Question 1

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) 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

Accepted Answer

A) General symptoms of shock that would necessitate an epinephrine injection include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.
B) General symptoms of shock that would necessitate an epinephrine injection include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.
C) General symptoms of shock that would necessitate an epinephrine injection include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.
D) General symptoms of shock that would necessitate an epinephrine injection include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.
E) General symptoms of shock that would necessitate an epinephrine injection include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.

Question 2

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?
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.

Accepted Answer

A) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client's signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.
B) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client's signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.
C) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client's signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.
D) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client's signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.

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

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 a 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 a 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 a 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 a type III hypersensitivity reactions.

Question 4

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.
A) "It is recommended that the child wear a medical alert bracelet."
B) "This medication does not come pre-filled and must be measured."
C) "Keep the medication in the car at all times."
D) "Frequently check the expiration date of the medication."
E) "Keep the medication in one location that is easy to remember."

Accepted Answer

A) An EpiPen is a 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 provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen 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. The expiration date should be checked frequently to ensure accurate strength.
B) An EpiPen is a 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 provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen 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. The expiration date should be checked frequently to ensure accurate strength.
C) An EpiPen is a 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 provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen 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. The expiration date should be checked frequently to ensure accurate strength.
D) An EpiPen is a 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 provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen 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. The expiration date should be checked frequently to ensure accurate strength.
E) An EpiPen is a 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 provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen 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. The expiration date should be checked frequently to ensure accurate strength.

Question 5

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

Accepted Answer

A) RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia. If properly managed, RA is not considered to be a danger for pregnant women or their babies.
B) RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia. If properly managed, RA is not considered to be a danger for pregnant women or their babies.
C) RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia. If properly managed, RA is not considered to be a danger for pregnant women or their babies.
D) RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia. If properly managed, RA is not considered to be a danger for pregnant women or their babies.
E) RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia. If properly managed, RA is not considered to be a danger for pregnant women or their babies.

Question 6

The nurse is caring for a client who was diagnosed with rheumatoid arthritis (RA)last year.The client has recently been placed on prednisone for treatment.The nurse is teaching the client about safe medication administration.Which client statement indicates that the medication teaching was successful?
A) "I will not have to limit my consumption of canned vegetables."
B) "I will take this medication on a full stomach to enhance absorption."
C) "I will not need to monitor my blood sugar more frequently while on this medication."
D) "I will take the ordered dose at the same time every day."

Accepted Answer

A) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day. Steroids are taken with food to minimize GI distress, not to enhance absorption. Steroids can cause fluid retention, so sodium intake should be limited. A hidden source of sodium is canned vegetables. Steroids also increase blood sugar, so blood sugar may need to be monitored more frequently while on the medication regimen.
B) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day. Steroids are taken with food to minimize GI distress, not to enhance absorption. Steroids can cause fluid retention, so sodium intake should be limited. A hidden source of sodium is canned vegetables. Steroids also increase blood sugar, so blood sugar may need to be monitored more frequently while on the medication regimen.
C) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day. Steroids are taken with food to minimize GI distress, not to enhance absorption. Steroids can cause fluid retention, so sodium intake should be limited. A hidden source of sodium is canned vegetables. Steroids also increase blood sugar, so blood sugar may need to be monitored more frequently while on the medication regimen.
D) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day. Steroids are taken with food to minimize GI distress, not to enhance absorption. Steroids can cause fluid retention, so sodium intake should be limited. A hidden source of sodium is canned vegetables. Steroids also increase blood sugar, so blood sugar may need to be monitored more frequently while on the medication regimen.

Question 7

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? ?
A) Anaphylactic reaction to shellfish
B) A drug reaction to penicillin causing a rash
C) Glomerulonephritis
D) Dermatitis resulting from a response to changing laundry detergent

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 8

A nurse is caring for a client who was admitted to the hospital with an exacerbation of rheumatoid arthritis (RA).The client reports pain is a 3 on a scale from 1 to 10 today.Which non-pharmacological interventions can the nurse provide to enhance the client's comfort? Select all that apply.
A) Discourage any position changes.
B) Encourage relaxation techniques
C) Immobilize the extremity.
D) Offer a massage
E) Provide diversion activities.

