Question 1

The nurse is caring for a client in an allergy clinic. After completing the client history, the nurse selects the nursing diagnosis of Risk for Shock. Which item in the client's history supports the need for this nursing diagnosis?

Accepted Answer

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

Question 2

Which of the following statements is true with regard to food allergies and children?

Accepted Answer

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

Question 3

A nurse is caring for a pediatric client who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the client is experiencing a type I hypersensitivity reaction?

Accepted Answer

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

Question 4

The nurse is caring for a client who is experiencing anaphylactic shock following the administration of a medication. Based on this data, which position is the most appropriate for the nurse to place the client?

Accepted Answer

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

Question 5

A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee stings. Which clinical manifestations would necessitate injecting the child with epinephrine (EpiPen)? Select all that apply.

Accepted Answer

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

Question 6

The nurse is preparing to assess a client when one of the client's family members begins showing symptoms of latex sensitivity. Which action by the nurse is the most appropriate?

Accepted Answer

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

Question 7

The nurse is planning care for a pediatric client who is infected with the human immunodeficiency virus (HIV). The nurse selects Risk for Infection as a priority nursing diagnosis for this client. Based on this nursing diagnosis, which actions by the nurse are appropriate? Select all that apply.

Accepted Answer

A)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.
B)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.
C)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.
D)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.
E)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.

Question 8

The nurse is admitting a pediatric client to the hospital with a ventriculoperitoneal (VP)shunt malfunction. When gathering the history, the nurse learns that the client received the shunt at birth after a meningocele repair. Based on this data, which product should be avoided when providing care to this client?

Accepted Answer

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

Question 9

The nurse is caring for a client who is newly diagnosed with human immunodeficiency virus (HIV)infection. The client asks the nurse whether there are ways to protect the client's life partner from getting the virus. After the nurse provides the client with teaching related to this topic, which statement on the part of the client would indicate a need for further education?

Accepted Answer

A)The client statement regarding use of an oil-based lubricant indicates the need for further education. Clients should use only water-based lubricants, because oil-based lubricants can result in condom damage. The other statements by the client indicate appropriate understanding of the information presented by the nurse.
B)The client statement regarding use of an oil-based lubricant indicates the need for further education. Clients should use only water-based lubricants, because oil-based lubricants can result in condom damage. The other statements by the client indicate appropriate understanding of the information presented by the nurse.
C)The client statement regarding use of an oil-based lubricant indicates the need for further education. Clients should use only water-based lubricants, because oil-based lubricants can result in condom damage. The other statements by the client indicate appropriate understanding of the information presented by the nurse.
D)The client statement regarding use of an oil-based lubricant indicates the need for further education. Clients should use only water-based lubricants, because oil-based lubricants can result in condom damage. The other statements by the client indicate appropriate understanding of the information presented by the nurse.

Question 10

A nurse working in the pediatric intensive care unit (PICU)is caring for a client with human immunodeficiency virus (HIV). The client is severely symptomatic with the additional diagnoses of lymphoma and wasting syndrome. Based on this data, which clinical stage of HIV does the nurse anticipate for this client?

Accepted Answer

A)The 1994 Revised HIV Pediatric Classification System remains the standard for determining clinical staging and related treatment for children with HIV. The client described is Category C, a severely symptomatic client with lymphoma and wasting syndrome. The other choices are incorrect.
B)The 1994 Revised HIV Pediatric Classification System remains the standard for determining clinical staging and related treatment for children with HIV. The client described is Category C, a severely symptomatic client with lymphoma and wasting syndrome. The other choices are incorrect.
C)The 1994 Revised HIV Pediatric Classification System remains the standard for determining clinical staging and related treatment for children with HIV. The client described is Category C, a severely symptomatic client with lymphoma and wasting syndrome. The other choices are incorrect.
D)The 1994 Revised HIV Pediatric Classification System remains the standard for determining clinical staging and related treatment for children with HIV. The client described is Category C, a severely symptomatic client with lymphoma and wasting syndrome. The other choices are incorrect.

Question 11

The nurse is assessing a client who is receiving IV antibiotics. Which item in the client's health history increases the risk for experiencing a hypersensitivity reaction?

Accepted Answer

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

Question 12

A pediatric client with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen. Which statements are appropriate for the nurse to include in the discharge instructions for this client and family? Select all that apply.

Accepted Answer

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

Question 13

In what ways do type IV hypersensitivity reactions differ from other types of hypersensitivity reactions?

Accepted Answer

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

Question 14

The nurse is reviewing the laboratory results of a client who is newly diagnosed with acquired immunodeficiency syndrome (AIDS). Which result would be considered potentially problematic and should be reported to the client's healthcare provider?

