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During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest? |
2 Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated. Diminished visual acuity usually is not a problem; motor loss is greater than sensory loss, with paresthesia of the extremities being the most frequent sensory loss. Demyelination occurs rapidly early in the disease, and the muscles will not have had time to atrophy; this can occur later if rehabilitation is delayed. Only the peripheral nerves are involved; the central nervous system is unaffected. |
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The echoviruses can cause which diseases in clients? Select all that apply. |
2, 4 Echoviruses cause gastroenteritis and aseptic meningitis. Parotitis is caused by mumps. Burkitt’s lymphoma and mononucleosis are caused by the Epstein-Barr virus. |
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A 5-year-old-child is undergoing chemotherapy. The mother tells the nurse that the child is not up to date on the required immunizations for school. What is the best response by the nurse? |
3 Chemotherapy compromises the immune system. The vaccines may be administered after the completion of the chemotherapy protocol, once the immune system has returned to its previous state. The child has not developed sufficient antibodies; booster immunizations are needed, but not at this time. Administering immunizations at this time could prove fatal. |
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A nurse is reviewing the laboratory reports of four clients. Which client’s laboratory report indicates acquired immunodeficiency syndrome (AIDS)? |
3 The diagnosis of AIDS requires that the person should be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm 3 (200 cells/uL) or less than 14% or an opportunistic infection. Therefore client 3, with a CD4+ T-cell count of less than 200 cells/mm 3 (200 cells/uL) and who is HIV positive, is having AIDS-defining illness. A healthy client usually has at least 800 to 1000 CD4+ T-cells per cubic millimeter (mm 3) of blood. This number is reduced in the client with HIV disease. Client 1, with a CD4+ T-cell count of 750 cells/mm 3 and HIV positive, does not have AIDS. Client 2, with a CD4+ T-cell count of 550 cells/mm 3 and HIV positive, does not have AIDS. Client 4, having a CD4+ T-cell count of 450 cells/mm 3 and HIV positive does not have AIDS. |
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The bacteria Clostridium botulinum causes which condition in a client? |
4 Clostridium botulinum bacteria causes food poisoning with progressive muscle paralysis. Toxic shock syndrome is caused by the bacteria Staphylococcus aureus. Many viruses and bacteria can cause upper respiratory tract infection but Clostridium is not one of them. Klebsiella-Enterobacter organisms most likely cause urinary tract infections. |
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A nurse is teaching a health class about human immunodeficiency virus (HIV). Which basic methods are used to reduce the incidence of HIV transmission? Select all that apply. |
1, 3 HIV is found in body fluids such as blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, and cerebrospinal fluid. Therefore a client should use condoms to prevent contact between the vaginal mucus membranes and semen. Practicing sexual abstinence is the best method to prevent transmission of the virus. The HIV virus is not transmitted by sharing the same toilet facilities, casual contacts such as shaking hands and kissing, or by sharing the same household utensils. |
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A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation? |
1 Rehabilitation needs for a client with Guillain-Barré syndrome focus on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain-Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome. |
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A nurse instills an antibiotic ophthalmic ointment into a newborn’s eyes. What condition does this medication prevent? |
3 Ophthalmia neonatorum is caused by gonorrheal and/or chlamydial infections present in the vaginal tract. It is preventable with the prophylactic use of an antibiotic ophthalmic ointment applied to the neonate’s eyes. Herpes affects the neonate systemically. Retinopathy of prematurity (formerly retrolental fibroplasia) occurs as a result of prolonged exposure to a too-high oxygen concentration. Hemorrhagic conjunctivitis is usually caused by rapid expulsion of the fetus’s head from the vagina. |
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Which drug treats hay fever by preventing leukotriene synthesis? |
1 Zileuton [1] [2] is a leukotriene antagonist drug; this substance prevents the synthesis of leukotrienes and helps in managing and preventing hay fever. Cromolyn sodium stabilizes mast cells and prevents the opening of mast cell membranes in response to allergens binding to immunoglobulin E.. Chlorpheniramine and diphenhydramine are antihistamines and prevent the binding of histamine to receptor cells and decrease allergic manifestations. |
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What is the role of the plasma cell in the antigen-antibody response? |
2 In the antigen-antibody response, once the B-cell is sensitized, it divides and forms a plasma cell, which produces antibodies against the sensitizing antigen. Inactivation or neutralization is the process of making an antigen harmless without destroying it. Memory cells produce antibodies after the next exposure to an antigen that is recognized by the body. Agglutination is the clumping of antigens linked with antibodies, forming immune complexes. |
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A child who recently returned from a three-day camping trip over spring vacation is brought to the clinic after a rash, chills, and low-grade fever develop. What are the most important data for the nurse to assess when taking the child’s history? Select all that apply. |
3, 4, 5 It is important to know whether the signs and symptoms are related to a history of allergies, a communicable infection contracted during the trip, or some other factor. The nurse must gather information regarding the duration of signs and symptoms because they could be related to a variety of factors that may or may not be linked to the camping trip. It is important to determine whether the child was exposed to a known allergen so appropriate treatment may be initiated. It is not necessary to know when the child is expected back in school; this information is unrelated to the situation. The child’s problem is also unrelated to sports activities. |
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Which client has the highest risk for human immunodeficiency virus (HIV) infection? |
3 Clients who use equipment to snort (straws) and smoke (pipes) drugs are at the highest risk for becoming infected with HIV as their judgment may be impaired regarding the high-risk behaviors. Safe activities that prevent the risk of contracting HIV include mutual masturbation, masturbation, and other activities that meet the "no contact" requirements. A client who undergoes perinatal HIV voluntary testing may reduce the chances of getting infected. Insertive sex between partners who are not infected with HIV are not at risk of becoming infected with HIV. |
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Which vaccine is administered orally in children? |
2 Rotavirus vaccines are generally administered orally because these live viruses should replicate in the gut of the infant. MMR vaccines are generally administered subcutaneously in the upper region of the arm. Live influenza vaccines are administered nasally. Meningococcal conjugate vaccines (MCV4) are administered intramuscularly in the deltoid region. |
