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Foundations of Adult Health Nursing 3rd Edition White Duncan Baumle Test Bank

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Foundations of Adult Health Nursing 3rd Edition White Duncan Baumle Test Bank

ISBN-13: 978-1428317758

ISBN-10: 1428317759

 

Description

Foundations of Adult Health Nursing 3rd Edition White Duncan Baumle Test Bank

ISBN-13: 978-1428317758

ISBN-10: 1428317759

 

 

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Below you will find some free nursing test bank questions from this test bank:

Chapter 16—Immune System

 

MULTIPLE CHOICE

 

  1. How is active acquired immunity obtained?
a. by antibodies produced by another human being or an animal
b. by exposure to a disease itself or its vaccine
c. by innate resistance to illnesses specific to other species
d. by transmission of antibodies through fetal circulation

 

 

ANS:  B

In active acquired immunity, a reaction usually occurs on the first contact with the organism. This reaction produces antibodies for this organism.

 

PTS:   1                    DIF:    Knowledge    REF:   White (2010)

 

  1. A client has been cleaning window screens for the past 2 days and has now developed sneezing; thin, watery nasal discharge; and redness and itching of the eyes. Which type of allergic reaction should the nurse suspect?
a. allergic rhinitis c. animal dander hypersensitivity
b. anaphylaxis d. contact dermatitis

 

 

ANS:  A

Allergic rhinitis (hay fever) causes nasal congestion, sneezing, itching, and headache.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. The nurse is caring for a client who is having an anaphylactic reaction. Which of these medications does the nurse know is usually administered FIRST to a client who has an anaphylactic reaction?
a. aminophylline c. dopamine hydrochloride
b. ampicillin d. epinephrine

 

 

ANS:  D

Medical management of clients who have anaphylactic reactions involves life-supporting treatment measures (e.g., maintaining airway and administering intravenous fluids and medications such as epinephrine, antihistamines, vasopressors, and bronchodilators).

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse is caring for a client who just had an intravenous pyelogram (IVP). The client suddenly develops severe urticaria, angioedema, dyspnea, and cyanosis. Which of these actions should the nurse take first?
a. Administer epinephrine subcutaneously.
b. Maintain the airway and administer oxygen via mask.
c. Notify the health care provider for medication orders.
d. Start an IV line of D5W.

 

 

ANS:  A

Anaphylaxis is a potentially life-threatening type I systemic reaction to allergens. Clients who are extremely sensitive to a particular allergen (e.g., shellfish, chocolate, antibiotics) suddenly develop symptoms such as flushing, nasal and throat congestion, and severe dyspnea, which can lead to respiratory failure, severe hypotension, and death. Medical management of clients who have anaphylactic reactions involves life-supporting treatment measures. Administering epinephrine subcutaneously will decrease the client’s response and open the airway.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. A client who has previously required blood transfusions is admitted for another transfusion. Four hours after a unit of blood infuses, the client develops fever, chills, nausea, and headache. The nurse should suspect the client is experiencing which type of transfusion reaction?
a. acute hemolytic c. delayed hemolytic
b. allergic urticarial d. febrile nonhemolytic

 

 

ANS:  D

Reactions can be classified as febrile nonhemolytic, allergic urticarial, delayed hemolytic, acute hemolytic, or anaphylactic. The most common is the febrile nonhemolytic reaction, which occurs in people who have had previous blood transfusions; symptoms include fever, chills, nausea, headache, hypotension, and respiratory problems.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The client who is suspected of having an acute hemolytic transfusion reaction would receive all of the following emergency treatments. Which one should the nurse initiated FIRST?
a. Start an IV of normal saline.
b. Administer emergency drugs intravenously as ordered.
c. Maintain an airway.
d. Stop the transfusion.