Accepted Answer

A) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.
B) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.
C) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.
D) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.
E) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.

Question 9

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.
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.

Accepted Answer

A) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong grip, so typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.
B) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong grip, so typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.
C) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong grip, so typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.
D) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong grip, so typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.
E) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong grip, so typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.

Question 10

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?
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.

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 not realistic because the family member might experience exposure on another unit. (No hospital unit can be latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client's right's.
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 not realistic because the family member might experience exposure on another unit. (No hospital unit can be latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client's right's.
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 latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client's right's.
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 latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client's right's.

Question 11

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

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 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. 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 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. 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 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. 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 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. Placing the client in Fowler or high Fowler position allows optimal lung expansion and ease of breathing.

Question 12

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?
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."

Accepted Answer

A) One hallmark symptom of RA is extreme fatigue. The client's statement regarding the need for a nap supports the inclusion of Activity Intolerance in the plan of care. , The nurse would teach the client about frequent rest periods during the day to conserve energy. The client with RA will be stiff early in the morning, but that would not interfere with activities later in the day. Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does not affect the ability for activity.
B) One hallmark symptom of RA is extreme fatigue. The client's statement regarding the need for a nap supports the inclusion of Activity Intolerance in the plan of care. , The nurse would teach the client about frequent rest periods during the day to conserve energy. The client with RA will be stiff early in the morning, but that would not interfere with activities later in the day. Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does not affect the ability for activity.
C) One hallmark symptom of RA is extreme fatigue. The client's statement regarding the need for a nap supports the inclusion of Activity Intolerance in the plan of care. , The nurse would teach the client about frequent rest periods during the day to conserve energy. The client with RA will be stiff early in the morning, but that would not interfere with activities later in the day. Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does not affect the ability for activity.
D) One hallmark symptom of RA is extreme fatigue. The client's statement regarding the need for a nap supports the inclusion of Activity Intolerance in the plan of care. , The nurse would teach the client about frequent rest periods during the day to conserve energy. The client with RA will be stiff early in the morning, but that would not interfere with activities later in the day. Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does not affect the ability for activity.

Question 13

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?
A) Category N
B) Category C
C) Category A
D) Category B

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 14

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

Accepted Answer

A) Clients with a history of meningocele typically experience severe latex allergies. It is important for the nurse, and other healthcare providers, to use latex alternative products on this client. The other options are appropriate for this client.
B) Clients with a history of meningocele typically experience severe latex allergies. It is important for the nurse, and other healthcare providers, to use latex alternative products on this client. The other options are appropriate for this client.
C) Clients with a history of meningocele typically experience severe latex allergies. It is important for the nurse, and other healthcare providers, to use latex alternative products on this client. The other options are appropriate for this client.
D) Clients with a history of meningocele typically experience severe latex allergies. It is important for the nurse, and other healthcare providers, to use latex alternative products on this client. The other options are appropriate for this client.

Question 15

A nurse working in an intensive care unit (ICU)is assigned a client diagnosed with acquired immunodeficiency syndrome (AIDS).Based on this data,which type of precaution does the nurse implement when providing direct care?
A) Droplet
B) Reverse
C) Standard
D) Contact

Accepted Answer

A) Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the healthcare professionals treat all clients alike, eliminating the need to know their HIV status. 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, the healthcare professionals treat all clients alike, eliminating the need to know their HIV status. 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, the healthcare professionals treat all clients alike, eliminating the need to know their HIV status. 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, the healthcare professionals treat all clients alike, eliminating the need to know their HIV status. 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 nurse has been providing a young adult client with a history of hypersensitivity reactions.The nurse is preparing instructions on the correct w methods for using an EpiPen.Which client statement indicate understanding of the proper technique? Select all that apply.
A) "It's fine to leave the EpiPen out in the sun"
B) "I frequently check the expiration date"
C) "I make sure the EpiPen is always available."
D) "No one else in my family knows how to use the EpiPen."
E) "I don't need a medical alert tag."