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Which influenza vaccine is administered by way of the intranasal route? |
3 FluMist is given intranasally. Fluarix, Fluvirin, and Fluzone are also influenza vaccines administered via the intramuscular route. |
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A client asks the nurse what advantage breast-feeding holds over formula feeding. What major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula? |
2 The antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant. |
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The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). What does the nurse expect to find? |
1 The human immunodeficiency virus (HIV) infects helper T-cell lymphocytes; therefore 300 or fewer CD4 T cells per cubic millimeter of blood or CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS. The thymic hormones necessary for T-cell growth are decreased. An increase in immunoglobulin E is associated with allergies and parasitic infections. A decrease in the serum level of glucose-6-phosphate dehydrogenase is associated with drug-induced hemolytic anemia and hemolytic disease of the newborn. |
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Which vaccine may cause intussusception in children? |
1 Rotavirus vaccines very rarely cause intussusception, a form of bowel obstruction in which the bowel telescopes in on itself. Hepatitis vaccines can cause anaphylactic reactions. The measles, mumps, and rubella vaccine may cause thrombocytopenia. The diphtheria, tetanus, and pertussis vaccine carries a small risk of causing acute encephalopathy, convulsions, and a shock-like state. |
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The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should the nurse give about why the MMR vaccine is administered at 12 to 15 months of age? |
2 Maternal antibodies to measles, mumps, and rubella infection persist in the infant until approximately 15 months of age. Side effects are no more common among infants than in toddlers. The measles vaccination does not interfere with the effectiveness of other vaccines. Although the measles, mumps, and rubella do occasionally occur after the administration of the MMR vaccine during the first year of life, the vaccine is not given during this time because of the presence of maternal antibodies. |
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Why would a client with acquired immunodeficiency syndrome (AIDS) be administered pregabalin? |
1 Pregabalin is indicated for neuropathic pain based on its mechanism of interference with nerve signaling. Clients with AIDS generally exhibit emotional and behavioral changes, which can be managed with appropriate antidepressants and anxiolytics. AIDS clients who experience difficulty swallowing may have candidal esophagitis; this condition can be managed with antifungal mediations such as fluconazole or amphotericin B. Traditional analgesics are used to manage joint and muscle pain. |
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Which vaccine is administrated through the intranasal route? |
2 Influenza (live) vaccine is administered through the intranasal route. The rotavirus vaccine is administered orally. The varicella virus vaccine is given as a subcutaneous injection. The human papillomavirus vaccine is given as intramuscular injection. |
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The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond? |
4 Passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases. The spleen does not produce antibodies. Infants often are exposed to infectious diseases. The viruses in immunizations are inactivated or attenuated; they may cause irritability and fever but will not cause the related disease. |
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Which vaccination is given to young children to provide protection against tetanus and diphtheria but not pertussis? |
2 DT is given to children to provide protection from both tetanus and diphtheria. Td is used as a booster dose to protect adolescents and adults from tetanus and diphtheria. DTaP is given to children to provide protection from tetanus, diphtheria, and acellular pertussis. Tdap is used as a booster dose to protect adolescents and adults from tetanus, diphtheria, and acellular pertussis. |
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The nurse is caring for a client who is receiving azathioprine, cyclosporine, and prednisone before receiving a kidney transplant. What does the nurse identify as the purpose of these drugs? |
4 These drugs suppress the immune system, decreasing the body’s production of antibodies in response to the new organ, which acts as an antigen. These drugs decrease the risk of rejection. These drugs inhibit leukocytosis. These drugs do not provide immunity; they interfere with natural immune responses. Because these drugs suppress the immune system, they increase the risk of infection. |
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A teenager with allergies is using oxymetazoline nasal spray. What effect should the nurse assess the client for if more than the recommended dose is taken? |
4 With frequent and continued use, oxymetazoline can cause rebound congestion of mucous membranes. Nasal polyps may be associated with allergies but are unrelated to nasal spray use. Ringing in the ears (tinnitus) is not associated with oxymetazoline, although this medication may cause hypotension, tachycardia, and dizziness. Bleeding tendencies are related to inadequate clotting mechanisms, which are not associated with the use of this nasal spray. |
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Which cells are affected in DiGeorge syndrome? |
1 DiGeorge syndrome is a primary immune deficiency disorder in which T-cells are affected. The B-cells are affected in Bruton’s X-linked agammaglobulinemia; common variable hypogammaglobulinemia; and selective IgA, IgM, and IgG deficiency. Monocytes and polymorphonuclear cells are affected in chronic granulomatous disease and Job syndrome. |
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Which autoimmune disease affects the central nervous system? |
3 Multiple sclerosis is an autoimmune disease that affects the central nervous system. Uveitis is an autoimmune disease that affects the eyes. Celiac disease is an autoimmune disease that affects the gastrointestinal System. Goodpasture syndrome is an autoimmune disease that affects the kidneys. |
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A nurse is teaching parents of toddlers about why children receiving specific medications should not receive varicella vaccines. Which medication will be included in the discussion? |
2 Steroids have an immunosuppressive effect. It is thought that resistance to certain viral diseases, including varicella, is greatly decreased when a child takes steroids regularly. There is no known correlation between varicella and insulin. Because varicella is a viral disease, antibiotics will have no effect. There is no known correlation between varicella and anticonvulsants. |
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Which leukocytes should the nurse include when teaching about antibody-mediated immunity? Select all that apply. |
2, 4 Memory cells and B-lymphocytes are involved in antibody-mediated immunity. Monocytes are involved in inflammation. Helper T cells and cytotoxic T cells are involved in cell-mediated immunity. |
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Which are examples of a type IV hypersensitivity reaction? Select all that apply. |
1, 2 Sarcoidosis and poison ivy reactions are examples of type IV hypersensitivity reactions. In type IV hypersensitivity, the inflammation is caused by a reaction of sensitized T cells with the antigen and the resultant activation of macrophages due to lymphokine release. Myasthenia gravis is an example of a type II or cytotoxic hypersensitivity reaction. Rheumatoid arthritis and systemic lupus erythematosus are examples of type III immune complex-mediated reactions. |
