1. regarding self-care to a patient with an immunodeficiency. What teaching point should the nurse emphasize?
a. The need for thorough oral hygiene
2. A patient's primary immunodeficiency disease is characterized by the inability of white blood cells to initiate an A nurse is admitting a patient ...
1 a nurse is admitting a patient with an immunodeficiency to the medical unit in planning the care of this patient
1 a nurse is admitting a patient with an immunode
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ALLMedSurge Quiz 1 - 36 37 38 39
1. A nurse is admitting a patient with an immunodeficiency to the medical unit. In
planning the care of this patient, the nurse should assess for what common sign of
immunodeficiency?
a. Chronic diarrhea
2. A nurse is caring for a patient who has an immunodeficiency. What assessment
finding should prompt the nurse to consider the possibility that the patient is
developing an infection?
a. Persistent diarrhea
3. The nurse is applying standard precautions in the care of a patient who has an
immunodeficiency. What are key elements of standard precautions? Select all that
apply.
a. Using appropriate personal protective equipment
b. Using safe injection practices
c. Performing hand hygiene
4. A home health nurse is reinforcing health education with a patient who is
immunosuppressed and his family. What statement best suggests that the patient
has understood the nurse's teaching?
a. “My family needs to understand that I'll probably need lifelong
treatment.”
5. The nurse is preparing to administer IVIG to a patient who has an
immunodeficiency. What nursing guideline should the nurse apply?
a. Administer pretreatment medications as ordered 30 minutes prior to
infusion.
6. A nurse has created a plan of care for an immunodeficient patient, specifying that
care providers take the patient's pulse and respiratory rate for a full minute. What
is the rationale for this aspect of care?
a. These patients' blunted inflammatory responses can cause subtle
changes in status.
7. A nurse is providing health education regarding self-care to a patient with an
immunodeficiency. What teaching point should the nurse emphasize?
a. The need for thorough oral hygiene
8. A patient's primary immunodeficiency disease is characterized by the inability of
white blood cells to initiate an inflammatory response to infectious organisms.
What is this patient's most likely diagnosis?
a. Hyperimmunoglobulinemia E syndrome
9. A nurse is working with a patient who was diagnosed with HIV several months
earlier. The nurse should recognize that a patient with HIV is considered to have
AIDS at the point when the CD4+ T-lymphocyte cell count drops below what
threshold?
a. 200 cells/mm3 of blood
10.A patient has been diagnosed with AIDS complicated by chronic diarrhea. What
nursing intervention would be appropriate for this patient?
a. Obtain a stool culture to identify possible pathogens.
11.An 18-year-old pregnant female has tested positive for HIV and asks the nurse if
her baby is going to be born with HIV. What is the nurse's best response?
a. “It's possible that your baby could contract HIV, either
before, during, or after delivery.”
12.Since the emergence of HIV/AIDS, there have been significant changes in
epidemiologic trends. Members of what group currently have the greatest risk of
contracting HIV?
, a. Gay, bisexual, and other men who have sex with men
13.A hospital patient is immunocompromised because of stage 3 HIV infection and
the physician has ordered a chest radiograph. How should the nurse most
safely facilitate the test?
a. Arrange for a portable x-ray machine to be used
14.A patient's current antiretroviral regimen includes nucleoside reverse
transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide
based on the patient's medication regimen?
a. Take this medication without regard to meals.
15.A nurse is performing the admission assessment of a patient who has AIDS.
What components should the nurse include in this comprehensive assessment?
Select all that apply.
a. Current medication regimen
b. Identification of patient's support system
c. Immune system function
d. History of sexual practices
16.A patient is in the primary infection stage of HIV. What is true of this patient's
current health status?
a. The patient is infected with HIV but lacks HIV-specific antibodies.
17.A nurse is aware of the need to assess patients' risks for anaphylaxis. What
health care procedure constitutes the highest risk for anaphylaxis?
a. Computed tomography with contrast solution
18.A patient with multiple food and environmental allergies tells the nurse that he is
frustrated and angry about having to be so watchful all the time and wonders if it
is really worth it. What would be the nurse's best response?
a. “I can only imagine how you feel. Would you like to talk about it?
19.A nurse is caring for a patient who has allergic rhinitis. What intervention
would be most likely to help the patient meet the goal of improved breathing
pattern?
a. Modify the environment to reduce the severity of allergic symptoms.
20.The nurse in an allergy clinic is educating a new patient about the pathology of
the patient's health problem. What response should the nurse describe as a
possible consequence of histamine release?
a. Contraction of bronchial smooth muscle
21.A patient has presented with signs and symptoms that are consistent with
contact dermatitis. What aspect of care should the nurse prioritize when working
with this patient?
a. Identifying the offending agent, if possible
22.A patient's rheumatoid arthritis (RA) has failed to respond appreciably to first-
line treatments and the primary care provider has added prednisone to the
patient's drug regimen. What principle will guide this aspect of the patient's
treatment?
a. The drug should be used for as short a time as possible.
23.A patient with SLE has come to the clinic for a routine check-up. When
auscultating the patient's apical heart rate, the nurse notes the presence of a
distinct “scratching” sound. What is the nurse's most appropriate action?
a. Inform the primary care provider that a friction rub may be present.
