Med Surg I Final

Question 1

The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?

Answer 1

Trauma and microabrasions from a nonelectric razor may contribute to anemia.

Question 2

The registered nurse (RN) and licensed practical nurse (LPN) are preparing an educational program for clients who may be at risk for the development of iron-deficiency anemia. Which clients would receive the greatest benefit from this program?

Answer 2

• A young female client with bulimia nervosa
• An older adult client with a fixed income
• A client with crohn’s disease
• A client who is a vegetarian

Question 3

The need for iron increases during periods of rapid growth, pregnancy, and the female reproductive years when intermittent blood loss accompanies menses.
(T/F)

Answer 3

True

Question 4

Treatment for sickle cell disease is curative rather than supportive.
(T/F)

Answer 4

False

Question 5

Symptoms of hemolytic anemia are similar to those associated with hypovolemic anemia.
(T/F)

Answer 5

True

Question 6

Protective isolation is necessary if the leukocyte is extremely low.
(T/F)

Answer 6

True

Question 7

Hemophilia is an inherited disorder.

T/F

Answer 7

True

Question 8

One of the unique manifestations of sickle cell disease is __________, a type of pneumonia triggered by decreased hemoglobin and infiltrates in the lungs.

Answer 8

Acute Chest Syndrome

Question 9

Hereditary hemolytic anemias are referred to as __________.

Answer 9

Thalassemias

Question 10

__________ develops when client lacks intrinsic factor.

Answer 10

Pernicious anemia

Question 11

__________ refers to a decreased production of granulocytes.

Answer 11

Agranulocytosis

Question 12

__________ is a lower than normal number of platelets or thrombocytes.

Answer 12

Thrombocytopenia

Question 13

The rate of HIV infection is 6.5 times higher in African Americans than in Whites.
(T/F)

Answer 13

True

Question 14

There are only four known body fluids through which HIV is transmitted.
(T/F)

Answer 14

True

Question 15

AIDS is the first stage of HIV infection

T/F

Answer 15

False

Question 16

If results of a second ELISA test are positive for HIV, a second test is performed.
(T/F)

Answer 16

False

Question 17

When drug therapy is begun, clients are generally started on a combination of three antiretroviral drugs.
(T/F)

Answer 17

True

Question 18

Infections that usually do not occur in individuals with a healthy immune system are called __________.

Answer 18

Opportunistic Infections

Question 19

A type of connective tissue cancer common among those with AIDS is __________.

Answer 19

Kaposi’s Sarcoma

Question 20

People with HIV and AIDS are treated with __________ drugs.

Answer 20

Antiretroviral

Question 21

Clients who neglect to take antiretroviral drugs as prescribed risk development of __________

Answer 21

Drug resistance

Question 22

Immunosuppressed clients may develop serious __________ as a result of infection with a protozoan called Cryptosporidium.

Answer 22

Diarrhea

Question 23

The nurse is performing a physical assessment on a client with a suspected lymphatic disorder. What would be the nurse’s primary assessment for all clients with lymphatic disorders?

Answer 23

Enlargement of the lymph glands

Question 24

A client has just been admitted to the unit with a diagnosis of Hodgkin’s disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis?

Answer 24

Are you experiencing fever, chills, or night sweats?

Question 25

A client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?

Answer 25

How to apply an elastic sleeve or stocking

Question 26

The nurse is caring for a client with Hodgkin’s disease who has developed anemia. What would the nurse expect to be ordered for this client?

Answer 26

Transfusions

Question 27

The nurse is caring for a client newly admitted to the unit with a diagnosis of lymphangitis. What interventions would the nurse institute to help promote the resolution of the lymphangitis?

Answer 27

• Elevate the area
• Encourage independent activities of daily living
• Apply warm soaks/compresses to the area
• Note the response to antibiotic therapy

Question 28

A client had a left radical mastectomy with an axillary node dissection 6 months ago and is having a large amount of edema in the left arm down to the fingers. What should the nurse inform the client is the reason for the edema?

Answer 28

An accumulation of lymphatic fluid that results from impaired lymph circulation.

Question 29

The nurse is sending a client to be fitted for a compression garment for the treatment of lymphedema after having a mastectomy and node dissection. What does the nurse inform the client that will do to decrease the edema?

Answer 29

• Prevents tissue refilling with an excess volume of lymph
• Helps muscles to expel lymphatic drainage
• Increases local tissue pressure

Question 30

The nurse is caring for the client with infectious mononucleosis that has inflammation of the pharyngeal mucosa. What foods or liquids would be best to offer to this client?

Answer 30

Vanilla pudding and iced tea

Question 31

A client calls the clinic and informs the nurse that her boyfriend was diagnosed with infectious mononucleosis and wonders how long it would be before she got it. What does the nurse inform the client that the incubation period is for infectious mononucleosis?

