NCLEX Review Quiz 8 Saunder's Questions (Ch. 47, 48, 70, 71)

876. The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs/symptoms of which side/adverse effects of the medication? Select all that apply. 1. Ototoxicity 2. Palpitations 3. Nephrotoxicity 4. Bone marrow depression 5. Gastrointestinal (GI) effects 6. Increased white blood cell (WBC) count

3, 4, 5 Side/adverse effects include nephrotoxicity, bone marrow depression, GI effects, hepatotoxicity, dermatological effects, and some neurological symptoms including headache, dizziness, vertigo, ataxia, depression, and seizures. Options 1, 2, and 6 are unrelated to this medication.

484. The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? 1. "We need to encourage our child to drink fluids." 2. "Coughing spells may be triggered by dust or smoke." 3. "Vomiting may occur when our child has coughing episodes." 4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."

4 Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are accurate components of home care instructions.

478. A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray 2. Western blot 3. CD4+ cell count 4. p24 antigen assay

4 The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia.

881. A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse should monitor which most closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. Gastrointestinal function

1 Stavudine is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client's gait closely and ask the client about paresthesia. Options 2, 3, and 4 are unrelated to this medication.

862. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1 The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

482. The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant."

1 HIV is transmitted through blood, semen, vaginal secretions, and breast milk. The mother of an infant with HIV should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the child's diaper. Alcohol would not be effective in destroying the virus. Options 2, 3, and 4 are accurate instructions related to basic infection control.

864. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

1 Individuals most at risk for developing a latex allergy include health care workers, individuals who work in the rubber industry, or those who have had multiple surgeries, have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

866. The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions? 1. Lyme disease is caused by a tick carried by deer. 2. Lyme disease is caused by contamination from cat feces. 3. Lyme disease can be caused by the inhalation of spores from bird droppings. 4. Lyme disease can be contagious through skin contact with an infected individual.

1 Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodes scapularis or I. pacificus tick can become infected with the spirochete Borrelia burgdorferi. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Lyme disease cannot be transmitted from one person to another.

859. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

1 To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

871. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate for the nurse to perform? Select all that apply. 1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. 3. Estimate the size of the wheal and document the finding. 4. Tell the client to return to have the site inspected only if there is a reaction. 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

1, 2 Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected; a list of potential allergens is identified. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients only need to be monitored for about 30 minutes to assess for any adverse effects.

860. A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply. 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. 4. Leave the client briefly to contact a health care provider. 5. Keep the client supine regardless of the blood pressure readings. 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1, 2, 3 An anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. Although the health care provider and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per HCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal.

483. Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Monitor the child's weight. 2. Frequent hand-washing is important. 3. The child should avoid exposure to other illnesses. 4. The child's immunization schedule will need revision. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.

1, 2, 3, 5 AIDS is a disorder caused by HIV and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent hand-washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, and diarrhea and notifying the health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications and other medications as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; monitoring weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding sharing eating utensils. Gloves are worn for care, especially when in contact with body fluids and changing diapers; diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with the tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution (10:1 ratio of water to bleach).

865. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1, 2, 4, 5 If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

477. The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent? 1. The hepatitis B vaccine will not be given to the child. 2. The inactivated influenza vaccine will be given yearly. 3. The varicella vaccine will be given before 6 months of age. 4. A Western blot test needs to be performed and the results evaluated before immunizations.

2 Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. The inactivated influenza vaccine that is given intramuscularly will be administered (influenza vaccine should be given yearly). The hepatitis B vaccine is administered according to the recommended immunization schedule. Varicella-zoster virus vaccine should not be given because it is a live virus vaccine; varicella-zoster immunoglobulin may be prescribed after chickenpox exposure. Option 4 is unnecessary and is inaccurate.

863. A client calls the nurse in the emergency department and states that he was just stung by a bumble bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which nursing action should the nurse take? 1. Advise the client to soak the site in hydrogen peroxide. 2. Ask the client if he ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency department. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

2 In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

861. A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which description of this condition? 1. The presence of tiny red vesicles 2. An autoimmune disease that causes blistering in the epidermis 3. The presence of skin vesicles found along the nerve caused by a virus 4. The presence of red, raised papules and large plaques covered by silvery scales

2 Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.

491. A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of the child, the nurse should plan to place the child on which precautions? 1. Enteric 2. Airborne 3. Protective 4. Neutropenic

2 Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne droplet precautions are required, and persons in contact with the child should wear masks. The child is placed in a private room if hospitalized, and the hospital room door remains closed. Gowns and gloves are unnecessary, but standard precautions are used. Articles that are contaminated should be bagged and labeled. Special enteric precautions and protective (neutropenic) isolation are not indicated in rubeola.

