Question 1

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)   Erythema
B)   Fever
C)   Joint pain
D)   Hypotension D

Question 2

A nurse working in the emergency department is providing care for a group of clients.Which client demonstrates a decline immune response that typically occurs with the aging process?

Accepted Answer

A)   An 88-year-old client with pneumonia who has a temperature of 99.5°F
B)   A 70-year-old client who has swelling and redness around an abdominal incision from an open appendectomy
C)   A 58-year-old client who complains of redness and itching after developing a rash from contact with poison ivy
D)   A 56-year-old client who has 8 mm induration at the site of a PPD skin test 72 hours earlier A

Question 3

A client,recently diagnosed with rheumatoid arthritis (RA),asks the nurse whether RA will affect her in other ways.When responding to the client,which systems will the nurse include as possibly being affected by the diagnosis? Select all that apply.

Accepted Answer

A)   Respiratory
B)   Cardiovascular
C)   Exocrine
D)   Reproductive
E)   Hematologic A,B,C,E

Question 4

A nurse is caring for a pregnant client who has rheumatoid arthritis (RA).Based on this data,which does the nurse anticipate when providing care to this client?

Accepted Answer

A)   A higher risk for preterm delivery.
B)   An increased need for medication.
C)   An acute exacerbation of symptoms.
D)   A continued risk for anemia.

Question 5

A client with systemic lupus erythematosus (SLE)is being treated with immunosuppressant drugs and corticosteroids.When providing teaching for this client,which topics are appropriate for the nurse to include? Select all that apply.

Accepted Answer

A)   Avoid large crowds.
B)   Don't get a flu shot.
C)   Use contraception to prevent pregnancy
D)   Refrain from taking aspirin products.
E)   Report signs of infection to the healthcare provider.

Question 6

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 is the priority intervention for this client?

Accepted Answer

A)   Teach the client regarding using a kit that contains treatment for allergic reactions.
B)   Administer diphenhydramine (Benadryl)  by mouth every 4 hours per the healthcare provider's orders.
C)   Administer epinephrine 1:1,000 by subcutaneous injection per the healthcare provider's orders.
D)   Collect a detailed history from the client regarding the history of latex allergies.

Question 7

The nurse is caring for a client admitted to an urgent care clinic due to an arm infection.The client reports being bitten by a raccoon on a recent camping trip.Based on this data,which treatment option does the nurse anticipate for this client?

Accepted Answer

A)   An injection of immunoglobulin.
B)   A tetanus toxoid injection.
C)   Mother's breast milk with antibodies in it.
D)   An immunization for rabies.

Question 8

A nurse is developing a plan of care for a client who was recently diagnosed with human immunodeficiency virus (HIV).The client states,"I don't plan on giving up sex just because I am HIV positive." Based on this data,which nursing diagnosis is the priority for this client?

Accepted Answer

A)   Risk for Infection
B)   Death Anxiety
C)   Deficient Knowledge
D)   Social Isolation

Question 9

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

Accepted Answer

A)   Keep doors and windows open on high-allergen days to circulate air.
B)   Remain indoors if possible on high-allergen days.
C)   Maintain a clean, dust-free environment.
D)   Take antihistamine and leukotriene medication as ordered.
E)   Stop taking oral corticosteroids immediately once symptoms disappear.

Question 10

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 the need to inject the child with epinephrine (EpiPen)? Select all that apply.

Accepted Answer

A)   Skin that is cold and clammy to the touch
B)   Skin that is warm and dry to the touch
C)   The child is hyperactive and hyperverbal.
D)   Complaints of thirst
E)   Restlessness and confusion

Question 11

A nurse is caring for a client who is newly diagnosed with rheumatoid arthritis (RA).The client asks the nurse what the difference is between RA and osteoarthritis (OA).Which responses by the nurse are the most appropriate? Select all that apply.

Accepted Answer

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

Question 12

A client has just recently been diagnosed with rheumatoid arthritis (RA).The client asks the nurse if RA always causes crippling deformities.Which teaching topics will the nurse include as ways to decrease the likelihood of crippling deformities? Select all that apply.

Accepted Answer

A)   Ignore pain as a warning signal.
B)   Type instead of hand-writing items if possible.
C)   Use stronger joints for most activity.
D)   Avoid stress to any current area of deformity.
E)   Stop an activity if it is beyond your ability to perform.