Answer 31

30-50 days

Question 32

A client has been diagnosed with non-Hodgkin’s lymphoma but has no symptoms at this time. The client has received radiation and chemotherapy with responsiveness to this treatment. How would this disease be classified according to the lack of symptoms and responsiveness to treatment?

Answer 32

Indolent

Question 33

Which client does the nurse recognize as most likely to be diagnosed with non-Hodgkin’s lymphoma rather than Hodgkin’s lymphoma?

Answer 33

A 55 year old client with an immunosuppression disorder

Question 34

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?

Answer 34

T-cell lymphocytes survey proteins in the body and attack the invading antigens.

Question 35

A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?

Answer 35

Naturally acquired, active immunity

Question 36

An older male adult client, who leads a sedentary lifestyle, and a younger female client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. The nurse knows that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?

Answer 36

The male client because of his age

Question 37

What is the function of the thymus gland?

Answer 37

Programs T-lymphocytes to become regulator or effector T-cells

Question 38

A teenaged client has been brought to the clinic by his mother and is suspected of having an immune system disorder. What tests would the nurse expect to be ordered for this young client?

Answer 38

Complete blood count with differential

Question 39

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?

Answer 39

Naturally acquired, active immunity

Question 40

A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have?

Answer 40

Passive immunity transferred by the mother

Question 41

A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?

Answer 41

Artificially acquired immunity

Question 42

The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis?

Answer 42

The injection area swells if the client has developed antibodies against the antigen

Question 43

A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications?

Answer 43

Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.

Question 44

A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have?

Answer 44

The nurse ensures a written consent is obtained prior to testing

Question 45

What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction?

Answer 45

IgE

Question 46

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

Answer 46

Natural killer cells

Question 47

The nurse is instructing client’s about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?

Answer 47

A 65-year-old who had chicken pox when he was 12 years old

Question 48

Allergies can occur at any age, and the pattern of allergic response can vary in the same person during his or her life.
(T/F)

Answer 48

True

Question 49

To identify food allergens, meticulous record keeping of symptoms and a food diary listing all food and beverages consumed are necessary.
(T/F)

Answer 49

True

Question 50

Autoimmune disorders are usually cured with medications

T/F

Answer 50

False

Question 51

A triggering event, such as trauma or infection, has been linked to many autoimmune disorders.
(T/F)

Answer 51

True

Question 52

The cause of chronic fatigue syndrome is connected to chronic bacterial infections.
(T/F)

Answer 52

False

Question 53

A(n) __________ is characterized by a hyperimmune response to weak antigens that usually are harmless.

Answer 53

Allergic disorders

Question 54

__________ refers to a process of attracting migratory cells to a particular area in the body.

Answer 54

Chemotaxis

Question 55

The __________ is used to identify the offending substance in allergic contact dermatitis

Answer 55

Patch test

Question 56

The term __________ is used to describe an immune response that is waged against transplanted organs and tissues that carry nonself antigens.

Answer 56

Alloimmunity

Question 57

__________ is a complex of symptoms primarily characterized by profound fatigue with no identifiable cause

Answer 57

Chronic fatigue syndrome

Question 58

Lymphocytes, which are either T-cell or B-cell lymphocytes, comprise 50% to 60% of all leukocytes.
(T/F)

Answer 58

False

Question 59

Memory cells produce antibodies.

T/F

Answer 59

False

Question 60

The thymus gland becomes smaller during adolescence but retains some activity throughout the life cycle.
(T/F)

Answer 60

True

Question 61

Artificially acquired active immunity results when ready-made antibodies are given to a susceptible person.
(T/F)

Answer 61

False

Question 62

The nurse ensures that a written consent is obtained before testing for HIV and keeps the results of HIV testing confidential.
(T/F)

Answer 62

True

Question 63

__________ is the ability to cooperatively protect a person from external invaders and the body’s own altered cells.

Answer 63

Immunocompetence

Question 64

__________ are chemical substances that destroy foreign agents such as microorganisms.

Answer 64

Antibodies

Question 65

__________ is the process of engulfing and digesting bacteria and foreign material.

Answer 65

Phagocytosis

Question 66

The __________ is made up of many different proteins that are activated in a chain reaction when an antibody binds with an antigen.

Answer 66

Complement system

Question 67

__________ occurs as a direct result of infection by a specific microorganism.

Answer 67

Naturally acquired, active immunity

Question 68

Primary lymphedema occurs as a complication of another disorder.
(T/F)

Answer 68

False

Question 69

Staph infections are usually the cause of both lymphangitis and lymphadenitis
(T/F)

Answer 69

False

Question 70

The symptoms of infectious mononucleosis generally resolve in approximately 1 to 2 weeks unless complications develop.
(T/F)

Answer 70

False

Question 71

The risk of lymphoma is increased in older adults, primarily because of the immunologic changes of aging and prolonged exposure to carcinogens
(T/F)

Answer 71

True

Question 72

The incidence of non-Hodgkin’s lymphomas is six to seven times that of Hodgkin’s disease.
(T/F)

Answer 72

True

Question 73

__________ is an accumulation of lymphatic fluid that results from impaired lymph circulation.

Answer 73

Lymphedema

Question 74

__________ is inflammation of lymphatic vessels.

Answer 74

Lymphangitis

Question 75

The __________ causes infectious mononucleosis.

