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Immunity / ICR

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Immunity / ICR
Jeremy Tworoger
Quiz por Jeremy Tworoger, atualizado more than 1 year ago
Jeremy Tworoger
Criado por Jeremy Tworoger quase 5 anos atrás
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Resumo de Recurso

Questão 1

Questão
A client with severe dust mite allergies asks a nurse how to prevent outbreaks of rhinitis. The nurse instructs the client to take which actions? Select all that apply.
Responda
  • Clean all surfaces weekly with a bleach solution.
  • Keep floors bare and avoid carpeting.
  • Sleep in an air-conditioned room.
  • Use impermeable covers on pillows and mattresses.
  • Wear surgical face masks when sleeping.

Questão 2

Questão
A nurse provides discharge instructions to a client with human immunodeficiency virus (HIV). Which instructions does the nurse provide? Select all that apply.
Responda
  • Avoid being around individuals with symptoms of contagious infections.
  • Avoid sharing drinks or utensils with healthy family members.
  • Do not share your shaving razor or nail clippers with anyone.
  • Sexual partners should be tested for human immunodeficiency virus.
  • Use condoms consistently and correctly for vaginal or anal sex.

Questão 3

Questão
Which information does the nurse include when providing teaching to a female client with human immunodeficiency virus (HIV) who wants to get pregnant? Select all that apply.
Responda
  • Stop taking antiretroviral drugs during your pregnancy.
  • The baby could be exposed to HIV during birth.
  • The baby might not be born HIV-positive.
  • You will need to have a cesarean section.
  • Your partner is at risk while not using barrier birth control.

Questão 4

Questão
While providing discharge instructions to a client with systemic lupus erythematosus, the nurse includes which information? Select all that apply.
Responda
  • Exercise intensely three times per week.
  • Get adequate rest.
  • Monitor your temperature.
  • Take corticosteroid doses as needed.
  • Wear sunblock.

Questão 5

Questão
The phone triage nurse answers a call from a client who reports having a positive enzyme-linked immunosorbent assay (ELISA) test for HIV. The client anxiously asks the nurse to explain what this means. How does the nurse respond?
Responda
  • A Western blot test should be performed next.
  • The ELISA test provides information about the viral load.
  • This test indicates it is probable that you have acquired immunodeficiency syndrome or AIDS.
  • You will need a follow up blood test to help interpret your ELISA test results.

Questão 6

Questão
A nurse reviews laboratory results for a client admitted to the hospital with suspected systemic lupus erythematosus (SLE). Which results best support the diagnosis?
Responda
  • Elevated erythrocyte sedimentation rate.
  • Hemoglobin of 10.1 g/dL
  • Positive antinuclear antibody
  • Presence of urinary protein.

Questão 7

Questão
The nurse counsels a client who has testing negative for human immunodeficiency virus (HIV) after a recent exposure to contaminated blood. Which instruction does the nurse provide?
Responda
  • The test shows that you are not infected with HIV.
  • This indicates that you are not contagious.
  • This indicates that you have immunity to HIV.
  • You need to repeat the test in six months.

Questão 8

Questão
The family of a hospitalized client with acquired immunodeficiency syndrome (AIDS) brings raw fish with rice for the client's dinner. Which action does the nurse take?
Responda
  • Assist the client in hand washing before the client eats?
  • Encourage the client to enjoy this high-protein meal.
  • Inform the family that food from home is not allowed.
  • Remind the client of prescribed dietary restrictions.

Questão 9

Questão
A nurse assesses a client diagnosed with systemic lupus erythematosus (SLE). Which symptoms does the nurse expect to see? Select all that apply.
Responda
  • Chronic dry, itchy eyes.
  • Presistent fatique
  • Protein present on urinalysis
  • Raid, red facial rash.
  • Recurrent urinary tract infections.

Questão 10

Questão
A nurse assesses a client with systemic lupus erythematosus (SLE). Which findings does the nurse expect to see? Select all that apply.
Responda
  • Alopecia
  • Butterfly rash on the face.
  • Excessive hair growth.
  • Hyperthyroidism
  • Muscle stiffness.

Questão 11

Questão
A nurse provides human immunodeficiency virus (HIV) education at a community clinic. The nurse includes in the education that which factor affects the transmission of HIV? Select all that apply.
Responda
  • Age
  • Gender
  • Type of bodily fluid
  • Type of sexual contact.
  • Viral Load.

Questão 12

Questão
A client with acquired immunodeficiency syndrome (AIDS) has a body mass index (BMI) of 17.1. Which instructions does the nurse provide to the client?
Responda
  • Choose nutrient-rich foods.
  • Eat small, frequent meals.
  • Follow this meal plan carefully.
  • Strive to gain two pounds per week.
  • Take the prescribed megestrol acetate.