 

 

ANS:  D

Delayed hemolytic reactions are usually undetected and untreated. Emergency treatment is initiated for acute hemolytic and anaphylactic reactions. Nursing care includes carefully assessing baseline information, such as vital signs prior to transfusion, and checking the client’s type and crossmatch information and that of the scheduled transfusion product with another nurse. The nurse also monitors the client for any signs of transfusion reaction and stops the transfusion if a reaction occurs.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. In addition to careful observation for signs of rejection, which of these nursing interventions is appropriate for clients who have undergone a heart transplant?
a. weighing the client weekly
b. supporting frequent visits from family members
c. encouraging intake of fresh fruits and vegetables
d. placing the client in reverse isolation

 

 

ANS:  D

Nursing care of clients who undergo organ transplant focuses on assisting the client and family to deal with concerns about the procedure and monitoring client status (e.g., vital signs, nutritional status, mental status, and fluid balance) following the transplant. Clients must also be instructed about symptoms of rejection and the importance of preventing infection, including the use of reverse isolation techniques.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse is caring for a client who is taking immunosuppressive medications. The nurse recognized that this client is especially prone to which of the following adverse reactions?
a. developing infection c. hypotension
b. elevated glucose levels d. muscle wasting

 

 

ANS:  A

The immunosuppressive medications’ mechanism of action results in the suppression of the body’s immune response. This action places the client at greater risk for the development of infections.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse is teaching a client who had a liver transplant to observe for signs of rejection. The client’s understanding is verified when what sign is listed?
a. nausea and vomiting c. fever
b. altered mental status d. weight loss

 

 

ANS:  C

Manifestations of rejection include fever, weight gain, and edema or tenderness at the transplant site and symptoms of liver failure.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. A coworker who has just completed an aseptic client procedure is now flushed and wheezing and complains of chest tightness and shortness of breath. Vital signs are heart rate 76, respiratory rate 24, and blood pressure 86/67. The nurse should suspect the coworker is experiencing which of the following?
a. anaphylactic shock
b. hypersensitivity to the antiseptic used in the procedure
c. hypoglycemic shock
d. latex allergy

 

 

ANS:  D

The coworker is experiencing a potentially life-threatening type I systemic reaction to latex allergens. Clients who are extremely sensitive to a particular allergen suddenly develop symptoms such as flushing, nasal and throat congestion, and severe dyspnea, which can lead to respiratory failure, severe hypotension, and death.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. Education for the client with rheumatoid arthritis would include which of the following?
a. Wear protective clothing and sunscreen when going out in the sun.
b. Stay in bed most of the day to maintain strength.
c. Take a warm shower to relieve joint stiffness and pain.
d. Do isometric exercises throughout the day.

 

 

ANS:  C

Rheumatoid arthritis (RA) causes inflammation, swelling, and increased synovial fluid; as more joint structures are affected, results include joint calcification, pain, limited mobility, and deformity. Warm water can assist the joint with movement by relaxing the joint structures.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. Which of these medications is usually prescribed initially for the client who has rheumatoid arthritis?
a. antimalarials
b. corticosteroids
c. nonsteroidal anti-inflammatory drugs (NSAIDs)
d. salicylates

 

 

ANS:  B

Medical management focuses on reducing inflammation, relieving pain, maintaining normal joint function, and promoting general good health. A variety of medications may be prescribed, such as nonsteroidal anti-inflammatory drugs, aspirin, prednisone, gold salts, and sulfasalazine. A corticosteroid, such as prednisone, may be initially prescribed to rapidly reduce the inflammation.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. Which of these statements about systemic lupus erythematosus (SLE) is true?
a. It occurs most commonly in young white males.
b. It is characterized by periods of exacerbation and remission.
c. It can be cured with prescribed medications.
d. It is diagnosed by computerized tomography.

 

 

ANS:  B

SLE, a chronic, progressive autoimmune disease that involves multiple body organs, most frequently affects women of childbearing age. It is a disease of exacerbation and remissions.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. Which body system is at highest risk for tissue destruction in a large percentage of clients who have systemic lupus erythematosus (SLE)?
a. cardiac c. pulmonary
b. neurological d. renal

 

 

ANS:  D

Medical management of clients with SLE focuses on decreasing tissue inflammation and destruction, including monitoring for any damage to cardiac, neurological, renal, pulmonary, and hematologic systems. The renal system has the highest risk for tissue destruction in most clients with SLE.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. Client teaching related to systemic lupus erythematosus (SLE) would include which of these aspects?
a. Eat in a sitting position or with the head of the bed elevated.
b. Report joint pain to health care provider immediately.
c. Increase medication when symptoms increase in severity.
d. Direct sun exposure may increase symptoms and is contraindicated.