Answer 75

Epstein-Barr virus

Question 76

The term __________ applies to a group of cancers that affect the lymphatic system.

Answer 76

lymphoma

Question 77

__________ cells are characteristic of Hodgkin’s disease seen in lymph node biopsies.

Answer 77

Reed-Sternberg cells

Question 78

A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?

Answer 78

The spleen is a lymphatic structure and assists with phagocytosis

Question 79

A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion. He has been typed and cross-matched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client?

Answer 79

Type O

Question 80

The nurse is discussing vitamin replacement with a client in the clinic. Which vitamin should the nurse discuss with the client in order to increase the absorption of folic acid and iron?

Answer 80

Vitamin C

Question 81

A client is being treated for anemia and has a hemoglobin level of 9.6 g/dL. What does the nurse understand is the basic nutritional component of heme in hemoglobin that the client may be deficient in?

Answer 81

Iron

Question 82

A client is brought to the emergency department with suspected bleeding esophageal varices. Which hemoglobin level should the nurse immediately report to the physician?

Answer 82

5.0 g/dL

Question 83

A client informs the nurse that he is having a difficult time coping with seasonal allergies and have taken some over-the-counter medications to assist with control of symptoms. What results would indicate to the nurse that the client does have allergies?

Answer 83

Elevated eosinophils

Question 84

A client is scheduled for a Schilling test in the morning. What diagnostic results would be indicated if the test is positive? Select all that apply

Answer 84

• Pernicious anemia

- malabsorption syndromes

Question 85

The nurse is assisting the physician with obtaining a sample to determine the status of blood cell formation. What type of procedure will the nurse have prepared the client for?

Answer 85

A bone marrow aspiration

Question 86

A client is volunteering to donate blood for the second time and was mailed a letter telling him that he has type AB blood. If the client requires a blood transfusion in the future, what type of blood must he receive?

Answer 86

They can receive blood from persons with any type of blood if the Rh factor is compatible

Question 87

A client is taking a medication that has the side effect of depressing the hematopoietic system. What signs of leukopenia should the nurse monitor for while the client is taking this drug?

Answer 87

Fever, sore throat, and chills

Question 88

The nurse is observing the skin of a client who is taking medications that depress the hematopoietic system and notices multiple areas of ecchymosis on the arms; bleeding for a prolonged period after an IV was started; and reports of black, tarry stool. What does the nurse understand may be a side effect of this medication that the client displays?

Answer 88

Thrombocytopenia

Question 89

A client has laboratory studies that determine he is deficient in copper. What does the nurse understand is the importance of copper in the body?

Answer 89

Involved in the transfer of iron from storage to plasma

Question 90

The nursing instructor is talking with her clinical group about coagulopathies. How should the instructor define coagulopathies?

Answer 90

Coagulopathies are bleeding disorders that involve platelets or clotting factors

Question 91

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from?

Answer 91

• Abnormal erythrocyte production
• Blood loss
• Destruction of normally formed red blood cells

Question 92

A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find for this client when collecting objective data?

Answer 92

Postural hypotension

Question 93

The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

Answer 93

Place the client in a modified Trendelenburg postition

Question 94

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?

Answer 94

Dilute the liquid preparation with another liquid such as juice and drink with a straw

Question 95

A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?

Answer 95

Vascular occlusion in small vessels decreasing blood and oxygen to the tissues

Question 96

A client with sickle cell disease informs the nurse that he is having chest pain. The nurse hears the client coughing, wheezing, and breathing rapidly. What does the nurse suspect is occurring with this client?

Answer 96

Acute Chest Syndrome

Question 97

The nurse is admitting a client with Cooley’s anemia to the hospital with a hemoglobin of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client’s skin?

Answer 97

Bronzing of the skin

Question 98

The nurse is assigned to care for a client with polycythemia vera. When the nurse encourages the client to drink 3 L of fluid per day, the client states, Why do I have to drink so much? What is the best response by the nurse?

Answer 98

It helps adequately hydrate you and ensures a sufficient urine production

Question 99

A client is suspected of having leukemia and is having a series of laboratory and diagnostic studies performed. What does the nurse recognize as the hallmark signs of leukemia?

Answer 99

• Easy bruising
• Fatigue from anemia
• Frequent infections

Question 100

A teenaged client with hemophilia sustains a leg laceration after falling off of his skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be ordered for administration to control bleeding?

Answer 100

Fresh frozen plasma

Question 101

Yellow bone marrow manufactures blood cells and hemoglobin.

T/F

Answer 101

False

Question 102

In adults, the normal amount of hemoglobin is 12.0 to 17.4 g/dL.
(T/F)

Answer 102

True

Question 103

Albumin plays a key role in forming blood clots.

