Test 4: Immunity, Tissue Integrity, Infection, Perfusion

The nurse is performing a nutritional assessment of a client who weighs 185 lb and is 5 feet, 3 inches tall. This client's body mass index, rounded to the nearest hundredth, is ________.

32.77 BMI The nurse should use the formula [Weight in Pounds/(Height in inches × Height in inches)] × 703 for this calculation. The BMI is calculated by dividing weight in pounds (lb) by height in inches (in) squared and multiplying by a conversion factor of 703. The calculation would be 185 / 63 × 63 = 185 / 3969 = 0.0466112 × 703 = 32.77.

A nurse is working with an adolescent client who is attempting to lose weight. The client admits having difficulty being compliant with the diet prescribed by the healthcare provider. Which suggestion by the nurse might assist the client in being compliant with the prescribed diet in a way that is sensitive to the client's age? A) "It can be difficult to avoid unhealthy foods if that's what your friends are eating, but try to choose healthier options when you can." B) "Write down the exact foods you eat so that you can see what and how much you are eating." C) "Watch the nutrient content and number of calories in everything you eat." D) "Eat at the kitchen table so that you eat along with the rest of the family."

A Adolescence is a time of identity formation, and adolescents align with peers in regard to food selection. Keeping food diaries and monitoring the nutrient content and caloric values of food intake are helpful behavior modification strategies, but these don't take into account the age of the client, and studies on food consumption show that caloric information or nutrient content is not a major consideration in choice among adolescents. Parental food choices can have a strong impact on adolescents, but some adolescents rebel against these food choices, positively or negatively, and eating with the rest of the family is only beneficial if the family's habits are healthy.

Which of the following complications is not associated with a diagnosis of rheumatoid arthritis (RA)? A) Increased risk of cesarean delivery B) Increased risk of pleural effusion C) Increased likelihood of uveitis D) Increased risk of anemia

A All individuals with RA are at increased risk of plural effusion and uveitis, although the latter condition is most commonly associated with juvenile RA. Between 25% and 35% of clients with RA have mild anemia. However, pregnant women with RA are no more likely to undergo cesarean delivery than pregnant women without RA.

A patient with an allergy to latex develops contact dermatitis following an examination during which the nurse wore latex gloves. Which best describes the associated pathophysiology? A) An immune response that leads to issues with tissue integrity B) Impaired tissue integrity that leads to an immune response C) Impaired tissue integrity that leads to an infection D) Decreased perfusion that leads to issues with tissue integrity

A Allergic reactions are an example of an immune response that leads to issues with tissue integrity. Impaired tissue integrity, such as a cut, can lead to an immune response, but that is not the case in this scenario. If left untreated or exposed to bacteria or other infectious agents, the dermatitis could lead to an infection, but there is no evidence of that in this scenario. Decreased perfusion can lead to tissue damage or death, but not dermatitis

The nurse is working with a morbidly obese client who is seeking help to lose weight at a bariatric clinic. When planning this client's care, which nursing diagnosis is the priority? A) Activity Intolerance B) Disturbed Body Image C) Defensive Coping D) Constipation

A Along with diet, exercise is an important part of a weight loss program. A client with morbid obesity has a sedentary lifestyle and will have activity intolerance. Disturbed Body Image and Constipation may both be legitimate diagnoses, but Activity Intolerance is a greater priority if the client is to lose weight. There is no evidence that this client exhibits defensive coping.

The nurse is providing care to a client with a compromised immune system. Which independent nursing intervention is appropriate for the nurse to include in the client's plan of care? A) Educating the client on the importance of a nutritious diet B) Administering corticosteroids per order C) Prescribing prophylactic antibiotic therapy D) Recommending gene transfer therapy

A Although all of these interventions may be appropriate for a client with a compromised immune system, the only independent nursing intervention is educating the client on the importance of a nutritious diet. It is outside the scope of nursing practice to prescribe medication and to recommend therapies. However, the nurse can administer antibiotics and educate the client on gene transfer therapy if doing so is prescribed by the healthcare provider

Which of the following statements best characterizes vitamin use? A) Clients should be careful not to exceed recommended allowances for daily vitamin intake. B) Vitamin D is dangerous if taken in large quantities, but there is no upper limit to Vitamin C intake. C) Generally, two multivitamin pills a day is recommended for all clients regardless of diet. D) Fat-soluble vitamins in general present the least risk of toxicity to clients who take them in excess.

A Excess consumption of some vitamins, especially the fat-soluble vitamins, can lead to significant toxicity. The disorder is referred to as hypervitaminosis. When taken in excess, vitamin D can cause bone destruction, rather than contributing to bone formation. Excess intake of vitamin C can lead to diarrhea, nausea, and stomach cramps. Two multivitamin pills a day is probably excessive because one such vitamin typically contains the recommended intakes of most vitamins and minerals needed on a daily basis, and determinations of vitamin intake should always consider diet.

A nurse is working in a skilled nursing facility and is performing an assessment on an older adult client. The nurse notes that the client has hypopigmentation of the skin on both hands. The nurse should recognize that this condition is related to which age-related skin change? A) Hyperplasia of melanocytes B) Decreased perfusion of the dermis C) Increased permeability of the epidermal layer D) Hyperplasia of capillaries

A Hypopigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.

An adult burn patient is receiving fluid resuscitation of warm, lactated Ringer's solution during the first 24 hours following injury. The client's hourly urine output is being monitored to determine whether the resuscitation is adequate. The most recent reading is 1.10 mL/kg/hr. The nurse understands that this amount of urine output is A) slightly higher than the normal range. B) slightly lower than the normal range. C) within the normal range. D) extremely low.

A In adult patients with burn injuries who are receiving fluid resuscitation, urine production of 0.5-1 mL/kg/hr is considered normal. Therefore, the nurse would understand that this patient's output is slightly high.

An older adult client is admitted to the medical-surgical unit for a hip fracture. During postoperative recovery, the nurse notices a stage 1 pressure injury forming on the client's sacrum. Which action by the nurse is appropriate to reduce the progression of this injury? A) Maintain the head of the bed at a 30-degree angle, with the client positioned on the right or left side. B) Apply a heat lamp to the area to increase circulation. C) Apply a dry dressing to the pressure injury. D) Maintain the head of the bed at a 45-degree angle

A Keeping the head of the bed at an angle of 30 degrees or less decreases pressure on the sacrum. An angle of 45 degrees would be too severe and could exacerbate pressure injury formation on the sacrum. Dry dressings are not indicated with this stage of pressure injury. Heat lamps are no longer used in the treatment of pressure injuries because they do not provide therapeutic benefit.

Why are proton pump inhibitors often included as part of the pharmacologic treatment regimen for clients with rheumatoid arthritis (RA)? A) Proton pump inhibitors help reduce the unpleasant GI-related side effects of NSAIDs, which are the most common class of medications used in the treatment of RA. B) Proton pump inhibitors can dramatically decrease both inflammation and immune reactions and appear to slow the progression of joint destruction in RA. C) Proton pump inhibitors help reduce the body's autoimmune response, thereby limiting the effects of the autoimmune disease process that underlies RA. D) Proton pump inhibitors help reduce the risk of retinitis and vision loss in clients who are taking antimalarial agents as part of their therapeutic regimen for RA.

A NSAIDs are among the most common dugs used in the treatment of RA, although they may produce unpleasant gastric side effects like stomach lining irritation, erosions, and bleeding ulcers. Concurrent administration of proton pump inhibitors may reduce the risk for GI bleeding due to NSAIDs. Proton pump inhibitors do not affect the inflammation, immune reactions, and joint destruction associated with RA, nor do they reduce the body's autoimmune response. Furthermore, these drugs do not affect the risk of vision problems that accompanies use of antimalarial agents.

