Nursing Sem 2 Unit 3
A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. 1 Rye 2 Oats 3 Rice 4 Corn 5 Wheat
1 Rye, 2 Oats, 5 Wheat Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.
Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply. 1 Asthma 2 Hay fever 3 Sarcoidosis 4 Myasthenia gravis 5 Rheumatoid arthritis
1 Asthma 2 Hay fever Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions that are mediated by a reaction between IgE antibodies with antigens. It results in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis results from reactions between sensitized T cells with antigens. Myasthenia gravis results from a type II hypersensitivity reaction that occurs due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction that results from the formation of immune complexes between antigens and antibodies that results in inflammation.
A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN) via an infusion pump. What is most important for the nurse to do when administering TPN? 1 Change the TPN solution bag every 24 hours, even if there is solution left in the bag. 2 Monitor the client's blood glucose level every 2 hours at the bedside with a glucometer. 3 Instruct the client to breathe shallowly when changing the TPN tubing using sterile techniques. 4 Speed up the rate of the TPN infusion if the amount delivered has fallen behind the prescribed hourly rate.
1 Change the TPN solution bag every 24 hours, even if there is solution left in the bag. TPN solutions are high in glucose and are administered at room temperature, factors that increase the risk of microbial growth in the solution; they should be changed daily or sooner if they appear cloudy. Monitoring the blood glucose level every 2 hours is too frequent in ordinary circumstances; the client's blood glucose level should be monitored every 4 to 6 hours to identify the presence of hyperglycemia, a metabolic complication of TPN. The client should not breathe while the TPN catheter is changed because it may result in an air embolus; the Valsalva maneuver should be performed by the client for the few seconds it takes to switch the tubing. An excess amount of glucose will be infused if the rate of the TPN is increased, and the endogenous insulin will be inadequate to meet this demand, resulting in hyperglycemia.
An older client reports severe muscle weakness and dysphagia. The primary healthcare provider also observes periorbital edema with a lilac eyelid rash in the client. Which autoimmune disease will the nurse most likely see documented in the client's electronic medical record? 1 Dermatomyositis 2 Reiter's syndrome 3 Ankylosing spondylitis 4 Systemic necrotizing vasculitis
1 Dermatomyositis In dermatomyositis, an older client may have severe muscle weakness, dysphagia, and periorbital edema. A skin rash is diagnostic for dermatomyositis. Joint pain and eye infection causing redness, pain, and drainage may be present in a client with Reiter's syndrome. Chronic back pain may be present in clients with ankylosing spondylitis. Peripheral artery disease causing severe pain and necrosis of toes or fingers may be present in a client with systemic necrotizing vasculitis.
The nurse is caring for a client with sepsis who is hemodynamically stable. The client is complaining of abdominal pain. Which of these primary health care provider prescriptions should the nurse do first? 1 Draw peripheral blood cultures. 2 Administer levofloxacin 500 mg intravenously over 30 minutes. 3 Administer 1 L intravenous bolus of Ringer's lactate over 30 minutes. 4 Take the client to x-ray for an abdominal computed tomography (CT) scan.
1 Draw peripheral blood cultures. This question requires the learner to recall the priority treatments for clients with sepsis. Mortality in septic clients increases by 7.6% for every hour an antibiotic is delayed. Because this client is hemodynamically stable, the priority is to draw the blood cultures so the antibiotic can be initiated as soon as possible. Administering the antibiotic before obtaining blood cultures could mask the infection, delaying appropriate treatment. Taking the client to x-ray before obtaining the blood cultures would delay antibiotic initiation.
What should the nurse expect to assess in a client with a type IV delayed hypersensitivity reaction? Select all that apply. 1 Edema 2 Bruising 3 Ischemia 4 Induration 5 Tissue damage
1 Edema 3 Ischemia 4 Induration 5 Tissue damage A type IV delayed hypersensitivity reaction consists of edema, ischemia, induration, and tissue damage at the site. Bruising is not a typical occurrence in a type IV delayed hypersensitivity reaction.
Which drug can be administered via the intramuscular route to treat anaphylaxis? 1 Epinephrine 2 Methdilazine 3 Phenylephrine 4 Mycophenolate mofetil
1 Epinephrine Epinephrine is administered through the intramuscular route to treat anaphylaxis. Methdilazine is administered to treat allergic reactions and pruritus. Phenylephrine is administered orally, not intramuscularly, to treat anaphylaxis. Mycophenolate mofetil is administered intravenously as an immunosuppressant agent.
A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? Select all that apply. 1 Gloves 2 Gown 3 Mask 4 Goggles 5 Shoe covers 6 Hair bonnet
1 Gloves 2 Gown 4 Goggles Standard PPE, which should be used for performing colostomy care in a client positive for MRSA, includes gloves, gown, and goggles. A combination mask/eye shield may be used when caring for this client; however, a mask is not necessary. Shoe covers and hair bonnet are not required for the patient care situation described.
A client with human immunodeficiency virus (HIV) infection is diagnosed with tuberculosis. Before starting antitubercular pharmacotherapy, what essential test results should the nurse review? 1 Liver function studies 2 Pulmonary function studies 3 Electrocardiogram and echocardiogram 4 White blood cell counts and sedimentation rate
1 Liver function studies Antitubercular drugs, such as isoniazid (INH) and rifampin (RIF), are hepatotoxic; liver function should be assessed before initiation of pharmacologic therapy. Pulmonary function studies, electrocardiogram, and echocardiogram might be done; the results of these tests are not crucial for the nurse to review before administering antitubercular drugs. White blood cell counts and sedimentation will not provide information relative to starting antitubercular therapy or to its side effects.