T/F

Answer 103

False

Question 104

The lymphatic system filters and destroys pathogens and removes other potentially harmful substances.
(T/F)

Answer 104

True

Question 105

Some antibiotics and cancer drugs contribute to hematopoietic dysfunction.
(T/F)

Answer 105

True

Question 106

__________ is the manufacture and development of blood cells.

Answer 106

Hematopoiesis

Question 107

The rate of erythrocyte production is regulated by __________, a hormone released by the kidneys.

Answer 107

Erythropoietin

Question 108

An increased number of leukocytes is called __________.

Answer 108

Leukocytosis

Question 109

Blood type is ascertained by identifying the protein, or __________, on the red cell membranes.

Answer 109

Antigen

Question 110

A(n) __________ is used to diagnose pernicious anemia, macrocytic anemia, and malabsorption syndromes.

Answer 110

Schilling test

Question 111

The two variations of PD (Parkinson’s Disease) are

Answer 111

young onset and idiopathic

Question 112

In terms of prevalence, PD affects

Answer 112

0.3% of the general population

Question 113

The cardinal symptoms of PD are bradykinesia and

Answer 113

Tremor at rest and muscular rigidity

Question 114

Drugs that cause symptoms that mimicking PD include all of the following except

Answer 114

Valium (diazepam)

Question 115

Which statement about drug induced Parkinsonism is correct?

Answer 115

presentation of symptoms occurs within the first few weeks of drug therapy

Question 116

Which of the following is thought to be a risk factor for PD?

Answer 116

Drinking well water

Question 117

PD is diagnosed primarily through

Answer 117

Clinical signs

Question 118

What percentage of dopamine-producing cells is lost by the time that poor motor coordination occurs?

Answer 118

60-80%

Question 119

Which statement about tremors in PD is correct?

Answer 119

they’re the first symptoms in 70% of Patients

Question 120

Bradykinesia is best described as

Answer 120

slowness of voluntary movement and reduced automatic movement

Question 121

Postural instability is a major cause of

Answer 121

falls

Question 122

Some complications from autonomic nervous system involvement are postural hypotension, dysphagia, and

Answer 122

urinary dysfunction

Question 123

The gold standard of antiparkinson medication is

Answer 123

levodopa/carbidopa (sinemet)

Question 124

An important factor to consider when administering levodopa/carbodopa for PD is that

Answer 124

It should be given 1-2 hours before meals

Question 125

Which statement about adverse effects of medication used for PD is correct?

Answer 125

Avoid food with tyramine when taking selegiline (Eldepryl)

Question 126

Which neurosurgical procedure uses a probe to destroy brain tissue in treating musckle rigidity and Bradykinesia?

Answer 126

Pallidotomy

Question 127

Results from brain stem cell transplantation for PD have shown

Answer 127

Worsening of tremors in some patients

Question 128

Which of the following conditions may lead to an ischemic stroke?

Answer 128

a thrombus

Question 129

An Individual who experienced slurring of speech, weakness in an extremity, and a change in LOC that lasted for 10 minutes then disappeared without any long term effects most likely had a

Answer 129

TIA

Question 130

Hemorrhagic stroke can be caused by a

Answer 130

Ruptured arterial aneurysm

Question 131

All of the following are risk factors for a stroke except?

Looks for wrong answer

Answer 131

Age over 40

Question 132

The “S” in FAST mnemonic refers to

Answer 132

Slurring of speech

Question 133

One of the components of the CPSS assess for

Answer 133

Facial droop

Question 134

The first assessment using the NIHSS should be performed

Answer 134

As soon as a stroke is suspected

Question 135

Which NIHSS score suggests severe debilitation?

Answer 135

24

Question 136

A noncontrast CT scan should be performed within how many minutes of the patient;s arrival to the ED?

Answer 136

25

Question 137

For the patient eith an Ischemic stroke experiencing Hemianopsia, which threatment option may be used?

Answer 137

Thrombectomy

Question 138

According to the AHA stroke algorithm, the patient with suspected stroke should be seen by the stroke team with in how many minutes after arrival to the ED?

Answer 138

15

Question 139

Unless contraindicated, fibirinolytic therapy should be initiated within how many hours of stroke symptoms?

Answer 139

3

Question 140

The gold standard for treating acute ischemic stroke is

Answer 140

tPa

Question 141

A study found that 22.8% of patients with ischemic stroke treatment with tPA experienced which complication

Answer 141

bleeding

Question 142

Administration of tPA is contraindicated for patients with

Answer 142

international normalizing ratios greater than 2

Question 143

Surgical treatment options for a patients who have had a hemorragic stroke include

Answer 143

Aneurysm clipping

Question 144

Which intervention is most appropriate to help prevent aspiration in stoke victims?