The nurse is collecting a health history for a client being seen in an outpatient clinic who complains of joint pain and swelling that have lasted for about 2 months. The client is diagnosed with rheumatoid arthritis (RA). Which of the following statements made by this client supports the nursing diagnosis of Activity Intolerance? A) "I seem to get tired early in the day and require a nap." B) "My joints are stiffest at night before I go to sleep." C) "I find it difficult to move when I first get up in the morning." D) "I take ibuprofen for the pain as needed."

A One hallmark symptom of RA is extreme fatigue. The client's statement regarding the need for a nap supports the inclusion of Activity Intolerance in the plan of care. Based on this diagnosis, the nurse would teach the client about the need for frequent rest periods during the day to conserve energy. The joints of RA clients are usually stiffest in the morning, but that would not interfere with activities later in the day. Also, taking ibuprofen for pain does not affect the client's ability to engage in activity.

The nurse is completing a health screening for a school-age child with rheumatoid arthritis (RA). The parents ask the nurse to recommend activities that will promote exercise for their child. Which recommendation by the nurse is most appropriate? A) Swimming B) Football C) Softball D) Basketball

A Swimming exercises all the extremities without putting undue stress on joints. In contrast, softball, football, or basketball could all exacerbate joint discomfort.

A nurse who works in the emergency department is providing care for a group of clients. Which client demonstrates a declining immune response that typically occurs with the aging process? A) An 88-year-old client with pneumonia who has a temperature of 99.5°F B) A 70-year-old client who has swelling and redness around an abdominal incision from an open appendectomy C) A 58-year-old client who complains of redness and itching after developing a rash from contact with poison ivy D) A 56-year-old client who has 8 mm induration at the site of a PPD skin test administered 72 hours earlier

A The client who has only a slight elevation in temperature in response to pneumonia is exhibiting a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration

A nurse educator is teaching a group of student nurses about newborn skin and factors that relate to this concept. Which statement will the educator include in the teaching session? A) "The newborn's skin is about 40% to 60% thinner than an adult's skin at birth." B) "The newborn's skin contains less water than an adult's and has tightly attached cells." C) "The newborn's thicker skin decreases absorption of harmful chemical substances and topical medications." D) "The newborn's skin has a greater percentage of underlying subcutaneous fat compared to adults."

A The newborn's skin is about 40% to 60% thinner than an adult's, which makes the newborn's skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn's skin contains more water than an adult's and has loosely attached cells. The newborn's skin has less subcutaneous fat compared to adults.

Which form of juvenile idiopathic arthritis (JIA) primarily affects the knees, ankles, and elbows? A) Pauciarticular arthritis B) Polyarticular arthritis C) Systemic arthritis D) Osteoarthritis

A There are three types of JIA: pauciarticular, systemic, and polyarticular. Pauciarticular arthritis primarily affects the knees, ankles, and elbows. Systemic arthritis involves high fever, polyarthritis, and rheumatoid rash and also affects internal organs. Polyarticular arthritis affects many joints (five or more), particularly the small joints of the hands and fingers. It also may affect the hips, knees, feet, ankles, and neck. Osteoarthritis is a separate condition, not a form of JIA.

A nurse working in a community health center is counseling an adolescent regarding a suspected eating disorder. The adolescent is of normal weight but admits to periods of overeating, especially when his parents fight. This client's eating habits best demonstrate which risk factor for obesity? A) Cultural and environmental factors B) Heredity C) Low socioeconomic status D) Physical inactivity

A This client most often overeats because of stress, which is an environmental risk factor for obesity. The client's stress comes from the environment, such as problems at school or at home, and not from heredity, low socioeconomic status, or physical inactivity, although these are all risk factors as well.

The nurse is caring for a client in an allergy clinic. After completing the client history, the nurse selects the nursing diagnosis of Risk for Shock. Which item in the client's history supports the need for this nursing diagnosis? A) Anaphylactic reaction to shellfish B) A drug reaction to penicillin causing a rash C) Glomerulonephritis D) Dermatitis resulting from a response to laundry detergent

A Type I hypersensitivities, such as anaphylactic reactions, occur immediately and may be life-threatening. Because the client has a history of this type of reaction, Risk for Shock is an appropriate nursing diagnosis. The other items would not necessitate the need for this nursing diagnosis.

A nurse is caring for a client who is newly diagnosed with rheumatoid arthritis (RA). The client asks the nurse to explain the difference is between RA and osteoarthritis (OA). Which responses by the nurse are most appropriate? Select all that apply. A) "The onset of OA is gradual, whereas the onset of RA may be rapid." B) "With OA, multiple joints are symmetrically affected; RA affects one joint at a time." C) "The affected joints in RA feel cold to the touch, whereas the affected joints in OA are warm or hot to the touch." D) "OA is slowly progressive, whereas RA is characterized by exacerbations and remissions." E) "With RA, pain and stiffness occur with activity; with OA, pain and stiffness are predominant upon arising."

A, D The onset of OA is gradual, whereas the onset of RA may be rapid. RA affects multiple joints symmetrically, but OA affects one joint at a time. The affected joints in OA feel cold to the touch, whereas the affected joints in RA are warm or hot to the touch. OA is slowly progressive, whereas RA has exacerbations and remissions. With RA, pain and stiffness occur with activity; with OA, pain and stiffness are predominant upon arising.

When planning care for a client at risk for developing pressure injuries, which intervention(s) should be included? Select all that apply. A) Initiate a frequent toileting schedule. B) Raise the client's heels off the bed. C) Turn the client every 4 hours. D) Use inflatable doughnut-style devices to reduce pressure on the sacrum. E) Massage pressure areas with lotion every 4 hours.

A,B Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and the potential for skin breakdown. The client's heels should be raised off the bed to remove pressure on this area of the body. The client should be turned at least every 2 hours. Massaging pressure areas can cause friction and damage to problem skin areas. Inflatable doughnut-style devices are contraindicated, because they increase pressure and reduce perfusion to affected areas.

A client receives the yellow fever vaccine before traveling to the Amazon Basin and asks the nurse how the vaccine provides protection. Which responses by the nurse are most appropriate? Select all that apply. A) "Human macrophages engulf the weakened vaccine virus as if it is dangerous, and antigens stimulate the immune system to attack it." B) "In the lymph nodes, which are part of the lymphoid system, the macrophages present yellow fever antigens to T cells and B cells." C) "A response from yellow fever-specific T cells is activated. B cells secrete yellow fever antibodies." D) "The vaccine contains large amounts of protective antibodies that were produced in another host organism, so it provides immediate protection against yellow fever." E) "The initial weak infection is eliminated and the client is left with a supply of memory T and B cells for future protection against yellow fever."

A,B,C,E Administration of the vaccine introduces a small number of weakened yellow fever viruses into the body. Macrophages ingest these viruses while also presenting the viruses' antigens to T cells and B cells. Exposure to the antigens causes the T cells to attack the yellow fever viruses. It also triggers the B cells to begin secreting yellow fever antibodies, which attack and destroy yellow fever antigens. Thus, the initial weak infection is eliminated and the body is left with a supply of memory T and B cells that provide future protection against the yellow fever virus. In this way, vaccination leads to the development of active immunity, unlike administration of large amounts of antibodies that were produced in another host, which is a type of passive immunity.

During a home visit, the nurse is assessing an older adult client. Which assessment findings support the nursing diagnosis Imbalanced Nutrition: Less than Body Requirements? Select all that apply. A) Client reports a problem with dentures slipping while chewing. B) Client complains of occasional dry mouth and problems with feelings of nausea. C) Client's adult children arrive to eat dinner together several times a week. D) Client is prescribed 15 medications. E) Client's Social Security payments have gone down over the last year.

