Chapter 60
1. Which statement made by the client taking an immunosuppressive agent to manage rheumatoid arthritis would require further teaching by the nurse?
1. “I should drink a lot of fluids like grapefruit juice.”
2. “I know I’ll have to cope with having my blood drawn regularly.”
3. “This medication may cause damage to my kidneys.”
4. “If I experience any joint pain, I can take ibuprofen as needed every 4 hours.”
Answer: “I should drink a lot of fluids like grapefruit juice.”
Rationale:
Fluids should be increased to maintain good hydration and urinary output, but the client should avoid grapefruit juice, which can raise cyclosporine levels by 50% to 200% and increase the risk of toxicity. Immunosuppressive agents inhibit T cell development and activation. Nursing responsibilities would include monitoring BUN and creatinine for evidence of nephrotoxicity that would require frequent blood draws. Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with cytotoxic agents.
2. A client with a history of latex allergies has developed itching and hives after being admitted for a fractured left femur. The initial nursing intervention is to:
1. Ask if the client is experiencing any difficulty breathing.
2. Collect a detailed history from the client regarding the allergies.
3. Survey the client’s room for possible latex-containing items.
4. Alert the client’s health care provider concerning the client’s symptoms.
Answer: Ask if the client is experiencing any difficulty breathing.
Rationale:
A history of latex allergies in combination with the client’s symptoms would alert the nurse to the possibility of an allergic reaction. Such reactions can result in respiratory distress, so assessment of the airway is the nursing priority. The health care provider should be alerted if there is reason to believe the client’s condition warrants it, but not before assessing the airway. Conducting a nursing history and attempting to locate latex-containing items do not have priority over airway maintenance.
3. A client is suspected of having an allergic reaction to certain laundry detergents. The nurse recognizes that the diagnostic test result that would best confirm a hypersensitivity reaction would be:
1. Patch test with a 1-inch area of erythema.
2. Eosinophils of 2% of the total WBC.
3. Indirect Coombs’ showing no agglutination.
4. Rh antigen with negative results.
Answer: Patch test with a 1-inch area of erythema.
Rationale:
A patch test assesses a 1-inch area impregnated with the allergen. Positive responses are graded from mild (erythema in the exposed area) to severe (papules, vesicles, or ulcerations) and reflect the presence of an allergic reaction to the allergen. The indirect Coombs’ test detects the presence of circulating antibodies against RBCs. The eosinophil count is 1% to 4%, which is within normal range. Rh antigen results that are negative reflect the absence of the Rh factor in a client’s blood.
4. A client asks the nurse what a “hypersensitivity response” is. The nurse best answers the client’s question by responding:
1. “It’s why some people sneeze and have itchy, watery eyes when they’re around cats and some people don’t.”
2. “It’s the reaction your body shows when it overreacts to a substance it isn’t familiar with.”
3. “Are you familiar with the term allergy or being allergic?”
4. “Are you interested because you feel you may have the problem?”
Answer: “It’s why some people sneeze and have itchy, watery eyes when they’re around cats and some people don’t.”
Rationale:
While an immune hypersensitivity response occurs when the immune system does not maintain self-tolerance, in other words when it overreacts to the presence of a foreign antigen, the nurse’s best response is an example that the client is most likely able to understand. Asking whether the client is familiar with related terms or has a suspicion of being affected is not directly addressing the client’s question. Hypersensitivity response is not a reaction to an unfamiliar substance.
5. A client who believes he has a peanut allergy presents at the emergency department concerned about the possibility that he has ingested a small amount of commercially prepared food that may have contained peanut oil. The nurse best addresses the client’s risk for injury by asking:
1. “Have you ever experienced an allergic reaction to peanuts before?”
2. “What makes you think you are allergic to peanuts?”
3. “Have you every undergone testing for a peanut allergy?”
4. “Did you self-administer epinephrine?”
Answer: “Have you ever experienced an allergic reaction to peanuts before?”