Question 13

The nurse is admitting a pediatric client to the hospital with a VP shunt malfunction.The client's family speaks very little English.The interpreter has arrived and the nurse is obtaining a health history from the parents and learns that the client received the shunt at birth after a menigocele repair.Based on this data,which product should be avoided when providing care to this client?

Accepted Answer

A)   Synthetic rubber gloves
B)   Polyethylene gloves
C)   Non-powdered nitrile gloves
D)   Latex gloves

Question 14

A nurse working in the pediatric intensive care unit (PICU)is caring for a pediatric 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)   Category N
B)   Category C
C)   Category A
D)   Category B

Question 15

The client enters the outpatient clinic and states to the triage nurse,"I think I have the flu.I'm so tired,I have no appetite,and everything hurts." The triage nurse assesses the client and finds a butterfly rash over the bridge of nose and on the cheeks.Based on this data,which diagnosis does the nurse anticipate?

Accepted Answer

A)   Systemic lupus erythematosus
B)   Fibromyalgia
C)   Lyme disease
D)   Gout

Question 16

The nurse is caring for a client who is hospitalized on a medical unit for a systemic infection.The client asks the nurse which defenses the body has against infection.Which physiological barriers that protect the body against microorganisms will the nurse include in the response to the client? Select all that apply.

Accepted Answer

A)   Alcoholic beverages
B)   Adequate urinary output
C)   Intact skin
D)   Occasional smoking
E)   A surgical incision

Question 17

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

Accepted Answer

A)   Ask the family member to leave the unit.
B)   Transfer the client to a department that does not use latex products.
C)   Wait until Monday to report the problem to the supervisor of the unit.
D)   Obtain latex-free products for the client's room.

Question 18

The nurse is collecting a health history for a client being seen in an outpatient clinic who complains of joint pain and swelling that have lasted for about 2 months.The client is diagnosed with rheumatoid arthritis (RA).When planning care for this client,which statement supports the nursing diagnosis of Activity Intolerance?

Accepted Answer

A)   "I seem to get tired early in the day and require a nap."
B)   "My joints are stiffest at night before I go to sleep."
C)   "I find it difficult to move when I first get up in the morning."
D)   "I take ibuprofen for the pain as needed."

Question 19

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

Accepted Answer

A)   Trendelenburg position
B)   Flat, with legs slightly elevated
C)   Supine position
D)   High Fowler position

Question 20

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

Accepted Answer

A)   Swimming
B)   Football
C)   Softball
D)   Basketball

Exam 8: Immunity

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

A nurse working in the emergency department is providing care for a group of clients.Which client demonstrates a decline immune response that typically occurs with the aging process?

A client,recently diagnosed with rheumatoid arthritis (RA) ,asks the nurse whether RA will affect her in other ways.When responding to the client,which systems will the nurse include as possibly being affected by the diagnosis? Select all that apply.

A nurse is caring for a pregnant client who has rheumatoid arthritis (RA) .Based on this data,which does the nurse anticipate when providing care to this client?

A client with systemic lupus erythematosus (SLE) is being treated with immunosuppressant drugs and corticosteroids.When providing teaching for this client,which topics are appropriate for the nurse to include? Select all that apply.

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 is the priority intervention for this client?

The nurse is caring for a client admitted to an urgent care clinic due to an arm infection.The client reports being bitten by a raccoon on a recent camping trip.Based on this data,which treatment option does the nurse anticipate for this client?

A nurse is developing a plan of care for a client who was recently diagnosed with human immunodeficiency virus (HIV) .The client states,"I don't plan on giving up sex just because I am HIV positive." Based on this data,which nursing diagnosis is the priority for this client?

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

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 the need to inject the child with epinephrine (EpiPen) ? Select all that apply.

A nurse is caring for a client who is newly diagnosed with rheumatoid arthritis (RA) .The client asks the nurse what the difference is between RA and osteoarthritis (OA) .Which responses by the nurse are the most appropriate? Select all that apply.

A client has just recently been diagnosed with rheumatoid arthritis (RA) .The client asks the nurse if RA always causes crippling deformities.Which teaching topics will the nurse include as ways to decrease the likelihood of crippling deformities? Select all that apply.

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

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

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