A,B,D,E The improperly fitting dentures are causing a problem with chewing, which could lead to decreased protein and fruit and vegetable intake. Polypharmacy could negatively influence taste, and some medications promote nausea and vomiting, cause dry mouth, and suppress appetite, which could explain the dry mouth and nausea the client reports. Low finances could lead to decreased access to food. However, the client's adult children visiting and sharing a meal with the client would likely improve or support the older client's nutritional status.

The nurse is providing care to a client who is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of rheumatoid arthritis. When providing care to this client, which actions by the nurse are appropriate? Select all that apply. A) Monitoring for signs of allergic reaction B) Assuring the client that NSAIDs are safe for clients with cardiovascular disease C) Encouraging the client to take NSAIDs with a small snack to help avoid GI distress D) Monitoring for signs of renal problems E) Inquire about the use of herbal supplements such as feverfew, garlic, ginger, or ginkgo

A,C,D,E When providing care to a client who is receiving any medication, it is important to monitor for signs of allergic reaction. Taking NSAIDs with food may help reduce symptoms of GI distress that are often associated with these drugs. Clients who are on NSAIDs should be monitored for signs of renal problems, because these medications are potentially nephrotoxic. Clients should also avoid herbal supplements such as feverfew, garlic, ginger, and gingko, as these substances can increase the risk of bleeding associated with NSAID use. Because NSAIDs can cause blood pressure alterations, they may be dangerous for clients with cardiovascular disorders.

The nurse is conducting a physical assessment for a client with a compromised immune system. Which actions by the nurse are appropriate? Select all that apply. A) Assessing general appearance B) Recommending increased fluid intake C) Inspecting the mucous membranes of the nose and mouth D) Palpating the cervical lymph nodes E) Checking joint range of motion (ROM), including that of the spine

A,C,D,E The techniques of inspection and palpation are especially important in assessing a client's immune system. The nurse will assess the client's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the client's ROM, including that of the spine. Although recommending that the client increase fluid intake may be an appropriate nursing intervention, it is not an action that is conducted during the physical assessment for this client.

The public health nurse is providing community education aimed at promoting nutritional habits that decrease an individual's modifiable risk factors for heart disease. Which topics should the nurse include in this teaching session? Select all that apply. A) Benefits of consuming fruits and vegetables B) Importance of eliminating all fats C) Selecting lean protein sources D) Preparing balanced meals E) Strategies for maintaining recommended daily caloric intake

A,C,D,E The primary modifiable risk factors for nutrition alterations are food choice, portion size, and nutritional intake. Learning about the benefits of consuming fruits and vegetables, how to select lean protein sources, how to prepare balanced meals, and how to maintain the recommended daily caloric intake are all strategies for promoting good nutritional habits that decrease the risk for heart disease. In contrast, eliminating all fats should not be included, because some fats are considered "healthy" and need to be included in a heart-healthy diet.

The nurse is planning care for a client in the acute stage of a burn injury. Which aspects of care should the nurse identify as a priority? Select all that apply. A) Nutrition B) Psychosocial support C) Pain management D) Fluid resuscitation E) Wound care

A,C,E Nursing care for the client during the acute stage of burn injuries will include wound care, nutritional therapy, and pain management. Fluid resuscitation occurs during the emergency phase of burn care. Psychosocial support will be needed once the client has stabilized.

A pediatric client with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen. Which statements are appropriate for the nurse to include in the discharge instructions for this client and family? Select all that apply. A) "It is recommended that the child wear a medical alert bracelet." B) "This medication does not come prefilled and must be measured." C) "Keep the medication in the car at all times." D) "Frequently check the expiration date of the medication." E) "Keep the medication in one location that is easy to remember

A,D An EpiPen is a prefilled syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provide thorough teaching regarding use of the EpiPen. The nurse should recommend that the client wear a medical alert bracelet. The medication should not be kept in the car at all times, as it needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. Also, the EpiPens' expiration dates should be checked frequently to ensure accurate strength.

A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee stings. Which clinical manifestations would necessitate injecting the child with epinephrine (EpiPen)? Select all that apply. A) Skin that is cold and clammy to the touch B) Skin that is warm and dry to the touch C) Hyperverbal behavior D) Extreme anxiety and agitation E) Facial swelling

A,D,E General symptoms of shock that would necessitate an epinephrine injection include cold and clammy skin (which is indicative of decreased perfusion), extreme anxiety and agitation, and facial angioedema. Clients who are experiencing shock are unlikely to be hyperverbal due to respiratory symptoms that make breathing and speaking difficult.

The nurse is caring for an adult client with a BMI of 26.8 who complains of sleep apnea and gout. The nurse anticipates that treatment of this patient for obesity will consist of which therapies? Select all that apply. A) Pharmacotherapy B) Diet C) Exercise D) Behavior modification E) Surgery

B,C,D Clients with a BMI of 25-26.9 with two or more comorbidities-sleep apnea and gout in this case-would be treated with the therapies of diet, exercise, and behavior modification, but likely not pharmacotherapy or surgery

Which of the following statements is true with regard to food allergies and children? A) Over the past decade, the prevalence of peanut allergy has decreased in the pediatric population. B) Many children eventually outgrow egg, milk, and soy allergies. C) Teenagers with food allergies are at lower risk for an allergic reaction than younger clients because they are more aware of their trigger foods and how to avoid them. D) Peanut allergies are most common in pediatric clients over 5 years of age.

B It is not uncommon for people to outgrow allergies to egg, milk, soy, and wheat as they age; however, allergies to shellfish, peanuts, and fish usually persist throughout an individual's life. Among pediatric clients, the prevalence of peanut allergy has increased in recent years, with children under age 3 most commonly affected. As compared to younger children, teenagers with food allergies have the highest risk for an allergic reaction because they have a greater tendency to eat meals outside the home and are less likely to carry their medication.

What impact might corticosteroids have on tissue integrity? A) It may increase sensitivity to sunlight, leading to sunburns. B) It may cause thinning of the skin, making skin more easily injured. C) It may make skin appear shiny and lose its hair distribution. D) It may cause the skin to become overly dry.

B Some medications, such as corticosteroids, cause thinning of the skin, making it much more easily damaged. Antibiotics, chemotherapy drugs, and some psychotherapeutic drugs increase sensitivity to sunlight and can predispose the individual to sunburns. Impaired peripheral arterial circulation in the lower extremities may produce skin that appears shiny and has lost its hair distribution. Excessive cleansing can cause the skin to become overly dry.

A client who sustained burns to both lower extremities reports feeling frustrated by not being able to provide self-care. Which nursing diagnosis would be appropriate for the client at this time? A) Ineffective Coping B) Powerlessness C) Anxiety D) Situational Low Self-Esteem

B The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low self-esteem, ineffective coping, or anxiety.

The nurse is planning to provide care to extended family members spanning three generations who are being treated for burn injuries after a fire. Based on an understanding of lifespan factors, the nurse should anticipate that which of the following is true? A) The 38-year-old pregnant mother is more likely to require an allograft than the other members of the family. B) The 82-year-old grandmother is more likely to have burns to a greater percentage of her total body surface area (TBSA) than younger family members. C) The 14-year-old son is less likely to experience edema associated with his injuries than older members of the family. D) The 6-year-old daughter is more likely to go into burn shock than the other members of the family.

B The older adult population is more likely to suffer burns to a greater percentage of their TBSA than other age groups, largely because their skin is so much thinner and therefore more delicate than that of younger individuals. The other assumptions cannot be made based on patient age alone and depend on the depth and extent of the burns, which is information that is unavailable at this time.

A client requests a small inflated doughnut-style device to sit on to relieve pressure. Which response by the nurse is most appropriate? A) "I will need to get an order from the physician." B) "Using the doughnut can cause skin breakdown." C) "You will need to wait until discharge, then use the doughnut at home." D) "I will obtain the device for you."