A healthcare provider writes prescriptions for a young child with a tentative diagnosis of Wilms tumor. Which prescription should the nurse question? 1 Renal biopsy 2 Abdominal ultrasound 3 Computed tomography scan 4 Magnetic resonance imaging
1 Renal biopsy A renal biopsy is an invasive procedure. In the early stages, Wilms tumor is encapsulated. Any disruption of the tumor capsule may precipitate metastasis. Magnetic resonance imaging, computed tomography, and abdominal ultrasound are all helpful in making the diagnosis.
A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should the nurse report to the primary healthcare provider immediately? 1 Small amount of yellowish green oozing 2 Moderate area of serosanguineous oozing 3 Epithelialization under the nonadherent dressing 4 Separation of the edges of the nonadherent dressing
1 Small amount of yellowish green oozing Any amount of yellowish green oozing indicates infection and should be reported immediately. Serosanguineous oozing is expected. Epithelialization under the nonadherent dressing indicates healing and is desirable. Separation of the edges of the nonadherent dressing is not a problem.
A client is admitted with full-blown anaphylactic shock that developed due to a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? Select all that apply. 1 Stridor 2 Fissuring 3 Hypotension 4 Dyspnea 5 Cracking of the skin
1 Stridor, 3 Hypotension, 4 Dyspnea Full-blown anaphylactic shock produces stridor, hypotension, and dyspnea. Fissuring and cracking of the skin occurs in individuals with a type IV contact dermatitis.
Which conditions in clients are examples of cell-mediated immunity? Select all that apply. 1 Tuberculosis 2 Graft rejection 3 Allergic rhinitis 4 Contact dermatitis 5 Anaphylactic shock
1 Tuberculosis, 2 Graft rejection, 4 Contact dermatitis Conditions such as tuberculosis, graft rejection, contact dermatitis, and fungal infections are examples of cell-mediated immunity. T lymphocytes and macrophages sensitize T cells and cytokines to provide protection against fungus, viruses (intracellular), chronic infectious agents, and tumor cells. Allergic rhinitis and anaphylactic shock are examples of humoral immunity that are mediated by antibodies released by B lymphocytes.
The nurse provides discharge instructions to a male client who had an ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). For which indicators of a UTI should the nurse instruct the client? 1 Urgency or frequency of urination 2 An increase of ketones in the urine 3 The inability to maintain an erection 4 Pain radiating to the external genitalia
1 Urgency or frequency of urination Urgency or frequency of urination occur with a urinary tract infection because of bladder irritability; burning on urination and fever are additional signs of a UTI. Increase of ketones is associated with diabetes mellitus, starvation, or dehydration. The inability to maintain an erection is not related to a UTI. Pain radiating to the external genitalia is a symptom of a urinary calculus, not infection.
A client is diagnosed with hepatitis A. The nurse takes the client's history. Which employment history is most likely linked to the development of hepatitis A? 1 Works at a plumbing business 2 Works in a hemodialysis unit at a hospital 3 Works as a dishwasher at a local restaurant 4 Works at an occupational arsenic compound business
1 Works at a plumbing business Hepatitis A primarily is spread via a fecal-oral route; sewage-polluted water may harbor the virus. Working at a hemodialysis unit is closely linked to hepatitis types B, C, and D; these types are more often spread via the blood-borne route. Using disposable equipment and proper handling of syringes decreases the risk of spreading the virus. Working as a dishwasher at a local restaurant does not increase the risk of developing the disease, but it will increase the risk of an infected individual spreading the disease to others. Exposure to arsenic or carbon tetrachloride will not cause hepatitis A.
A spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test. The nurse reads the test and identifies an area of induration greater than 10 mm. What does this result indicate to the nurse? 1 No further action is required. 2 Additional tests are necessary. 3 Repeating the skin test is indicated. 4 Results are positive, indicating infection.
2 Additional tests are necessary. The test does not indicate whether TB is dormant or active. However, a client with an induration of 5 mm or greater is considered positive if there is repeated close contact with a person diagnosed with pulmonary tuberculosis or if the client has a disease causing decreased resistance; this requires further diagnostic study, such as chest x-rays and sputum culture. A newly infected client will receive preventive therapy with isoniazid (INH). Isoniazid will be continued for 6 months if chest x-rays are normal, or 12 months if chest x-rays are abnormal. Repeating the skin test is not necessary; the test is considered positive.
Which finding in the client's laboratory report enables the nurse to conclude that the client has a stage 3 human immunodeficiency (HIV) infection according to the Centers for Disease Control and Prevention (CDC) classification? Select all that apply. 1 CD4+ T-cell count 800 cells/mm 3 or a percentage of 32% 2 CD4+ T-cell count 100 cells/mm 3 or a percentage of 11% 3 CD4+ T-cell count of an unknown percentage and Kaposi's sarcoma 4 CD4+ T-cell count of an unknown percentage and Burkitt's lymphoma 5 CD4+ T-cell count 150 cells/mm 3 or a percentage of 12% and Kaposi's sarcoma
2 CD4+ T-cell count 100 cells/mm 3 or a percentage of 11% 5 CD4+ T-cell count 150 cells/mm 3 or a percentage of 12% and Kaposi's sarcoma The CDC has classified four stages of HIV infection. Stage 3 is characterized by a CD4+ T-cell count less than 200 cells/mm 3 or a percentage less than 14%. A T-cell count of greater than 500 cells/mm 3 or a percentage of 29% or greater is regarded as stage 1 HIV. A client whose HIV infection is confirmed with no information on the CD4+ T-cell count but who has an acquired immunodeficiency syndrome-defining illness such as Kaposi's sarcoma or Burkitt's lymphoma is considered to be in stage 4 HIV.
