HIV/AIDS
The Human Immunodeficiency Virus (HIV) mainly attacks what type of cells in the human body?
A. Red Blood Cells
B. CD4 positive cells
C. Stem Cells
D. Platelets
The answer is B. The HIV virus attacks the human body’s immune system, specifically the CD4 positive cells…mainly the helper t cells. These cells are white blood cells that help the immune system fight infection.
Transfusion reactions and Rh incompatibility are both examples of which type of hypersensitivity reaction?
A) Type I
B) Type II
C) Type III
D) Type IV
Answer: B
Explanation: A) Type I, or immediate hypersensitivity, reactions are characterized by rapid development of symptoms after exposure to an antigen; an example is anaphylaxis. Type II, or cytotoxic hypersensitivity, reactions involve the rupture of cells targeted by the immune responsethat may affect a variety of organs and tissues; examples include transfusion reactions and Rh incompatibility. Type III, or immune-complex, reactions include inflammatory response in the targeted tissues that leads to tissue damage; examples include autoimmune disorders such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Finally, type IV, or delayed-type hypersensitivity, reactions involve a major histocompatibility complex and are characterizedby tissue damage at the site of antigen contact within 24-48 hours of exposure; an example is allergic contact dermatitis.
A 58 year old female is experiencing a flare-up with rheumatoid arthritis. While assisting the patient with her morning routine, the patient verbalizes a pain rating of 7 on 1-10 scale in the right and left wrist along with severe stiffness. You note the wrist joints to be red, warm, and swollen. What nonpharmalogical nursing interventions can you provide to this patient to help alleviate pain and stiffness? Select-all-that-apply:
A. Exercise the affected joints
B. Assist the patient with a warm shower or bath
C. Perform deep massage therapy to the wrist joints
D. Assist the patient with applying wrist splints
The answers are B and D. During flare-ups of RA the joint should be rested (not exercised) and should not be deep massaged because this can further damage the joint (in addition cause the patient more pain). Heat therapy, like a warm shower or bath, will help alleviate the stiffness. Furthermore, cold therapy can be used to reduce the inflammation along with splinting the affected joints to protect and rest them.
A patient is diagnosed with Systemic Lupus Erythematous (SLE). You note the patient has a red rash that starts on the nose and expands onto the cheeks of the face. This is known as what type of rash?
A. Discoid
B. Malar
C. Miliaria
D. Eczema
The answer is B: Malar (it’s also called a butterfly rash).
The nurse is caring for a client with chronic constipation. Which findings in the client's health history could be the cause of the current constipation? Select all that apply.
A) Bedrest
B) High-fiber diet
C) Low-fiber foods
D) Chronic laxative use
E) Depression
Answer: A, C, D, E
Explanation: A) Factors that contribute to chronic constipation include lack of activity, such as bedrest; a diet low in fiber; chronic laxative use; and emotional disturbances such as depression. A high-fiber diet is a treatment option for chronic constipation
A 48-year-old patient is HIV positive. The patient has no signs and symptoms and has a CD4 count of 400 cells/mm3. In addition, no opportunistic infections or diseases are present. These findings correlate with what stage of HIV?
A. Acute
B. Chronic
C. AIDS
The answer is B: Chronic. These findings correlate with the Chronic Stage (also called the Asymptomatic Stage) of HIV. Signs and symptoms may not be experienced, the viral load is lower than the Acute Stage, but the virus is still replicating and destroying the cells. The patient can still transmit the virus to others. In addition, the CD4 count should be more than 200 cells/mm3 to about 500 cells/mm3. In addition, no opportunistic infections or diseases should be present.
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
Answer: D
Explanation: A) Clinical manifestations associated with a type I hypersensitivity reaction include hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria. Erythemaand fever are associated with type IV hypersensitivity reactions. Fever and joint pain are associated with type III hypersensitivity reactions
Disease-modifying antirheumatic drugs (DMARDS) are used to treat rheumatoid arthritis. Select-all-the drugs below that are DMARDS:
A. Dexamethasone (Decadron)
B. Hydroxychloroquine (Plaquenil)
C. Teriparatide (Forteo)
D. Calcitonin
E. Leflunomide (Arava)
F. Methotrexate (Trexall)
The answers are B, E, and F. These are DMARDs that can be prescribed for RA. Option A is a corticosteroid. Option C and D are sometimes prescribed in osteoporosis.
A patient is undergoing testing for the evaluation of Systemic Lupus Erythematous. What lab findings below are associated with this condition? Select all that apply:
A. Decreased ESR and CRP
B. Positive ANA
C. Positive Anti-dsDNA
D. Negative Anti-Sm
E. Low C3 and C4
The answers are B, C, and E. A positive ANA (anti-nuclear antibodies) demonstrates there are autoantibodies the body created against the nuclei of the dying cells (almost all patient with lupus will have a positive ANA), but these anti-nuclear antibodies can also be present with other autoimmune disorders. A positive anti-dsDNA (anti-double stranded DNA anti-body) is a particular anti-nuclear antibody found in some patients with lupus and is not typically present in patients who don’t have lupus. An INCREASE in ESR and CRP would be found in a patient with lupus (especially during a flare) along with a POSITIVE Anti-Sm antibody (which is a particular antibody found in the nucleus that is present in lupus).