 

 

ANS:  D

Nursing care includes assessing client symptoms and teaching clients about the condition, including how to maintain skin integrity, use stress-management techniques, adapt lifestyle choices, and understand the medication regimen. Clients should also be encouraged to avoid direct sun exposure, as it may increase the symptoms of SLE.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse recognizes that which statement about myasthenia gravis (MG) is TRUE?
a. It is a chronic, progressive, incurable autoimmune disease affecting multiple body organs.
b. It involves the body’s inability to transmit nerve impulses to voluntary muscles, causing extreme muscle weakness and fatigue.
c. It is a hypersensitive immune response.
d. It is an inadequate immunological response by the body.

 

 

ANS:  B

MG, an autoimmune disease affecting the transmission of nerve impulses to voluntary muscles, results in extreme muscle weakness and fatigue that increases after activity and improves after rest periods.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. A client who has myasthenia gravis (MG) has all of the following nursing diagnoses. Which would reflect the greatest threat to the client?
a. Risk for aspiration
b. Impaired verbal communication
c. Knowledge deficit related to disease process
d. Altered urinary elimination

 

 

ANS:  A

Nursing care of clients who have MG includes monitoring respiratory status, preventing aspiration, and teaching about living with the disease (e.g., avoiding excessive activity, eating a snack before taking medications to minimize gastrointestinal irritation).

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. A client who has myasthenia gravis (MG) exhibits increased muscle weakness, difficulty swallowing, and respiratory distress. Cholinergic crisis is diagnosed and is medically treated by:
a. administrating atropine c. providing oxygen by a mask
b. conducting a Tensilon test d. performing a tracheotomy

 

 

ANS:  A

Myasthenia crisis occurs when the client experiences difficulty swallowing, chewing, or talking; increased muscle weakness; and respiratory crisis. Myasthenia crisis is a medical emergency. Medical management includes prescribed anticholinesterase medications (atropine).

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse is teaching the client with myasthenia gravis (MG) about living with the disease. The nurse would include which of these aspects in the teaching?
a. Eat a diet high in fiber.
b. Get plenty of aerobic exercise.
c. Suction secretions as needed.
d. Wear a protective mask when going outside.

 

 

ANS:  C

The client teaching should include the need for suctioning secretions to maintain a patent airway. In addition, the client should be taught to avoid excessive activity and eat a snack before taking medications, to minimize gastrointestinal irritation.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. When educating a client who has human immunodeficiency virus (HIV), the nurse should include the information that it is possible to remain asymptomatic for:
a. up to 2 years c. up to 10 years
b. up to 5 years d. 10 or more years

 

 

ANS:  D

While most people remain symptom-free for 10 or more years, others develop symptoms within months; these symptoms include enlarged lymph nodes, weight loss, fever and sweats, lack of energy, persistent skin rashes or flaky skin, frequent oral or vaginal yeast infections, and herpes infection.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. When caring for a client with a diagnosis of human immunodeficiency virus (HIV), the nurse  understands that HIV is transmitted by:
a. airborne droplets
b. exchange of body fluids
c. exposure to infected animals or their waste products
d. sexual activity only

 

 

ANS:  B

HIV infection can be transmitted by blood, semen, vaginal secretions, and breast milk. High-risk behaviors that contribute to the spread of human immunodeficiency virus (HIV) include engaging in unprotected sexual intercourse, having multiple sex partners, withholding information about HIV status, and sharing needles or syringes. Transmission of HIV to health care professionals is possible, but the risk can be reduced with the use of Standard Precautions.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. As the disease progresses, symptoms of human immunodeficiency virus (HIV) become evident when which of the cells of the immune system decrease?
a. B cells c. neutrophils
b. macrophages d. CD4 T cells

 

 

ANS:  D

CD4 T cells are the immune response for cellular immunity. HIV attach to the T cells, causing depletion. B cells are the humoral immune response system.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. A client is undergoing drug treatment for human immunodeficiency virus (HIV) with nucleoside analog reverse transcriptase inhibitors (NRTIs). The nurse is aware that the outcomes of this treatment is:
a. delayed onset of opportunistic infection
b. prolonged progression of HIV in early symptomatic stage
c. prevention of transmission to others
d. increase of viral load