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Which client is most likely to develop IgE antibodies? |
1 A client with a pollen allergy develops IgE antibodies that may result in an anaphylactic reaction. A client with poison ivy develops delayed hypersensitivity, which is mediated by T lymphocytes. A client with a bacterial infection develops IgG and IgM antibodies. A client undergoing blood transfusion may develop IgG and IgM type II hypersensitivity reactions. |
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Which bacteria colonies are commonly found in a client’s large intestine? |
1 Escherichia coli are bacteria that are part of the normal flora in the large intestine. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease. Staphylococcus aureus secretes toxins that damage cells and causes skin infections, pneumonia, urinary tract infections, acute osteomyelitis, and toxic shock syndrome. Haemophilus influenzae causes nasopharyngitis, meningitis, and pneumonia. |
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Which preparations use toxoids but not live viruses? Select all that apply. |
4, 5 PEDIARIX consists of diphtheria and tetanus toxoids plus inactivated bacterial components of pertussis, inactive viral antigen of hepatitis B, and inactivated poliovirus vaccine. DAPTACEL is a preparation consisting of toxoids plus inactive bacterial and viral components of diphtheria and tetanus toxoids and acellular pertussis vaccine. Rotarix, Varivax, and M-M-R II are preparations containing live viruses. |
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The nurse is reviewing the laboratory report of four clients. Which does the nurse suspect to have acquired immunodeficiency syndrome (AIDS)? |
1 The normal lymphocyte count is between 5000 and 10,000 cells/mm 3. A client with AIDS is leukopenic and has a lymphocyte count less than 3500 cells/mm 3. Therefore, client A has AIDS. Clients B, C, and D have normal lymphocyte counts. |
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Which diseases are caused by viruses? Select all that apply. |
1, 3, 4 Mumps is a swelling of the parotid glands caused by a virus. Measles is a highly contagious viral disease characterized by rash and high fever. Hepatitis B (a serious liver infection) is caused by a virus. Tetanus is caused by Clostridium tetani and diphtheria is caused by Corynebacterium diphtheriae. Both are gram-positive bacilli bacterial strains. |
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Which cytokine increases growth and maturation of myeloid stem cells? |
4 Granulocyte-macrophage colony-stimulating factor is a cytokine that increases growth and maturation of myeloid stem cells. Interleukin-2 is a cytokine that increases growth and differentiation of T-lymphocytes. Thrombopoietin is a cytokine that increases growth and differentiation of platelets. Granulocyte colony-stimulating factor is a cytokine that increases numbers and maturity of neutrophils. |
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The mother of an 8-year-old child with the diagnosis of acute poststreptococcal glomerulonephritis (APSGN) is concerned that a 4-year-old sibling may also have the disorder. What does the nurse recall when preparing to explain the cause of the disease process? |
3 The β-hemolytic Streptococcus immune complex becomes trapped in the glomerular capillary loop, causing acute poststreptococcal glomerulonephritis. APSGN is usually precipitated by a localized pharyngitis. Clots do not form in the small renal tubules with APSGN. Prevention depends on treating an individual with a group A β-hemolytic Streptococcus infection with antibiotics to eliminate the organism before an immune response can occur. APSGN is an acquired, not an inherited, disorder. |
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A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. |
1, 2, 5 Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided. |
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Which cytokine is used to treat multiple sclerosis? |
1 β-Interferon is a cytokine used to treat multiple sclerosis. Interleukin-2 is used to treat metastatic melanoma. Erythropoietin is a cytokine used to treat anemia related to chemotherapy. Colony-stimulating factor is a cytokine used to treat chemotherapy-induced neutropenia. |
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A client reports disturbed sleep due to itching caused by an allergy. Which medication would be prescribed to help the client sleep well and treat the allergic symptoms? |
4 Chlorpheniramine [1] [2] is an antihistamine that helps to manage allergic symptoms by preventing vasodilation and decreasing allergic symptoms. Sedation is a side effect of chlorpheniramine; therefore this drug is prescribed to clients experiencing sleep issues due to allergic symptoms. Cetirizine effectively blocks histamine from binding to receptors and has less sedating potential. Fexofenadine and desloratadine are also less sedating antihistamine drugs. |
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Which type of hypersensitivity reaction will occur when the client’s T cytotoxic cells are involved as the mediators of injury? |
4 Type IV hypersensitivity reaction will occur when the T cytotoxic cells are involved as the mediators of injury. Type I IgE-mediated reaction will occur when histamine is involved as the mediators of injury. Type II cytotoxic reaction will occur when complement lysis is the mediator of injury. Type III immune complex reaction will occur when neutrophils are involved as the mediators of injury. |
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A client has a kidney transplant. The nurse should monitor for which assessment findings associated with rejection of the transplant? Select all that apply. |
1, 2, 5 Fever is a characteristic of the systemic inflammatory response to the antigen (transplanted kidney). Oliguria or anuria occurs when the transplanted kidney is rejected and fails to function. Weight gain can occur from fluid retention when the transplanted kidney fails to function or as a result of steroid therapy; this response must be assessed further. Jaundice is unrelated to rejection. Polydipsia is associated with diabetes mellitus; it is not a clinical manifestation of rejection. |
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What does the nurse explain to a client that a positive diagnosis for human immunodeficiency virus (HIV) infection is based on? |
4 Positive ELISA and Western blot tests confirm the presence of HIV antibodies that occur in response to the presence of the HIV. Performance of high-risk sexual behaviors places someone at risk but does not constitute a positive diagnosis. Evidence of extreme weight loss and high fever do not confirm the presence of HIV; these adaptations are related to many disorders, not just HIV infection. The diagnosis of just an opportunistic infection is not sufficient to confirm the diagnosis of HIV. An opportunistic infection (included in the Centers for Disease Control and Prevention surveillance case definition for acquired immunodeficiency syndrome [AIDS]) in the presence of HIV antibodies indicates that the individual has AIDS. |
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Which organ-specific autoimmune disorder is associated with a client’s kidney? |
3 Goodpasture syndrome is an autoimmune disorder associated with the client’s kidney. Graves’ disease and Addison’s disease are autoimmune disorders associated with the endocrine system. Guillain-Barré syndrome is an autoimmune disorder associated with the central nervous system. |