Rationale:
The priority is to determine whether the client is allergic to peanuts and at risk for injury in the form of an allergic reaction. Confirming a past reaction to ingestion of peanuts is the best way to determine that possibility for this client at this particular time. Asking why the client believes he is allergic or whether he has undergone allergy testing may result in the needed information, but does not directly address the information needed. Self-administration of epinephrine is directed more toward management of a reaction than confirming the possibility of a reaction.
6. The nurse is providing discharge education for a client who experienced an anaphylactic reaction as a result of a bee sting. In order to best assure the client will receive prompt, appropriate medical care in the event of another bee sting, the nurse encourages the client to:
Select al that apply.
1. Wear a medical alert bracelet that identifies his allergy to bee venom.
2. Always have quick access to an epinephrine pen.
3. Be aware of how quickly the symptoms occur and exacerbate.
4. Minimize the amount of time spent out of doors.
5. Apply insect repellant before spending time outside.
Answer: 1. Wear a medical alert bracelet that identifies his allergy to bee venom.
2. Always have quick access to an epinephrine pen.
3. Be aware of how quickly the symptoms occur and exacerbate.
Rationale:
Wear a medical alert bracelet that identifies his allergy to bee venom. The nurse can further promote patient health and safety by encouraging patients with a history of anaphylactic reactions to wear a medical alert bracelet or other form of medical identification tag that identifies allergies. Always have quick assess to an epinephrine pen. Carrying a self-administered epinephrine kit to use in the event of an anaphylactic reaction is essential. Be aware of how quickly the symptoms occur and exacerbate. Being aware of symptom and the speed with which anaphylactic shock can occur will be vital to the client receiving appropriate, prompt medical care. Minimize the amount of time spent out of doors. Minimizing the time spent outdoors may decrease the potential of being stung, but does not affect prompt, appropriate care in the event of a sting. Apply insect repellant before spending time outside. Wearing insect repellant may decrease the potential of being stung, but does not affect prompt, appropriate care in the event of a sting.
7. The home health nurse is discussing nutritional needs with a client diagnosed with HIV. The nurse stresses the importance of daily vitamin and mineral supplements based on the knowledge that:
Select all that apply.
1. Research has shown that such supplements have an impact on retarding the progress of the disease.
2. Vitamins A, C, and E assist the body’s immune system to combat infections.
3. Being vitamin and mineral deficient contributes to increasing HIV replication.
4. Multivitamin supplements contribute to the decreased risk of mouth ulcers in HIV clients.
5. The use of megavitamin supplementation has resulted in the long-term improvement of T-cell counts in some HIV clients.
Answer: 1. Research has shown that such supplements have an impact on retarding the progress of the disease.
2. Vitamins A, C, and E assist the body’s immune system to combat infections.
3. Being vitamin and mineral deficient contributes to increasing HIV replication.
4. Multivitamin supplements contribute to the decreased risk of mouth ulcers in HIV clients.
Rationale:
Research has shown that such supplements have an impact on retarding the progress of the disease. There is indication from research studies that clearly indicates the efficacy of vitamin supplements for HIV patients for retarding the progress of the disease. Vitamins A, C, and E assist the body’s immune system to combat infections. Vitamins and minerals needed for the immune system to fight infections include A, B-complex, C, and E, and selenium and zinc. Being vitamin and mineral deficient contributes to increasing HIV replication. In addition, deficiencies of antioxidant vitamins and minerals contribute to oxidative stress, which may accelerate immune cell death and increase the rate of HIV replication. Multivitamin supplements contribute to the decreased risk of mouth ulcers in HIV clients. Research has found that supplementation with multivitamins reduces the incidence of complications, including oral ulcers. The use of megavitamin supplementation has resulted in the long-term improvement of T-cell counts in some HIV clients. There is no research to support the positive affect of megavitamin supplementation on the long-term improvement of T-cell counts of HIV clients—such results remain anecdotal.