Answer 144

Elevate head of bed at least 30%

Question 145

The primary goal of nursing interventions for a patient who’s had a stroke is support of

Answer 145

Airway, breathing, and circulation

Question 146

One key characteristic of dementia is

Answer 146

Global impairment

Question 147

The confusion assessment method tool is used to

Answer 147

Identify delirium

Question 148

Which lobe of the brain controls the ability to concentrate and focus

Answer 148

Frontal

Question 149

Patients with deficits in which part of the brain are prone to falls and injuries?

Answer 149

Parietal lobe

Question 150

Which is identified as treatable dementia?

Answer 150

Vitamin B12 deficiency

Question 151

Patients in the second stage of AD develop

Answer 151

Aphasia

Question 152

Which ISN’T included in the four “A”s of AD?

Looking for wrong answer

Answer 152

Agitation

Question 153

Which drugs may be given to patients with AD for short term increased in functionality?

Answer 153

Cholinesterase inhibitors

Question 154

To help reduce anxiety in patients with AD, nurses should

Answer 154

Establish and follow a routine

Question 155

Vascular dementia is caused by

Answer 155

Reduced blood flow to the brain

Question 156

Which isn’t used to treat vascular dementia?

Answer 156

Antipsychotic medication

Question 157

Treating the underlying causes of the disease is the focus for

Answer 157

Vascular dementia

Question 158

Of patients affected by PD for 2 years, about what proportion suffers from Parkinson dementia?

Answer 158

One third

Question 159

Symptoms of Parkinson dementia include

Answer 159

Fluctuations in attention and alertness

Question 160

When do most cases of Frontotemporal Dementia occur?

Answer 160

Before age 65

Question 161

The first symptoms of Frontotemporal dementia are

Answer 161

Behavioral and social skill problems

Question 162

Which type of Dementia is characterized by early executive functioning problems?

Answer 162

Lewy body

Question 163

Which symptom is frequently noted in Lewy body dementia ?

Answer 163

Visual hallucinations

Question 164

The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?

Answer 164

Progressive tissue damage without any verifiable etiology

Question 165

The nurse is caring for a client with chronic fatigue syndrome. What is a realistic nursing intervention when taking care of a client with this diagnosis?

Answer 165

Educate the client about the disease process.

Question 166

The nursing instructor is discussing allergic reactions with her clinical group. What allergic reactions would the nursing instructor talk about?

Answer 166

• Immune complex
• Cytotoxic
• Atopic

Question 167

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?

Answer 167

For their immunosuppressant effects

Question 168

A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse?

Answer 168

“The doctor could prescribe an anti-inflammatory drug.”

Question 169

A client comes to the clinic and states he has broken out in hives and itching since eating strawberries this morning.” The client states he has never had problems with strawberries before. What is the best response by the nurse?

Answer 169

It is possible to develop an allergic reaction to something you have had prior exposure to previously.

Question 170

The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?

Answer 170

Airway obstruction

Question 171

The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states he is allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?

Answer 171

Apply an allergy bracelet and flag the chart

Question 172

A client has been having joint pain and swelling in the left foot and is diagnosed with rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and the client has significant joint destruction. What type of disease is this considered?

Answer 172

Autoimmune

Question 173

A client with Crohn’s disease, an autoimmune disorder, informs the nurse that he has not had any symptoms of the disease in 8 months. What does the nurse understand this asymptomatic period is referred to?

Answer 173

Remission

Question 174

The nurse is collecting data from a client with the autoimmune disorder, endocarditis. What does the nurse recognize as symptom of an acute exacerbation?

Answer 174

Temperature of 100.9

Question 175

A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included?

Answer 175

Be alert for signs and symptoms of infection and report immediately

Question 176

A client visits the nurse complaining of diarrhea every time he eats. The client has AIDS and wants to know what he can do to stop having diarrhea. What should the nurse advise?

Answer 176

Avoid fibrous foods, lactose, fat, and caffeine

Question 177

A woman infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV?

Answer 177

Gynecologic problems

Question 178

A client who is HIV/AIDS positive has orders for laboratory tests to be performed. What precautions should the nurse observe whenever there is a risk of exposure to the blood and body fluids of an infected client?

Answer 178

Transport the specimens of body fluids in leak-proof containers

Question 179

A client with AIDS is brought to the clinic by his family. The family tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?

Answer 179

AIDS dementia complex (ADC)

Question 180

A public health nurse is giving an informational presentation on HIV/AIDS at a nearby college. How would the nurse best define AIDS?

Answer 180

Acquired immunodeficiency syndrome is a potentially life-threatening infection that profoundly weakens the immune system

Question 181

When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by ____.

Answer 181

HIV-1 is more prevalent than HIV-2 subtypes

Question 182

A teenaged client with a diagnosis of HIV presents at the public health clinic complaining of pharyngitis, rash on the palms and soles of his feet, and diarrhea. What would the nurse suspect the client is suffering from?

Answer 182

Acute Retroviral Syndrome (ARS)

Question 183

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus?