Questão 13

Questão
An adult client arrives at the emergency department and reports being stung by wasps. The nurse assesses the client for which signs indicating anaphylaxis?
Responda
  • A feeling of impending doom.
  • Audible stridor.
  • Blood pressure of 168/92.
  • Nausea and vomiting.
  • Pulse of 120 beats/min.

Questão 14

Questão
A client diagnosed with systemic lupus erythematosus (SLE) asks the nurse whether the client's children will get the disease. The nurse provides which information to the client? Select all that apply.
Responda
  • SLE is more common is Caucasians.
  • SLE is more common females than in males.
  • SLE is more common in underweight people.
  • SLE is usually diagnosed after age 50.
  • SLE runs in families.

Questão 15

Questão
A nurse providing care to a client with multiple environmental allergies recognizes which WBCs as being responsible for histamine release?
Responda
  • Basophils
  • Eosinophils
  • Lymphocytes
  • Neutrophils

Questão 16

Questão
The nurse educates a client on passive exercises following a stroke. Which action demonstrates client understanding?
Responda
  • The client uses the unaffected hand to bend and straighten the elbow on the affected side.
  • The client provides support to the affected arm by placing it on a pillow when at rest.
  • The client lifts and lowers a three pound dumbell for five repetitions on the unaffected side.
  • The client contracts and relaxes the quadriceps, hamstrings, calves, and tibialis in both legs.

Questão 17

Questão
A nurse educates a client following a transient ischemic attack (TIA). The nurse recognizes further education is needed following which client statement?
Responda
  • "I need to manage my high blood pressure to reduce my risk of stroke."
  • "I understand TIAs may result in permanent damage to my brain tissue."
  • "I need to alert my HCP about any symptoms lasting longer than on hour."
  • "I now have a high risk of stroke since I've had a transient ischemic attack."

Questão 18

Questão
The nurse plans care for a client recovering from a right cerebral stroke. The nurse expects to see which client behaviors?
Responda
  • The client demonstrates word finding difficulty.
  • The client expresses a feeling of worthlessness.
  • The client's mood quickly changes from happiness to anger.
  • The client behaves in an impulsive manner.

Questão 19

Questão
The nurse assesses the client with a head injury and potential damage to the hypothalamus. The nurse evaluates what assessment findings as direct evidence of hypothalamic damage? Select All That Apply
Responda
  • Respiratory rate
  • Temperature
  • Sodium level
  • Urinary output
  • Pupillary response

Questão 20

Questão
The nurse cares for a client with traumatic brain injury. The nurse observes a yellow ring surrounding a clear, damp area on the client's pillow underneath the area of the ear. The nurse takes which action?
Responda
  • The nurse recognizes the ring as an emergency and alerts the nursing supervisor and rapid response team.
  • The nurse suspects the ring is cerebrospinal fluid drainage that should be monitored and reported to the HCP.
  • The nurse assesses the client for symptoms of ear infection including pain, difficulty hearing, and poor balance.
  • The nurse recognizes the ring as an expected occurence following traumatic brain injury and documents this change.

Questão 21

Questão
The nurse cares for a client admitted with subarachnoid hemorrhage following a ruptured aneurysm. The nurse intervenes after becoming aware of which action?
Responda
  • The UAP keeps the window shades closed and the lights dimmed.
  • The UAP limits client visitors and encourages all visitors to speak quietly.
  • The UAP reports the client has been on the bedpan for 20 minutes.
  • The UAP assists with range of motion exercises of the upper body.

Questão 22

Questão
The nurse cares for a client following a head injury. Based on the Glasgow Coma Scale, which assessment would place the client in the classification of moderate traumatic brain injury?
Responda
  • The client opens eyes to pain only, uses incomprehensible speech, and flexes in response to painful stimuli.
  • The client opens eyes spontaneously, is oriented, and obeys commands for movement.
  • The client opens eyes to command, uses inappropriate words, and demonstrates purposeful movement to painful stimuli.
  • The client has no eye response to pain, has no verbal response, and extends in response to painful stimuli.

Questão 23

Questão
A nurse cares for a client who is one day post-craniotomy. Upon neurological assessment, the nurse notes the client's right eye does not turn laterally. Which cranial nerve does the nurse suspect is damaged?
Responda
  • Cranial nerve VII
  • Cranial nerve VI
  • Cranial nerve V
  • Cranial nerve II

Questão 24

Questão
The nurse cares for a client following traumatic brain injury. The client's Glasgow Coma Scale score is 11. Which signs and symptoms does the nurse report immediately to the HCP?
Responda
  • The client reponds to pain only, has incomprehensible speech, and withdraws only to pain.
  • The client responds to verbal command, is confused, and obeys command for movement.
  • The client opens eyes spontaneously, is oriented, and obeys commands for movement.
  • The client reponds to verbal command, answers questions appropriately, and withdraws to touch.