B Use of a doughnut-style device applies pressure and results in tissue anoxia. The client may indeed feel that pressure is lessened with use of the device, but this is due to the loss of sensation. Use of a doughnut-style device should be avoided whether at the hospital or at home.

Transfusion reactions and Rh incompatibility are both examples of which type of hypersensitivity reaction? A) Type I B) Type II C) Type III D) Type IV

B ) Type I, or immediate hypersensitivity, reactions are characterized by rapid development of symptoms after exposure to an antigen; an example is anaphylaxis. Type II, or cytotoxic hypersensitivity, reactions involve the rupture of cells targeted by the immune response that may affect a variety of organs and tissues; examples include transfusion reactions and Rh incompatibility. Type III, or immune-complex, reactions include inflammatory response in the targeted tissues that leads to tissue damage; examples include autoimmune disorders such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Finally, type IV, or delayed-type hypersensitivity, reactions involve a major histocompatibility complex and are characterized by tissue damage at the site of antigen contact within 24-48 hours of exposure; an example is allergic contact dermatitis.

The nurse is providing care to a pediatric client who was admitted to the pediatric intensive care unit (PICU) with a partial-thickness thermal burn. When planning care for this client, which should the nurse consider regarding this type of burn? A) Partial-thickness burns are deeper than superficial burns but still involve the epidermis only. B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. C) A deep partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. D) A superficial partial-thickness burn is less painful than a deep partial-thickness burn.

B A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.

The nurse suspects that the client is experiencing a reaction to a specific antigen. Which laboratory result supports the conclusion made by the nurse? A) Indirect Coombs test showing no agglutination B) Patch test with a 1-inch area of erythema C) 2% eosinophils in the WBC count D) Rh antigen test with negative results

B An area of erythema after a patch test indicates a positive response to a specific antigen. In contrast, an indirect Coombs test detects the presence of circulating antibodies against RBCs; no agglutination is considered a normal finding. Similarly, an eosinophil count of 2% is within the normal range. Finally, an Rh antigen test with a negative result indicates that the client does not carry the antigen; accordingly, this result is not an indicator of a reaction to a specific antigen.

Why are second-generation antihistamines often preferred to first-generation histamines in the treatment of hypersensitivity reactions? A) Second-generation antihistamines are faster acting than first-generation antihistamines. B) Second-generation antihistamines are less likely than first-generation antihistamines to cause drowsiness. C) Second-generation antihistamines are available over the counter, whereas first-generation antihistamines require a prescription. D) Second-generation antihistamines can be administered either orally or parenterally, whereas first-generation antihistamines can only be given via the oral route.

B An important difference between first- and second-generation antihistamines is that unlike the first-generation drugs, the newer second-generation drugs do not cause drowsiness. Both first- and second-generation antihistamines are available by prescription and over the counter. The preferred route of administration for both first- and second-generation antihistamines is oral, although diphenhydramine (a first-generation drug) and some other medications may be given parenterally. Second-generation antihistamines are not universally faster-acting than their first-generation counterparts.

The nurse is caring for a client who was diagnosed with rheumatoid arthritis (RA) last year. The client has just been prescribed methotrexate as part of his RA treatment regimen. The nurse is teaching the client about use of this medication. Which client statement indicates that this teaching was successful? A) "It's not safe for me to take nonsteroidal anti-inflammatory drugs (NSAIDs) while on methotrexate therapy." B) "I can help control the side effects of methotrexate by taking folic acid." C) "I should expect to see beneficial results within 3 to 5 days of starting methotrexate therapy." D) "It's important that I take my methotrexate at the same time every day."

B Clients who are on methotrexate therapy should be advised to take folic acid, as this can help control side effects such as gastric irritation and stomatitis. Methotrexate is typically taken once per week (not daily), and it can be safely used along with NSAIDs in the treatment of RA. Clients may see beneficial effects of methotrexate therapy is as few as 2-4 weeks (not 3-5 days).

A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered? A) Skin biopsy B) Culture C) Wood's lamp D) Patch test

B Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood's lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.

Based on gender and age alone, which of the following clients is most likely to experience the new onset of rheumatoid arthritis (RA)? A) A 31-year-old man B) A 42-year-old woman C) A 65-year-old woman D) An 18-year-old man

B RA is the most common form of autoimmune arthritis, affecting from 1% to 2% of the worldwide population. RA affects three times as many women as men, and while the typical age of onset is between 40 and 60 years, this disease strikes people of all ages.

An older adult client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client's intake and output, which of the following should be taken into consideration? A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase. C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins. D) The amount of urine output will be greatest in the first 24 hours after the burn injury.

B The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.

The nurse is caring for a client who is hospitalized on a medical unit for a systemic infection. The client asks the nurse which defenses the body has against infection. Which physiologic barriers that protect the body against microorganisms should the nurse include in the response to the client? Select all that apply. A) The spleen B) Adequate urinary output C) Intact skin D) Generalized inflammation E) The thymus gland

B, C Physiologic barriers include adequate urinary output and intact skin. The act of voiding flushes out organisms that might try to access the body through the urinary meatus. Intact skin is a physiologic barrier that prevents a variety of microorganisms from entering the body. Although the inflammatory response helps fight infection, it occurs when the body's physiologic barriers to microorganisms have already been breached. Similarly, while the spleen and thymus gland are part of the immune system, they are not physiologic barriers but rather internal organs in which lymphoid cells proliferate and/or mature

The nurse is providing care to an adolescent client who presents at the clinic for a routine health assessment. Which immunizations should the nurse anticipate administering to the client during this visit? Select all that apply. A) Herpes zoster vaccine B) Papillomavirus vaccine C) Rotavirus vaccine D) Meningococcal vaccine E) Hepatitis B vaccine

B, D The papillomavirus and meningococcal vaccines are administered during adolescence. In contrast, the herpes zoster vaccine is typically given to older adults, while the rotavirus and hepatitis B vaccines are usually administered to infants.

A nurse is caring for a client with seasonal hypersensitivity reactions. What teachings should the nurse provide to improve this client's comfort? Select all that apply. A) Keep doors and windows open on high-allergen days to circulate air. B) Remain indoors if possible on high-allergen days. C) Maintain a clean, dust-free environment. D) Take antihistamine and leukotriene medications as ordered. E) Stop taking oral corticosteroids immediately once symptoms disappear.

B,C A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include information about taking antihistamine and antileukotriene medications, not leukotriene medications. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.

The nurse is preparing educational materials for a client with hypertension. Which of the following elements should the nurse include when preparing this material? Select all that apply. A) Advising the client to avoid all sodium in the diet B) Explaining the effects of sodium on blood pressure C) Teaching the client how to read nutritional labels D) Helping the client to recognize foods that are low in sodium E) Showing the client how to follow the DASH eating plan

B,C,D,E Sodium is important in the diet, and not all sodium should be avoided; however, consumption of sodium should be according to the USDA dietary guidelines for recommended intake. In some people, an increase in sodium intake leads to fluid retention and increases blood pressure. The nurse should prepare to teach the client how to read nutritional labels, how to identify foods that are low in sodium, and the DASH eating plan

A client who was recently diagnosed with rheumatoid arthritis (RA) asks the nurse if RA always causes crippling deformities. What information should the nurse include when teaching this client about ways to decrease the likelihood of crippling deformities? Select all that apply. A) Ignore pain as a warning signal. B) Type instead of hand-writing items if possible. C) Use the strongest joints possible to complete most tasks. D) Avoid stress to any current area of deformity. E) Stop an activity immediately if it is beyond your ability to perform.

