Question 1

The nurse is teaching a group of parents at the local elementary school health fair about immunity and the importance of vaccination.Which scenario will the nurse provide as one in active immunity is acquired?
A) Receiving a rabies shot after being bitten by a rabid dog
B) Having measles
C) Receiving an injection of gamma globulin
D) Becoming ill with tetanus and receiving tetanus toxoid

Accepted Answer

A) When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.
B) When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.
C) When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.
D) When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.

Question 2

The nurse is caring for a client who is newly diagnosed with human immunodeficiency virus (HIV).The client asks the nurse if there are ways to protect the client's life partner from getting the HIV virus.After educating the client,which statement indicates the need for further education?
A) "I know to use an oil-based lubricant to prevent spread of the disease to my partner."
B) "I can still kiss and hug my partner to show affection."
C) "I will not share my razor with my partner."
D) "I know I have to practice safer sex with my partner by using a latex condom."

Accepted Answer

A) The nurse should educate the client on methods that will decrease the risk of transmitting the HIV. The client statement regarding the use of an oil-based lubricant requires further education. The client should use only water-based lubricants-not oil-based, such as petroleum jelly, which can result in condom damage. The other statements by the client indicate appropriate understanding of the information presented by the nurse.
B) The nurse should educate the client on methods that will decrease the risk of transmitting the HIV. The client statement regarding the use of an oil-based lubricant requires further education. The client should use only water-based lubricants-not oil-based, such as petroleum jelly, which can result in condom damage. The other statements by the client indicate appropriate understanding of the information presented by the nurse.
C) The nurse should educate the client on methods that will decrease the risk of transmitting the HIV. The client statement regarding the use of an oil-based lubricant requires further education. The client should use only water-based lubricants-not oil-based, such as petroleum jelly, which can result in condom damage. The other statements by the client indicate appropriate understanding of the information presented by the nurse.
D) The nurse should educate the client on methods that will decrease the risk of transmitting the HIV. The client statement regarding the use of an oil-based lubricant requires further education. The client should use only water-based lubricants-not oil-based, such as petroleum jelly, which can result in condom damage. The other statements by the client indicate appropriate understanding of the information presented by the nurse.

Question 3

The nurse is providing care to a pediatric client who is HIV-positive.The client's mother is describing the child's current condition and activities to the nurse.Which statements by the mother indicate that the child is currently exhibiting positive outcomes related to the diagnosis? Select all that apply.
A) "My child attends school and doing well in class."
B) "My child seems somewhat isolated and doesn't have any real friends."
C) "My child has a good appetite and eats regular meals."
D) "My child hasn't shown any sign of infection."
E) "We attend a weekly support group for kids with HIV."

Accepted Answer

A) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.
B) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.
C) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.
D) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.
E) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.

Question 4

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

Accepted Answer

A) While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the client statement, "I don't plan on giving up sex just because I am HIV positive." The client requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners.
B) While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the client statement, "I don't plan on giving up sex just because I am HIV positive." The client requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners.
C) While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the client statement, "I don't plan on giving up sex just because I am HIV positive." The client requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners.
D) While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the client statement, "I don't plan on giving up sex just because I am HIV positive." The client requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners.

Question 5

The nurse is providing care to an adolescent client who presents at the clinic for a routine health assessment.Which immunizations does the nurse anticipate administering to the adolescent during this visit? Select all that apply.
A) MMR booster
B) Papillomavirus vaccine
C) TDaP booster
D) Meningococcal vaccine
E) Hepatitis B vaccine

Accepted Answer

A) The immunizations that the nurse anticipates administering during this routine visit for the adolescent client is the papillomavirus and meningococcal vaccines. The MMR and TDaP boosters would be anticipated for an adult client. A hepatitis B vaccine would be anticipate for an infant client.
B) The immunizations that the nurse anticipates administering during this routine visit for the adolescent client is the papillomavirus and meningococcal vaccines. The MMR and TDaP boosters would be anticipated for an adult client. A hepatitis B vaccine would be anticipate for an infant client.
C) The immunizations that the nurse anticipates administering during this routine visit for the adolescent client is the papillomavirus and meningococcal vaccines. The MMR and TDaP boosters would be anticipated for an adult client. A hepatitis B vaccine would be anticipate for an infant client.
D) The immunizations that the nurse anticipates administering during this routine visit for the adolescent client is the papillomavirus and meningococcal vaccines. The MMR and TDaP boosters would be anticipated for an adult client. A hepatitis B vaccine would be anticipate for an infant client.
E) The immunizations that the nurse anticipates administering during this routine visit for the adolescent client is the papillomavirus and meningococcal vaccines. The MMR and TDaP boosters would be anticipated for an adult client. A hepatitis B vaccine would be anticipate for an infant client.