 

 

ANS:  A

NRTIs are a substance that closely resemble nucleosides, which are chemicals that form DNA. The viral genetic code is altered and cannot replicate. They do not prevent HIV transmission, but slow down replication of HIV in the body, delaying onset of other opportunistic infections.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse caring for a client with human immunodeficiency virus (HIV) understands that a client is considered to have acquired immunodeficiency syndrome (AIDS) when which of the following occurs?
a. appearance of flulike symptoms
b. CD4 T cell count of less than 200 cells/mm3 and one defined clinical condition
c. enlarged lymph nodes for more than 3 months
d. one positive enzyme-linked immunosorbent assay (ELISA) test

 

 

ANS:  B

Diagnosis of AIDS is made when the client’s CD4 T cell count is of less than 200 cells/mm3 and there is one defined clinical condition. Flu-like symptoms appear with the acute phase of HIV. Enlarged lymph nodes for more than 3 months can be associated with opportunistic infections. The diagnosis of HIV requires two positive enzyme-linked immunosorbent assay (ELISA) tests and a confirmatory Western blot.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse is usually responsible for which of the following actions prior to a client being tested for human immunodeficiency virus (HIV)?
a. explaining venipuncture to client and obtaining specimen for testing
b. obtaining a signed consent only
c. pretest counseling and ensuring a signed consent is completed
d. pretest counseling only

 

 

ANS:  C

The nurse provides pretest and posttest counseling to the client regarding transmission, preventions, and risk reduction. Testing for HIV requires that an informed consent  be signed prior to testing. The nurse will ensure the consent has been signed prior to the testing.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. A nurse is clarifying information for a client whose ELISA test is negative. After reviewing the test results with the client, which aspect should be included?
a. Assess the client’s risk behavior and strategies for reducing risk.
b. Make a follow-up appointment for further testing.
c. Review the symptoms of disease progression.
d. Discuss the medication regimen.

 

 

ANS:  A

Posttest counseling should include reviewing transmission, prevention, and risk reduction with the client. The client’s test was negative and does not require medications or knowledge of symptoms. In addition, there is no need for further follow-up.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse recognizes the MOST common opportunistic infection occurring in over half of clients with acquired immunodeficiency syndrome (AIDS) is:
a. Kaposi’s sarcoma
b. mycobacterium avium complex (MAC)
c. non-Hodgkin’s lymphoma
d. Pneumocystis carinii pneumonia

 

 

ANS:  D

Pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection, but since the advance in antiretroviral medications, the patient is able to maintain a higher CD4 count, thus reducing the PCP incidence.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. When is a health care worker at greatest risk of being exposed to tuberculosis (TB)?
a. during and after procedures that induce coughing in clients with TB
b. when handling blood products of a client with HIV
c. when caring for clients at risk for developing TB, such as clients who are HIV-positive
d. when caring for clients who have come to the United States from other countries

 

 

ANS:  A

TB involves an acid-fast aerobic bacilli that is transmitted through inhalation. Clients should be placed in negative pressure precautions to avoid transmission.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. Mycobacterium avium complex (MAC) initially infects which system in persons who have AIDS?
a. bone marrow c. gastrointestinal (GI) tract
b. central nervous system d. lymphatic

 

 

ANS:  C

These organisms are found in contaminated soil and water. They find their way into the host by way of the GI and respiratory tract.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. Which of these conditions belongs to the herpes virus group and lies dormant in tissues waiting to be reactivated in the immunocompromised client?
a. cryptosporidium enteritis c. Pneumocystis carinii pneumonia
b. cytomegalovirus d. tuberculosis

 

 

ANS:  B

Most people have been exposed to cytomegalovirus (active/latent), but it becomes a problem when the client becomes immunosuppressed. Exposure occurs during preschool (congenital infection, child to child, vaginal delivery, breast milk) and the sexually active years (intercourse, kissing).

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. Which of these statements about the medical treatment for cryptosporidiosis is TRUE?
a. It is aimed at palliative treatment.
b. It consists of antibiotic therapy such as penicillin G IV over a period of 14 to 21 days.
c. It consists of antifungal therapy IV for a period of 6 weeks.
d. It consists of radiation therapy for the gastrointestinal (GI)tract.