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Which leukocyte releases vasoactive amines during a client’s allergic reactions? |
3 Eosinophils release vasoactive amines during allergic reactions to limit the extent of the allergic reactions. Neutrophils are phagocytes and increase in inflammation and infection. Monocytes are involved in the destruction of bacteria and cellular debris. Macrophages are involved in nonspecific recognition of foreign protein and microorganisms. |
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A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse’s priority goal when providing pin care? |
3 Pin sites provide a direct avenue for organisms into the bone. Pin care will not ease pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented. |
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Which hypersensitivity reaction may occur in a newborn with hemolytic disease? |
2 Hemolytic disease in a pregnant woman may result in erythroblastosis fetalis, a type II hypersensitivity reaction. Type I reactions involve immunoglobulin E (IgE)-mediated reactions such as anaphylaxis and wheal-and-flare reactions. Type III reactions are immune complex reactions such as rheumatoid arthritis or systemic lupus erythematosus. Type IV reactions are delayed hypersensitivity reactions such as contact dermatitis. |
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An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which standard of the nursing practice as defined by the American Nurses Association does the nurse follow? |
4 The nurse will administer the tetanus as per the doctor’s regime. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis refers to analysis of the client’s biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis. |
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Which autoantigens are responsible for the development of Crohn’s disease? |
1 Crypt epithelial cells are considered to be the autoantigens responsible for Crohn’s disease. Thyroid cell surfaces are autoantigens responsible for Hashimoto’s thyroiditis. The pulmonary and glomerular basement membranes act as autoantigens responsible for Goodpasture syndrome. |
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A mother with the diagnosis of acquired immunodeficiency syndrome (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine? |
2 Epidemiologic evidence has identified breast milk as a source of human immunodeficiency virus (HIV) transmission. Kissing is not believed to transmit HIV. When the baby last received antibiotics is unrelated to transmission of HIV. HIV transmission does not occur from contact associated with caring for a newborn. |
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A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? |
4 The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority. |
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Which autoimmune disease is directly related to the client’s central nervous system? |
2 Multiple sclerosis is a central nervous system-specific autoimmune disease. Rheumatic fever is related to the heart. Myasthenia gravis is a muscle-related autoimmune disease. Goodpasture syndrome is a kidney-related autoimmune disease. |
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A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client’s PaO 2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first? |
2 This decrease in PaO 2 indicates respiratory failure; it warrants immediate medical evaluation. Most facilities have a protocol to increase the oxygen flow rate to keep oxygen saturation greater than 92%. The client PaO 2 of 65 mm Hg is not severe enough to intubate the client without first increasing flow rate to determine if the client improves. Decreasing the tension of oxygen in the plasma is inappropriate and will compound the problem. The PaO 2 is a measure of the pressure (tension) of oxygen in the plasma; this level is decreased in individuals who have perfusion difficulties, such as those with pneumonia. Having the arterial blood gases redone to verify accuracy is negligent and dangerous; a falling PaO 2 level is a serious indication of worsening pulmonary status and must be addressed immediately. Drawing another blood sample and waiting for results will take too long. |
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Which client organ is protected by microglial cells? |
3 Microglial cells are macrophages present in the brain. The lungs are protected by alveolar macrophages. The liver is protected by Kupffer cells. Mesangial cells are present in the kidneys. |
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Which type of cytokine is used to treat anemia related to chronic kidney disease? |
4 Erythropoietin is used to treat anemia related to chronic kidney disease. α-Interferon is used to treat hairy cell leukemia or malignant melanoma. Interleukin-2 is used to treat metastatic renal carcinoma. Interleukin-11 is used to prevent thrombocytopenia after chemotherapy. |
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Which type of immunity is acquired through the transfer of colostrum from the mother to the child? |
3 Natural passive immunity is acquired through the transfer of colostrum from the mother to the child. Natural active immunity is acquired when there is a natural contact with an antigen through a clinical infection. Artificial active immunity is acquired through immunization with an antigen. Artificial passive immunity is acquired by injecting serum from an immune human. |
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A nurse is caring for a client who is human immunodeficiency virus (HIV) positive. Which complication associated with this diagnosis is most important for the nurse to teach prevention strategies? |
1 The client has a weakened immune response. Instructions regarding rest, nutrition, and avoidance of unnecessary exposure to people with infections help reduce the risk for infection. Clients can be taught cognitive strategies to cope with depression, but the strategies will not prevent depression. The client may experience social isolation as a result of society’s fears and misconceptions; these are beyond the client’s control. Although Kaposi sarcoma is related to HIV infection, there are no specific measures to prevent its occurrence. |
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Which type of hypersensitivity reaction is associated with rheumatoid arthritis? |
4 Rheumatoid arthritis is an autoimmune disorder associated with an immune-complex type of hypersensitivity reaction. Contact dermatitis caused by poison ivy is associated with a delayed type of hypersensitivity reaction. Goodpasture’s syndrome is associated with a cytotoxic type of hypersensitivity reaction. Asthma is associated with an IgE-mediated type of hypersensitivity reaction. |
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Which sexually transmitted disease is caused by a virus? |
3 Genital warts are caused by a sexually transmitted virus. Bacteria cause syphilis, gonorrhea, and chlamydial infections. |
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Which process does the IgD immunoglobulin support? |
3 IgD is present on the lymphocyte surface; this immunoglobulin differentiates B-lymphocytes. IgE causes symptoms of allergic reactions by adhering to mast cells and basophils. IgE also helps to defend the body against parasitic infections. IgA lines the mucous membranes and protects the body surfaces. IgM provides the primary immune response. |
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Which type of immune preparation, made from donated blood, contains antibodies that provide passive immunity? |
4 Specific immune globulins contain a high concentration of antibodies directed at specific antigens. Toxoid vaccines contain a bacterial toxin that has been changed to a nontoxic form. Killed vaccines contain killed microbes or isolated microbes. Live attenuated vaccines are composed of live microbes that have been weakened or rendered completely avirulent. |