B,C,D,E The client with RA should never attempt to push a joint beyond its ability. Pain is a warning signal, so the client with RA should immediately stop any activity that causes pain. The client should also use the strongest joints possible to complete tasks, and he or she should avoid activities (like writing) that require a strong grip. In addition, when performing tasks, the client should avoid stress in any current area of deformity to help prevent further deformities.

The community health nurse reviews data collected during interviews with community members during a health fair and decides to create a brochure on how to improve iron intake. Which of the following action items might the nurse include that would help vegans and vegetarians increase their iron intake? Select all that apply. A) Take calcium supplements. B) Consume tofu. C) Consume lentils. D) Increase intake of vitamin C. E) Consume Swiss chard.

B,C,D,E Vegan diet plans can lead to deficiencies in certain nutrients, including iron. All vegetarians should ensure that they get adequate amounts of iron, and to facilitate the absorption, vitamin C should also be plentiful in the diet. Tofu, lentils, and Swiss chard are all foods that both vegans and vegetarians might eat that can provide needed iron. However, although calcium supplements are good for vegetarians and vegans to take to ensure adequate calcium intake, they do not specifically provide iron.

The nurse is caring for an older adult. Which age-related changes should the nurse identify as increasing the risk of dry skin? Select all that apply. A) Reduction in elastin B) Depleted moisture in epidermal cells C) Decreased size of sebaceous glands D) Thinner subcutaneous skin layer E) Poor nutrition

B,C,E As the individual ages, moisture transfer from the dermis to the epidermis declines. This contributes to a dry, rough skin appearance. Sebaceous glands also decrease in size with age, resulting in skin that is dry and easily bruised, damaged, or broken. Poor nutrition could also cause dry skin. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.

The nurse is assessing a client who has recently had several blood tests done. Which laboratory results would the nurse identify as indicators of malnutrition? Select all that apply. A) PAB 30 mg/dL B) PAB 100 mg/L C) Cholesterol 120 mg/dL D) Cholesterol 180 mg/dL E) PAB 12 mg/dL

B,C,E A normal prealbumin (PAB) level for adult men and women is 15-36 mg/dL or 150-360 mg/L. A 30 mg/dL PAB level would not be a cause for concern, but a 100 mg/L or 12 mg/dL level would be. A normal cholesterol range is between 160 and 200 mg/ dL in adult men and women. A 120 mg/dL cholesterol level would be a possible indicator of malnutrition, but a 180 mg/dL level would not be.

During a health assessment, a client states, "I only eat carbohydrates and low-fat foods. I don't understand why I am still gaining weight!" Which principles of nutrition should guide the nurse's response? Select all that apply. A) Carbohydrates should only be eaten at breakfast. B) Eating too many carbohydrates leads to excess glucose, which is converted to fat. C) Excess carbohydrates can lead to obesity. D) A carbohydrate-limited diet is the only way to not gain weight. E) Carbohydrates should be high in fiber and low in sugar

B,C,E Carbohydrates should be eaten throughout the day. Carbohydrates are converted to glucose; when carbohydrates are consumed in excess, the excess glucose is converted to glycogen, or fat, and stored in adipose tissue, which can lead to weight gain and an increased risk for obesity. Carbohydrate deficiencies lead to protein tissue wasting. Carbohydrates should come from the consumption of foods high in fiber and low in added sugars. A carbohydrate-limited diet is not the only way to avoid weight gain.

A nurse is caring for a client who was admitted to the hospital with an exacerbation of rheumatoid arthritis (RA). The client reports that her pain is a 3 on a scale from 0 (none) to 10 (high) today. Which nonpharmacologic interventions can the nurse provide to enhance the client's comfort? Select all that apply. A) Discourage any position changes. B) Encourage relaxation techniques. C) Immobilize the extremity. D) Offer heat and/or cold packs. E) Provide distraction activities.

B,D,E Nonpharmacologic activities for pain relief include relaxation, distraction, and application of heat and cold. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.

A nurse is caring for a client with who is experiencing leukocytosis. When providing care to this client, which action by the nurse is most appropriate? A) Instructing the client on the use of an electric razor and soft toothbrush B) Evaluating the client for bleeding and bruising C) Assessing the client for the source of infection D) Placing the client in reverse isolation

C A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm3), which is an indication of infection. The appropriate action by the nurse is to assess the client for the source of infection. Providing instruction on the use of an electric razor and soft toothbrush and evaluating for bleeding and bruising would be appropriate actions for a client with thrombocytopenia, or decreased platelet levels. Reverse isolation would be appropriate for a client with neutropenia, or a decrease in the number of neutrophils

A client has a pressure injury on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. When documenting this finding, which terminology is appropriate for the nurse to use? A) Partial-thickness loss of dermis B) Nonblanchable erythema C) Suspected deep tissue injury D) Full-thickness tissue loss

C A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Nonblanchable erythema refers to a stage 1 pressure injury. Partial-thickness loss of dermis refers to a stage 2 pressure injury. Full-thickness tissue loss refers to stage 3, stage 4, and unstageable pressure injuries.

A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified? A) Minor B) Moderate C) Major D) Significant

C According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.

The nurse is assessing a client who is receiving IV antibiotics. Which item in the client's health history increases the risk for experiencing a hypersensitivity reaction? A) 26 years of age B) Caucasian race C) Previous antibiotic therapy D) Concurrent chronic illness

C Anyone can have a hypersensitivity reaction. However, risk generally increases with previous exposure, because antigens must be formed with the first exposure before hypersensitivity is likely to occur. Age, sex, concurrent illnesses, and previous reactions to related substances have all been identified as having a role in risk for hypersensitivity; however, previous exposure presents the greatest risk.

A client has a documented stage 3 pressure injury on the right hip. Which nursing diagnosis is most appropriate for this client? A) Impaired Skin Integrity B) Risk for Injury C) Impaired Tissue Integrity D) Ineffective Peripheral Tissue Perfusion

C Because a stage 3 pressure injury involves tissue, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure injuries result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity involves the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury, so Risk for Injury does not apply.

Which of the following statements best explains why young children develop infections more often than older children and adolescents? A) Cell-mediated immunity doesn't achieve full function until a child is roughly 5 years old. B) The thymus doesn't begin to function until adolescence, so prior to this time, children don't produce enough T cells to adequately protect them from infectious agents. C) Children don't develop all of the immunoglobulins they need to protect against infection until they are about 6 or 7 years of age. D) Young children have comparatively small lymphoid tissues, which means they are less able to fight infection than are older children.

C Children do not develop adequate levels of certain immunoglobulins (namely, IgA, IgE, and IgG) until they are 6 or 7 years old, so prior to this time, they are at increased risk of infection. Note, however, that cell-mediated immunity achieves full function early in life. This occurs in part because the thymus begins producing T cells during the fetal period, and also because young children have lymphoid tissues that are quite large in comparison to the rest of their bodies.

The nurse is caring for a client with a history of latex allergies. The client develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which of the following is the priority intervention for this client? A) Teach the client regarding use of a kit that contains treatment for allergic reactions. B) Administer diphenhydramine (Benadryl) by mouth every 4 hours per the healthcare provider's orders. C) Administer epinephrine 1:1000 by subcutaneous injection per the healthcare provider's orders. D) Collect a detailed history from the client regarding the history of latex allergies

C For reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the nature and severity of symptoms. Diphenhydramine may also be given, but it would likely be administered by injection rather than mouth due to the need for rapid drug onset. Although providing client teaching and collecting a detailed history are also important, the nurse does not have time to do these things until the client's immediate and potentially dangerous physical symptoms are addressed.