What is the nurse's primary consideration when caring for a client with rheumatoid arthritis? 1 Surgery 2 Comfort 3 Education 4 Motivation
2 Comfort Because pain is an all-encompassing and often demoralizing experience, the client should be kept as pain-free as possible. Surgery is used to correct deformities and facilitate movement, which is not the priority. Concentration and motivation are difficult when a client is in severe pain.
A client presents with red, inflamed skin covered with papules, vesicles, and bullae from a type IV hypersensitivity reaction. Which condition/disease will the nurse most likely observe written in the client's electronic medical record? 1 Allergic rhinitis 2 Contact dermatitis 3 Goodpasture syndrome 4 Systemic lupus erythematosus (SLE)
2 Contact dermatitis Contact dermatitis is a type of type IV delayed hypersensitivity reaction. Type IV hypersensitivity involves a cell-mediated response that may result in tissue damage and skin lesions. The skin lesions with redness of skin are characterized by the presence of papules, vesicles, and bullae. This indicates the presence of erythematosus resulting in contact dermatitis. Sneezing, lacrimation, swelling with airway obstruction, and pruritus around the eyes, nose, throat, and mouth are symptoms that occur due to hypersensitivity reaction resulting in allergic rhinitis, a type 1 hypersensitivity reaction mediated by immunoglobulin E. Goodpasture syndrome, a type II hypersensitivity reaction, is a disorder involving the lungs and kidneys that causes deposits of immunoglobulin G to form along the basement membranes of the lungs or kidneys. Systemic lupus erythematosus (SLE) is an autoimmune disorder that is characterized by damage to multiple organs such as kidneys, joints, and the brain; SLE is a type III hypersensitivity reaction.
A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, what should the nurse emphasize? 1 Medical treatment is curative; surgery is not required. 2 For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. 3 For most clients, surgery is recommended early in the course of treatment. 4 Medical treatment is all that will be needed if the client can maintain emotional stability.
2 For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. That medical treatment for colitis is curative and that surgery is not required is untrue; medical treatment is symptomatic, not curative. It usually is performed as a last resort. Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.
A laboratory report shows that a client tested positive for human epidermal growth factor (HER), and a medical report reveals the presence of advanced breast cancer. Which medication would be used to treat this condition? 1 Erlotinib 2 Lapatinib 3 Rituximab 4 Tositumomab
2 Lapatinib HER-2 is overexpressed in clients with advanced breast cancer. Lapatinib inhibits epidermal growth factor-r (EGFR)-tyrosine kinase (TK) and binds HER-2. Erlotinib is an EFGR-TK inhibitor prescribed to treat non-small cell lung cancer and advanced pancreatic cancer. Rituximab and tositumomab are administered to treat non-Hodgkin's lymphoma.
The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should the nurse give about why the MMR vaccine is administered at 12 to 15 months of age? 1 There is an increased risk of side effects in infants. 2 Maternal antibodies provide immunity for about 1 year. 3 It interferes with the effectiveness of vaccines given during infancy. 4 There are rare instances of these infections occurring during the first year of life.
2 Maternal antibodies provide immunity for about 1 year. Maternal antibodies to measles, mumps, and rubella infection persist in the infant until approximately 15 months of age. Side effects are no more common among infants than in toddlers. The measles vaccination does not interfere with the effectiveness of other vaccines. Although the measles, mumps, and rubella do occasionally occur after the administration of the MMR vaccine during the first year of life, the vaccine is not given during this time because of the presence of maternal antibodies.
Which medication will cause the nurse to monitor the client closely for hemolytic anemia? 1 Tacrolimus 2 Methyldopa 3 Azathioprine 4 Procainamide
2 Methyldopa Hemolytic anemia is an autoimmune disorder in which red blood cells are destroyed and removed from the bloodstream before the end of their normal life span. It may result after administration of methyldopa. Tacrolimus may cause adverse effects such as nephrotoxicity, lymphoma, and leukopenia. Azathioprine is administered as an immunosuppressant, which may cause bone marrow suppression. Procainamide can induce the formation of antinuclear antibodies and cause a lupus-like syndrome.
Which is a late effect of radiation therapy on the heart that the nurse should monitor as a priority? 1 Trismus 2 Pericarditis 3 Lymphedema 4 Pulmonary fibrosis
2 Pericarditis Pericarditis is a late effect of radiation therapy on the heart. Trismus is a late effect of radiation therapy on the head and neck. Lymphedema is a late effect of radiation therapy on the chest wall of the client. Pulmonary fibrosis is a late effect of radiation therapy on the lungs of the client.
An infant with a myelomeningocele is admitted to the pediatric intensive care unit. While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention? 1 Using disposable diapers 2 Placing the infant in the prone position 3 Performing neurologic checks above the site of the lesion 4 Washing the area below the defect with a nontoxic antiseptic
2 Placing the infant in the prone position The prone position is the best position for preventing pressure on the sac. Diapers should not be applied because they may irritate or contaminate the sac. Assessment of the area below the defect is essential in determining motor and sensory function. There is no indication for the use of an antiseptic.
A client with rheumatoid arthritis is receiving etanercept therapy. Which instruction should the nurse share with the client? 1 Report chest pain 2 Report site reaction 3 Report blurry vision 4 Report difficulty in breathing during infusion
2 Report site reaction The nurse should teach a client who is receiving etanercept therapy to report signs of site reaction, as they are very painful. The nurse should teach a client who is receiving infliximab therapy to report chest pain. Blurry vision does not occur with etanercept. The nurse should teach a client who is receiving infliximab therapy to report difficulty in breathing during intravenous infusion; etanercept is given subcutaneously.
