1. A nurse is admitting a patient with an immunodeficiency to the medical unit. In
planning the care of this patient, the nurse should assess for what common sign of
immunodeficiency?
a. Chronic diarrhea
2. A nurse i
...
1. A nurse is admitting a patient with an immunodeficiency to the medical unit. In
planning the care of this patient, the nurse should assess for what common sign of
immunodeficiency?
a. Chronic diarrhea
2. A nurse is caring for a patient who has an immunodeficiency. What assessment
finding should prompt the nurse to consider the possibility that the patient is
developing an infection?
a. Persistent diarrhea
3. The nurse is applying standard precautions in the care of a patient who has an
immunodeficiency. What are key elements of standard precautions? Select all that
apply.
a. Using appropriate personal protective equipment
b. Using safe injection practices
c. Performing hand hygiene
4. A home health nurse is reinforcing health education with a patient who is
immunosuppressed and his family. What statement best suggests that the patient
has understood the nurse's teaching?
a. “My family needs to understand that I'll probably need lifelong
treatment.”
5. The nurse is preparing to administer IVIG to a patient who has an
immunodeficiency. What nursing guideline should the nurse apply?
a. Administer pretreatment medications as ordered 30 minutes prior to
infusion.
6. A nurse has created a plan of care for an immunodeficient patient, specifying that
care providers take the patient's pulse and respiratory rate for a full minute. What
is the rationale for this aspect of care?
a. These patients' blunted inflammatory responses can cause subtle
changes in status.
7. A nurse is providing health education regarding self-care to a patient with an
immunodeficiency. What teaching point should the nurse emphasize?
a. The need for thorough oral hygiene
8. A patient's primary immunodeficiency disease is characterized by the inability of
white blood cells to initiate an inflammatory response to infectious organisms.
What is this patient's most likely diagnosis?
a. Hyperimmunoglobulinemia E syndrome
9. A nurse is working with a patient who was diagnosed with HIV several months
earlier. The nurse should recognize that a patient with HIV is considered to have
AIDS at the point when the CD4+ T-lymphocyte cell count drops below what
threshold?
a. 200 cells/mm3 of blood
10. A patient has been diagnosed with AIDS complicated by chronic diarrhea.
What nursing intervention would be appropriate for this patient?
a. Obtain a stool culture to identify possible pathogens.
11. An 18-year-old pregnant female has tested positive for HIV and asks the
nurse if her baby is going to be born with HIV. What is the nurse's best response?
a. “It's possible that your baby could contract HIV, either before,
during, or after delivery.”
12. Since the emergence of HIV/AIDS, there have been significant changes in
epidemiologic trends. Members of what group currently have the greatest risk of
contracting HIV?
a. Gay, bisexual, and other men who have sex with men
13. A hospital patient is immunocompromised because of stage 3 HIV infection
and the physician has ordered a chest radiograph. How should the nurse most
safely facilitate the test?
a. Arrange for a portable x-ray machine to be used
14. A patient's current antiretroviral regimen includes nucleoside reverse
transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide
based on the patient's medication regimen?
a. Take this medication without regard to meals.
15. A nurse is performing the admission assessment of a patient who has AIDS.
What components should the nurse include in this comprehensive assessment?
Select all that apply.
a. Current medication regimen
b. Identification of patient's support system
c. Immune system function
d. History of sexual practices
16. A patient is in the primary infection stage of HIV. What is true of this patient's
current health status?
a. The patient is infected with HIV but lacks HIV-specific antibodies.
17. A nurse is aware of the need to assess patients' risks for anaphylaxis. What
health care procedure constitutes the highest risk for anaphylaxis?
a. Computed tomography with contrast solution
18. A patient with multiple food and environmental allergies tells the nurse that
he is frustrated and angry about having to be so watchful all the time and wonders
if it is really worth it. What would be the nurse's best response?
a. “I can only imagine how you feel. Would you like to talk about it?
19. A nurse is caring for a patient who has allergic rhinitis. What intervention
would be most likely to help the patient meet the goal of improved breathing
pattern?
a. Modify the environment to reduce the severity of allergic symptoms.
20. The nurse in an allergy clinic is educating a new patient about the pathology
of the patient's health problem. What response should the nurse describe as a
possible consequence of histamine release?
a. Contraction of bronchial smooth muscle
21. A patient has presented with signs and symptoms that are consistent with
contact dermatitis. What aspect of care should the nurse prioritize when working
with this patient?
a. Identifying the offending agent, if possible
22. A patient's rheumatoid arthritis (RA) has failed to respond appreciably to
first-line treatments and the primary care provider has added prednisone to the
patient's drug regimen. What principle will guide this aspect of the patient's
treatment?
a. The drug should be used for as short a time as possible.
23. A patient with SLE has come to the clinic for a routine check-up. When
auscultating the patient's apical heart rate, the nurse notes the presence of a
distinct “scratching” sound. What is the nurse's most appropriate action?
a. Inform the primary care provider that a friction rub may be present.
24. A nurse is educating a patient with gout about lifestyle modifications that
can help control the signs and symptoms of the disease. What recommendation
should the nurse make?
a. Limiting intake of alcohol
25. A nurse is planning the care of a patient who has a long history of chronic
pain, which has only recently been diagnosed as fibromyalgia. What nursing
diagnosis is most likely to apply to this woman's care needs?
a. Ineffective Role Performance Related to Pain
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