The nurse is caring for a client who has come to an urgent care clinic due to an arm infection. The client reports being bitten by a raccoon on a recent camping trip. Based on this data, which treatment option does the nurse anticipate for this client? A) Injection of rabies immunoglobulin only B) Administration of rabies vaccine only C) Both injection of rabies immunoglobulin and administration of rabies vaccine D) Neither injection of rabies immunoglobulin nor administration of rabies vaccine

C In this case, exposure to rabies may have already occurred, so the client requires immediate protection (passive immunity) from the virus. Such protection is provided by the injection of rabies immunoglobulin produced in another living host. However, passive immunity does not confer lasting immunity, so the client will also require rabies vaccine to start the process of antibody development (active immunity).

Development of leukopenia suggests that an individual A) is immunocompetent. B) is experiencing an infection somewhere in the body. C) may have suppressed bone marrow activity. D) has an abnormally high number of circulating leukocytes.

C Leukopenia involves a decrease in the number of circulating leukocytes in the body. Because leukocytes are produced in the bone marrow, the presence of leukopenia suggests that an individual may have suppressed bone marrow activity. Low leukocyte levels disrupt the body's ability to adequately respond to infection and may result in immunodeficiency, not immunocompetence. In individuals with proper immune system function, the presence of infection should cause an elevation in circulating leukocytes (leukocytosis) rather than leukopenia.

What is the definition of the basal metabolic rate? A) The amount of energy stored in fat each day B) The speed of triglyceride breakdown C) The cost in kilocalories of being alive D) The speed at which glucose is converted to energy

C More than 70% of the energy expended each day goes to maintaining the basal metabolic rate (BMR)-essentially, the "cost" (in kilocalories) of being alive. It is not a measure of triglyceride breakdown, storage of energy in fat, or the conversion of glucose to energy

The nurse is caring for a client who failed to meet the outcome of healing of a stage 2 pressure injury over the coccyx. Which should the nurse identify as a likely contributing factor? A) The rubber doughnut pressure relief device was not delivered by central supply. B) The client's serum albumin increased over the last month. C) A right side-back-left side-back turning schedule was used. D) Nurses did not document disinfection of the wound with alcohol at each dressing change.

C Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.

Why does breastfeeding confer some degree of passive immunity to an infant? A) The infant receives maternal antibodies via breastmilk, and these antibodies stimulate the infant's immune system to begin producing antibodies of its own. B) Consumption of breastmilk introduces certain antigens into the infant's body, thereby stimulating the infant's immune system to begin producing antibodies to these antigens. C) The infant receives maternal antibodies via breastmilk, and these antibodies provide the infant with immediate protection against specific antigens. D) Consumption of breastmilk introduces certain antigens into the infant's body, thereby stimulating the infant's immune system to begin producing antigens of its own.

C Passive immunity occurs when individuals receive antibodies from another person rather than by producing them through their own immune system. This type of immunity is immediate, and it can be acquired through the passing of antibodies between mother and newborn via breastmilk.

The nurse is teaching a client scheduled for Roux-en-Y gastric bypass surgery about potential postsurgical complications and how to reduce them. Which client statement best indicates that teaching has been effective? A) "I need to eat at least one meal a day that is high in simple carbohydrates." B) "Complications of this surgery are likely to be limited to mild gastrointestinal issues for several days." C) "I need to be alert for the indications of infection or malnutrition." D) "I will not continue my exercise program following this surgery."

C Possible postoperative complications for a procedure such as a gastric bypass include anastomosis leak with peritonitis, abdominal wall hernia, gallstones, wound infections, deep venous thrombosis, nutritional deficiencies, and gastrointestinal (GI) symptoms. If the client recognizes a need to be alert to the signs of infection and malnutrition, this shows awareness of some of the complications that might be expected. Mild GI issues are not the only significant complication of this surgery. The client likely should continue the exercise program. Eating meals high in simple carbohydrates can bring on dumping syndrome, a complication in which stomach contents move rapidly through the small intestine, drawing fluid into the intestine by osmosis.

A burn patient is currently in the acute stage. When did this stage begin, and when will it end? A) It began with the onset of the burn injury and will end with fluid resuscitation. B) It began with wound closure and will end when the patient's health is fully restored. C) It began with the start of diuresis and will end with the closure of the burn wound. D) It began with the onset of the burn injury and will end with the closure of the burn wound

C The acute stage begins with the start of diuresis and ends with the closure of the burn wound, either by natural healing or by use of skin grafts. The emergent/resuscitative stage begins with the onset of the burn injury and ends with successful fluid resuscitation. The rehabilitative stage begins with wound closure and ends when the patient returns to the highest level of health restoration, which may take years.

The nurse is caring for a client who is to receive mechanical debridement of burn wounds. Which methods should the nurse anticipate using to complete this treatment? Select all that apply. A) Homograft B) Application of a topical agent to dissolve necrotic tissue C) Irrigation of the burn wounds D) Application of wet-to-dry gauze dressings E) Hydrotherapy

C,D,E Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement

The nurse is planning a teaching seminar for a group of young adult clients who are at risk for obesity. Which statement by the nurse best addresses their needs? A) There are drugs that are good to use to reduce weight. B) Obesity often leads to low self-esteem and depression. C) Proper diet and exercise programs can not only prevent obesity but also potentially improve the ability to think and the positivity of self-perception. D) Maternal obesity often leads to menstrual irregularities and higher incidences of infertility.

C The young adults who are at risk for obesity need education about changing lifestyles and the importance of preventing obesity as opposed to treating it. Education should include tips on eating healthy and exercising, which can lead to other benefits than preventing obesity. Drugs are used to manage obesity, not prevent it. Information about maternal obesity is not necessarily relevant to all individuals and does not address health promotion. Although obesity is a risk factor for low self-esteem and depression, emphasizing these negative effects does not empower clients to address their risk factors.

Three weeks after receiving a donor liver, a client begins to experience fever, tachycardia, right upper quadrant pain, and increased accumulation of fluid in the abdomen. The transplanted liver also becomes dangerously enlarged. In this scenario, the client is likely experiencing which of the following conditions? A) Hyperacute rejection B) Chronic rejection C) Acute rejection D) Delayed rejection

C There are three types of transplant rejection: hyperacute, acute, and chronic. Hyperacute rejection occurs within minutes or hours of transplantation and is characterized by organ swelling, clot formation, and hemorrhage. Acute rejection occurs in the weeks following transplantation and is marked by pain, swelling, and enlargement of the transplanted organ. Chronic rejection occurs months after transplantation and involves slow, insidious organ failure

A nurse is caring for a client who weighs 209 pounds and is 1.67 meters tall. The client eats a high-protein diet and lifts weights to increase muscle mass. The client presents with complications such as sleep apnea, which is often caused by obesity. Which statement regarding this client is true? A) A body mass index calculation should provide an accurate measure of the client's amount of fat. B) A body mass index calculation is the best possible means of measuring this client's fat if combined with the client's waist-to-hip ratio. C) This client's body mass index calculation might indicate a false positive for obesity. D) The client should be given a bioelectrical impedance test to most accurately measure the client's fat.

C This client's weight might be at least partially from body building efforts, and so a body mass index calculation, which only uses the parameters of weight and height, might not accurately indicate whether this client is actually obese. Even if combined with the client's waist-to-hip ratio, a BMI calculation is not the best possible means of measuring a client's fat, and neither is a bioelectrical impedance test. Underwater weighing is considered the most accurate way to determine body fat.

A nurse is conducting a skin assessment of a patient. Upon palpating skin temperature, the nurse notes the skin is warm and red. This is an abnormal sign that may be indicative of A) decreased hydration. B) decreased blood flow to the skin. C) inflammation and elevated body temperature. D) hypothyroidism.

C Warm, red skin indicates inflammation and elevated body temperature. Decreased skin temperature is indicative of decreased blood flow to the skin. Excessively dry skin is indicative of hypothyroidism. Poor skin turgor is indicative of decreased hydration.