A sexually active client presents with a sore throat and a generalized rash. The client states that a chancre that had been present healed approximately 3 months ago. The physical assessment and the serologic test findings indicate a diagnosis of syphilis. Which stage should the nurse determine the client is in at this time? 1 Primary 2 Secondary 3 Latent 4 Tertiary
2 Secondary The client has secondary syphilis, which occurs 1 to 3 months after healing of the primary lesion and lasts for several weeks to as long as a year; it is the stage at which the individual is most infectious. Primary syphilis is the stage of initial infection and is characterized by the presence of a chancre, a painless lesion at the site of infection. Latent syphilis occurs after the secondary stage and before the late stage of syphilis; in latent syphilis the immune system is able to suppress the infection and there are no clinical signs and symptoms. Tertiary syphilis, also known as late syphilis, is the final stage of syphilis. At this stage it is a slowly progressive inflammatory disease that can involve many organs; the skin, brain, and heart can be affected.
After many years of coping with ulcerative colitis, a client makes the decision to have a colectomy as advised by the primary healthcare provider. Which is most likely the significant factor that impacted on the client's decision? 1 It is temporary until the colon heals. 2 Surgical treatment cures ulcerative colitis. 3 Ulcerative colitis can progress to Crohn disease. 4 Without surgery, eating table foods is contraindicated.
2 Surgical treatment cures ulcerative colitis. When the diseased bowel is removed, the client's symptoms cease. Surgical removal of a body part is not temporary, but permanent. Ulcerative colitis does not progress to Crohn disease; clients with ulcerative colitis have an increased risk for colorectal cancer. Without surgery, eating table foods is contraindicated is not a true statement; these clients can still eat table food.
After administration of the MMR vaccine, a child develops pain, fever, and soreness. The primary healthcare provider asks the nurse to assess the child for joint swelling and to send a blood sample for a blood platelet count. Which is the most appropriate reason behind these interventions? 1 To evaluate the immunity level 2 To assess the risk of thrombocytopenia 3 To assess the risk of an anaphylactic reaction 4 To anticipate a prescription of appropriate drugs
2 To assess the risk of thrombocytopenia The MMR vaccine may cause thrombocytopenia in some cases; therefore, the nurse should check the blood platelet count. If administered to an immunodeficient client, the MMR vaccine may cause adverse effects. However, the client's immunity level should be checked before the vaccination. MMR contains trace amount of neomycin antibiotic and some clients who are allergic may result in anaphylactic-like reactions. The administration of the MMR vaccine generally causes some mild side effects such as fever, soreness, and body pain, which subsides via the administration of nonsteroidal antiinflammatory drugs (NSAIDs).
Which hypersensitivity reaction may occur in a newborn with hemolytic disease? 1 Type I 2 Type II 3 Type III 4 Type IV
2 Type II Hemolytic disease in a pregnant woman may result in erythroblastosis fetalis, a type II hypersensitivity reaction. Type I reactions involve immunoglobulin E (IgE)-mediated reactions such as anaphylaxis and wheal-and-flare reactions. Type III reactions are immune complex reactions such as rheumatoid arthritis or systemic lupus erythematosus. Type IV reactions are delayed hypersensitivity reactions such as contact dermatitis.
A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do? 1 Put on a gown and gloves. 2 Wear a particulate respirator mask. 3 Avoid touching objects in the client's room. 4 Limit contact with the client's nonexposed family members.
2 Wear a particulate respirator mask. Tubercle bacilli are transmitted through air currents; therefore personal protective equipment, such as a particulate respirator that filters out organisms as small as 1 µm, is necessary. Gowns and gloves are not necessary. Tuberculosis is spread by airborne microorganisms; gloves are necessary only when touching articles contaminated with respiratory secretions. It is only necessary to avoid contact with objects in the client's room that are contaminated with respiratory secretions. Limiting contact with the client's nonexposed family members is unnecessary.
A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction? 1 "I should practice respiratory hygiene/cough etiquette." 2 "I should avoid contact with the elderly or children." 3 "I should obtain a pneumococcal vaccination each year." 4 "I should allow visitors for short periods of time only."
3 "I should obtain a pneumococcal vaccination each year." The client should be encouraged to receive an influenza vaccine each year. Pneumococcal vaccines will not prevent influenza. The nurse should stress the importance of practicing respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable populations such as the elderly and children. Visitors for clients in isolation for influenza should be limited to persons who are necessary for the client's emotional well-being and care. Visitors who have been in contact with the client before and during hospitalization are a possible source of influenza for other clients, visitors, and staff.
A registered nurse is teaching a student nurse regarding the precautions to be followed while caring for a client infected with Ebola virus. Which statement by the student nurse indicates the need for further teaching? 1 "I will isolate the infected client in a private room." 2 "I will use standard, contact, and droplet precautions." 3 "I will not touch the prepared food for the infected client." 4 "I will avoid direct contact with body fluids of the infected client."
3 "I will not touch the prepared food for the infected client." The Ebola virus is not spread via air, water, or food. Therefore avoiding the touching of prepared food for the infected client may not help in preventing Ebola. The nurse should correct this misconception. All the other statements are correct. Clients with Ebola should be isolated in a single room to prevent the spread of infection. While caring for a client with Ebola, the nurse should use standard, contact, and droplet precautions to prevent Ebola infection. The nurse should avoid direct contact with body fluids of the infected client to prevent the spread of Ebola infection.
Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling). Which of these is evidence of a stress ulcer? 1 Unexplained shock 2 Melena for several days 3 A sudden massive hemorrhage 4 A gradual drop in the hematocrit value
3 A sudden massive hemorrhage Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding. Shock is the outcome of massive hemorrhage; it is not unexplained because the sudden gastrointestinal bleeding will be identified. Sudden massive bleeding occurs, not the slow oozing that causes melena. A gradual drop in the hematocrit value indicates slow blood loss.