Answer 183

• Vaginal secretions
• Breastmilk
• Blood
• Semen

Question 184

A female client informs the nurse that she is considering beginning sexual relations and wants to know the best way to protect herself from a sexually transmitted infection and HIV. What is the best response by the nurse?

Answer 184

Using a condom (latex) and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV.

Question 185

A client requires a blood transfusion for anemia and informs the nurse that he refuses because he doesn’t want to contract acquired immune deficiency syndrome (AIDS). What is the best response by the nurse?

Answer 185

The blood is screened very carefully; the risk is approximately 1 in 2,000,000.

Question 186

The nurse is administering an injection to a client with AIDS and, when finished, attempts to recap the needle and sustains a needlestick injury to the finger. What is the priority action by the nurse?

Answer 186

Report the incident to the supervisor

Question 187

The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm3, and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse?

Answer 187

The client has converted from HIV infection to AIDS

Question 188

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. What is the next step for the nurse to explain to the client for confirmation of the diagnosis?

Answer 188

Perform a Western Blot Test for confirmation of diagnosis

Question 189

The nurse is caring for a client with an autoimmune disease. What is
a characteristic of autoimmune disorders?

Answer 189

Progressive tissue damage without any verifiable etiology

Question 190

A client who is symptomatic after having a been stung by a bee is brought to the Emergency room. Which of the following is the initial priority nursing assessment?

Answer 190

Repiratory status

Question 191

When the nurse provides teaching about an autoimmune disorder, what statement by the client demonstrates a correct understanding?

Answer 191

I will be in remission or have occasional exacerbation

Question 192

When all nursing assessment findings are normal for an older adult client who reports being chronically fatigued, it is most appropriate for the nurse to further evaluate the client for which of the following?

Answer 192

Depression

Question 193

A client makes an appointment with a physician because of weight loss and swollen lymph nodes in the axilla and groin. What situation places the client at highest risk for becoming HIV positive?

Answer 193

The client is an IV drug user

Question 194

A nurse is obtaining a clients consent for receiving blood. The client asks if there is any way that HIV can be acquired from the transfusion. Which of the following statements would the nurse be most truthful and accurate in response?

Answer 194

Antibody screening will not detect HIV in donated blood if sufficient antibodies have not yet been produced

Question 195

What causes death in a client with AIDS, which is most correct.

Answer 195

An opportunistic infection

Question 196

Which laboratory test is performed initially to diagnose antibodies to HIV?

Answer 196

Enzyme-linked immunosorbent assay (ELISA) test

Question 197

Patient suspects they have candidiasis. Which signs and symptoms would be observed?

Answer 197

White oral plaque

Question 198

Which statement should the nurse make about an IM injection of immune globulin to a client following exposure to hepatitis A

Answer 198

this Medicaiton provides an immune response more quickly than the body can produce it

Question 199

Preparing to administer varicella immunization to a client. Which should the nurse ask?

Answer 199

Are you pregnant

Question 200

A nurse is reinforcing teaching about self care with a client who has SLE (Systemic Lupus Erythematosis). Which of the following statements by the client indicates understanding?

Answer 200

I should use a milky hair shampoo

Question 201

The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?

Answer 201

Progressive tissue damage without any verifiable etiology

Question 202

What is a realistic nursing intervention when taking care of a client with chronic fatigue?

Answer 202

Educate the client about the disease process

Question 203

Client has hives after eating strawberries, they say they have had strawberries and never had issues before, what is the best response by the nurse?

Answer 203

it is possible to develop an allergic reaction to something you have had prior exposure to previously

Question 204

A complete a blood counts indicates that a client is anemic. What disorder in the clients history is most likely a contributing cause for the reduction in the Red Blood Cells?

Answer 204

Renal failure

Question 205

When the nurse reviews a clients complete blood count, what is the most suggestive that the client is at risk for an infection?

Answer 205

A low number of granulocytes

Question 206

A physician tells a client that her body is not making enough blood cells. after the physician leaves, the client appears very upset and states, “I do not even know how my body make blood cells.” what is the simplest, yet correct, instruction for the nurse to give the client at this time?

Answer 206

The bone marrow produces blood cells

Question 207

What blood type could be transfused into anyone if there is no time to perform a type and crossmatch of the recipients blood?

Answer 207

O, Rh negative

Question 208

After completion of a bone marrow aspiration, what is most important for the nurse to monitor?

Answer 208

Bleeding from the puncture sites

Question 209

The nurse is caring for three clients who have the following blood count values: Client A with 24,500/mm3 white blood cells, Client B with 13.4 g/dL hemoglobin, and client C with 250,000/mm3 platelet count. Which statement correctly describes the condition of each client?

Answer 209

Client A has a higher WBC count than normal, Client B has normal hemoglobin count, and Client C has a normal platelet count

Question 210

A Client’s family member asks what hematopoiesis is. What should the nurse tell the family member?

Answer 210

the manufacture and development of blood cells

Question 211

A student is having difficulty understanding the function of globulins. What information can the client provide to the student regarding the function of globulins?