867. A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night.

2 Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present.

868. A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which nursing actions are most appropriate? Select all that apply. 1. Tell the client that testing is not necessary unless arthralgia develops. 2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibodies that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5. Tell the client if this happens again to never remove the tick but vigorously scrub the area with an antiseptic.

2, 3, 4 A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic. Options 1 and 5 are incorrect.

874. The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity

2, 3, 4 Aminoglycosides are administered to inhibit the growth of bacteria. Adverse effects of this medication include confusion, ototoxicity, renal toxicity, gastrointestinal irritation, palpitations (dysrhythmias), blood pressure changes, and hypersensitivity reactions. Therefore, the remaining options are incorrect.

875. Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.

2, 3, 5 Ketoconazole is an antifungal medication. There is no reason for the client to restrict fluid intake; in fact, this could be harmful to the client. The medication is hepatotoxic, and the nurse monitors liver function. It is administered with food (not on an empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure absorption. The client is also instructed to avoid alcohol. In addition, the client is instructed to avoid exposure to the sun because the medication increases photosensitivity.

492. The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. Mother reports that the child is having intermittent episodes of diarrhea. 4. Mother reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. Mother reports that the child has recently been exposed to an infectious disease.

2, 5 The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women. A vaccine is administered with caution to an individual with a moderate or severe acute illness, with or without fever. Options 1, 3, 4, and 6 are not contraindications to receiving a vaccine.

879. Amikacin is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the health care provider (HCP) immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches

3 Amikacin (Amikin) is an aminoglycoside. Side/adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the HCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the HCP immediately if nausea occurs. If nausea persists or results in vomiting, the HCP should be notified.

877. The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine. The nurse interprets that the client may have the medication discontinued by the health care provider if which elevated result is noted? 1. Serum protein level 2. Blood glucose level 3. Serum amylase level 4. Serum creatinine level

3 Didanosine can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

858. The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wear a gown and gloves to change the bed linens and gloves only for the bath

3 Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage, or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

878. The nurse is caring for a postrenal transplantation client taking cyclosporine. The nurse notes an increase in one of the client's vital signs and the client is complaining of a headache. What vital sign is most likely increased? 1. Pulse 2. Respirations 3. Blood pressure 4. Pulse oximetry

3 Hypertension can occur in a client taking cyclosporine (Sandimmune) and, because this client is also complaining of a headache, the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.

869. The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellents because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants."

3 In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

486. A child is scheduled to receive inactivated polio vaccine (IPV), and the nurse preparing to administer the vaccine reviews the child's record. The nurse questions the administration of IPV if which is documented in the child's record? 1. Recent recovery from a cold 2. A history of frequent respiratory infections 3. A history of an anaphylactic reaction to neomycin 4. A local reaction at the site of injection of a previous IPV

3 Inactivated poliovirus vaccine (IPV) contains neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to IPV. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is not a contraindication to receiving a vaccine.

870. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3 Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

490. The clinic nurse prepares to administer a measles, mumps, rubella (MMR) vaccine to a 5-year-old child. The nurse should administer this vaccine by which best route and in which best site? 1. Subcutaneously in the gluteal muscle 2. Intramuscularly in the deltoid muscle 3. Subcutaneously in the outer aspect of the upper arm 4. Intramuscularly in the anterolateral aspect of the thigh

3 Measles, mumps, rubella (MMR) vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is not recommended for injections. MMR vaccine is not administered by the intramuscular route.

480. A 6-year-old child with human immunodeficiency virus (HIV) has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child? 1. "The pain will go away if you lie still and let the medicine work." 2. "Try not to think about it. The more you think it hurts, the more it will hurt." 3. "I know it must hurt, but if you tell me when it does, I will try and make it hurt a little less." 4. "Every time it hurts, press on the call button and I will give you something to make the pain go all away."

3 The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. The nurse must acknowledge the child's pain and let the child know that everything will be done to decrease the pain. Telling the child that movement or lack there of would eliminate the pain is inaccurate.Allowing a child to think that he or she can control the pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken "all away" is neither truthful nor realistic.

487. A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? 1. Eggs 2. Penicillin 3. Sulfonamides 4. A previous dose of hepatitis B vaccine or component

4 A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

481. The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should plan care with the understanding that which childhood psychosocial need occurs at this age? 1. Expressing fear, withdrawal, and denial 2. Beginning to understand that something is wrong 3. Unable to grasp the concept of illness and death 4. Beginning to conceptualize the death process as involving physical harm

4 A preschool child begins to conceptualize the death process as involving physical harm. A child from birth to 2 years of age is unable to grasp the concept of illness and death. A school-age child begins to understand that something is wrong. An adolescent expresses fear, withdrawal, and denial.