 

 

ANS:  A

Cryptosporidiosis is a protozoan that infects epithelial cells of the GI tract. It is transmitted by the fecal-oral route and through contaminated water or food. Interventions include a focus on symptoms (palliative care), including antidiarrheals given on programmed schedule, not prn; fluid/electrolyte replacements; maintaining nutritional status with low residue, high protein, calories; and careful attention to skin care.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. The nurse caring for a client who is HIV positive notes the client is experiencing an explained weight loss of more than 10% of body weight that is associated with chronic diarrhea or fever. The nurse plans care, knowing that this condition is:
a. anorexia c. HIV-wasting syndrome
b. histoplasmosis d. malabsorption syndrome

 

 

ANS:  C

HIV-wasting syndrome is associated with a weight loss of greater than 10% body weight and one of the following for more than 30 days: weakness, diarrhea, or fever. Causes are related to poor intake, malabsorption, metabolic changes, and medication side effects.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. What oral fungal infection produces symptoms such as creamy, white intraoral lesions; mucosal tenderness; and painful swallowing in clients who are immunocompromised?
a. cryptosporidium colitis c. oral candidiasis
b. Epstein-Barr virus d. oral hairy leukoplakia

 

 

ANS:  C

Oral candidiasis appears as white plaques on the tongue, gums, or other mucous membranes. It may appear as flat, bright red areas on the hard palate, buccal mucosa, or tongue. Data collection includes: dysphagia, dry mouth, unpleasant taste, tender gums, painful swallowing, and white cheesy lesions, which if wiped away leave erythematous or even bleeding mucosal lesions.

 

PTS:   1                    DIF:    Knowledge    REF:   White (2010)

 

  1. The majority of clients who have oral hairy leukoplakia receive which kind of treatment?
a. none c. nystatin suspension
b. acyclovir sodium d. oral fluconazole

 

 

ANS:  A

Oral hairy leukoplakia appears as white patches on side of tongue, irregular surface of lesions, resembles hair, and can not be scraped off. Interventions are necessary in most cases as it is usually not bothersome and may regress spontaneously.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. What is the MOST common initial infection occurring in women who are human immunodeficiency virus (HIV) positive?
a. candidiasis c. Epstein-Barr virus
b. cryptosporidium d. hairy leukoplakia

 

 

ANS:  A

Vaginal candidiasis is the most common initial fungal infection occurring in HIV infected women.

 

PTS:   1                    DIF:    Knowledge    REF:   White (2010)

 

  1. Early signs and symptoms of acquired immunodeficiency syndrome (AIDS) dementia complex include:
a. psychotic behaviors c. hyperactive behavior
b. depression d. inability to concentrate

 

 

ANS:  D

Early signs and symptoms of acquired immunodeficiency syndrome (AIDS) dementia include vague onset of symptoms such as poor concentration, forgetfulness and lose of balance.

 

PTS:   1                    DIF:    Comprehension                               REF:   White (2010)

 

  1. The nurse is caring for a client who is human immunodeficiency virus (HIV) positive with a diagnosis of toxoplasmosis. Confirmation the diagnosis of toxoplasmosis in the client is made by which of these signs?
a. recent onset of neurological abnormality
b. presence of CD4 T cells
c. presence of white patches on tongue or oral mucosa
d. evidence of elevated protein level in cerebrospinal fluid

 

 

ANS:  A

Diagnosis is confirmed by a recent onset of neurological abnormalities such as headache, lethargy, poor coordination, seizures, and coma.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse is aware that when caring for the client who is human immunodeficiency virus (HIV) positive, once initial treatment for acute cryptococcal meningitis is completed, interventions should include:
a. avoiding fresh juice and fruit
b. being reevaluated every 2 to 4 weeks for reoccurrence
c. recognizing the signs and symptoms of meningitis, so any reoccurrence can be identified soon
d. beginning lifelong suppressive therapy

 

 

ANS:  D

Interventions for acute cryptococcal meningitis would include initial IV drug therapy followed by lifelong suppressive drug therapy.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. What is the name of the vascular malignancy that can occur anywhere in the body, but whose first lesions often appear on the face or oral cavity in clients with acquired immunodeficiency syndrome (AIDS)?
a. Kaposi’s sarcoma c. oral hairy leukoplakia
b. oral candidiasis d. non-Hodgkin’s lymphoma

 

 

ANS:  A

Kaposi’s sarcoma is cancer of the cells of the lymph system. It may occur anywhere in the body, but the first lesions usually appear on the face or in the oral cavity. It may develop in a person with a normal immune system, but spreads more rapidly in the immunosuppressed person.