24.A nurse is educating a patient with gout about lifestyle modifications that can
help control the signs and symptoms of the disease. What recommendation
should the nurse make?
a. Limiting intake of alcohol
,25.A nurse is planning the care of a patient who has a long history of chronic pain,
which has only recently been diagnosed as fibromyalgia. What nursing diagnosis
is most likely to apply to this woman's care needs?
a. Ineffective Role Performance Related to Pain
Test Bank Questions Not On Quiz 1
CHP 36
1. A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral
antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed
diagnostic workup that reveals a phagocytic disorder. This patient faces an
increased risk of what complication?
a. Neutropenia
2. A patient is admitted for the treatment of a primary immunodeficiency and
intravenous immunoglobulin (IVIG) is ordered. What should the nurse monitor for
as a potential adverse effect of IVIG administration?
a. Anaphylaxis
3. A young couple visits the nurse practitioner stating that they want to start a family.
The husband states that his brother died of a severe infection at age 6 months. He
says he never knew what was wrong but his mother had him undergo ìblood
testingî as a child. Based on these statements, what health problem should the
nurse practitioner suspect?
a. X-linked agammaglobulinemia
4. The parents of a 1-month-old infant bring their child to the pediatrician with
symptoms of congestive heart failure. The infant is ultimately diagnosed with
DiGeorge syndrome. What will prolong this infant's survival?
a. Thymus gland transplantation
5. A patient who has received a heart transplant is taking cyclosporine, an
immunosuppressant. What should the nurse emphasize during health
education about infection prevention?
a. Perform frequent hand-washing
6. The nurse is caring for a patient who has a diagnosis of paroxysmal nocturnal
hemoglobinuria. When planning this patient's care, the nurse should recognize the
patient's heightened risk of what complication?
a. Venous thromboembolism
7. A patient diagnosed with common variable immune deficiency (CVID) has been
admitted to the acute medicine unit. When reviewing this patient's laboratory
findings, the nurse should prioritize what values?
a. Hemoglobin and vitamin B12
8. Patient teaching regarding infection prevention for the patient with an
immunodeficiency includes which of the following guidelines?
a. Cook all food thoroughly
9. A nurse has admitted a patient diagnosed with severe combined immunodeficiency
disease (SCID) to the unit. The patient's orders include IVIG. How will the patient's
dose of IVIG be determined?
a. The dose will be determined by the patient's response
10. IVIG has been ordered for the treatment of a patient with an
immunodeficiency. Which of the following actions should the nurse perform before
administering this blood product?
a. Weigh the patient before administration to verify the correct dose.
11. A patient with a diagnosis of common variable immunodeficiency begins to
develop thick, sticky, tenacious sputum. The patient has a history of episodes of
, pneumonia at least one time per year for the last 10 years. What does the nurse
suspect the patient is developing?
a. Bronchiectasis
12. A nurse is admitting an adolescent patient with a diagnosis of ataxia-
telangiectasis. Which of the following nursing diagnoses should the nurse include
in the patient's plan of care?
a. Risk for Falls Due to Loss of Muscle Coordination
13. A 20-year-old patient with an immunodeficiency is admitted to the unit with
an acute episode of upper airway edema. This is the fifth time in the past 3 months
that the patient has had such as episode. As the nurse caring for this patient, you
know that the patient may have a deficiency of what?
a. C1esterase inhibitor
14. A patient with Wiskott-Aldrich syndrome is admitted to the medical unit.
The nurse caring for the patient should prioritize which of the following?
a. Protective isolation
15. The nurse is admitting a patient to the unit with a diagnosis of ataxia-
telangiectasia. The nurse's assessment should reflect the patient's increased risk
for what complication?
a. Cancer
16. The nurse is working with the interdisciplinary team to care for a patient who
has recently been diagnosed with severe combined immunodeficiency disease
(SCID). What treatment is likely of most benefit to this patient?
a. Hematopoietic stem cell transplantation (HSCT)
17. A patient has been admitted with a phagocytic cell disorder and the nurse is
reviewing the most common health problems that accompany these disorders. The
nurse should identify which of the following? Select all that apply.
a. Chronic otitis media
b. Cutaneous abscesses
c. Pneumonia
18. A nurse is caring for a patient with a phagocytic cell disorder. The patient
states, ìMy specialist says that I will likely be cured after I get my treatment
tomorrow. To what treatment is the patient most likely referring?
a. Hematopoietic stem cell transplantation
19. A nurse educator is explaining that patients with primary immunodeficiencies
are living longer than in past decades because of advances in medical treatment.
This increased longevity is associated with an increased risk of what?
a. Cancer
20. The nurse educator is differentiating primary immunodeficiency diseases
from secondary immunodeficiencies. What is the defining characteristic of primary
immunodeficiency diseases?
a. They have a genetic origin
21. The nurse is caring for a patient with an immunodeficiency who has
experienced sudden malaise. The nurse's colleague states, ìI'm pretty sure that it's
not an infection, because the most recent blood work looks fine.î What principle
should guide the nurse's response to the colleague?
a. Immunodeficient patients will usually exhibit subtle and atypical
signs of infection
22. A patient with a diagnosis of primary immunodeficiency informs the nurse
that he has been experiencing a new onset of a dry cough and occasional
shortness of breath. After determining that the patient's vital signs are within
reference ranges, what action should the nurse take?
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