
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
strawberries
Which immune cells are disrupted when a child is infected with human immunodeficiency virus (HIV)? Select all that apply.
t cells b cells phagocytes
A client is taking nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain from rheumatoid arthritis. What instruction should the nurse give the client about NSAIDs?
take the prescribed medication with food and fluids
The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
take with food or antacid
A client with acquired immunodeficiency syndrome (AIDS) is ordered zidovudine, 200 mg P.O. every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
take zidovudine every 4 hours around the clock
Which step must be done first when administering a blood transfusion?
verify the physicians order
A nurse applies standard precautions when caring for a client with human immunodeficiency virus (HIV). The nurse takes what action when applying standard precautions?
wearing gloves for providing mouth care
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
western blot test with ELISA
A nurse is providing care to a child with HIV who is prescribed therapy with a nucleoside reverse transcriptase inhibitor. What would the nurse expect to administer?
zidovudine
During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
joint abnormalities
Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat?
lamb and peaches
A client has had heavy menstrual bleeding for 6 months. Her healthcare provider diagnoses microcytic hypochromic anemia and orders ferrous sulfate, 300 mg P.O. daily. The nurse should question this order based on what client information?
the client has ulcerative colitis
When providing discharge instructions to a child who was admitted to the hospital following stridor, wheezing, and urticaria after taking penicillin, which nursing action is priority?
Encourage the child to wear a medical alert bracelet for penicillin.
After an extensive diagnostic workup, a client is diagnosed with systemic lupus erythematosus (SLE). Which statement about the incidence of SLE is true?
SLE tends to occur in families
The parents of a 10-year-old with HIV have never told their child that he has the virus. The child asks the nurse why he is "on so many medications." What action should the nurse take?
the nurse should encourage the child to talk with his parents about his medication
What occurs with complement activation? Select all that apply.
chemotaxis phagocytosis lysis of the foreign antigen
A child is diagnosed with a latex allergy. When developing the teaching plan for this child, the nurse would include which of the following foods to avoid? Select all that apply.
bananas, cherries, pineapples
The nurse is assisting with skin testing for allergies in a pediatric client. What will the nurse do to ensure the results are accurate?
be certain the child has not recd an antihistamine in the past 8 hours
Which treatments are common to both systemic lupus erythematosus and juvenile idiopathic arthritis? Select all that apply.
corticosteroids nonsteroidal anti-inflammatory drugs (NSAIDs)
The nurse is caring for a child who is receiving an intravenous immunoglobulin treatment. The client calls the nurse and reports she vomited. What action should be completed first?
discontinue the infusion
which of the following should be avoided during the first year"?
eggs peanuts shrimp
In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
extent of immune system damage
A nurse is conducting a physical examination of a 12-year-old girl with suspected systemic lupus erythematosus (SLE). How would the nurse best interview the girl?
have you noticed any hair loss or redness on your face
A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
listen and show interest as the client expresses feelings
A group of nursing students are reviewing information about the immune system. The students demonstrate understanding of the information when they identify which of the following being produced by the thymus?
lymphocyte T cells
In an individual with Sjögren's syndrome, nursing care should focus on:
moisture replacement
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
monitor body temp
Which symptom is an early indication that the client's serum potassium level is below normal?
muscle weakness in the legs
Which action should the nurse take when a client diagnosed with human immunodeficiency virus (HIV) infection refuses treatment?
recognize that the client might not be ready to make treatment decisions
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instructions should the nurse include in the teaching plan?
stay out of direct sunlight monitor body temp taper corticosteroid as ordered
How should a nurse respond when asked by a family member of a client with human immunodeficiency virus (HIV) infection why she's performing passive range-of-motion (ROM) exercises on the client?
these exercises help prevent contractures by keeping his joints mobile
The nurse is caring for a child with juvenile idiopathic arthritis (JIA). There is involvement of five or more small joints and it is affecting the body symmetrically. This tells the nurse that the child:
has polyarticular JIA
A child with systemic lupus erythematosus is receiving hydroxychloroquine sulfate. Which instruction would the nurse emphasize when teaching the child and parents about this drug?
importance of yearly eye examinations
The nurse is caring for a school-age child recently diagnosed with an allergy to peanuts. Which nursing action is a priority?