The nurse is caring for a client who has experienced a sports-related injury to the knee. During The morning assessment, which signs of inflammation should the nurse anticipate? Select all that apply.
A) Pitting edema
B) Pallor
C) Swelling
D) Warmth
E) Pain
Answer: C, D, E
Explanation: A) Swelling, warmth, and pain are all signs of inflammation. Pallor is not a sign of inflammation; redness is. Pitting edema is not a sign of inflammation. Pg. 670
A patient arrives to the clinic and requests an HIV test. The patient had unprotected sexual intercourse 2 days ago with a person who may have HIV. As the nurse you know there is a window period for detecting an infection of HIV. What statements should you provide to the patient about this window period and testing for HIV? Select all that apply:
A. No test is available at this time to show immediate infection.
B. The window period is the time when you become infected with HIV to when a test can deliver positive results.
C. Window periods vary depending on the type of HIV test administered.
D. The absolute earliest an HIV test can detect HIV is about 3 months.
The answers are A, B, C. These are correct statement. Option D is incorrect because the NAT (nucleic acid test) can detect HIV the earliest of all the test types. It can detect around 10 days after exposure for some patients. It assesses for the virus’ genetic material and measures the amount of virus present in the blood. It is not commonly ordered and is used only for high risk patients.
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 laundry detergent
Answer: A
Explanation: 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.
A physician suspects a patient may have rheumatoid arthritis due to the patient’s presenting symptoms. What diagnostic testing can be ordered to help a physician diagnose rheumatoid arthritis? Select all that apply:
A. Rheumatoid factor
B. Uric acid level
C. Erythrocyte sedimentation
D. Dexa-Scan
E. X-ray imaging
The answers are A, C, and E. These are diagnostic tests to help diagnose RA. Option B is used in gout, and option D is used with osteoporosis.
A patient with Systemic Lupus Erythematosus is experiencing a complication called Lupus Nephritis. What are some signs and symptoms that correlate with this complication of SLE? Select all that apply:
A. Decreased Creatinine
B. Increased BUN
C. 48 hour urinary output of 720 mL
D. Proteinuria
E. Weight loss
F. Edema in upper and lower extremities
The answers are B, C D, and F. Lupus nephritis is a serious complication of SLE. It is a condition that affects the functional units of the kidneys called the nephrons. In severe cases, renal failure develops which leads to an INCREASED BUN/Creatinine, low UOP (<30 mL/hr), proteinuria, weightGAIN, and swelling in the upper and lower extremities.
The nurse, caring for an older school-age client recovering from an appendectomy, is preparing to help the family ambulate the child for the first time after surgery. Which nonpharmacologic nursing strategy would be most appropriate for this client?
A) Placing a warm, moist pack over the site of the incision
B) Holding a splint pillow against the abdomen when moving or coughing
C) Administering appropriate narcotic analgesics
D) Applying an ice pack over the site of the incision
Answer: B
Explanation: A) A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. Administering a narcotic is considered a pharmacologic nursing strategy.
Select the criteria below that is used to help diagnosed a patient with Acquired Immunodeficiency Syndrome (AIDS):
A. CD4 count <200 cells/mm3
B. Presence of opportunistic infection
C. CD4 count >1500 cells/mm3
D. WBC 9500
E. Absence of opportunistic infection
The answers are A and B. A patient is diagnosed with AIDS if: CD4 count drops to less than 200 cells/mm3 or an opportunistic infection is present
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 injecting 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) Hyperverbal behavior
D) Extreme anxiety and agitation
E) Facial swelling
Answer: A, D, E
Explanation: A) General symptoms of shock that would necessitate an epinephrine injection include cold and clammy skin (which is indicative of decreased perfusion), extreme anxiety and agitation, and facial angioedema. Clients who are experiencing shock are unlikely to be hyperverbal due to respiratory symptoms that make breathing and speaking difficult.
During a routine health check-up visit a patient states, “I’ve been experiencing severe pain and stiffness in my joints lately.” As the nurse, you will ask the patient what questions to assess for other possible signs and symptoms of rheumatoid arthritis? Select-all-that-apply:
A. “Does the pain and stiffness tend to be the worst before bedtime?”
B. “Are you experiencing fatigue and fever as well?”
C. “Is your pain and stiffness symmetrical on the body?”
D. “Is your pain and stiffness aggravated by extreme temperature changes?”
The answers are B and C. Patients with RA will experience pain and stiffness in the morning (for more than 30 minutes) not bedtime. It is common for patients to have a fever and be fatigued…remember RA affects the whole body not just the joints. It will also affect the same joints on the opposite side of the body. Therefore, if the right wrist is inflamed, painful, and stiff the left wrist will be as well. RA is NOT aggravated by extreme temperatures. This is found in osteoarthritis.