Answer 211

Immunologic agents

Question 212

Undifferentiated cells that migrate to the thymus gland develop into which of the following?

Answer 212

T lymphocytes

Question 213

A client with end-stage renal disease has a decreased red blood cell production. What Medication can the nurse administer with physician’s order that will increase the production of erythrocytes

Answer 213

Epoetin Alfa

Question 214

A client arrives at the emergency room after a motorcycle accident. Vital signs are T. 97.7, P: 122. R 28. BP 96/54. The client has suffered profuse blood loss. From the clinical picture, what position is the best for the nurse to place the client?

Answer 214

Modified trendelenburg

Question 215

The nurse is assessing a client with anemia possibly resulting from malaria. What information would be the most important to ascertain to assist the physician in making a correct diagnosis?

Answer 215

Foreign travel

Question 216

A client has been diagnosed with pernicious anemia. She says “I am worried because my grandmother died of the disease years ago.” What nursing explanation is most accurate?

Answer 216

We now give Vitamin B12 to control the disease

Question 217

The client was admitted to the emergency department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would the nurse assess for?

Answer 217

Reduced urine output

Question 218

A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in his arms and legs. What do these symptoms indicate?

Answer 218

Neurologic involvement

Question 219

A client diagnosed with polycythemia Vera has come into the clinic because he has developed a nighttime cough, fatigue, and shortness of breath. From these clinical manifestations, what complication would the nurse suspect in this client?

Answer 219

Congestive Heart Failure

Question 220

The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures?

Answer 220

Osteoclasts break down bone cells so pathologic fractures occur

Question 221

A client comes to the walk in clinic complaining of weakness and fatigue. while assessing this client, the nurse finds evidence of petechiae and ecchymoses. the nurse notes that the spleen appears enlarged. what would the nurse suspect is wrong with this client?

Answer 221

Aplastic anemia

Question 222

The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. what disease would the instructor list with a primary characteristic of erythrocytosis

Answer 222

Polycythemia Vera

Question 223

The nurse is instructing the client with sickle cell disease about the use of an inhaled vasodilator that may reduce sickling. what medication is the nurse instructing the client about?

Answer 223

Nitric oxide

Question 224

Which organ of the lymphatic system is responsible for maturation of T-cells?

Answer 224

The thymus

Question 225

What condition is characterized by erythrocytosis, or an increase in circulating erythrocytes?

Answer 225

Polycythemia Vera

Question 226

Cellular and humoral immunity are affected by age-related changes in the lymphatic system, including decreases in primary antigen, T-cell and B-cell responses and antigen production
(T/F)

Answer 226

False

Question 227

Which supplement may play a role in depression, especially for the elderly?

Answer 227

Folic acid

Question 228

While analyzing a client’s complete blood cell count, the nurse finds a decrease number of ____ which indicates a risk for the client to acquire an infection

Answer 228

Granulocytes

Question 229

A nurse is educating an elderly client about the most likely reason they have acquired pernicious anemia. Which of the following of the client’s individual factors are the most likely cause of their pernicious anemia?

Answer 229

Use of antacid medication

Question 230

Albumin, which is formed in the kidneys, is the most abundant protein in plasma
(T/F)

Answer 230

False

Question 231

A nursing student is asked to draw a CBC on a patient to check for erythrocyte count. The student knows that factors that influence erythrocyte counts include: select all that apply:

Answer 231

• Age
• Altitude
• Gender

Question 232

A client has been brought to the emergence room do to a MVA and needs a blood transfusion. The nurse knows that because the client’s blood type is AB that the client is:

Answer 232

Is the universal recipient

Question 233

The nurse knows that the client needs additional teaching for their diagnosis of Hodgkin’s disease when stress: (Looking for a wrong answer)

Answer 233

I will eat as much as possible during meals to keep my strength

Question 234

A woman is being administered oral radiolabeled vitamin B12, this administration is performed in 4 stages. What test is being performed?

Answer 234

Schilling Test

Question 235

A man presented himself at the hospital complaining of severe swelling of his legs after traveling to India after a vacation. What type of parasite can cause severe swelling of extremities?

Answer 235

Roundworm

Question 236

What type of groups are globulins categorized by?

Answer 236

Alpha group, Beta group, Gamma group

Question 237

What are the clinical symptoms of anemia with inadequate RBC volume?

Answer 237

• Orthostatic hypotension
• Thready pulses
• Oliguria
• Heart murmur

Question 238

Which client statement indicates a good understatement of the nutritional modifications needed to manage iron-deficiency anemia?

Answer 238

Adding fish and eggs to my diet will help reduce my risk of pernicious anemia

Question 239

An elderly gentleman is brought to the emergency room after suffering a major blood loss. He needs a blood transfusion in order to save his life but it will take too long to wait for a blood type and cross test. What blood do you give him?

Answer 239

Type O Blood

Question 240

What infectious agent is a common cause of lymphangitis and/or lymphadenitis?