The mother of an 8-year-old child with the diagnosis of acute poststreptococcal glomerulonephritis (APSGN) is concerned that a 4-year-old sibling may also have the disorder. What does the nurse recall when preparing to explain the cause of the disease process? 1 A systemic infection causing clots in the small renal tubules 2 A factor that is unknown and therefore is difficult to prevent 3 An immune complex disorder occurring after a group A β-hemolytic Streptococcus infection 4 An autosomal recessive trait, meaning that there is an increased probability that a sibling will also have the disease
3 An immune complex disorder occurring after a group A β-hemolytic Streptococcus infection The β-hemolytic Streptococcus immune complex becomes trapped in the glomerular capillary loop, causing acute poststreptococcal glomerulonephritis. APSGN is usually precipitated by a localized pharyngitis. Clots do not form in the small renal tubules with APSGN. Prevention depends on treating an individual with a group A β-hemolytic Streptococcus infection with antibiotics to eliminate the organism before an immune response can occur. APSGN is an acquired, not an inherited, disorder.
The nurse is reviewing the laboratory reports of a client who has sustained a significant reaction to the tuberculin skin test but has negative findings on bacteriologic studies. The reports further reveal the absence of x-ray findings compatible with tuberculosis (TB) and clinical evidence of TB. Which class of TB does the nurse suspect? 1 Class 0 2 Class 1 3 Class 2 4 Class 3
3 Class 2 In class 2 TB, the client demonstrates a significant reaction to the tuberculin skin test but bacteriologic studies are negative and there is no clinical or radiographic evidence of TB. The client with class 2 TB has been exposed to latent TB infection but has no disease. In class 0 TB, the client has had no exposure to TB and has negative results on skin testing. In class 1, a client has been exposed to TB but demonstrates no evidence of infection (e.g., a negative result on tuberculin skin testing). In class 3, the client has clinically active TB infection.
A client who takes high-dose aspirin for arthritis has an acute episode of right ventricular heart failure. The healthcare provider prescribes furosemide and lowers the client's usual dosage of aspirin. The client asks the nurse the reason for the lower dose. On what principle does the nurse base a response? 1 Aspirin accelerates metabolism of furosemide and decreases the diuretic effect. 2 Aspirin in large doses after an acute stress episode increases the bleeding potential. 3 Competition for renal excretion sites by the drugs causes increased serum levels of aspirin. 4 Use of furosemide and aspirin concomitantly increases formation of uric acid crystals in the nephron.
3 Competition for renal excretion sites by the drugs causes increased serum levels of aspirin. Because furosemide and aspirin compete for the same renal excretory sites, salicylate toxicity may occur even with lower dosages. Aspirin does not affect furosemide metabolism. The response "Aspirin in large doses after an acute stress episode increases the bleeding potential" does not take into account other drugs that the client is receiving. Although furosemide has a hyperuricemic effect similar to that of thiazide diuretics, it is not potentiated by aspirin.
A client is diagnosed with gastroenteritis. What does the nurse determine is the basic intention underlying the unique dietary management for this client? 1 Provide optimal amounts of all important nutrients. 2 Increase the amount of bulk and roughage in the diet. 3 Eliminate chemical, mechanical, and thermal irritation. 4 Promote psychological support by offering a wide variety of foods.
3 Eliminate chemical, mechanical, and thermal irritation. Irritation of the mucosa may cause increased bleeding or perforation and therefore should be avoided. All clients' diets should be nutritionally balanced; this is not specific to this client's problem. Bulk and roughage may irritate the mucosa and should be decreased. Psychological support is not the primary goal; efforts should be made to include foods that are psychologically beneficial but eliminate foods that are irritating to the mucosa.
Which leukocyte releases vasoactive amines during a client's allergic reactions? 1 Neutrophil 2 Monocyte 3 Eosinophil 4 Macrophage
3 Eosinophil Eosinophils release vasoactive amines during allergic reactions to limit the extent of the allergic reactions. Neutrophils are phagocytes and increase in inflammation and infection. Monocytes are involved in the destruction of bacteria and cellular debris. Macrophages are involved in nonspecific recognition of foreign protein and microorganisms.
Which medication class helps to prevent human immunodeficiency virus (HIV) incorporating its genetic material into the client's cell? 1 Entry inhibitors 2 Protease inhibitors 3 Integrase inhibitors 4 Reverse transcriptase inhibitors
3 Integrase inhibitors Integrase inhibitors such as raltegravir and dolutegravir bind with integrase enzymes and prevent HIV from incorporating its genetic material into the host (client's) cell. Entry inhibitors prevent the binding of HIV. Protease inhibitors prevent the protease enzyme from cutting HIV proteins into the proper lengths needed to allow viable virions to assemble. Reverse transcriptase inhibitors inhibit the action of reverse transcriptase.
A nurse is counseling a client who has gonorrhea. What additional fact about gonorrhea, besides the fact that it is highly infectious, should the nurse teach this client? 1 It is easily cured. 2 It occurs very rarely. 3 It can produce sterility. 4 It is limited to the external genitalia.
3 It can produce sterility. Inflammation associated with gonorrhea may lead to destruction of the epididymis in males and tubal mucosal destruction in females, causing sterility. Many gonococci have become penicillin resistant and difficult to treat. Gonorrhea is a common sexually transmitted infection. Neisseria gonorrhoeae will invade internal structures, particularly the epididymis in males and the fallopian tubes in females.
A 1-year-old exhibits a runny nose and cough after being administered a vaccine via the intranasal route. Which vaccine may have been administered to the child? 1 Rotavirus 2 Inactivated influenza 3 Live attenuated influenza 4 Haemophilus influenzae type b
3 Live attenuated influenza Live attenuated influenza vaccines administered intranasally may cause such mild side effects as a runny nose and cough. Rotavirus vaccines may cause a runny nose, but these vaccines are administered orally. Inactivated influenza vaccine is administered intramuscularly. Haemophilus influenzae type b vaccine is administered intramuscularly and may cause fever and local reactions.