include the child when discussing foods that contain peanuts
The client who does not respond adequately to fluid replacement has a prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug is having the desired effect, what should the nurse assess?
increased cardiac output
A child is scheduled to undergo hyposensitization. The nurse understands that this therapy attempts to achieve which of the following?
increased concentration of IgG
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
fat
A 13-year-old is being evaluated for lupus. The teen asks who is at risk for this condition. What information can be provided by the nurse? Select all that apply.
females are at higher risk than males. excessive sun exposure is linked to devp of lupus some clients have had a recent infection
A nurse is reviewing the history and physical examination of an infant diagnosed with juvenile idiopathic arthritis. Which sign would the nurse identify as often being first?
fussiness
A 9-year-old client presents to the emergency department after a bee sting and experiencing bouts of nausea and vomiting. The nurse notes the client's blood pressure is 68/40 mm Hg, pulse is 48 beats/minute, O2 saturation is 86%, and the child is dyspneic. Which action will the nurse take?
give epinephrine
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
increased weight, hyperstension, and insomnia
The nurse is providing education to a 16-year-old who has recently been diagnosed with myasthenia gravis. Which statement(s) by the adolescent indicates an understanding of the information provided? Select all that apply.
it is important i avoid triggers getting a flu shot will be important i am going to incorportate a short nap into my daily routine
The nurse has been able to draw the daily blood specimen from a client's Hickman catheter only after requesting that the client raise the arms and cough. The client asks the nurse why this is necessary. The nurse should tell the client:
the catheter may be lodged against a blood vessel wall
The nurse is preparing to administer the child's dose of intravenous immune globulin (IVIG). Which actions should the nurse take? Select all that apply.
Take baseline vital signs and monitor the vital signs during the infusion. Prepare to give acetaminophen to the child. Prepare to give diphenhydramine to the child.
The nurse is speaking with a teenager who has requested HIV testing. Which is the best statement by the nurse regarding HIV testing?
The ELISA method detects antibodies so a person may have a false negative test for up to six months after exposure.
The registered nurse (RN) and unlicensed assistive personnel (UAP) are caring for a pediatric client with an immune disorder receiving a stem cell transplant. Which action by the UAP will cause the RN to intervene?
The UAP takes a rectal temperature on the client.
A nurse is giving a talk to high school students about preventing the spread of human immunodeficiency virus (HIV). What does the nurse identify as ways in which HIV is spread? Select all that apply.
Transfusion of contaminated blood Perinatally from mother to fetus Through breastfeeding Exposure to blood and body fluids through sexual contact Sharing contaminated needles
After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which activity observed by the nurse indicates the need for additional teaching?
carrying a laundry basket with clinched fingers and fists
The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of greatest concern?
elevated BP
The nurse is helping the parents of a toddler identify foods that are causing allergic symptoms in the child. Which strategy should the nurse encourage the parents to use?
elimination diet
The nurse is working with a pregnant client who is HIV positive and has been prescribed oral zidovudine. Which statement by the nurse explains the primary rationale for taking this medication?
it is to help prevent transmission of the disease to your infant
A client was diagnosed with AIDS several years ago and now has a CD4 T-lymphocyte count of 110 units/L. Which outcome is appropriate for this client?
no development of opportunistic infections
A client with AIDS develops a fever, severe headache, and stiff neck and begins to vomit. Family members state they have noticed that the client does not seem to be as alert and oriented as before. What is the nurse's priority intervention?
protecting the client's airway
An RN preceptor is assisting a new graduate to access a port-a-cath with a Huber needle. Which action by the new graduate would require intervention by the RN preceptor?
rotating the needle immediately after access
The nurse is instructing a group of women of childbearing age about human immunodeficiency virus (HIV) during pregnancy. What would be a priority recommendation in this setting?
screening for HIV
A client with toxic shock has been receiving ceftriaxone sodium, 1 g every 12 hours. In addition to culture and sensitivity studies, which other laboratory finding does the nurse monitor?
serum creatinine
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to
sit upright, leaning slightly forward.