Accepted Answer

A)A CD4 cell count of less than 200/mm³ should be reported to the healthcare provider because it indicates that that opportunistic infections and cancer are likely. Otherwise, both a negative tuberculin test and a WBC count of 6500/mm³ are considered normal, and a viral load of 5000-10,000 copies/mL in a client who is known to have AIDS does not indicate the need for changes in the treatment regimen.
B)A CD4 cell count of less than 200/mm³ should be reported to the healthcare provider because it indicates that that opportunistic infections and cancer are likely. Otherwise, both a negative tuberculin test and a WBC count of 6500/mm³ are considered normal, and a viral load of 5000-10,000 copies/mL in a client who is known to have AIDS does not indicate the need for changes in the treatment regimen.
C)A CD4 cell count of less than 200/mm³ should be reported to the healthcare provider because it indicates that that opportunistic infections and cancer are likely. Otherwise, both a negative tuberculin test and a WBC count of 6500/mm³ are considered normal, and a viral load of 5,000-10,000 copies/mL in a client who is known to have AIDS does not indicate the need for changes in the treatment regimen.
D)A CD4 cell count of less than 200/mm³ should be reported to the healthcare provider because it indicates that that opportunistic infections and cancer are likely. Otherwise, both a negative tuberculin test and a WBC count of 6500/mm³ are considered normal, and a viral load of 5,000-10,000 copies/mL in a client who is known to have AIDS does not indicate the need for changes in the treatment regimen.

Question 15

Which type of precaution should the nurse implement when providing direct care in the intensive care unit (ICU)to a client diagnosed with acquired immunodeficiency syndrome (AIDS)?

Accepted Answer

A)Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, healthcare workers treat all high-risk body fluids as if they are infectious and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.
B)Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, healthcare workers treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.
C)Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, healthcare workers treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.
D)Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, healthcare workers treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.

Question 16

A home health nurse is conducting home visits for several clients who are diagnosed with acquired immunodeficiency syndrome (AIDS). Which client would the nurse see first?

Accepted Answer

A)All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation)and the report of new onset of fever and shortness of breath, the nurse should visit the client with Pneumocystis jiroveci pneumonia first to obtain vital signs and perform a respiratory assessment.
B)All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation)and the report of new onset of fever and shortness of breath, the nurse should visit the client with Pneumocystis jiroveci pneumonia first to obtain vital signs and perform a respiratory assessment.
C)All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation)and the report of new onset of fever and shortness of breath, the nurse should visit the client with Pneumocystis jiroveci pneumonia first to obtain vital signs and perform a respiratory assessment.
D)All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation)and the report of new onset of fever and shortness of breath, the nurse should visit the client with Pneumocystis jiroveci pneumonia first to obtain vital signs and perform a respiratory assessment.

Question 17

A nurse is caring for a client with seasonal hypersensitivity reactions. What teachings should the nurse provide to improve this client's comfort? Select all that apply.

Accepted Answer

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

Question 18

A nurse is caring for a client with HIV who just learned she is several weeks pregnant. The client states that she is concerned about how her HIV diagnosis might affect the health of her child. Which of the following statements should the nurse include in her teaching for this client?

Accepted Answer

A)Women with HIV should be advised that most HIV medications are safe during pregnancy, and taking them can reduce the risk of maternal-fetal transmission. The nurse should also inform pregnant clients that virus transmission is possible both across the placenta and at birth, although cesarean delivery carries a lower risk of transmission than vaginal delivery. In addition, pregnant clients with HIV should be educated about the increased risk of fetal loss and neonatal mortality associated with their diagnosis.
B)Women with HIV should be advised that most HIV medications are safe during pregnancy, and taking them can reduce the risk of maternal-fetal transmission. The nurse should also inform pregnant clients that virus transmission is possible both across the placenta and at birth, although cesarean delivery carries a lower risk of transmission than vaginal delivery. In addition, pregnant clients with HIV should be educated about the increased risk of fetal loss and neonatal mortality associated with their diagnosis.
C)Women with HIV should be advised that most HIV medications are safe during pregnancy, and taking them can reduce the risk of maternal-fetal transmission. The nurse should also inform pregnant clients that virus transmission is possible both across the placenta and at birth, although cesarean delivery carries a lower risk of transmission than vaginal delivery. In addition, pregnant clients with HIV should be educated about the increased risk of fetal loss and neonatal mortality associated with their diagnosis.
D)Women with HIV should be advised that most HIV medications are safe during pregnancy, and taking them can reduce the risk of maternal-fetal transmission. The nurse should also inform pregnant clients that virus transmission is possible both across the placenta and at birth, although cesarean delivery carries a lower risk of transmission than vaginal delivery. In addition, pregnant clients with HIV should be educated about the increased risk of fetal loss and neonatal mortality associated with their diagnosis.

Question 19

The nurse suspects that the client is experiencing a reaction to a specific antigen. Which laboratory result supports the conclusion made by the nurse?

Accepted Answer

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

Question 20

The nurse is caring for a client with a history of latex allergies. The client develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which of the following is the priority intervention for this client?

Accepted Answer

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

Quiz 8: Immunity