A 5-month-old infant is brought to the pediatric clinic because of exposure to an adolescent sibling with measles. The infant's mother asks the nurse whether her baby can be vaccinated against measles at this age. What should the nurse consider before replying? 1 The infant's immunizations 2 The infant's previous viral illnesses 3 Maternal diseases and immunizations 4 Maternal exposure to tuberculosis and herpes genitalis
3 Maternal diseases and immunizations It is important to determine whether the infant has maternally transmitted antibodies against measles. Vaccination against measles is performed when the infant reaches 12 to 15 months of age. The infant's previous viral illnesses have no relationship to the present exposure to measles. Maternal exposure to tuberculosis and herpes genitalis is not relevant in the determination of whether the infant has passive immunity to measles.
A young pregnant adolescent is diagnosed as having bacterial vaginosis. What further complications related to bacterial vaginosis may occur during pregnancy? Select all that apply. 1 Neonatal sepsis 2 Cervical dysplasia 3 Preterm labor and birth 4 Intraamniotic infection 5 Postpartum endometritis
3 Preterm labor and birth 4 Intraamniotic infection 5 Postpartum endometritis Preterm birth and labor may occur because bacteria that enters the cervix irritates the uterus, which cause contractions. Bacterial vaginosis is associated with high risk of intraamniotic infection and postpartum endometritis. Neonatal sepsis occurs because of gonococcal infections. Cervical dysplasia occurs in clients with human immunodeficiency virus infections.
A 7-year-old child is brought to the emergency department with a puncture wound on the sole. It is determined that the child's history of immunizations is uncertain, and tetanus immune globulin and tetanus vaccine are prescribed and administered. What is the priority reason for using tetanus immune human globulin instead of tetanus antitoxin? 1 It is as effective as the antitoxin. 2 It is safe to give to everyone who needs it. 3 The risk for an anaphylactic reaction is less. 4 Skin tests are not needed with the human globulin.
3 The risk for an anaphylactic reaction is less. Tetanus immune human globulin is less likely to cause anaphylaxis. However, because it is derived from human serum there is always a risk of a reaction to a foreign protein. Tetanus immune human globulin is not as effective as the antitoxin, but it is not derived from horse serum and should not cause anaphylaxis. These medications always carry the risk of hypersensitivity; it cannot be assumed that they may be given safely to everyone. It is necessary to perform skin tests for both types of medications to determine the presence of sensitivity.
A client reports severe itching with redness and wheals on the uncovered parts of the legs after sleeping in an old bed. The primary healthcare provider prescribes antihistamines and topical corticosteroids. Which assessment finding made by the nurse supports the intervention? 1 Spreading, ring-like rash with erythema border after 3 to 4 weeks 2 Presence of burrows with erythematous papules with possible vesiculation 3 Utricaria grouped in threes surrounded by vivid flare, transforming into persistent lesion 4 Progression of minute red points to papular wheal-like lesions with secondary excoriation
3 Utricaria grouped in threes surrounded by vivid flare, transforming into persistent lesion Bedbugs reside in furniture, bedding, and walls and usually feed during night time. Bedbug bites manifest as urticaria grouped in threes surrounded by vivid flare, transforming into persistent lesion. Severe itching due to bedbug bites is treated with antihistamines or topical corticosteroids. Tick bites manifest as spreading, ring-like rash with erythema border after 3 to 4 weeks and are treated with oral and intravenous antibiotics. Scabies manifest with the presence of burrows with erythematous papules with possible vesiculation and interdigital web crusting. It is treated with 5% permethrin topical lotion. Head lice bites manifest as minute, red, noninflammatory points flush with the skin that progress to papular wheal-like lesions with secondary excoriation in intrascapular region. These bites are treated with γ-benzene hexachloride or pyrethrins.
A client has glomerulonephritis. To prevent future attacks of glomerulonephritis, the nurse planning discharge teaching includes which instruction? 1 "Restrict fluid intake." 2 "Take showers instead of bubble baths." 3 "Avoid situations that involve physical activity." 4 "Seek early treatment for respiratory infections."
4 "Seek early treatment for respiratory infections." A common cause of glomerulonephritis is a streptococcal infection. This infection initiates an antibody formation that damages the glomeruli. Any fluid restriction is moderated as the client improves; fluid is allowed to prevent urinary stasis. The alkalinity of bubble baths is linked to urinary tract infections, not glomerulonephritis. Moderate activity is helpful in preventing urinary stasis, which can precipitate urinary infection.
A client who has a gastric ulcer asks what to do if epigastric pain occurs. The nurse evaluates that teaching is effective when the client makes which statement? 1 "Eliminating fluids with meals will prevent pain." 2 "I will increase my food intake to avoid an empty stomach." 3 "Taking an aspirin with milk will relieve my pain and coat my ulcer." 4 "Taking an antacid preparation will decrease pain due to gastric acid."
4 "Taking an antacid preparation will decrease pain due to gastric acid." Over-the-counter antacid preparations neutralize gastric acid and relieve pain. Although eating food initially prevents gastric acid from irritating the gastric walls, it can precipitate acid production. Aspirin is contraindicated because it irritates gastric mucosa and promotes bleeding by preventing platelet aggregation. Reduction of fluids with meals does not affect pain.