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A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. What does the nurse explain to the client regarding the diagnostic criterion for acquired immunodeficiency syndrome (AIDS)? |
4 AIDS is diagnosed when an individual with human immunodeficiency virus (HIV) develops one of the following: a CD4+T-cell lymphocyte level of less than 200 cells/µL (60%), wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flulike syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain) 1 to 3 weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS. |
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A father asks the nurse about the immunization schedule for his 15-month-old toddler, who is being treated for acute lymphoid leukemia. What vaccine is contraindicated for a child undergoing chemotherapy? |
3 The MMR vaccine contains attenuated live virus and should not be administered to a child undergoing chemotherapy because of the compromise of the child’s immune system. There are no contraindications to administering the Hib vaccine, Hep B vaccine, or DTaP vaccine to a child who is immunosuppressed. |
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What are the symptoms of tuberculosis? Select all that apply. |
1, 2, 4 Tuberculosis is an infectious respiratory disease caused by Mycobacterium tuberculosis. The symptoms of tuberculosis are fatigue, nausea, low-grade fever, weight loss, and anorexia. |
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A child is found to be allergic to dust. The nurse is preparing a teaching plan for the parents. What should the nurse include in the plan? |
2 Although dust cannot be avoided completely, use of a damp cloth helps eliminate the quantity of airborne particles that might be inhaled. Hiring professional housecleaners is unnecessary and unrealistic. There are ways to limit the quantity of airborne particles. Redecorating will not eliminate dust; it is part of our environment |
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A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction? |
3 Fever is a common reaction to immunizations, and acetaminophen may be given to minimize discomfort. A central nervous system reaction is rare and requires notification of the healthcare provider. Aspirin should not be given to infants and children because it is linked to Reye syndrome. Infants do not tolerate the application of ice, which will increase discomfort. Fever is a common reaction to the immunizations; it is not necessary to notify the healthcare provider. |
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Why would a client with acquired immunodeficiency syndrome (AIDS) be prescribed diphenoxylate hydrochloride? |
2 Diphenoxylate hydrochloride is an antidiarrheal drug prescribed to clients with AIDS to manage frequent diarrhea experienced by a client with AIDS. Opioid analgesics such as tramadol are used to manage pain. Ketoconazole can be used to treat candidal esophagitis associated with AIDS. Behavioral problems are managed with psychotropic drugs. |
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A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect? |
3 A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex. |
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Which virus can cause encephalitis in adults and children? |
4 The West Nile virus causes encephalitis. German measles is caused by rubella. Gastroenteritis is caused by parvovirus. Rotavirus also causes gastroenteritis. |
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What is the function of a client’s natural killer cells? |
4 Natural killer cells attack non-selectively on non-self cells, especially body cells that have undergone mutation and become malignant. Plasma cells secrete immunoglobulins in response to the presence of a specific antigen. Cytotoxic T-cells attack selectively and destroy non-self cells, including virally infected cells. Helper T-cells enhance immune activity through secretion of various factors, cytokines, and lymphokines. |
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What finding in the client is a sign of allergic rhinitis? |
4 Reduced transillumination on the skin overlying the sinuses indicates allergic rhinitis. This effect is caused by the sinuses becoming inflamed and blocked with thick mucoid secretions. Generally, fever does not accompany allergic rhinitis unless the client develops a secondary infection. In allergic rhinitis, the client is unable to breathe through the nose because it gets stuffy and blocked. Instead the client will resort to mouth breathing. Clients with allergic rhinitis will have clear or white nasal discharge. |
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According to the Healthcare Personnel Vaccination Recommendations, what meningococcal conjugate vaccine dose should a nurse administer to a 12-year-old with an HIV infection? |
4 A 12-year-old with HIV would require two primary meningococcal conjugate vaccine delivered two months apart initially and a booster dose at the age of 16 years old. The client would require two initial doses, not a single initial dose, and a booster at 16 years old, not 3, 5, or 7 years later. |
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A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the most appropriate nursing action? |
1 A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse should apply cold compresses to the affected area to reduce the pain in the client. A client with Candida albicans infection should keep his or her skin clean and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may suffer from cardiac, arthritic, and neurologic manifestations. Therefore the nurse has to monitor for these symptoms. Direct contact may transmit a Sarcoptes scabiei infection; the nurse should make sure that the client’s clothes are bleached to prevent the transmission of the infection. |
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The nurse suspects that a client with inhalation anthrax is in the fulminant stage of the disease. Which symptom supports the nurse’s conclusion? |
3 Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. This disease has two stages of illness, the prodromal stage and the fulminant stage. The symptom of the fulminant stage is hematemesis. The symptoms of the prodromal stage are fever, dry cough, and mild chest pain. |
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What type of hypersensitivity reaction is the cause of systemic lupus erythematosus? |
3 Anaphylaxis is an example of a type I or immediate hypersensitive reaction. Cytotoxic or type II hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions that are caused by delayed or type IV hypersensitivity reactions. |
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A nurse is teaching a client about human immunodeficiency virus (HIV). What are the various ways HIV is transmitted? Select all that apply. |
2, 3, 5 Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites or kissing. |
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Which viral infection will cause the nurse to observe for warts? |
4 Warts are caused by papillomavirus. Pox viruses cause smallpox. Rhabdovirus causes rabies. Epstein-Barr causes mononucleosis and Burkitt’s lymphoma. |
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A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium? |
3 An untoward response to the iodinated dye used as a contrast is anaphylaxis, a life-threatening allergic response. Anaphylaxis is manifested by respiratory distress, hypotension, and shock; counteractive measures must be instituted. A feeling of warmth or flushing is an expected minor side effect. A salty taste is an expected minor side effect. |