Questão 25

Questão
A nurse assesses a client for a potential cerebral vascular accident. Which sign does the nurse assess for? Select All That Apply
Responda
  • Difficulty understanding speech
  • Inability to move an extremity
  • Ptosis of the eyelid
  • Sudden, severe headache
  • Dull, aching pain in the jaw

Questão 26

Questão
A client presents to the emergency department after hitting his head on the floor during a basketball game. The nurse obtains a Glasgow Coma Score (GCS) as follows: Best Eye Opening = 3 Best Verbal Response = 4 Best Motor Response = 6 Total GCS = 13 How does the nurse interpret these findings?
Responda
  • Spontaneous eye opening, oriented, and obeys commands.
  • Opens eyes to pain, no verbal response, and flexes arm to pain.
  • No eye opening, confused, and no motor response.
  • Opens eyes to verbal command, confused, and obeys commands.

Questão 27

Questão
The nurse teaches a client in the emergency department following mild traumatic brain injury. Which client statement indicates further education is needed?
Responda
  • "I will go the the emergency room if I begin to vomit."
  • "I will take a sedative tonight to help me rest."
  • "I will avoid the gym for the next two days."
  • "I will take acetaminophen to treat my headache."

Questão 28

Questão
The nurse assesses a client brought to emergency after a motor vehicle collision and suspects a closed head injury. The nurse prioritizes what assessment finding as requiring the most urgent intervention?
Responda
  • A temperature of 101.1 F (38.4 C).
  • A blood pressure of 160/100 mmHg.
  • A heart rate of 115 beats per minute.
  • A respiratory rate of 8 breaths per minute.

Questão 29

Questão
The nurse cares for a client with a right-sided cerebral vascular accident (CVA). Which assessment findings does the nurse associate with this condition?
Responda
  • Impaired comprehension
  • Impaired speech
  • Impaired judgment
  • Impulsivity
  • Hemiplegia

Questão 30

Questão
The nurse is preparing an adult client for an electroencephalogram (EEG). When providing education on the procedure, the nurse performs which action first?
Responda
  • Explain to the client that the adhesive has a strong odor.
  • Instruct the client to remain still once EEG recording begins.
  • Ensure the client's environment is quiet and provides adequate light.
  • Describe the attachment of electrodes to the scalp using adhesive.

Questão 31

Questão
A nurse conducts an hourly neurological assessment on a client recovering from a CVA. The client moans and withdraws to pain without eye opening. What Glasgow coma scale number does the nurse document?
Responda
  • 15
  • 10
  • 7
  • 3

Questão 32

Questão
A nurse monitors a client who had a stroke 36 hours ago. The nurse monitors the client for increased intracranial pressure (ICP). Which finding related to ICP does the nurse report to the health care provider? Select all that apply.
Responda
  • Client report of a headache
  • Declining level of consciousness
  • Decerebrate posturing
  • Severe hypotension
  • Pinpoint and nonreactive pupils

Questão 33

Questão
The nurse cares for a client with traumatic brain injury. The nurse notes the client's intracranial pressure (ICP) is elevating. Which actions does the nurse perform to decrease the ICP? Select All that Apply.
Responda
  • Maintain normal temperature and blood pressure ranges according to client baseline.
  • Position the head in a midline, neutral position.
  • Monitor oxygen saturation.
  • Assess pupil reactivity.
  • Administer mannitol as prescribed.

Questão 34

Questão
The nurse plans care for an adult client with expressive aphasia. Which intervention would the nurse implement to promote client communication?
Responda
  • Provide a communication board to point to needs.
  • Provide children's books to practice reading.
  • Provide a pad of paper and pen for writing.
  • Provide a microphone and speaker to amplify voice.

Questão 35

Questão
The nurse cares for a client with severe traumatic brain injury (TBI) on mechanical ventilation. The nurse implements which interventions? Select All that Apply
Responda
  • Cluster nursing care activities during each shift.
  • Suction airway secretions every 30 minutes.
  • Keep the head of the bed elevated as prescribed.
  • Maintain a quiet room with dimmed lights.
  • Encourge family members to visit in groups.

Questão 36

Questão
The nurse cares for a client with traumatic brain injury on continuous mechanical ventilation. The nurse assesses sluggish pupils and an increase in blood pressure. Which intervention does the nurse implement first?
Responda
  • Palpate carotid and radial pulses noting rate, strength, and regularity.
  • Dim room lights, turn off the TV, and quiet machine alarms if possible.
  • Auscultate four quadrants of the client's abdomen to complete assessment.
  • Call the HCP to recommend and request to hyperventilate the client.