Question 6

Human immunodeficiency virus (HIV)infects and destroys CD4 cells.List the following events in the order in which they occur for a client who is HIV-positive.
A) Virus invades helper T cell
B) Viral RNA converts with reverse transcriptase to viral DNA
C) Viral DNA integrates with host cell DNA.
D) Virus remains latent, or actively replicates.
E) Virus sheds protein coat.

Accepted Answer

The answer of Human immunodeficiency virus (HIV)infects and destroys CD4...

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

Accepted Answer

A) Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples of artificially acquired passive immunity, but would not be used in the case of an animal bite. Mother's breast milk is another example of passive immunity, but would not be used in the case of an animal bite.
B) Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples but would not be used in the case of an animal bite. Mother's breast milk is another example of passive immunity, but would not be used in the case of an animal bite.
C) Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples but would not be used in the case of an animal bite. Mother's breast milk is another example of passive immunity, but would not be used in the case of an animal bite.
D) Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples but would not be used in the case of an animal bite. Mother's breast milk is another example of passive immunity, but would not be used in the case of an animal bite.

Question 8

A nurse is caring for a client with who is experiencing leukocytosis.When providing care to this client,which action by the nurse is the most appropriate?
A) Instruct the client on the use of an electric razor and soft toothbrush.
B) Assess for bleeding and bruising.
C) Assess for source of infection.
D) Place the patient in reverse isolation precautions.

Accepted Answer

A) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm³) which is an indication of infection. The appropriate action by the nurse is to assess the client for a source of the infection. Instructing the client on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a client with decreased platelet levels, or thrombocytopenia. Placing the client in reverse isolation precautions would be appropriate for the client with neutropenia, a decrease in the number of neutrophils.
B) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm³) which is an indication of infection. The appropriate action by the nurse is to assess the client for a source of the infection. Instructing the client on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a client with decreased platelet levels, or thrombocytopenia. Placing the client in reverse isolation precautions would be appropriate for the client with neutropenia, a decrease in the number of neutrophils.
C) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm³) which is an indication of infection. The appropriate action by the nurse is to assess the client for a source of the infection. Instructing the client on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a client with decreased platelet levels, or thrombocytopenia. Placing the client in reverse isolation precautions would be appropriate for the client with neutropenia, a decrease in the number of neutrophils.
D) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm³) which is an indication of infection. The appropriate action by the nurse is to assess the client for a source of the infection. Instructing the client on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a client with decreased platelet levels, or thrombocytopenia. Placing the client in reverse isolation precautions would be appropriate for the client with neutropenia, a decrease in the number of neutrophils.

Question 9

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) 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

Accepted Answer

A) The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration.
B) The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration.
C) The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration.
D) The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration.

Question 10

The nurse is providing care to a client with a compromised immune system.Which independent nursing intervention is appropriate for the nurse to include in the client's plan of care?
A) Educating on the importance of a nutritious diet
B) Administering corticosteroids, per order
C) Prescribing prophylactic antibiotic therapy
D) Recommending gene transfer therapy

Accepted Answer

A) While of these may be appropriate treatment for a client who is experiencing a compromised immune system, the only independent nursing intervention is educating the client on the importance of a nutritious diet. Administering corticosteroids, per order, is a collaborative intervention. It is outside the scope of nursing practice to prescribe medication and to recommend therapies. The nurse can administer antibiotics and educate the client on gene transfer therapy, if prescribed by the health care provider.
B) While of these may be appropriate treatment for a client who is experiencing a compromised immune system, the only independent nursing intervention is educating the client on the importance of a nutritious diet. Administering corticosteroids, per order, is a collaborative intervention. It is outside the scope of nursing practice to prescribe medication and to recommend therapies. The nurse can administer antibiotics and educate the client on gene transfer therapy, if prescribed by the health care provider.
C) While of these may be appropriate treatment for a client who is experiencing a compromised immune system, the only independent nursing intervention is educating the client on the importance of a nutritious diet. Administering corticosteroids, per order, is a collaborative intervention. It is outside the scope of nursing practice to prescribe medication and to recommend therapies. The nurse can administer antibiotics and educate the client on gene transfer therapy, if prescribed by the health care provider.
D) While of these may be appropriate treatment for a client who is experiencing a compromised immune system, the only independent nursing intervention is educating the client on the importance of a nutritious diet. Administering corticosteroids, per order, is a collaborative intervention. It is outside the scope of nursing practice to prescribe medication and to recommend therapies. The nurse can administer antibiotics and educate the client on gene transfer therapy, if prescribed by the health care provider.