While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128, and a blood pressure of 70/38. What type of reaction does the nurse conclude that the client probably is experiencing? 1 Panic 2 Pyrogenic 3 Hemolytic 4 Anaphylactic
4 Anaphylactic Anaphylactic reactions result from hypersensitivity to a product in the blood. Signs and symptoms are due to bronchospasm, systemic vasodilation, and compensatory tachycardia. The client may go into life-threatening shock without prompt treatment. Panic reactions (also known as panic attacks) involve high levels of anxiety and may be coupled with autonomic symptoms such as tachycardia. Bacterial pyrogens are present in contaminated blood and can cause a febrile transfusion reaction; signs include fever and chills. Hemolytic reaction results from the incompatibility of a recipient's antibodies with transfused red blood cells (RBCs); the reactions result from RBC hemolysis, agglutination, and capillary plugging.
A school nurse is teaching high school girls regarding the importance of immunizations. Which newborn anomaly can occur if rubella is contracted during the first trimester of pregnancy? 1 Limb abnormalities 2 Hydrocephalus 3 Down syndrome 4 Cardiac anomalies
4 Cardiac anomalies Heart development occurs between the second and eighth weeks of gestation; any type of maternal infection during this time may result in cardiac anomalies in the newborn. The congenital absence of the proximal portion of a limb is associated with the intake of teratogenic drugs, not with rubella infection. Hydrocephalus is a neural tube defect that is not associated with rubella; however, the infant may have microcephaly. Down syndrome is a chromosomal disorder; it is not caused by a maternal infection.
What does a shift to the left indicate in the white blood cell count differential? 1 Heightened phagocytosis 2 Functioning bone marrow 3 Infection is being contained 4 Immature neutrophils in the blood
4 Immature neutrophils in the blood A shift to the left in the white blood cell count differential indicates that immature neutrophils are being released into the blood. The immature neutrophils are not capable of phagocytizing. The bone marrow is unable to produce mature neutrophils, and the infection is continuing, not being contained.
A 2½-year-old toddler is admitted with a fever of 103° F (39.4° C), stiffness of the neck, and general malaise. The diagnosis is acute bacterial meningitis. What is the priority nursing intervention for this child? 1 Increasing fluids 2 Administering oxygen 3 Giving a tepid sponge bath 4 Instituting droplet precautions
4 Instituting droplet precautions Droplet precautions prevent the spread of infection to others; isolation is a priority and should be implemented immediately. There is no indication that the child is dehydrated; fluid maintenance is a continuing goal. There is no indication that the child needs oxygen. Oxygen is not given routinely; it is given if the child has a decreased oxygen saturation level. A sponge bath is not given because these children are sensitive to stimuli, and movement causes increased discomfort.
A client undergoing corticosteroid therapy is admitted with a peptic ulcer, osteoporosis, and hypertension. Which medication may have caused this condition? 1 Everolimus 2 Azathioprine 3 Mycophenolate acid 4 Methylprednisolone
4 Methylprednisolone Methylprednisolone is a corticosteroid that suppresses inflammatory responses and inhibits both cytokine production and T-cell activation. This drug may cause a peptic ulcer, osteoporosis, and hypertension. Everolimus may cause urinary tract infections, hyperlipidemia, and peripheral edema. Azathioprine may cause bone marrow suppression, neutropenia, and thrombocytopenia. Mycophenolate acid may cause diarrhea, neutropenia, and increased incidence of malignancies.
A client visits the primary healthcare provider and complains of vaginal discharge with a fishy odor. The primary healthcare provider diagnoses the client with bacterial vaginosis and suggests an oral medication. Which medication would be prescribed? 1 Tinidazole 2 Miconazole 3 Clotrimazole 4 Metronidazole
4 Metronidazole Bacterial vaginosis is a condition in which the hydrogen peroxide producing lactobacilli are replaced with high concentrations of anaerobic bacteria. Metronidazole is an oral medication used to treat bacterial vaginosis. Tinidazole is used to treat trichomoniasis. Miconazole and clotrimazole are used to treat candidiasis.
A school-aged child who has just arrived from Africa has been exposed to diphtheria, and a nurse in the pediatric clinic is to administer the antitoxin. Which type of immunity does the antitoxin confer? 1 Active natural 2 Passive natural 3 Active artificial 4 Passive artificial
4 Passive artificial In the creation of passive artificial immunity an antibody is produced in another organism and then injected into the infected or presumed infected person to provide immediate immunity against the invading organism. Active natural immunity takes too much time to develop; this child needs immediate protection. Passive natural immunity is acquired from the mother and is effective only during the first few months of life. Active artificial immunity takes too much time to develop; the child needs immediate protection.
Which action should the nurse take when caring for a client with malaria? 1 Institute seizure precautions. 2 Prepare for blood transfusions. 3 Maintain isolation precautions. 4 Provide nutrition between paroxysms.
4 Provide nutrition between paroxysms. Maintaining adequate nutritional and fluid balance is essential to life and must be accomplished during periods when intestinal motility is not excessive so that absorption can occur. Although shaking chills may occur, seizures generally do not occur. Blood transfusions are not used in the treatment of malaria. Maintaining isolation precautions is unnecessary; infection can occur only through direct serum contact or a bite from an infected Anopheles mosquito.
Which medications act by binding with integrase enzyme and prevent human immunodeficiency virus (HIV) from incorporating its genetic material into the client's cell? Select all that apply. 1 Ritonavir 2 Nelfinavir 3 Tenofovir 4 Raltegravir 5 Elvitegravir
4 Raltegravir, 5 Elvitegravir Raltegravir and elvitegravir are integrase inhibitors. They act by binding with integrase enzyme and prevent HIV from incorporating its genetic material into the client's cell. Ritonavir and nelfinavir are protease inhibitors. They act by preventing the protease enzyme from cutting HIV proteins into the proper lengths needed to allow viable virions to assemble and bud out from the cell membrane. Tenofovir is a nucleotide reverse transcriptase inhibitor. It acts by combining with reverse transcriptase enzyme to block the process needed to convert HIV ribose nucleic acid into HIV deoxyribose nucleic acid.