The nurse presses a finger into swollen skin tissue on a client's feet and ankles and notes that it creates an indentation. The nurse should correctly document a finding of which alteration in skin integrity? A) Poor turgor B) Ascites C) Peripheral edema D) Hypothermia

C Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Skin turgor is the skin's elasticity and is assessed by gently pinching the skin over the sternum or collarbone. Skin temperature is assessed through palpation

What does the nurse anticipate finding in a client with impetigo? A) An infection in the hair follicles B) Loss of skin color in blotches or sections C) An itchy rash with clusters of fluid-filled vesicles D) A fungal infection in the skinfolds

C Impetigo is a superficial skin infection common on the face, arms, and legs of children that presents as an itchy rash with clusters of fluid-filled vesicles that rupture easily. Ruptured vesicles develop a honey-colored crust over the lesions. Folliculitis is an infection of hair follicles. Vitiligo is a loss of skin color in blotches or sections that occur when the cells that produce melanin die or stop functioning. Candidiasis is a fungal infection commonly known as thrush and found in skinfolds.

A client with rheumatoid arthritis (RA) is being seen in the outpatient clinic for a progress checkup. Which of the following statements on the part of the client suggests that she has met a goal of treatment? A) "I sleep for 10 hours at night." B) "I have increased pain in my joints all the time now." C) "I have delegated many household chores to my children and spouse." D) "I do not perform household chores at all anymore

C One technique for reducing stress on the joints is to delegate household tasks to family members; however, the client does not need to refrain from all household chores. Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. Increased joint pain would indicate that goals have not been met.

The nurse observes flakes of greasy white dandruff in a client's hair. The nurse should correctly identify this as which type of secondary lesion? A) Nodule B) Macule C) Scales D) Crusts

C Scales are flakes of greasy, keratinized skin tissue that vary in color from white, to gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break.

The nurse is assessing the nutritional status of an older client. Which finding is most likely to suggest xerostomia? A) The client refuses food because it is difficult to chew with missing teeth. B) The client frequently becomes dehydrated due to failure to remember to drink water. C) The client has a chronically dry mouth despite adequate intake of fluids. D) The client does not enjoy foods due to diminished taste

C Xerostomia is decreased salivation due to decreased function of salivary glands. It may decrease the taste of food, impair chewing, and lead to avoidance of certain foods. The client with a dry mouth most clearly demonstrates xerostomia. Eating patterns may be altered in clients who are missing teeth, have impaired cognition and become dehydrated, or have diminished taste buds, but these are unrelated to xerostomia.

Which statements regarding upper body obesity are accurate? Select all that apply. A) Upper body obesity is also called peripheral obesity. B) Upper body obesity is when the waist-to-hip ratio in men is greater than 0.8 in men or greater than 1 in women. C) Upper body obesity is associated with a greater risk of hypertension. D) Young women tend to have more intra-abdominal fat than men. E) Postmenopausal women tend to have upper body obesity.

C,E Upper body obesity (also called central obesity) is identified by a waist-to-hip ratio of greater than 1 in men or 0.8 in women. Upper body obesity is associated with a greater risk of complications such as hypertension, abnormal blood lipid levels, heart disease, stroke, and elevated insulin levels. Men tend to have more intra-abdominal fat than women, although women develop a central fat distribution pattern after menopause.

Which data supports the nurse's concern that a client is at a high risk for a burn injury? Select all that apply. A) Part-time employment at a convenience store B) Diagnosis of hypertension C) Age 71 years D) Uses public transportation for grocery shopping E) Currently smokes one pack of cigarettes per day

C,E Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, senses of smell and hearing, and because of impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.

The nurse is concerned that a client is at risk for pressure injuries. Which assessment data supports the nurse's concern? Select all that apply. A) Age 54 B) Body temperature within normal limits C) Low serum albumin level D) Continence of urine and stool E) Prescribed bedrest

C,E Risk factors for pressure injury development include immobility and inadequate nutrition. The client who is prescribed bedrest is at risk for immobility, and a low serum albumin level is evidence of inadequate nutrition. Continence of urine and stool would reduce the risk of pressure injury development. Although advanced age increases the risk of pressure injuries, this client is only 54 years old. Finally, normal body temperature does not increase the client's risk for pressure injury development.

The nurse is admitting a pediatric client to the hospital with a ventriculoperitoneal (VP) shunt malfunction. When gathering the history, the nurse learns that the client received the shunt at birth after a meningocele repair. Based on this data, which product should be avoided when providing care to this client? A) Synthetic rubber gloves B) Polyethylene gloves C) Non-powdered nitrile gloves D) Latex gloves

D Meningocele is a form of spina bifida, and clients with a history of spina bifida are at increased risk for latex allergy. Thus, it is important for the nurse and other healthcare providers to use latex alternative products on this client, such as synthetic rubber gloves, polyethylene gloves, and non-powdered nitrile gloves.

A nurse is conducting a training session with new staff members at a nursing home. One of the staff members asks why the facility's older adult clients are at elevated risk for pressure injuries. Which response is best? A) "As people age, their epidermis becomes more elastic. This increased elasticity makes older adults' skin more susceptible to damage." B) "As compared to younger clients, older adults have higher average body temperatures, and excess body heat is a risk factor for pressure injuries." C) "Due to increased oil production, the skin of older adults tends to be moister than that of younger clients. Increased moistness increases the risk for impaired skin integrity." D) "Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity."

D ) Several factors put older adults at increased risk for pressure injuries; these include loss of lean body mass; generalized thinning of the epidermis; decreased strength and reduced elasticity of the skin; and diminished venous and arterial flow due to aging vascular walls. Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands also increases the risk for impaired skin integrity in older adults. Although excess body heat is a risk factor for pressure injuries, older adults tend to have lower average body temperatures than younger clients.

The nurse is caring for an adult female client who is admitted to the hospital with a possible hip fracture. Following the admission assessment, the nurse determines that the client is obese. The client's BMI is 33.2 and her waist circumference is 90 cm. How should the nurse classify her obesity and associated disease risk? A) Class I, high B) Class II, very high C) Class III, extremely high D) Class I, very high

D A BMI of 33.2 would be in the range for Class I obesity (30.0-34.9), which is the same for men and women. However, although a 90 cm waist circumference for a man who is Class I obese would indicate high associated disease risk, for woman a 90 cm waist circumference is above the 88 cm threshold for women, and therefore her associated disease risk is very high. Her BMI would have to be higher to be classified as Class II or Class III.

The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status? A) Creatine phosphokinase (CPK) B) Blood urea nitrogen (BUN) levels C) Hemoglobin D) Albumin level

D Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent on the fluid status.

A client is evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause of this manifestation? A) Decreased osmotic pressure in the burned tissue B) Reduced microvascular permeability at the site of the burned area C) Increased potassium in the intracellular compartment D) Inability of the damaged capillaries to maintain fluids in the cell walls

D Burn shock occurs during the first 24-36 hours after the injury. During this period, there is a shifting of fluid volume that is the direct result of lost cell wall integrity at the injury site and in the capillary bed. There is an increase in microvascular permeability at the burn site. The osmotic pressure is also increased, causing fluid accumulation. Potassium ions leave the intracellular compartment, putting patients at risk for cardiac dysrhythmia due to hypokalemia

A nurse is caring for a pediatric client who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the client is experiencing a type I hypersensitivity reaction? A) Erythema B) Fever C) Joint pain D) Hypotension

D Clinical manifestations associated with a type I hypersensitivity reaction include hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria. Erythema and fever are associated with type IV hypersensitivity reactions. Fever and joint pain are associated with type III hypersensitivity reactions.