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What causes medications used to treat AIDS to become ineffective? |
2 The most important reason for the development of drug resistance in the treatment of AIDS is missing doses of drugs. When doses are missed, the blood drug concentrations become lower than what is needed to inhibit viral replication. The virus replicates and produces new particles that are resistant to the drugs. Taking the medications 90% of the time prevents medications from becoming ineffective. Taking medications from different classes prevents the drugs from becoming ineffective. Immune reconstitution inflammatory syndrome (IRIS) occurs when T-cells rebound with medication therapy and become aware of opportunistic infections. |
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A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client? |
1 The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states that standard precautions should be used for all clients; these precautions include wearing of gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact and discouraging long visits from family members will unnecessarily isolate the client. |
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Which is the first antibody formed after exposure to an antigen? |
4 IgM (immunoglobulin M) is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms. |
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The nurse administers an initial dose of Haemophilus influenzae type b (Hib) vaccine to a 2-month-old infant. When should the nurse administer the final dose of the vaccine to the infant? |
3 The Haemophilus influenzae type b (Hib) vaccine is administered in four doses, finishing at the age of 12-15 months. Following the first dose at 2 months, the second is administered at 4 months, and the third at 6 months. For the final dose, 6-8 months and 8-10 months would be too soon; 16-18 months would be too late. |
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Which conditions result in humoral immunity? Select all that apply. |
2, 3, 4 Atopic diseases, bacterial infections, and anaphylactic shock are disease conditions that trigger humoral immunity. Tuberculosis and contact dermatitis result in cell-mediated immunity. |
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What is the mechanism of action of norepinephrine in managing anaphylaxis? |
3 Norepinephrine is a vasopressor that elevates the blood pressure and cardiac output in clients suffering from anaphylactic reactions. Diphenhydramine HCL blocks the effects of histamine on various organs. Corticosteroids such as dexamethasone prevent the degranulation of mast cells. Epinephrine works by rapidly stimulating alpha- and beta-adrenergic receptors. |
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After assessing an older client’s medical report, the nurse finds that the client is at an increased risk for bacterial and fungal infections. Which change in immune function may have occurred? |
3 A decrease in circulating T-lymphocytes occurs with cell-mediated immunity, resulting in an increased risk of bacterial and fungal infections. A client would need booster shots for old vaccinations and immunizations when there is a decline in natural antibodies. A reduced neutrophil function may be an implication when neutrophil function is decreased. The older adult should receive immunizations, such as flu shots, when the number of colony-forming B-lymphocytes is diminished. |
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Which diseases can be transmitted from client to client by droplet infection? Select all that apply. |
4, 5 Pertussis and diphtheria are infectious diseases that are known to be transmitted by droplet infection. Shingles and measles are infectious diseases that are known to be transmitted by air. Scabies is an infectious disease that is transmitted by direct contact. |
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A client has undergone scratch testing but the causative allergen is yet to be identified. What would be the next step to confirm a strongly suspected allergen? |
2 An intradermal test is administered when a strongly suspected allergen tests negative with the scratch test. A testing dose of sera is injected intradermally into the arm and any signs of allergy are observed to confirm the allergen. Allergy shots are a therapeutic method of reducing sensitivity to a known allergen when exposure cannot be avoided. An oral food challenge is done to confirm an ingested allergen if skin testing completely fails. Radioallergosorbent testing is useful to measure immunoglobulin E levels to ascertain the presence of an allergic reaction. |
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Which medications act by binding with integrase enzyme and prevent human immunodeficiency virus (HIV) from incorporating its genetic material into the client’s cell? Select all that apply. |
4, 5 Raltegravir and elvitegravir are integrase inhibitors. They act by binding with integrase enzyme and prevent HIV from incorporating its genetic material into the client’s cell. Ritonavir and nelfinavir are protease inhibitors. They act by preventing the protease enzyme from cutting HIV proteins into the proper lengths needed to allow viable virions to assemble and bud out from the cell membrane. Tenofovir is a nucleotide reverse transcriptase inhibitor. It acts by combining with reverse transcriptase enzyme to block the process needed to convert HIV ribose nucleic acid into HIV deoxyribose nucleic acid. |
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What functions of leukocytes are involved in inflammation? Select all that apply. |
1, 3 Leukocytes such as monocytes and eosinophils are involved in inflammation. Their functions include the destruction of bacteria and cellular debris and the release of vasoactive amines during allergic reactions to limit these reactions. Helper/inducer T-cells and cytotoxic cells selectively attack and destroy non-self cells and secrete immunoglobulins in response to the presence of a specific antigen. B-lymphocytes, or plasma cells, secrete immunoglobulins in response to the presence of a specific antigen. Helper/inducer T-cells are involved in cell-mediated immunity, enhancing immune activity through the secretion of various factors, cytokines, and lymphokines. |
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When taking the blood pressure of a client who has acquired immunodeficiency syndrome (AIDS), what must the nurse do? |
4 Because this procedure does not involve contact with blood or secretions, additional protection other than washing the hands thoroughly is not indicated. Donning clean gloves and using barrier techniques are necessary only when there is risk of contact with blood or body fluid. A mask and gown are indicated only if there is a danger of secretions or blood splattering on the nurse (for example, during suctioning). |
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The nurse educates a client on decreasing the risk of developing antibiotic-resistant infections. Which statement made by the nurse will be most significant? |
2 Antibiotic-resistant infection develops when the hardiest bacteria survive and multiply. This may happen when a client stops taking an entire course of antibiotics, which leads to infections that are resistant to many antibiotics. Therefore a client should not skip any dose of an antibiotic. Hand washing is required to prevent infections; it is not related to antibiotic-resistant infections. Antibiotics should not be stopped even if the client has started feeling better; the full course of treatment should be taken. Non-compliance in taking the full course of prescribed antibiotics can lead to an antibiotic-resistant infection. It is dangerous to take the unfinished antibiotics at a later time; it may prove fatal if the antibiotics are outdated. |