 

PTS:   1                    DIF:    Knowledge    REF:   White (2010)

 

  1. The nurse caring for a client with systemic lupus erythematosus (SLE) provides teaching about measures to avoid fatigue. The nurse recognizes that the client needs additional teaching if the client states he or she should:
a. Avoid long periods of rest.
b. Perform activities sitting whenever possible.
c. Take a hot shower.
d. Engage in low-impact exercise when well rested.

 

 

ANS:  C

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

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. A client has received testing for human immunodeficiency virus (HIV). The client’s results of two enzyme-linked immunosorbent assay (ELISA) tests have been positive. In explaining the next step, the nurse’s response is based on the understanding that:
a. the client will have a bone marrow biopsy to confirm the diagnosis
b. a Western blot test will be done to confirm the diagnosis
c. a CD4+ cell count will be obtained to measure T-helper lymphocytes
d. the client will be diagnosed as HIV-positive and begin medical treatment

 

 

ANS:  B

Once the results of two ELISA tests are positive, the Western blot test is done to confirm the diagnosis. If the result of the Western blot test is positive, the client is diagnosed as positive for HIV.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse is caring for a client with a diagnosis of human immunodeficiency virus (HIV). The nurse understands that the therapeutic management of the client does NOT include:
a. using antiretrovirals to prolong the HIV stage
b. preventing opportunistic infections from occurring
c. radiation to inhibit HIV replication
d. medications to treat opportunistic infections

 

 

ANS:  C

Medical management of clients who have HIV/AIDS focuses on minimizing disease progression by keeping the viral load as low as possible for as long as possible, thus preventing opportunistic infections from occurring.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

  1. The nurse is educating the client with histoplasmosis about prevention methods for future exposure. The nurse evaluates that the client needs future instruction if the client states that the possible sources include which of the following?
a. cleaning bird cages c. fruit trees
b. chicken coops d. mushroom cellars

 

 

ANS:  C

Histoplasmosis is a fungal infection caused from bird droppings, chicken coops, soil in the Mississippi, and in caves. It may have been dormant in the body following exposure and becomes prevalent when a client becomes immunosuppressed.

 

PTS:   1                    DIF:    Application    REF:   White (2010)

 

MULTIPLE RESPONSE

 

  1. Which interventions would apply when caring for a client at high risk for an allergic response to a latex allergy? (Select all that apply.)
a. Use nonlatex gloves.
b. Keep a latex-free supply cart available for the client’s use.
c. Only use a blood pressure cuff from an electronic device to measure the blood pressure.
d. Use medications from glass ampoules.
e. Do not puncture rubber stoppers with needles.

 

 

ANS:  A, B, D, E

All equipment and items that enter the client’s room should be latex-free. Blood pressure cuffs, unless specifically latex free, use a bladder made of latex despite the type of device.

 

PTS:   1                    DIF:    Analysis         REF:   White (2010)

 

  1. The nurse is caring for a client with systemic lupus erythematosus (SLE). The nurse plans care for this client, knowing that this disorder is which of the following? (Select all that apply.)
a. a local rash that occurs as a result of allergy
b. an inflammatory disease of collagen contained in connective tissue
c. a disease frequently affecting women of childbearing age
d. a disease caused by the continuous release of histamine in the body

 

 

ANS:  B, C

SLE, a chronic, progressive autoimmune disease that involves multiple body organs, most frequently affects women of childbearing age. It is a disease of exacerbation and remissions. Immune complexes that are formed as a result of antibody production cause inflammation and tissue damage in the skin, brain, kidney, lung, heart, or joints.

 

PTS:   1                    DIF:    Analysis         REF:   White (2010)