Question 11

The nurse suspects that the client is experiencing a reaction to a specific antigen.Which laboratory result supports the conclusion made by the nurse?
A) Indirect Coombs' showing no agglutination
B) Patch test with a 1-inch area of erythema
C) 2% eosinophils in the WBC count
D) Rh antigen with negative results

Accepted Answer

A) An area of erythema after a patch test indicates a positive response to a specific antigen. Indirect Coombs' test detects the presence of circulating antibodies against RBCs. No agglutination is considered a normal finding. An eosinophil count of 2% is within the normal range. An Rh antigen with a negative result indicates that the client does not carry the antigen and 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. Indirect Coombs' test detects the presence of circulating antibodies against RBCs. No agglutination is considered a normal finding. An eosinophil count of 2% is within the normal range. An Rh antigen with a negative result indicates that the client does not carry the antigen and 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. Indirect Coombs' test detects the presence of circulating antibodies against RBCs. No agglutination is considered a normal finding. An eosinophil count of 2% is within the normal range. An Rh antigen with a negative result indicates that the client does not carry the antigen and 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. Indirect Coombs' test detects the presence of circulating antibodies against RBCs. No agglutination is considered a normal finding. An eosinophil count of 2% is within the normal range. An Rh antigen with a negative result indicates that the client does not carry the antigen and is not an indicator of a reaction to a specific antigen.

Question 12

The nurse is planning care for a pediatric client diagnosed with human immunodeficiency virus (HIV).The nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric client.Based on this nursing diagnosis,which actions by the nurse are appropriate? Select all that apply.
A) Administering tuberculosis skin tests every six months
B) Teaching proper food-handling techniques to the family
C) Instructing on the importance of consuming ample fresh fruits and vegetables
D) Assessing the health status of all visitors
E) Monitoring hand-washing techniques used by the famly

Accepted Answer

A) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. Tuberculosis skin tests should be administered annually, not every six months. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.
B) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. Tuberculosis skin tests should be administered annually, not every six months. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.
C) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. Tuberculosis skin tests should be administered annually, not every six months. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.
D) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. Tuberculosis skin tests should be administered annually, not every six months. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.
E) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. Tuberculosis skin tests should be administered annually, not every six months. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.

Question 13

The nurse is providing care to a client who is receiving nonsteroidal anti-inflammatory drugs (NSAIDs)in the treatment of rheumatoid arthritis.When providing care to this client,which actions by the nurse are appropriate? Select all that apply.
A) Monitoring for signs of allergic reaction
B) Assuring the client that there is no relationship between NSAIDs and heart disease
C) Encouraging the client to take with a full glass of water, milk, or small snack to help avoid GI distress
D) Monitoring for signs of renal problems
E) Advising against abrupt discontinuation of drugs

Accepted Answer

A) When providing care to a client who is receiving any medication, it is important to monitor the client for signs of an allergic reaction. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects. NSAIDs have been linked to heart failure; therefore, this action by the nurse is not appropriate when providing care to this client.
B) When providing care to a client who is receiving any medication, it is important to monitor the client for signs of an allergic reaction. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects. NSAIDs have been linked to heart failure; therefore, this action by the nurse is not appropriate when providing care to this client.
C) When providing care to a client who is receiving any medication, it is important to monitor the client for signs of an allergic reaction. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects. NSAIDs have been linked to heart failure; therefore, this action by the nurse is not appropriate when providing care to this client.
D) When providing care to a client who is receiving any medication, it is important to monitor the client for signs of an allergic reaction. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects. NSAIDs have been linked to heart failure; therefore, this action by the nurse is not appropriate when providing care to this client.
E) When providing care to a client who is receiving any medication, it is important to monitor the client for signs of an allergic reaction. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects. NSAIDs have been linked to heart failure; therefore, this action by the nurse is not appropriate when providing care to this client.