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A client who has been living in another country for 10 years is undergoing diagnostic testing to identify the causative organisms of the infection that has been acquired. When caring for this client, what should the nurse recall about active immunity? |
2 Active immunity occurs when the individual’s cells produce antibodies in response to an agent or its products; these antibodies will destroy the agent (antigen) should it enter the body again. Antigens do not fight antibodies; they trigger antibody formation that in turn attacks the antigen. Antigens are foreign substances that enter the body and trigger antibody formation. Sensitized lymphocytes do not act as antibodies. |
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A nurse who is caring for a 7-year-old child with acute glomerulonephritis assesses the child for cerebral complications. What signs and symptoms indicate cerebral involvement? |
1 Headache, drowsiness, and vomiting may occur if the blood pressure remains increased and leads to cerebral edema. Drowsiness, not restlessness, will occur; generalized edema and anorexia are not specific to cerebral edema. Although fever and confusion may occur, anuria is not specific to cerebral edema. Although the pulse may be altered and vomiting may occur, cardiac decompensation is not related to cerebral involvement. |
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A primary healthcare provider has prescribed pyrazinamide to a client with tuberculosis. Which instruction by the nurse will be beneficial to the client? Select all that apply. |
1, 2 A client undergoing pyrazinamide therapy may require extra fluids to help prevent uric acid formation from precipitating and causing gout or kidney problems. Therefore the client should drink at least 8 ounces of water with the medication. The client should also avoid alcoholic beverages, which could potentiate liver toxicity. Staining is a common problem with rifampin, not pyrazinamide. The client should also report any darkening of urine because this may be a sign of liver toxicity or damage. The client should report any vision changes if he or she is taking etambutol. |
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A client with a diagnosis of polyarteritis nodosa asks the nurse for information about this disorder. What information should the nurse include in the response? |
3 An autoimmune response plays a role in the development of polyarteritis, although drugs and infections may precipitate it. The disorder often is fatal, usually as a result of heart or renal failure. Men are affected three times more often than women. Arteriolar pathology can affect any organ or system. |
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When preparing discharge teaching for a client who had a kidney transplant, in addition to a corticosteroid, the nurse expects what other medications to be prescribed to prevent kidney rejection? |
4 Standard triple therapy includes a corticosteroid prednisone (methylprednisolone), an antimetabolite (mycophenolate), and a calcineurin inhibitor (tacrolimus and cyclosporine). Although sirolimus is used for immunosuppression, furosemide is a diuretic. Neither of these medications are immunosupressives. Cefazolin is an antibiotic, and methotrexate is a folic acid antagonist used in cancer chemotherapy. Although methylprednisolone is used for immunosuppression, phenytoin is an antiseizure medication. |
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Which age-related effects on the immune system are seen in the older client? |
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Which type of hepatitis virus spreads through contaminated food and water? |
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A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? |
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A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved? |
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Which type of immunoglobulin is present in tears, saliva, and breast milk? |
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Confidence: Nailed It |
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The nurse suspects that a client is in the chronic persistent stage of Lyme disease. Which symptoms support the nurse’s suspicion? Select all that apply. |
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The nurse is counseling a client infected with human immunodeficiency virus (HIV) regarding prevention of HIV transmission. Which statement by the client indicates the nurse needs to follow up? |
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Which antimicrobial medication acts on susceptible pathogens by inhibiting nucleic acid synthesis? |
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Which immunoglobulin crosses the placenta? |
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Confidence: Just a Guess |
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Confidence: Nailed It |
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Which cytokine stimulates the liver to produce fibrinogen and protein C? |
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What is the mechanism of action of penicillin? |
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Confidence: Nailed It |
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Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? |
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What is the causative organism for syphilis? |
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When is the first dose of Rotarix vaccine administered in infants? |
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Confidence: Nailed It |
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Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply. |
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Which is a leukotriene antagonist used to manage and prevent allergic rhinitis? |
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Confidence: Nailed It |
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Which statement is true regarding Sjögren’s syndrome? |
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Confidence: Nailed It |
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Confidence: Just a Guess |
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Which bacteria causes toxic shock syndrome in female clients? |
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A client making her first visit to the prenatal clinic asks which immunization can be administered safely to a pregnant woman. What should the nurse tell her? |
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A primigravida has just given birth. The nurse is aware that the client has type AB Rh-negative blood. Her newborn’s blood type is B positive. What should the plan of care include? |
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A nurse is counseling the family of a child with AIDS. What is the most important concern that the nurse should discuss with the parents? |
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Which dietary modifications can help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? |
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Which virus is responsible for causing infectious mononucleosis in clients? |
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Which is the first medication approved to reduce the risk of human immunodeficiency virus (HIV) infection in unaffected individuals? |
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Which medication should be immediately started when a client has an anaphylactic attack? |
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What is the function of IgG in the body? |