The nurse admits a 1-year-old child to the hospital with the diagnosis of sickle cell crisis. The nurse explains to the parents that which condition leads to local tissue damage during a sickle cell crisis?
obstruction to circulation
Which nursing action is most appropriate when caring for a child with positive serum IgE antibodies, a white blood cell count of 6,000/mm3, and 10% eosinophils?
obtain a careful health history --this indicates allergies
The nurse assesses the mouth and oral cavity of a client with human immunodeficiency virus (HIV) infection because the most common opportunistic infection initially presents with which symptom?
oral candidiasis
The nurse is preparing an informational brochure about risk factors for immune disorders. Which disease process can indicate a potential underlying immunologic disorder? Select all that apply.
persistent oral thrush chronic cough extensive eczema
The nurse is reviewing the immunization schedule with the parent of a child who is HIV positive. What information should the nurse provide? Select all that apply.
pneumococcal can be given varicella should not be given if symtomatic if cd4 count is low, MMR should not be given.
The nurse is teaching the parents of a child with sickle cell disease. What information should the nurse give the family on how to prevent sickle cell crisis?
drink at least 2 quarts of fluids per day
The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant the child gets a rash. It just does not make sense to me." How should the nurse respond?
has your child ever been tested for a peanut allergy
The nurse is educating a client with systemic lupus erythematosus (SLE) about self-management. For what sign or symptom does the nurse tell the client to seek immediate medical attention?
having decreased urine output. -- urinary symptoms are a big complication.
The parents of an adolescent tell the nurse, "Our child seems to have allergy symptoms every time we visit our favorite cafe. I don't understand since the only allergy indicated in the testing was to eggs?" How should the nurse respond?
"Does your child get a whipped cream or foam topping on their favorite drink?"
A nurse is providing care for a client with progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?
risk for impaired skin integrity -- degenerative changes of the skin, synovial membranes, and digital arteries. prone to diarrhea
The nurse is caring for a 6-month-old infant with Wiskott-Aldrich syndrome. Which teaching does the nurse provide the parent?
do not insert anything in the rectum
After teaching an adolescent how to use an epinephrine autoinjector, the nurse observes the adolescent attempting to self-administer the medication. The adolescent indicates the site to be used, pointing to the abdomen just below the umbilicus. Which action should the nurse take next?
stop the adolescent from continuing and review the appropriate site to use
A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity?
swimming in rivers or lakes
The nurse is providing family education about the administration of cyclosporine A. Which response by the family indicates a need for further teaching?
the medication is best absorbed with vitamin c in citrus juices. -- should NOT be taken with grapefruit juice
A nurse is preparing a presentation for a group of new parents and is planning to discuss nutrition during the first year. As part of the presentation, the nurse is planning to address foods that should be avoided to reduce the risk of possible food allergies. Which foods would the nurse most likely include? Select all that apply.
Eggs Shrimp Peanuts
A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101° F (38° C) The client also reports a headache and appears flushed. In what order, from first to last, should the nurse perform the actions? All options must be used.
Stop the blood infusion. Infuse normal saline to keep the vein open. Obtain a blood culture from the client. Send the blood bag and administration set to the blood bank.
A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order from first to last should the nurse provide care for this client? All options must be used.
Stop the transfusion. Keep the vein open with normal saline solution. Administer an antihistamine as directed. Send the blood bag and blood slip to the blood bank.
A client on the oncology floor requires a blood transfusion. The nurse ensures proper consent is obtained by taking what action?
ensuring client is aware of indications, risks, and alternatives to recieving blood
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?
hypercalcemia -- calcium is released when bone is destroyed
A nurse in the infection prevention and control program is conducting an assessment of infection control practices. The nurse is evaluating the infection control actions taken on the unit for a client with a decreased white blood cell count. Which infection control practice does the nurse consider most important for this client?
adhering strictly to aseptic technique.
A client who is sexually active asks the nurse about using pre-exposure prophylaxis (PrEP) for HIV. The nurse should tell the client the drug, a combination of 300 milligrams tenofovir disoproxil fumarate and 200 milligrams emtricitabine (TDF/FTC) can be used for which group of people who are at risk for becoming infected with HIV?
anyone who is in an ongoing sexual relationship with an HIV-infected partner
The nurse is caring for a child with HIV. The doctor will most likely order which test to monitor the child's progress?
lymphocyte immunophenotyping T-cell quantification
The nurse is assisting with a bone marrow aspiration and biopsy. Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. All options must be used.