8. Which of the following statements by the client who has HIV would require further teaching by the health care professional?
1. “I will use an oil-based lubricant when I use condoms.”
2. “I know I have to assume responsibility when I have sex.”
3. “I will not share my toothbrush or razor with my partner.”
4. “I know I can’t donate blood anymore since I have HIV.”
Answer: “I will use an oil-based lubricant when I use condoms.”
Rationale:
The nurse should educate the client regarding the prevention of the spread of HIV. The client will need further education when he states that he will use an oil-based lubricant. The client should be educated to use latex condoms for oral, vaginal, or anal intercourse, and to avoid natural or animal skin condoms, which allow passage of HIV. The client should use only water-based lubricants—not oil-based, such as petroleum jelly, which can result in condom damage. The client is correct in stating that it is not an acceptable practice to share toothbrushes or razors. The client is also correct in stating that blood donation is prohibited and in stating his role in engaging only in safe sex.
9. A client with a diagnosis of AIDS has asked the nurse for information regarding the use of complementary therapies for the treatment of the disease. The nurse’s response is based on the knowledge that:
1. Many HIV/AIDS clients find the complementary treatments helpful.
2. Incorporating such treatments could severely undermine the effectiveness of the current treatment plan.
3. These treatments will most likely neither help nor hurt the client physically.
4. With a terminal disease, the client deserves to make whatever choices he or she wants.
Answer: Many HIV/AIDS clients find the complementary treatments helpful
Rationale:
There is growing support among HIV-infected patients for the use of complementary and alternative treatments in symptom management. There is no compelling evidence that complementary therapies undermine the effectiveness of the medical treatment clients are already receiving. There is no basis for the statement that the treatments will neither help or hurt the client physically. All clients, terminal or otherwise, have the right to make choices regarding their medical treatments.
10. The home health nurse is revising the care plan of a client diagnosed with HIV who has developed a vaginal yeast infection. Nursing diagnoses related to this opportunistic infection include:
Select all that apply.
1. Acute/Chronic Pain.
2. Impaired Skin Integrity.
3. Deficient Knowledge.
4. Anxiety.
5. Infection transmission.
Answer: 1. Acute/Chronic Pain.
2. Impaired Skin Integrity.
3. Deficient Knowledge.
4. Anxiety.
Rationale:
Acute/Chronic Pain. The nursing diagnosis of acute/chronic pain is related to the sensations of irritation and itching created by the infection. Impaired Skin Integrity. The nursing diagnosis of impaired skin integrity is related to the mucous membranes of the vaginal walls being affected by the infection. Deficient Knowledge. The nursing diagnosis of deficient knowledge is related to the vaginal disease process, treatment, and prognosis. Anxiety. The nursing diagnosis of anxiety is related to anticipatory fear of physical decline and the dying process. Infection transmission. Infection transmission is not appropriate, since the vaginal yeast infection is not contagious in nature.
11. A nurse is performing an admission assessment on a client with AIDS. To best evaluate the client for the risk of contracting an opportunistic infection, the nurse asks:
1. “What were the results of your last CD4 and T-cells test?”
2. “Can you identify the signs and symptoms of a possible infection?”
3. “Are you sexual active with persons who also have AIDS?”
4. “Have you had any fever, diarrhea, or chills over the last 48 hours?”
Answer: “What were the results of your last CD4 and T-cells test?”
Rationale:
Opportunistic infections occur in HIV-infected individuals as the virus destroys sufficient numbers of CD4+ T cells and the body is not able to protect itself. As CD4+ counts drop to 2,500 oz/day if not contraindicated in order to maintain hydration and keep mucous membranes moist. Offer to quit smoking with the client. By offering to quit smoking with the client, they are encouraging him to avoid smoking, thus decreasing the drying and irritation to mucous membranes. Assist the client with oral care three times a day. Assist with oral care every 2 hours by rinsing oral mucosa with saline and dilute hydrogen peroxide solution; this decreases spread of lesions.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