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Which medication should be immediately started when a client has an anaphylactic attack? |
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Confidence: Nailed It |
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What are the mediators of injury in IgE-mediated hypersensitivity reactions? Select all that apply. |
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Which cytokine medication is administered to treat chemotherapy-induced neutropenia? |
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The nurse is teaching parents about the side effects of immunization vaccines. What expected side effect associated with the Haemophilus influenzae (Hib) vaccine will the nurse include in the teaching? |
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A client is diagnosed with psoriasis, and the nurse is providing health teaching concerning skin care at home. Which recommendation does the nurse include in the teaching? |
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Which medications are administered to inhibit purine synthesis and suppress cell-mediated and humoral immune responses? Select all that apply. |
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Which type of vaccines triggers the recipient’s immune system to produce antitoxins? |
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Which complication will the nurse suspect in a client with genital herpes disease? |
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Which parameter should the nurse consider while assessing the psychologic status of a client with acquired immune deficiency syndrome (AIDS)? |
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Which malnutrition condition may predispose a client to secondary immunodeficiency? |
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What is the role of shark cartilage in the management of human immunodeficiency (HIV) and acquired immunodeficiency syndrome (AIDS)? |
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Confidence: Just a Guess |
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A nurse is reviewing several charts. Which condition is an autoimmune disorder? |
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Which activity by the community nurse can be considered an illness prevention strategy? |
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Which organ-specific autoimmune disorder is associated with a client’s kidney? |
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The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should the nurse give about why the MMR vaccine is administered at 12 to 15 months of age? |
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What is the function of IgG in the body? |
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A nurse is reviewing several charts. Which condition is an autoimmune disorder? |
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Which process does the IgD immunoglobulin support? |
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The nurse is counseling a client infected with human immunodeficiency virus (HIV) regarding prevention of HIV transmission. Which statement by the client indicates the nurse needs to follow up? |
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Confidence: Nailed It |
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The nurse administers an initial dose of Haemophilus influenzae type b (Hib) vaccine to a 2-month-old infant. When should the nurse administer the final dose of the vaccine to the infant? |
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What type of hypersensitivity reaction is the cause of systemic lupus erythematosus? |
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Which are examples of a type IV hypersensitivity reaction? Select all that apply. |
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Confidence: Just a Guess |
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A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse’s priority goal when providing pin care? |
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When is the first dose of Rotarix vaccine administered in infants? |
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Which parameter should the nurse consider while assessing the psychologic status of a client with acquired immune deficiency syndrome (AIDS)? |
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What is the function of a client’s natural killer cells? |
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Which autoantigens are responsible for the development of Crohn’s disease? |
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A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved? |
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Confidence: Just a Guess |
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A nurse is teaching parents of toddlers about why children receiving specific medications should not receive varicella vaccines. Which medication will be included in the discussion? |
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Confidence: Just a Guess |
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Confidence: Pretty Sure |
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A laboratory report shows that a client tested positive for human epidermal growth factor (HER), and a medical report reveals the presence of advanced breast cancer. Which medication would be used to treat this condition? |
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A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food borne disease would be suspected in this client? |
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A nurse is teaching a group of healthcare workers about the prevention of human immunodeficiency virus (HIV) transmission by healthcare workers. Which statements made by a healthcare worker indicate the need for the further teaching? Select all that apply. |
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The 8-year-old son of migrant farm workers is brought to the county health clinic. He has no history of immunizations. After measles is diagnosed, the public health nurse goes to the migrant camp to search for people with a greater-than-average chance of contracting the disease. What is the name of this variable? |
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A client’s laboratory report shows severe neutropenia and thrombocytopenia. Which medication may have caused this condition? |
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Which symptoms are observed in a client with Sjögren’s syndrome? Select all that apply. |
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A nurse in the pediatric clinic plans to administer a booster immunization for polio to a child. Which vaccine should the nurse administer? |
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A registered nurse is educating a client who has just undergone thoracentesis on the manifestations of pneumothorax. Which statements made by the client indicate effective learning? Select all that apply. |
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The nurse is caring for a client with human immunodeficiency virus (HIV) infection. Which clinical manifestations in the client should be immediately reported to the primary healthcare provider? |
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A client has received ABO-incompatible blood from a donor by mistake. Which type of hypersensitivity reaction will occur in the client? |
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Confidence: Pretty Sure |
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The T lymphocytes in a healthy older adult client are 120 cells/mm 3 (120 cells/uL). The chest x-ray reveals shrinkage of the thymus gland. What might have led to the client’s condition? |
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