Accepted Answer

A) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the client, someone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.
B) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the client, someone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.
C) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the client, someone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.
D) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the client, someone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.
E) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the client, someone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.

Question 17

A client recently diagnosed with rheumatoid arthritis (RA)asks the nurse if the disease is caused by ethnicity.Which response by the nurse is the most appropriate?
A) "RA affects those of German descent most often."
B) "RA is most prevalent in Caucasian females."
C) "RA is most prevalent in men under the age of 20 years."
D) "RA affects all races at the same rate."

Accepted Answer

A) RA affects 12% of the total population across all races. It affects women 3 times more than men, and the onset is usually between the ages of 20 and 40 years.
B) RA affects 12% of the total population across all races. It affects women 3 times more than men, and the onset is usually between the ages of 20 and 40 years.
C) RA affects 12% of the total population across all races. It affects women 3 times more than men, and the onset is usually between the ages of 20 and 40 years.
D) RA affects 12% of the total population across all races. It affects women 3 times more than men, and the onset is usually between the ages of 20 and 40 years.

Question 18

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

Accepted Answer

A) Swimming exercises all the extremities without putting undue stress on joints. Softball, football, or basketball could exacerbate joint discomfort.
B) Swimming exercises all the extremities without putting undue stress on joints. Softball, football, or basketball could exacerbate joint discomfort.
C) Swimming exercises all the extremities without putting undue stress on joints. Softball, football, or basketball could exacerbate joint discomfort.
D) Swimming exercises all the extremities without putting undue stress on joints. Softball, football, or basketball could exacerbate joint discomfort.

Question 19

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) 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.

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 instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. 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 instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. 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 instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. 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 instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. 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 instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.

Question 20

A client with rheumatoid arthritis (RA)is being seen in the outpatient clinic for a progress check-up.The nurse is reviewing the client's plan of care and determines that the client has met a goal of treatment when the client makes which statement?
A) "I sleep for 10 hours at night."
B) "I have increased pain in my joints all the time now."
C) "I have delegated many household chores to my children and spouse."
D) "I do not perform household chores at all anymore."

Accepted Answer

A) One technique for reducing stress on the joints is to delegate household tasks to family members. The client does not need to refrain from all household chores. Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. Increased joint pain would indicate that goals have not been met.
B) One technique for reducing stress on the joints is to delegate household tasks to family members. The client does not need to refrain from all household chores. Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. Increased joint pain would indicate that goals have not been met.
C) One technique for reducing stress on the joints is to delegate household tasks to family members. The client does not need to refrain from all household chores. Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. Increased joint pain would indicate that goals have not been met.
D) One technique for reducing stress on the joints is to delegate household tasks to family members. The client does not need to refrain from all household chores. Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. Increased joint pain would indicate that goals have not been met.

Quiz 8: Immunity

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.

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?

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 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.

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.

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? ?

A nurse is caring for a client who was admitted to the hospital with an exacerbation of rheumatoid arthritis (RA) .The client reports pain is a 3 on a scale from 1 to 10 today.Which non-pharmacological interventions can the nurse provide to enhance the client's comfort? 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?

A nurse working in an intensive care unit (ICU) is assigned a client diagnosed with acquired immunodeficiency syndrome (AIDS) .Based on this data,which type of precaution does the nurse implement when providing direct care?

A nurse has been providing a young adult client with a history of hypersensitivity reactions.The nurse is preparing instructions on the correct w methods for using an EpiPen.Which client statement indicate understanding of the proper technique? Select all that apply.

A client recently diagnosed with rheumatoid arthritis (RA) asks the nurse if the disease is caused by ethnicity.Which response by the nurse is the most appropriate?

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?

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 client with rheumatoid arthritis (RA) is being seen in the outpatient clinic for a progress check-up.The nurse is reviewing the client's plan of care and determines that the client has met a goal of treatment when the client makes which statement?