Question 14

The nurse is conducting a physical assessment for a client with a compromised immune system.Which actions by the nurse are appropriate? Select all that apply.
A) Assessing general appearance
B) Recommending increased fluid intake
C) Inspecting the mucous membranes of the nose and mouth for color and condition
D) Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness
E) Checking joint range of motion (ROM), including that of the spine

Accepted Answer

A) The techniques of inspection and palpation are especially important in assessing a client's immune system: The nurse will assess the client's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the client's ROM, including that of the spine. While recommending that the client increase fluid intake may be an appropriate intervention, this is not an action that is conducted during the physical assessment for this client.
B) The techniques of inspection and palpation are especially important in assessing a client's immune system: The nurse will assess the client's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the client's ROM, including that of the spine. While recommending that the client increase fluid intake may be an appropriate intervention, this is not an action that is conducted during the physical assessment for this client.
C) The techniques of inspection and palpation are especially important in assessing a client's immune system: The nurse will assess the client's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the client's ROM, including that of the spine. While recommending that the client increase fluid intake may be an appropriate intervention, this is not an action that is conducted during the physical assessment for this client.
D) The techniques of inspection and palpation are especially important in assessing a client's immune system: The nurse will assess the client's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the client's ROM, including that of the spine. While recommending that the client increase fluid intake may be an appropriate intervention, this is not an action that is conducted during the physical assessment for this client.
E) The techniques of inspection and palpation are especially important in assessing a client's immune system: The nurse will assess the client's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the client's ROM, including that of the spine. While recommending that the client increase fluid intake may be an appropriate intervention, this is not an action that is conducted during the physical assessment for this client.

Question 15

A client receives the yellow fever vaccine before traveling to the Amazon Basin and asks the nurse how the vaccine provides protection.Which responses by the nurse is the most appropriate? Select all that apply.
A) "Human macrophages engulf the weakened vaccine virus as if it is dangerous and antigens stimulate the immune system to attack it."
B) "In the lymph nodes, part of the lymphoid system, the macrophages present yellow fever antigens to T cells and B cells."
C) "A response from yellow fever-specific T cells is activated. B cells secrete yellow fever antibodies."
D) "The body's immune system eats away at the protective sheath (myelin) that covers the nerves."
E) "The initial weak infection is eliminated and the client is left with a supply of memory T and B cells for future protection against yellow fever."

Accepted Answer

A) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.
B) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.
C) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.
D) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.
E) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.

Question 16

The nurse is discharging a pediatric who recently developed acquired immunodeficiency syndrome (AIDS).When discussing appropriate health promotion activities for this child,which immunization is not appropriate for this client to receive due to AIDS diagnosis?
A) Varicella vaccine
B) Haemophilus influenzae type B (HIB conjugate vaccine)
C) Hepatitis B vaccine (hep
D) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

Accepted Answer

A) A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.
B) A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.
C) A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.
D) A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.

Question 17

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?
A) A client who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count
B) A client with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath
C) A client with wasting syndrome who needs modifications and education regarding dietary changes
D) A client who is receiving IV antibiotics daily for toxoplasmosis

Accepted Answer

A) The home health nurse should see the client with PCP because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain vital signs and perform a respiratory assessment.
B) The home health nurse should see the client with PCP because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain vital signs and perform a respiratory assessment.
C) The home health nurse should see the client with PCP because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain vital signs and perform a respiratory assessment.
D) The home health nurse should see the client with PCP because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain vital signs and perform a respiratory assessment.

Question 18

The nurse is reviewing the laboratory values of a client who is newly diagnosed with acquired immunodeficiency syndrome (AIDS).Which values should be reported to the client's healthcare provider? Select all that apply.
A) CD4 cell count 1,100/mm³
B) T4 cell count 150
C) CD4 lymphocytes 12%
D) Viral load 11,500 copies/mL
E) WBC 6,500

Accepted Answer

A) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm³. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range.
B) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm³. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range.
C) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm³. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range.
D) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm³. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range.
E) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm³. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range.

Question 19

A nurse is performing an admission assessment on a client with symptoms that indicate the client may have human immunodeficiency virus (HIV).Which question from the nurse addresses a major risk factor for contracting HIV?
A) "Has your partner been experiencing these symptoms?"
B) "When was your first sexual experience?"
C) "Have you had any fever, diarrhea, or chills over the last 48 hours?"
D) "Have you ever experimented with intravenous drugs?"