Questão 37

Questão
The nurse cares for a client with a ventro-peritoneal shunt. The nurse recognizes which signs of increased intracranial pressure (ICP)? Select All That Apply
Responda
  • The client demonstrates hypotension.
  • The client reports a headache.
  • The client demonstrates bradycardia.
  • The client demonstrates sluggish pupils.
  • The client experiences vomiting.

Questão 38

Questão
The nurse performs a neurological assessment on a client admitted with traumatic brain injury. Which new finding does the nurse report the HCP immediately?
Responda
  • Fasciculations are noted around the face and eyes.
  • The client's exhibits 3+ cutaneous reflexes.
  • The client scores 12 on the Glasgow coma scale.
  • The client demonstrates decerebrate posturing.

Questão 39

Questão
The nurse cares for a client admitted with a traumatic brain injury. The client is confused but cooperative. The nurse includes which intervention in the client's care plan?
Responda
  • Encourage frequent visitors to assist with client orientation.
  • Perform neurological assessments frequently to monitor for changes.
  • Maintain bright lighting to promote orientation to the environment.
  • Apply soft wrist restraints to reduce the risk for injury.

Questão 40

Questão
A client is admitted for care after a traumatic brain injury. The client has a history of atrial fibrillation and obesity. Which prescribed medication does the nurse question?
Responda
  • Pantoprazole
  • Mannitol
  • Ondansetron
  • Warfarin

Questão 41

Questão
A client taking valproate acid reports hair loss. Which action taken by the nurse is appropriate?
Responda
  • Tell the client not to worry, that it will grow back.
  • Notify the health care provider immediately.
  • Explain that this is an expected side effect.
  • Contact the provider and ask for the client to be given a prescription shampoo.

Questão 42

Questão
A client with chronic renal failure and a history of seizures has a phenytoin level of 28 mcg/mL. The nurse monitors the client for which symptoms?
Responda
  • Nystagmus
  • Hypertension
  • Constipation
  • Ataxia
  • Agitation

Questão 43

Questão
The nurse administers IV mannitol every six hours for a client with a closed head injury. Within two hours of mannitol administration, the nurse observes which therapeutic responses to mannitol from the client? Select All That Apply
Responda
  • Increased urinary output
  • Increased respiratory rate
  • Decreased heart rate
  • Decreased potassium level
  • Decreased intracranial pressure

Questão 44

Questão
A client is prescribed long-term methylprednisolone. What does the nurse teach the client about methylprednisolone therapy? Select All That Apply
Responda
  • "Monitor your blood pressure periodically."
  • "Take this medication at bedtime with a snack."
  • "Hold the dose if you notice fluid around the ankles."
  • "Increase your intake of foods with potassium."
  • "Increase your intake of calcium and vitamin D."

Questão 45

Questão
A client on mechanical ventilation receives high-dose propofol. The nurse monitors the client for what adverse effects? Select All That Apply
Responda
  • Hypercalcemia
  • Hypercapnia
  • Hyperkalemia
  • Metabolic acidosis
  • Bradycardia

Questão 46

Questão
A client is prescribed prednisone for long-term use. The nurse instructs the client to incorporate what dietary modifications while taking prednisone? Select All That Apply
Responda
  • Increase intake of calcium-rich foods.
  • Avoid foods high in potassium.
  • Limit intake of high-sodium foods.
  • Increase intake of complex carbohydrates.
  • Increase intake of lean protein.

Questão 47

Questão
A client is prescribed ondansetron. The nurse assesses the client for what side effects? Select All That Apply
Responda
  • Hyperkalemia
  • Bradycardia
  • Hypertension
  • Headache
  • Constipation

Questão 48

Questão
A client with severe brain trauma has been prescribed pentobarbital. How does the nurse best explain the purpose of administering the medication to this client?
Responda
  • "Barbiturates like pentobarbital are prescribed to prevent seizure activity related to brain injury."
  • "Pentobarbital sedates the client to prevent complications during mechanical ventilation."
  • "This barbiturate creates sedation and reduces the overall basal metabolic rate, inducing a coma."
  • "Pentobarbital slows cerebral blood flow and metabolism, reducing intracranial pressure."

Questão 49

Questão
A client admitted for traumatic brain injury with a depressed skull fracture becomes restless. The nurse performs which interventions related to these findings? Select All That Apply
Responda
  • Prepare the client for surgery as prescribed.
  • Prevent skin breakdown while immobile.
  • Initiate prescribed therapeutic hypothermia treatment.
  • Perform a focused assessment.
  • Place the call bell within reach.

Questão 50

Questão
The health care provider prescribes a mechanical altered diet for a client who is recovering from a cerebrovascular accident (CVA). Which food choices does the nurse offer the client? Select All That Apply
Responda
  • Cooked diced carrots
  • Baked potato with skin
  • Raw pineapple chunks
  • Pasta with meat sauce
  • Peanut butter sandwich

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