Answer 240

Streptococcal bacteria

Question 241

All of the following are associated with the lymphatic system except: (looking for the wrong answer)

Answer 241

Kidneys

Question 242

The nurse knows that non-hodgkin’s lymphoma may originate from the following potential causes:

Answer 242

• Genetic factors
• Environmental triggers such as chemical herbicides, pesticides, or hair dye
• The administration of immunosuppressive drugs to prevent transplant rejection

Question 243

A healthy 65 year old male has made an appointment to get his yearly flu shot. After initial assessment, what other vaccines might be appropriate for this patient?

Answer 243

• Shingles vaccine

- Pneumovax (for pneumonia)

Question 244

Which of the following is the function of macrophages and neutrophils?

Answer 244

Phagocytosis

Question 245

Immunity to a disease after recover is possible because the first exposure to the pathogen has stimulated the formation of which of the following?

Answer 245

Memory cells

Question 246

Which cells are white blood cells with immune functions?

Answer 246

Lymphocytes

Question 247

Which cells have the lifespan of 1 to 2 days and perform phagocytosis?

Answer 247

Leukocytes

Question 248

What immunoglobulin interferes with the entry of pathogens

Answer 248

IgA

Question 249

The Epstein Barr virus causes mononucleosis, and is a contributor to Hodgkin’s lymphoma, what are the key points for this virus?

Answer 249

• Affects people 15-25 years old
• Is transmitted by talking
• Is prevalent in close living quarters

Question 250

The family nurse practitioner is performing a physical assessment on a client with a suspected lymphatic disorder. What would be the nurse practitioner’s primary assessment for all clients with lymphatic disorders?

Answer 250

Enlargement of the lymph glands

Question 251

A client has just been admitted to your unit with a diagnosis of Hodgkin’s disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis?

Answer 251

Are you experiencing fever, chills, or night sweats?

Question 252

The thoracic ducts drain lymph from all areas of the body except…

Answer 252

Axillary nodes

Question 253

A pregnant woman receives a T-dap injection at her 34 week OB appointment, the student nurse understands that when the baby is born, it will have what type of immunity because of the Tdap that the mother received?

Answer 253

Passive Immunity

Question 254

The nurse is preparing to assess a patient’s cognitive function. What should the nurse include in this assessment?

Answer 254

• Orientation to time and place

- Ability to recall recent and past events

Question 255

Autoimmune disorders are those in which…

Answer 255

Killer T cells and autoantibodies attack or destroy natural cells (self cells)

Question 256

After new-hire training for a recent nursing school graduate, the training facilitator realizes the new nurse needs additional training on how to reduce occupational risk for contracting HIV and other blood-born pathogens:
(Looking for wrong answer)

Answer 256

I should always put the cap back on the needle after the blood draw

Question 257

The nurse was accidentally stuck with a needle used on an HIV positive patient. After reporting this, what care should this nurse first receive?

Answer 257

Combination antiretroviral therapy

Question 258

A patient reports “feeling under the weather” for several weeks and is having blood work done to try and determine the cause. The physician is including the ELISA test in the blood work. What would be the expected next step if the ELISA test is positive?

Answer 258

Repeat the ELISA test

Question 259

In the interest of public health, CDC has developed HIV Transmission Prevention strategies. THe strategies address the routes by which HIV can be transmitted and steps that can be taken to reduce or eliminate transmission. Which categories of risk are addressed by these strategies?

Answer 259

• Sexual activity

- Illegal drugs

Question 260

A nurse is teaching a client about AIDS and HIV and notes that the client needs further education when she states.
(Looking for wrong answer)

Answer 260

AIDS is transmitted before HIV

Question 261

A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What action is of primary importance upon admission?

Answer 261

Maintain airway

Question 262

Which are the appropriate interventions to help a client with autoimmune disorder deal with joint pain secondary to inflammation, malaise, and fatigue?

Answer 262

• Exercise regularly during periods of remission
• Use non-pharmacological pain management strategies
• Rest during periods of severe exacerbation

Question 263

TPA (tissue plasminogen activator) is indicated for which of the following:

Answer 263

Ischemic stroke

Question 264

Primary nursing assessments and interventions for a client who recently suffered a stroke includes all of the following except:

Answer 264

Blood glucose levels

Question 265

Which part of the brain is responsible for the sensation of touch, pain, and temperature and responsible for speech, language, and though expressions?

Answer 265

Perietal Lobe

Question 266

How long after patient arrives at the ER with stroke symptoms should CT scan results be available for the stroke team and decision of treatment made?

Answer 266

45 mins

Question 267

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells, before explaining the procedure to the client, the nurse should ask which initial question?

Answer 267

Have you ever had a transfusion before?

Question 268

Dementia can affect adults of any age

T/F

Answer 268

True

Question 269

Types of dementia include

Answer 269

• Alzheimer’s
• Vascular
• Parkinson’s
• Lewy body