The nurse is providing teaching to a female client about dietary modifications to promote weight loss. Which statement by the nurse is accurate? A) "Your diet should consist of 1200-1600 calories per day, with calorie consumption increasing toward the end of the day." B) "Your diet should consist of 750-1000 calories per day, with just one big meal and then intermittent snacking." C) "Your diet should simply cut 500 calories per day from your normal intake, with a special attention to eliminating all fats from your diet." D) "Your diet should consist of 1000-1200 calories per day and be low in fat, high in fiber, and include a variety of foods."

D Collaboration with a nutritionist helps clients to identify healthy foods that appeal to them and that can make up a diet plan to create a daily 500- to 1000-kcal deficit. Ideally, the recommended diet should be low in kilocalories and fat, contain adequate nutrients and minerals, and be high in dietary fiber. The client should eat regular meals with small servings. A gradual, slow weight loss of no more than 1-2 lb/week is recommended. For most individuals, this means a diet of 1000-1200 kcal/day for most women and 1200-1600 kcal/day for men. Fewer than 1200 kcal each day may lead to loss of lean tissue and nutritional deficiencies.

An adult burn patient is brought in to the intensive care unit (ICU) for treatment. Prior to sustaining the injury, the client was considered underweight for her height. The nurse understands that this may have important implications for the client because A) she will have lower fluid resuscitation calculations than patients of normal weight. B) she will be at greater risk for developing cardiac or renal insufficiencies. C) she will require more supportive care than patients who are normal weight. D) she will lose as much as 20% of her preburn weight during rehabilitation

D During the acute and rehabilitative phases of the burn injury, the patient loses as much as 20% of preburn weight. This has significant implications for all patients, especially those who are underweight at the time of injury. Fluid resuscitation calculations are based on the time of injury, not body weight. Patients with a past medical history of cardiac or renal problems are at an increased risk for cardiac and renal insufficiency regardless of weight. Children and older adults require more supportive care than other client populations because of differences in their skin and healing, not because of their body weight

How should the nurse position a client who is returned to the burn unit following a graft procedure to the leg? A) Place the client flat with the affected extremity abducted. B) Elevate the head of bed 30 degrees C) Maintain the head of bed flat D) Elevate the affected extremity

D Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.

A client's spouse reports the presence of a reddened area on the client's coccyx and wants to massage the area. Which response by the nurse is appropriate? A) "I will need to obtain an order from the healthcare provider to perform a massage." B) "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care." C) "I will record these findings in the medical record." D) "Massage may actually cause more harm to a potentially compromised area of skin."

D Redness may indicate the presence of a stage 1 pressure injury. Evidence suggests that massage over bony prominences like the coccyx can cause or worsen deep tissue trauma in patients at risk for a pressure injury. Massage should thus be restricted when problems are noted. Even when appropriate and therapeutic for a client, massages do not require a healthcare provider's order.

The nurse is caring for a client who is experiencing anaphylactic shock following the administration of a medication. Based on this data, which position is the most appropriate for the nurse to place the client? A) Trendelenburg position B) Flat, with legs slightly elevated C) Supine position D) High-Fowler position

D The Trendelenburg position elevates the foot of the bed and is no longer recommended for the treatment of shock, as it causes the abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. Lying flat is not recommended. A person in a supine position may not be able to maintain an open airway. Instead, placing the client in Fowler or high-Fowler position allows optimal lung expansion and ease of breathing.

An 84-year-old client with poor skin turgor has slipped down in the hospital bed. Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown? A) Using the bed sheet to slide the client up in bed B) Placing the bed in reverse Trendelenburg position C) Using the client's arms to pull the client up in bed D) Lifting the client, using the client's legs and arms for assistance

D The client is of advanced age and has poor skin turgor. Both of these factors put the client at increased risk for alterations in skin integrity, including damage due to shearing forces. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client up in bed may cause skin shearing. Sliding the client on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg position will not facilitate appropriate positioning of the client in the bed.

A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries. Which nursing intervention is appropriate when caring for this client? A) Clean the pressure injury as needed. B) Use hydrogen peroxide for chemical debridement of wound bed as needed. C) Maintain the head of the client's bed at 30 degrees. D) Avoid placing the client in the side-lying position.

D The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions. In addition, the nurse should clean the client's pressure injury at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.

A nurse is caring for a pregnant client who has rheumatoid arthritis (RA). Based on this data, what should the nurse anticipate when providing care to this client? A) A higher risk for preterm delivery B) An increased need for medication C) An acute exacerbation of symptoms D) A continued risk for anemia

D The pregnant client with RA is at continued risk for anemia. Many pregnant clients with RA have prolonged gestations and often experience a remission during pregnancy and relapse after delivery. Due to remission, a decrease in medication is often necessitated

What is the largest lymphoid organ in the human body? A) Thymus gland B) Bone marrow C) Tonsils D) Spleen

D The spleen is the largest lymphoid organ in the body. Although the thymus and tonsils are also lymphoid organs, they are not as large as the spleen. Bone marrow is not an organ, but rather a tissue with several lymphoid functions

Which of the following cells would be classified as granulocytes? A) Helper T cells B) Macrophages C) Natural killer (NK) cells D) Eosinophils

D There are three types of granulocytes: neutrophils, eosinophils, and basophils. Macrophages are mature monocytes and thus would not be classified as granulocytes. Helper T and NK cells are both lymphocytes, not granulocytes.

The nurse is preparing to assess a client when one of the client's family members begins showing symptoms of latex sensitivity. Which action by the nurse is the most appropriate? A) Ask the family member to leave the unit. B) Transfer the client to a department that does not use latex products. C) Wait until Monday to report the problem to the unit supervisor. D) Obtain latex-free products for the client's room.

D When symptoms of sensitivity to latex occur on exposure, latex-free products should be supplied. Transferring the client to a department that does not use latex products is unrealistic because the family member might experience exposure on another unit. (No hospital unit can be completely latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client's rights.

In what ways do type IV hypersensitivity reactions differ from other types of hypersensitivity reactions? A) Unlike other types of hypersensitivity reactions, type IV reactions are antibody-mediated responses and develop almost immediately. B) Unlike other types of hypersensitivity reactions, type IV reactions are cell-mediated responses and develop almost immediately. C) Unlike other types of hypersensitivity reactions, type IV reactions are antibody-mediated responses and take 24 hours or more to develop. D) Unlike other types of hypersensitivity reactions, type IV reactions are cell-mediated responses and take 24 hours or more to develop.

D Explanation: A) Type IV reactions differ from other hypersensitivity responses in two ways. First, they are cell-mediated immune responses, not antibody-mediated responses, that involve the T cells of the immune system. Second, type IV reactions are delayed rather than immediate, developing 24-48 hours after exposure to an antigen.

Bariatric surgery is an option for which category of clients? A) Overweight B) Pregnant women C) Adolescents D) Morbidly obese

D For people with morbid obesity, bariatric or lap band surgery is an option. Bariatric surgery may be considered in adolescents in severe cases of obesity resistant to previous weight loss attempts, but not simply adolescents as a group regardless of their obesity. Bariatric surgery would not be considered for clients who are only overweight or for pregnant women.

A middle-age adult client states to the nurse, "I do not want to have brown spots on my skin like my parents did as they got older." Which instruction by the nurse is appropriate? A) Spend at least 15 minutes each day in the sun. B) Increase the intake of calcium. C) Increase the intake of dietary fat. D) Avoid the sun or use a sunscreen to reduce skin damage.

D Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun. The intake of dietary fat or calcium will not affect the development of liver spots.

The nurse is providing care to a client who is experiencing skin inflammation and pruritus. Which of the following medications does the nurse anticipate will be prescribed for this client? Select all that apply. A) Erythromycin B) Bacitracin C) Gentamycin D) Desoximetasone E) Desonide

D,E Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.