Which statement is true regarding Sjögren's syndrome? 1 Sjögren's syndrome increases lacrimation. 2 Sjögren's syndrome increases body secretions. 3 Sjögren's syndrome decreases the risk for infection. 4 Sjögren's syndrome decreases the digestion of carbohydrates.
4 Sjögren's syndrome decreases the digestion of carbohydrates. Sjögren's syndrome decreases the digestion of carbohydrates because of insufficient secretion of saliva. Sjögren's syndrome decreases lacrimation. Sjögren's syndrome also decreases body secretions and saliva, therefore increasing the risk of infection.
The nurse is advising a client with acquired immunodeficiency syndrome (AIDS) to avoid the consumption of undercooked meat. Which infection can be prevented in the client by following this measure? 1 Tuberculosis 2 Cryptococcosis 3 Cryptosporidiosis 4 Toxoplasmosis encephalitis
4 Toxoplasmosis encephalitis Toxoplasmosis encephalitis is caused by Toxoplasma gondii, which may occur due to the ingestion of infected undercooked meat or by contact with contaminated cat feces. Tuberculosis is caused by Mycobacterium tuberculosis and is spread by airborne routes. Cryptococcosis is caused by Cryptococcus neoformans, which is a debilitating meningitis and can be a widely spread infection in AIDS. Cryptosporidiosis is an intestinal infection caused by Cryptosporidium organisms.
Which virus can cause encephalitis in adults and children? 1 Rubella virus 2 Parvovirus 3 Rotaviruses 4 West Nile virus
4 West Nile virus The West Nile virus causes encephalitis. German measles is caused by rubella. Gastroenteritis is caused by parvovirus. Rotavirus also causes gastroenteritis.
A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will best elicit information that supports this diagnosis? 1 "Have you experienced an infection recently?" 2 "Is there a history of this disorder in your family?" 3 "Did you receive a head injury during the past year?" 4 "What medications have you taken in the last several months?"
1 "Have you experienced an infection recently?" Symptoms usually appear one to three weeks after an acute infection; this syndrome is linked to diseases such as viral hepatitis, the Epstein-Barr virus, and infectious mononucleosis. There is no known familial tendency that exists in the development of Guillain-Barré syndrome. This syndrome is unrelated to head trauma. Drug therapy is not implicated as a contributing factor in Guillain-Barré syndrome.
What is the mechanism of action of penicillin? 1 Prevents reproduction of the pathogen 2 Inhibits cell wall synthesis of the pathogen 3 Inhibits nucleic acid synthesis of the pathogen 4 Injures the cytoplasmic membrane of the pathogen
2 Inhibits cell wall synthesis of the pathogen
A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? 1 "My blood type is A positive." 2 "I smoke one pack of cigarettes a day." 3 "I have been overweight most of my life." 4 "My blood pressure has been high lately."
2 "I smoke one pack of cigarettes a day." Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.
Which virus is responsible for causing infectious mononucleosis in clients? 1 Parvovirus 2 Coronavirus 3 Rotavirus 4 Epstein-Barr virus
4 Epstein-Barr virus Epstein-Barr virus is responsible for mononucleosis and possibly Burkitt's lymphoma. Parvovirus and rotavirus cause gastroenteritis. Corona virus causes upper respiratory tract infections.
What type of a reaction is contact dermatitis? 1 Type I 2 Type II 3 Type III 4 Type IV
4 Type IV Contact dermatitis is an example of a delayed hypersensitivity reaction, a type IV reaction. This is also called a cell-mediated immune response. Anaphylactic reactions are type I reactions that occur only in susceptible people who are highly sensitized to specific allergens. Hemolytic transfusion reactions are type II reactions that occur when a recipient receives ABO-incompatible blood from a donor. Tissue damage will occur in type III reactions, which are immune-complex reactions that usually occur secondary to antigen-antibody complexes.
Which cells are affected in DiGeorge syndrome? 1 T-cells 2 B-cells 3 Monocytes 4 Polymorphonuclear cells
1 T-cells DiGeorge syndrome is a primary immune deficiency disorder in which T-cells are affected. The B-cells are affected in Bruton's X-linked agammaglobulinemia; common variable hypogammaglobulinemia; and selective IgA, IgM, and IgG deficiency. Monocytes and polymorphonuclear cells are affected in chronic granulomatous disease and Job syndrome.
What is the causative organism for syphilis? 1 Treponema pallidum 2 Campylobacter jejuni 3 Trichomonas vaginalis 4 Chlamydia trachomatis
1 Treponema pallidum The causative organism for syphilis is Treponema pallidum. Campylobacter jejuni is the causative organism for proctitis. Trichomonas vaginalis is the causative organism for vulvovaginitis. Chlamydia trachomatis is the causative organism for salpingitis.
A primigravida has just given birth. The nurse is aware that the client has type AB Rh-negative blood. Her newborn's blood type is B positive. What should the plan of care include? 1 Determining the father's blood type 2 Preparing for a maternal blood transfusion 3 Observing the newborn for signs of ABO incompatibility 4 Obtaining a prescription to administer Rho(D) immune globulin to the mother
Rho(D) immune globulin will prevent sensitization resulting from Rh incompatibility that may arise between an Rh-negative mother and an Rh-positive newborn. Determining the father's blood type is unnecessary because only the mother's and infant's Rh factors are relevant. Preparing for a maternal blood transfusion is unnecessary; if a transfusion were needed, it would be for the newborn, not the mother. There is no ABO incompatibility; incompatibility might occur if the mother were O positive and the newborn had type A, B, or AB blood.