A client asks the nurse whether there are any conditions that can exacerbate systemic lupus erythematosus (SLE). Which response by the nurse is the most appropriate?
A) "Conditions that cause hypotension often worsen SLE."
B) "GI upset is often associated with SLE exacerbation."
C) "Pregnancy is often associated with a worsening of SLE.
"D) "Fever is a known trigger for SLE exacerbation."
Answer: C
Explanation: A) Pregnancy can be associated with an exacerbation of SLE due to the associated rise in estrogen levels. Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.
A client is experiencing weight gain and foamy dark urine 4 weeks after being treated with antibiotics for a sore throat. Which client statement, made during the health history assessment, suggests that the nurse should provide the client with further instruction?
A) "I've been trying to get plenty of rest since I've been sick."
B) "I've started eating a more nutritious diet."
C) "I felt better after 1 week of the antibiotics, so I stopped taking them."
D) "I've gained a bit of weight over the last 2 weeks."
Answer: C
Explanation: A) The client probably had strep throat and did not take the full course of antibiotics, which accounts for the current symptoms that indicate glomerulonephritis. The nurse should teach this client about the importance of taking all medications as prescribed to prevent further complications of a disease. Resting when ill is appropriate, as is changing to a more nutritious diet. Gaining weight would support the nurse's suspicion that the client has glomerulonephritis.
A 30-year-old patient is in the Acute Stage of HIV. What findings below correlate with this stage of HIV? Select all that apply:
A. CD4 level <500 cells/mm3
B. No present of Opportunistic Infections
C. High viral load
D. Patient reports flu-like symptoms
E. Patient is asymptomatic
The answers are B, C, and D. The Acute Stage of HIV is the first stage and tends to occur a couple of weeks to a month after becoming infected. The patient’s viral load is very HIGH during this time, but the CD4 count should be greater than 500 cells/mm3. Therefore, NO opportunistic infections are present during this time (the CD4 count is high enough to fight off these types of infections/diseases). In addition, the patient may report flu-like symptoms (aches, joint pain, headache, fever, fatigue, sore throat, swollen lymph nodes, GI upset, and rash). The patient is usually asymptomatic in the 2nd stage (Chronic Stage of HIV).
In what ways do type IV hypersensitivity reactions differ from other types of hypersensitivity reactions?
A) Unlike other types of hypersensitivity reactions, type IV reactions are antibody-mediated responses and develop almost immediately.
B) Unlike other types of hypersensitivity reactions, type IV reactions are cell-mediated responsesand develop almost immediately.
C) Unlike other types of hypersensitivity reactions, type IV reactions are antibody-mediated responses and take 24 hours or more to develop.
D) Unlike other types of hypersensitivity reactions, type IV reactions are cell-mediated responsesand take 24 hours or more to develop.
Answer: D
Explanation: A) Type IV reactions differ from other hypersensitivity responses in two ways. First, they are cell-mediated immune responses, not antibody-mediated responses, that involve the T cells of the immune system. Second, type IV reactions are delayed rather than immediate, developing 24-48 hours after exposure to an antigen
A patient with severe rheumatoid arthritis is scheduled for a procedure called an arthrodesis. The nursing student you are precepting asks what type of procedure this is. Your response is:
A. “It is a procedure where the affected joint is removed and each end of the bones found within that joint are fused together.”
B. “It is a procedure that involves replacing the joint with an artificial one.”
C. “It is a procedure where the surgeon goes in with a scope and cleans out the affected joint.”
D. “It is a procedure where the synovium is completely removed within the joint, which helps decrease inflammation of the joint.
The answer is A. An arthrodesis (also called joint fusion) is where the affected joint is removed and the bones within it are fused together. Option B describes a joint replacement. Option C is known as a surgical cleaning. Option D is known as a synovectomy.
A female client with systemic lupus erythematosus (SLE) is being treated with immunosuppressant drugs and corticosteroids. When providing teaching to this client, which of the following points are appropriate for the nurse to include? Select all that apply.
A) Avoid large crowds.
B) Don't get a flu shot.
C) Use contraception to prevent pregnancy.
D) Refrain from taking aspirin products.
E) Report any signs of infection to the healthcare provider.
Answer: A, C, D, E
Explanation: A) Crowds may increase exposure to infection, which is potentially dangerous for clients who are taking immunosuppressants. Annual influenza vaccination is recommended, although clients with significant immunosuppression should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects, so contraception is important. Aspirin products may increase the risk of bleeding, which would further impair immune function. Chills, fever, sore throat, fatigue, or malaise should be reported so related infections can be treated as quickly as possible
The nurse is caring for a client who develops a fever and productive cough after abdominal surgery. Which orders should the nurse expect from the healthcare provider? Select all that apply.
A) Sputum cultures
B) Antibiotics
C) Chest physiotherapy
D) Bronchial washing for culture
E) Isolation precautions
Answer: A, B, C
Explanation: A) The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. Bronchial washings are not included in routine testing for this scenario. The client likely has an infectious disease that is not contagious. Isolation precautions are usually not ordered for noncontagious infections.