Accepted Answer

A) One risk factor for contracting HIV is the use of intravenous recreational drugs. This question is appropriate to determine the client's risk for HIV. The client's first sexual experience is not applicable to the client's current risk for HIV. Assessing recent symptoms, and asking if the client's partner is experiencing the same symptoms, does not assess the client's risk factors for HIV transmission.
B) One risk factor for contracting HIV is the use of intravenous recreational drugs. This question is appropriate to determine the client's risk for HIV. The client's first sexual experience is not applicable to the client's current risk for HIV. Assessing recent symptoms, and asking if the client's partner is experiencing the same symptoms, does not assess the client's risk factors for HIV transmission.
C) One risk factor for contracting HIV is the use of intravenous recreational drugs. This question is appropriate to determine the client's risk for HIV. The client's first sexual experience is not applicable to the client's current risk for HIV. Assessing recent symptoms, and asking if the client's partner is experiencing the same symptoms, does not assess the client's risk factors for HIV transmission.
D) One risk factor for contracting HIV is the use of intravenous recreational drugs. This question is appropriate to determine the client's risk for HIV. The client's first sexual experience is not applicable to the client's current risk for HIV. Assessing recent symptoms, and asking if the client's partner is experiencing the same symptoms, does not assess the client's risk factors for HIV transmission.

Question 20

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

Accepted Answer

A) Physiological barriers that protect the body against microorganisms include adequate urinary output and intact skin. The act of voiding flushes organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. The consumption of alcoholic beverages has been known to increase the risk for infection. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. A surgical incision can both allow microorganisms to enter the body.
B) Physiological barriers that protect the body against microorganisms include adequate urinary output and intact skin. The act of voiding flushes organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. The consumption of alcoholic beverages has been known to increase the risk for infection. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. A surgical incision can both allow microorganisms to enter the body.
C) Physiological barriers that protect the body against microorganisms include adequate urinary output and intact skin. The act of voiding flushes organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. The consumption of alcoholic beverages has been known to increase the risk for infection. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. A surgical incision can both allow microorganisms to enter the body.
D) Physiological barriers that protect the body against microorganisms include adequate urinary output and intact skin. The act of voiding flushes organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. The consumption of alcoholic beverages has been known to increase the risk for infection. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. A surgical incision can both allow microorganisms to enter the body.
E) Physiological barriers that protect the body against microorganisms include adequate urinary output and intact skin. The act of voiding flushes organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. The consumption of alcoholic beverages has been known to increase the risk for infection. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. A surgical incision can both allow microorganisms to enter the body.

Quiz 8: Immunity

The nurse is teaching a group of parents at the local elementary school health fair about immunity and the importance of vaccination.Which scenario will the nurse provide as one in active immunity is acquired?

The nurse is caring for a client who is newly diagnosed with human immunodeficiency virus (HIV) .The client asks the nurse if there are ways to protect the client's life partner from getting the HIV virus.After educating the client,which statement indicates the need for further education?

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?

The nurse is providing care to an adolescent client who presents at the clinic for a routine health assessment.Which immunizations does the nurse anticipate administering to the adolescent during this visit? Select all that apply.

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 caring for a client with who is experiencing leukocytosis.When providing care to this client,which action by the nurse is the most appropriate?

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?

The nurse is providing care to a client with a compromised immune system.Which independent nursing intervention is appropriate for the nurse to include in the client's plan of care?

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

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

The nurse is providing care to a client who is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of rheumatoid arthritis.When providing care to this client,which actions by the nurse are appropriate? Select all that apply.

The nurse is conducting a physical assessment for a client with a compromised immune system.Which actions by the nurse are appropriate? Select all that apply.

A client receives the yellow fever vaccine before traveling to the Amazon Basin and asks the nurse how the vaccine provides protection.Which responses by the nurse is the most appropriate? Select all that apply.

The nurse is discharging a pediatric who recently developed acquired immunodeficiency syndrome (AIDS) .When discussing appropriate health promotion activities for this child,which immunization is not appropriate for this client to receive due to AIDS diagnosis?

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?

The nurse is reviewing the laboratory values of a client who is newly diagnosed with acquired immunodeficiency syndrome (AIDS) .Which values should be reported to the client's healthcare provider? Select all that apply.

A nurse is performing an admission assessment on a client with symptoms that indicate the client may have human immunodeficiency virus (HIV) .Which question from the nurse addresses a major risk factor for contracting HIV?