Verify the client has signed an informed consent. Position the client in a side-lying position. Clean the skin with an antiseptic solution. Apply ice to the biopsy site.
A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. The client's family members report that the client has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms?
hypercalcemia
The nurse is teaching the parents of a child with a suspected diagnosis of juvenile idiopathic arthritis about the disease. Which statement by the parents demonstrates the need for further teaching?
if our child does not have a positive rheumatoid factor, our child does not have the disease.
The nurse is caring for a child who has a depressed immune system due to chemotherapy treatments. The child is due for scheduled immunizations according to CDC recommendations. The nurse must ensure that the child does not receive which type of immunization?
live vaccine
Interferon alfa-2b has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which common adverse effects?
flulike symptoms
The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. What is the most appropriate goal for this client?
gradually increase activity tolerance
The nurse is providing education regarding 2030 Health Goals to reduce the incidence of acquired immunodeficiency syndrome (AIDS) within the community. Which goal will the nurse choose as a primary prevention strategy?
Provide education to sexually active females about proper condom usage.
A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address?
The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising.
The nurse is caring for a client in sickle cell crisis. What nursing action is the highest priority?
administering analgesics as prescribed
A client with idiopathic thrombocytopenic purpura (ITP) is being treated with prednisone and rituximab. The nurse prioritizes what aspect of care planning?
infection control measures
A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which statement indicates the client has adequate knowledge?
"I will dilute the medication and drink it with a straw
The nurse is speaking with the parent of a child who has experienced an allergic reaction to peanuts. Which statement by the parent would indicate a need for further education?
"If my child has gastrointestinal upset, my child is not having anaphylactic shock." -- bloating, diarrhea, abd pain, and vomiting may be symptoms of anaphylaxis.
The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education?
"If we need to use the EpiPen® we will need to notify her physician's office the next business day."
The nurse is monitoring the CD4 count of an infant who has contracted HIV from the mother in utero. The nurse is concerned that treatment with antiretroviral therapy is not effective when noting which CD4 level?
1300/mm -- normal is 1500, so anything below may indicate that therapy is not effective
Which lab values should the nurse report to the health care provider (HCP) when the client has anemia?
intrinsic factor, absent
A nurse is teaching a young adult female client about self-management of systemic lupus erythematosus (SLE). The client is prescribed ibuprofen, hydroxychloroquine, and cyclophosphamide. The client asks the nurse about the possibility of becoming pregnant while being treated for SLE. What is the nurse's best response?
you should speak with your hcp about alternatives to taking cyclophosphamide.
A 25-year-old client taking hydroxychloroquine for rheumatoid arthritis reports difficulty seeing out of the left eye. What does this finding indicate?
possible retinal degeneration
The nurse interviews a client with systemic lupus erythematosus (SLE) who reports to the emergency department with severe back pain after a minor fall. What aspect of the client's medical history is most relevant to the potential cause of this injury?
prescription for prednisone
To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which position in bed several times a day?
prone
The nurse is educating a client about allergy management at home. What information should the nurse include in the teaching? Select all that apply.
put pull shades on windows use steam for heating
A nurse is caring for a client with human immunodeficiency virus (HIV). To determine the effectiveness of treatment the nurse expects the physician to order:
quantification of T-lymphocytes
A child is brought to the emergency department with bronchospasm, wheezing, and urticaria. The primary health care provider prescribes the medications listed below. Which medication will the nurse administer first?
epinephrine
The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my health care provider let me try that?" Which response by the nurse would be most appropriate?
every person is different. what works for one client may not always be effective for the next.
A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that the client has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
ineffective tissue perfusion: cerebral, cardiopulmonary, GI
The mother of a child with myasthenia gravis has called the clinic and reports her child appears very anxious and the child's heart is beating very fast. What action by the nurse is indicated?
instruct the child to be brought to the ED promptly
A pregnant client who is HIV positive asks the nurse if she will be able to breastfeed the newborn. Which response by the nurse is most appropriate?
breastfeeding will increase your newborn's risk of contracting HIV
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. What vital sign values most support the nurse's analysis?
bp 80/40 pulse 130