476. The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching? 1. "I will wash my hands frequently." 2. "I will keep my child's immunizations up to date." 3. "I will avoid direct unprotected contact with my child's body fluids." 4. "I can send my child to day care if he has a fever, as long as it is a low-grade fever."

4 AIDS is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. A child with AIDS who is sick or has a fever should be kept home and not brought to a day care center. Options 1, 2, and 3 are correct statements and would be actions a caregiver should take when the child has AIDS.

475. An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for symptoms indicative of human immunodeficiency virus (HIV) infection. The nurse assesses the infant, knowing that which infection is the most common opportunistic infection of children infected with HIV? 1. Meningitis 2. Gastroenteritis 3. Cytomegalovirus infection 4. Pneumocystis jiroveci pneumonia

4 AIDS is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. The most common opportunistic infection of children infected with HIV is P. jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection. Although neurological abnormalities and gastrointestinal disturbances may occur in a child with HIV infection, options 1 and 2 are not specific opportunistic infections noted in the HIV-infected child.

479. The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. The nurse should make which most appropriate response to the mother? 1. "I am so pleased also that everything has turned out fine." 2. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection." 3. "Everything looks great, but be sure that you return with your infant next month for the scheduled visit." 4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

4 AIDS is caused by HIV and characterized by generalized dysfunction of the immune system. Most children infected with HIV develop symptoms within the first 9 months of life. The remaining infected children become symptomatic sometime before age 3 years. With their immature immune systems, children have a much shorter incubation period than adults. Options 1, 2, and 3 are incorrect.

489. A parent brings her 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? 1. Varicella, hepatitis B vaccine (HepB) 2. Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps, rubella (MMR); inactivated poliovirus vaccine (IPV) 3. MMR, Haemophilus influenzae type b (Hib), DTaP 4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus (RV)

4 Diphtheria, tetanus, acellular pertussis vaccine (DTaP), Haemophilus influenzae type b conjugate vaccine (Hib), inactivated poliovirus vaccine (IPV), pneumococcal vaccine (PCV), and rotavirus vaccine (RV) are administered at 4 months of age. DTaP is administered at 2, 4, and 6 months of age; at 15 to 18 months of age; and at 4 to 6 years of age. Hib is administered at 2, 4, and 6 months of age and at 12 to 15 months of age. IPV is administered at 2, 4, and 6 months of age and at 4 to 6 years of age. PCV is administered at 2, 4, and 6 months of age and at 12 to 15 months of age. The first dose of measles, mumps, rubella (MMR) vaccine is administered at 12 to 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of hepatitis B vaccine is administered at birth, the second dose is administered at 1 month of age, and the third dose is administered at 6 months of age. Varicella-zoster vaccine is administered at 12 to 15 months of age and again at 4 to 6 years of age.

880. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication? 1. CD4 cell count 2. Lymphocyte count 3. Serum albumin level 4. Serum creatinine level

4 Foscarnet is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency.

873. The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F. The nurse continues to assess the client, knowing that this sign most likely indicates which condition? 1. That the dose of the medication is too low 2. That the client is experiencing toxic effects of the medication 3. That the client has developed inadequacy of thermoregulation 4. That the client has developed another infection caused by leukopenic effects of the medication

4 Frequent side/adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

872. The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

4 Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen. Options 1, 2, and 3 are unrelated to latex allergy.

488. The home health nurse visits a child with infectious mononucleosis and provides home care instructions to the parents about the care of the child. Which instruction should the nurse give to the parents? 1. Maintain the child on bed rest for 2 weeks. 2. Maintain respiratory precautions for 1 week. 3. Notify the health care provider (HCP) if the child develops a fever. 4. Notify the HCP if the child develops abdominal pain or left shoulder pain.

4 Infectious mononucleosis is caused by Epstein-Barr virus. The parents need to be instructed to notify the HCP if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens also are instructed to avoid contact sports until splenomegaly resolves. Bed rest is unnecessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen (Tylenol) or ibuprofen (Motrin IB) per health care provider preference.

485. An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.

4 On occasion, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with cold packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the infant back to the clinic is unnecessary. Option 1 may be an appropriate intervention, but is not specific to the subject of the question, a localized reaction at the injection site. Hot packs are not applied and can be harmful by causing burning of the skin.