Chapter 16: Altered Immune Response and Transplantation PDF

lOMoARcPSD|14578492 Chapter 16: Altered Immune Response and Transplantation Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. Chickenpox is an example of which of the following types of immunities? a. Innate...

lOMoARcPSD|14578492 Chapter 16: Altered Immune Response and Transplantation Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. Chickenpox is an example of which of the following types of immunities? a. Innate b. Natural active c. Artificial d. Cell-mediated ANS: B Chickenpox is an example of natural active immunity. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a client in the outpatient clinic who has an immune deficiency involving the T-lymphocytes. Which of the following areas should the nurse teach the client about the need for more frequent screening? a. Allergies b. Malignancy c. Antibody deficiency d. Autoimmune disorders ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by humoral immunity. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. Which of the following antibodies is involved with an anaphylactic reaction? a. IgE b. IgA c. IgM d. IgG ANS: A Serum IgE causes the symptoms of allergic reactions and is the antibody involved with an anaphylactic reaction. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with which of the following types of immunity? a. Innate b. Active c. Passive Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 d. Cell-mediated ANS: C Colostrum provides passive immunity through antibodies from the mother; these antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Innate immunity is present at birth and occurs without exposure to an antigen. Active immunity requires that the infant manufacture antibodies after exposure to an antigen. Cell-mediated immunity is acquired through T-lymphocytes and is a form of active immunity. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is assessing a client for possible atopic dermatitis. Which of the following laboratory values should the nurse review? a. IgE b. IgA c. Basophils d. Neutrophils ANS: A Serum IgE causes the symptoms of allergic reactions and is elevated in type 1 hypersensitivity disorders. The eosinophil level will be elevated, rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a client who has symptoms of atopic dermatitis. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse is conducting an annual health examination on an older adult client who states, “I don’t understand why I need to have so many cancer screening tests now. I feel just fine!” Based upon this statement, which of the following topics will the nurse include in the clients’ teaching plan? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-stimulating infections in older individuals ANS: A The primary impact of aging on immune function is on the activity of T cells, which are responsible for tumour immunity. Antibody function is not impacted as much by aging and does not protect against malignancy. Poor nutrition does contribute to decreased immunity, but there is no evidence that it is a contributing factor for this client. Although some types of cancers are associated with specific infections, this client does not have an active infection. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. The nurse discusses the prevention and management of allergic reactions with a client who is a beekeeper and has developed a hypersensitivity to bee stings. Which of the following client statements indicates a need for additional teaching? Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 a. “I will plan to take oral antihistamines daily before going to work.” b. “I will get a prescription for epinephrine and learn to self-inject it.” c. “I should wear a Medic Alert bracelet indicating my allergy to bee stings.” d. “I am going to need job retraining so that I can work in a different occupation.” ANS: A Since the client is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the client’s hypersensitivity reaction. The other client statements indicate a good understanding of management of the problem. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 8. Which of the following instructions should the nurse include when teaching a client with possible allergies about intradermal skin testing? a. “Do not eat anything for about 6 hours before the testing.” b. “Take an oral antihistamine about an hour before the testing.” c. “Plan to wait in the clinic for 20–30 minutes after the testing.” d. “Reaction to the testing will take about 48–72 hours to occur.” ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the client will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is caring for a client who receives weekly immunotherapy and has missed the previous appointment. Which of the following actions should the nurse implement when the client comes for the next injection? a. Schedule an additional dose that week. b. Administer the usual dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the client’s sensitivity to the allergen with a repeat skin test. ANS: C Because there is an increased risk for adverse reactions after a client misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is obtaining a health history from a client who works as a laboratory technician and learns that the client has a history of allergic rhinitis, asthma, and multiple food allergies. Which of the following actions is most important for the nurse to implement? a. Encourage the client to carry an epinephrine kit in case a type IV allergic reaction Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 to latex develops. b. Advise the client to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. Document the client’s allergy history and be alert for any clinical manifestations of a type I latex allergy. d. Recommend that the client use vinyl gloves instead of latex gloves in preventing bloodborne pathogen contact. ANS: C The client’s allergy history and occupation indicate a risk for development of latex allergy, and the nurse should be prepared to manage any symptoms that occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. A client diagnosed with systemic lupus erythematosus (SLE) is scheduled for plasmapheresis. Which of the following pathophysiological events should the nurse plan to teach the client about this procedure? a. It eliminates eosinophils and basophils from blood. b. It removes antibody-antigen complexes from circulation. c. It prevents foreign antibodies from damaging various body tissues. d. It decreases the damage to organs caused by attacking T-lymphocytes. ANS: B Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T-lymphocytes, foreign antibodies, eosinophils, and basophils do not contribute to the tissue damage in SLE. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 12. Which of the following adverse reactions should the nurse monitor when a client is undergoing plasmapheresis? a. Shortness of breath b. High blood pressure c. Transfusion reactions d. Hypotension and paresthesia ANS: D Hypotension and paresthesia may occur as the result of plasmapheresis. Citrate is used as an anticoagulant and may cause hypocalcemia, which may manifest as headache, paresthesias, and dizziness. The other clinical manifestations are not associated with plasmapheresis. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 13. The nurse is completing an assessment and health history with a client. Which of the following statements made by the client should alert the nurse to a possible immunodeficiency disorder? a. “I take one baby Aspirin every day to prevent stroke.” b. “I usually eat eggs or meat for at least two meals a day.” c. “I had my spleen removed many years ago after a car accident.” d. “I had a chest x-ray 6 months ago when I had walking pneumonia.” ANS: C Splenectomy increases the risk for septicemia from bacterial infections. The client’s protein intake is good and should improve immune function. Daily Aspirin use does not impact immune function. A chest x-ray does not have enough radiation to suppress immune function. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. The nurse is caring for a client who had a bone marrow transplant for treatment of leukemia and has developed a skin rash 10 days after the transplant. The nurse recognizes this reaction as an indication of which of the following? a. Donor T cells are attacking the client’s skin cells. b. The client’s antibodies are rejecting the donor bone marrow. c. The client is experiencing a delayed hypersensitivity reaction. d. The client will need treatment to prevent hyperacute rejection. ANS: A The client’s history and symptoms indicate that the client is experiencing graft-versus-host disease, in which the donated T cells attack the client’s tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 15. The nurse is caring for a client who has experienced Goodpasture’s syndrome. Which of the following adverse effects should the nurse be aware of? a. Thrombocytopenia b. Leukopenia c. Angioedema d. Pulmonary hemorrhage ANS: D Goodpasture’s syndrome is a rare disorder involving the lungs and the kidneys. An antibody-mediated autoimmune reaction occurs involving the glomerular and alveolar basement membranes. The circulating antibodies combine with tissue antigen to activate the complement system which causes deposits of IgG to form along the basement membranes of the lungs or the kidneys. This reaction may result in pulmonary hemorrhage and glomerulonephritis. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 16. The nurse is teaching a client on immunosuppressant therapy after a kidney transplant about the post-transplant drug regimen. Which of the following statements by the client should alert the nurse that additional teaching is required? a. “If I develop an acute rejection episode, I will need to have other types of drugs given IV.” b. “I need to be monitored closely because I have a greater chance of developing malignant tumours.” c. “After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor.” d. “The drugs are given in combination because they inhibit different aspects of transplant rejection.” ANS: C The calcineurin inhibitor will need to be continued for life. The other client statements are accurate and indicate that no further teaching is necessary about those topics. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 17. Which of the following adverse effects is related to cyclosporine administration? a. Nephrotoxicity b. Aseptic necrosis c. Peptic ulcer d. Leukopenia ANS: A Nephrotoxicity is the most severe adverse effect of cyclosporine. Aseptic necrosis, peptic ulcer, and leukopenia are all adverse effects of the use of corticosteroids, for example, prednisone. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. The nurse is admitting a client to the hospital with a diagnosis of an acute rejection of a kidney transplant. Which of the following actions should the nurse anticipate implementing? a. Administration of immunosuppressant medications b. Insertion of an arteriovenous graft for hemodialysis c. Placement of the client on the transplant waiting list d. Drawing blood for human leukocyte antigen (HLA) and ABO compatibility matching ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is reversible, there is no indication that the client will require another transplant, hemodialysis, or HLA/ABO testing. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 19. The nurse is admitting a client to hospital who has an acute rejection of an organ transplant. Which of the following clients is the most appropriate roommate? Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 a. A client who has viral pneumonia b. A client with second-degree burns c. A client who is recovering from an anaphylactic reaction to a bee sting d. A client with graft-versus-host disease after a recent bone marrow transplant ANS: C Treatment for a client with acute rejection includes administration of additional immunosuppressants, and the client should not be exposed to increased risk for infection as would occur from clients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a client with anaphylaxis. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 20. For early detection of an anaphylactic reaction in a client who has received allergen testing using the cutaneous scratch method, which of the following actions should the nurse take first? a. Check blood pressure and pulse rate. b. Auscultate the lung sounds bilaterally. c. Monitor pupil size and reaction to light. d. Assess the arm at the site of the skin testing. ANS: D The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 21. After being stung by a wasp, a client is brought to the clinic by a coworker. Upon arrival the client is anxious and having difficulty breathing. Which of the following actions is priority for the nurse to implement? a. Have the client lie down. b. Assess the client’s airway. c. Administer high-flow oxygen. d. Remove the stinger from the site. ANS: B The initial action with any client with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. Immediately after the nurse administers an intradermal injection of an allergen on the forearm, a client complains of itching at the site and of weakness and dizziness. Which of the following actions is priority for the nurse to implement? a. Remind the client to remain calm. b. Administer subcutaneous epinephrine. Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 c. Apply a tourniquet above the injection site. d. Rub a local anti-inflammatory cream on the site. ANS: C Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local anti-inflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the client to remain calm, but this is not an adequate initial nursing action. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse is caring for a client at an outpatient clinic who is experiencing an allergic reaction to an unknown allergen. Which of the following actions is most appropriate for the nurse to implement? a. Perform a focused physical assessment. b. Obtain the health history from the client. c. Teach the client about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method. ANS: D The immediate priority is to administer skin testing by the cutaneous scratch method as the client is experiencing an allergic reaction. After the allergic reaction is treated, an assessment of health history, focused physical assessment, and client teaching could follow. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 24. To determine whether a client’s angioedema has responded to prescribed therapies, which of the following actions should the nurse take first? a. Ask about any clear nasal discharge. b. Obtain blood pressure and heart rate. c. Check for swelling of the lips and tongue. d. Assess extremities for wheal and flare lesions. ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions; clear nasal drainage; and hypotension and tachycardia are characteristics of other allergic reactions. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 25. Which information about client and donor tissue typing results for a client who needs a kidney transplant is most important for the nurse to communicate to the health care provider? a. Client is Rh positive and donor is Rh negative. b. Six antigen matches are present in HLA typing. c. Results of client-donor crossmatching are positive. d. Panel of reactive antibodies (PRA) percentage is low. Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation, since hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the client and potential donor is acceptable. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 26. Which information about a client who is receiving immunotherapy and has just received an allergen injection is most important to communicate to the health care provider? a. The client’s IgG level is increased. b. The injection site is red and swollen. c. The client’s allergy symptoms have not improved. d. There is a 3-cm wheal at the site of the allergen injection. ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1–2 years to achieve an effect, an improvement in the client’s symptoms is not expected after a few months. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity OTHER 1. The nurse is caring for a client who is receiving an IV antibiotic and develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? a. Discontinue the antibiotic infusion. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Start 100% oxygen using a nonrebreather mask. ANS: A, E, C, B, D The nurse should initially discontinue the antibiotic, since it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Since the client currently does not have evidence of hypotension, the dopamine infusion can be prepared last. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 Chapter 17: Infection and Human Immunodeficiency Virus Infection Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. A client who has vague symptoms of fatigue and headaches is found to have a positive enzyme immunoassay (EIA) for human immunodeficiency virus (HIV) antibodies. In discussing the test results with the client, which of the following information should the nurse include? a. The EIA test will need to be repeated to verify the results. b. A viral culture will be done to determine the progress of the disease. c. It will probably be 10 or more years before the client develops acquired immunodeficiency syndrome (AIDS). d. The Western blot test will be done to determine whether AIDS has developed. ANS: A After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not part of HIV testing. Because the nurse does not know how recently the client was infected, it is not appropriate to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. A client is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and HIV testing is positive. Based on diagnostic criteria established by the World Health Organization (WHO), which of the following diagnoses should the nurse anticipate? a. Acute infection b. Early chronic infection c. Intermediate chronic infection d. Late chronic infection or AIDS ANS: D Development of PCP pneumonia meets the diagnostic criterion for AIDS. The other responses indicate an earlier stage of HIV infection than is indicated by the PCP infection. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. After having a positive rapid-antibody test for HIV, a client is anxious and does not appear to hear what the nurse is saying. Which of the following actions should the nurse implement? a. Teach the client about the medications available for treatment. b. Inform the client how to protect sexual and needle-sharing partners. c. Remind the client about the need to return for retesting to verify the results. d. Ask the client to notify individuals who have had risky contact with the client. ANS: C Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 After an initial positive antibody test, the next step is retesting to confirm the results. A client who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 4. A client who has diagnosed with AIDS tells the nurse, “I have lots of thoughts about dying. Do you think I am just being morbid?” Which of the following responses by the nurse is most appropriate? a. “Thinking about dying will not improve the course of AIDS.” b. “It is important to focus on the good things about your life now.” c. “Do you think that taking an antidepressant might be helpful to you?” d. “Can you tell me more about the kind of thoughts that you are having?” ANS: D More assessment of the client’s psychosocial status is needed before taking any other action. The statements, “Thinking about dying will not improve the course of AIDS.” and “It is important to focus on the good things in life.” discourage the client from sharing any further information with the nurse and decrease the nurse’s ability to develop a trusting relationship with the client. Although antidepressants may be helpful, the initial action should be further assessment of the client’s feelings. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. A pregnant woman with a history of early chronic HIV infection is seen at the clinic. Which of the following information should the nurse include when teaching the client? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Since she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral drug therapy (ART). ANS: B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. The nurse is caring for a client whose HIV status is unknown. Which of these client exposures is most likely to require postexposure prophylaxis for the nurse? a. Needle stick with a needle and syringe used to draw blood b. Splash into the eyes when emptying a bedpan containing stool c. Contamination of open skin lesions with client vaginal secretions d. Needle stick injury with a suture needle during a surgical procedure ANS: A Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 Puncture wounds are the most common means for workplace transmission of bloodborne diseases, and a needle with a hollow bore that had been contaminated with the client’s blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. Replication of HIV is enhanced when the client is taking which of the following herbs? a. Echinacea b. St. John’s wort c. Fish oil d. Saw palmetto ANS: A Some herbs (e.g., echinacea, astragalus) should not be used because they can enhance the replication of HIV. St. John’s wort can interfere with ART rather than enhance replication of HIV. Saw palmetto does not enhance HIV replication. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a client with HIV who has a CD4+ cell count of 400/µL. Which of the following factors is most important to consider when determining whether antiretroviral therapy (ART) will be initiated for this client? a. Client social support system b. HIV genotype and phenotype c. Potential medication adverse effects d. Client ability to comply with ART schedule ANS: D Drug resistance develops quickly unless the client takes ART medications on a stringent schedule, and this endangers both the client and the community. The other information is also important to consider, but clients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. Which of the following clients will the nurse working in an HIV testing and treatment clinic anticipate teaching about antiretroviral therapy (ART)? a. A client who is currently HIV negative but has unprotected sex with multiple partners b. A client who was infected with HIV 15 years ago and now has a CD4+ count of 840/µL c. An HIV-positive client with a CD4+ count of 120/µL who drinks a fifth of whiskey daily d. A client who tested positive for HIV 2 years ago and has cytomegalovirus (CMV) disease ANS: D Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 CMV disease is an AIDS-defining illness and indicates that the client is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative client would not be offered ART. A client with a CD4+ count in the normal range would not typically be started on ART. A client who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 10. When assessing an individual who has diagnosed with early chronic HIV infection and has a normal CD4+ count, which of the following assessments should the nurse conduct? a. Check neurological orientation. b. Ask about problems with diarrhea. c. Palpate the regional lymph nodes. d. Examine the oral mucosa for lesions. ANS: C Persistent generalized lymphadenopathy is common in the early stage of chronic infection. Diarrhea, oral lesions, and neurological abnormalities would occur in the later stages of HIV infection. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. Which of the following tests does the Canadian Blood Services use to detect HIV genetic material in blood? a. CD4+ T-cell count b. HIV RNA polymerase chain reaction test c. Nucleic acid amplification test d. CD4 fraction ANS: C In 2001, a new, highly sensitive nucleic acid amplification test (NAAT) was implemented by the Canadian Blood Services to detect HIV genetic material in blood of potential donors. The NAAT has a much shorter window period than antibody testing and is now the standard test for donated blood in Canada. CD4+ T-cell count, CD4 fraction, and the HIV RNA polymerase chain reaction test are not used by Canadian Blood Services. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 12. A young adult who uses injectable illegal drugs asks the nurse about preventing AIDS. Which of the following information should the nurse inform the client is the best way to reduce the risk of HIV infection from drug use? a. Participate in a needle-exchange program. b. Clean drug injection equipment before use. c. Ask those who share equipment to be tested for HIV. d. Avoid sexual intercourse when using injectable drugs. ANS: A Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 Participation in needle and syringe exchange programs has been shown to control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practised by individuals in withdrawal. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 13. Which of the following nursing actions will be most useful in assisting a young adult college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the client detailed information about possible medication adverse effects. b. Remind the client of the importance of taking the medications as scheduled. c. Encourage the client to join a support group for students who are HIV positive. d. Check the client’s class schedule to help decide when the ART should be taken. ANS: D The best approach to improve adherence is to learn about important activities in the client’s life and adjust the ART around those activities. The other actions also are useful, but they will not improve adherence as much as individualizing the ART to the client’s schedule. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 14. The nurse is caring for a client with HIV infection who has developed Mycobacterium avium complex infection. Which of the following goals is most appropriate for this client? a. Be free from injury. b. Receive immunizations on time. c. Ensure adequate oxygenation. d. Maintain intact perineal skin. ANS: D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc.) associated with HIV infection. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. A client who has been treated for HIV infection for 7 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. Which of the following topics should the nurse include in the client teaching plan? a. The benefits of daily exercise b. Foods that are higher in protein c. Treatment with antifungal agents d. A change in antiretroviral therapy ANS: D Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 A frequent first intervention for metabolic disorders is a change in ART. Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 16. The nurse is preparing to give the following medications to an HIV-positive client who is hospitalized with Pneumocystis jiroveci pneumonia (PCP). Which of the following medications is most important to administer at the right time? a. Nystatin tablet b. Oral abacavir c. Aerosolized pentamidine d. Oral acyclovir ANS: B It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day. DIF: Cognitive Level: Analysis TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. Which of the following tests is used to evaluate the effectiveness of ART? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immuno-fluorescence assay ANS: A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. Which information about an HIV-positive client who is taking antiretroviral medications is most important for the nurse to address when planning care? a. The client’s blood glucose level is 168 mg/dL. b. The client complains of feeling “constantly tired.” c. The client is unable to state the adverse effects of the medications. d. The client states “sometimes I miss a dose of zidovudine (AZT).” ANS: D Since missing doses of ART can lead to drug resistance; this client statement indicates the need for interventions such as teaching or changes in the drug scheduling. Elevated blood glucose and fatigue are common adverse effects of ART. The nurse should discuss medication adverse effects with the client, but this is not as important as addressing the skipped doses of AZT. Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 19. Ten years after seroconversion, an HIV-infected client has a CD4+ cell count of 800 cells per microlitre and an undetectable viral load. Which of the following actions is the priority nursing intervention at this time? a. Monitor for symptoms of AIDS. b. Teach about the effects of antiretroviral agents. c. Encourage adequate nutrition, exercise, and sleep. d. Discuss likelihood of increased opportunistic infections. ANS: C The CD4+ level for this client is in the normal range, indicating that the client is the early chronic stage of infection, when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although initiation of ART is highly individual, it would not be likely that a client with a normal CD4+ level would receive ART. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. The nurse is caring for a pregnant client who has recently been diagnosed with HIV. The client asks the nurse, “How soon after delivery of my baby can ART treatment be started?” Which of the following provide the basis for the nurse’s response? a. It can be initiated while you are pregnant. b. It will start as soon as your baby is born. c. It depends upon whether you are breastfeeding your baby or not. d. It cannot begin until 7 days postpartum. ANS: A Women infected with HIV should receive optimal ART immediately, regardless of whether or not they are pregnant. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 21. The nurse is designing a program to teach a community group about decreasing the incidence of HIV infection in their community. Which of the following information is a priority that the nurse include in the education session? a. Methods to prevent perinatal HIV transmission. b. How to prevent transmission between sexual partners. c. Ways to sterilize needles used by injectable drug users. d. Means to prevent transmission through blood transfusions. ANS: B Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide education about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 MULTIPLE RESPONSE 1. The nurse is caring for a client who has just diagnosed with early chronic HIV infection. Which of the following prophylactic measures should the nurse anticipate being included in the plan of care? (Select all that apply.) a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella-zoster immune globulin ANS: A, B, C Prevention of other infections is an important intervention in clients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease, when the CD4 count has dropped or when infection has occurred. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 Chapter 32: Nursing Assessment: Hematological System Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. The nurse is providing discharge teaching to a client who has had an emergency splenectomy following an automobile accident. Which of the following events should the nurse inform the client that they are at an increased risk of developing? a. Infection b. Lymphedema c. Chronic anemia d. Prolonged bleeding ANS: A The spleen plays a major role in immune function. Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after splenectomy. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is obtaining a health history from a client and notes numerous petechiae. Which of the following assessments should the nurse anticipate? a. Bruising on the skin b. Pinpoint purplish-red lesions c. Small focal red lesions d. Brown spots on mucous membranes ANS: B Petechiae are small, purplish-red lesions. Ecchymosis is bruising on the skin. Small focal red lesions are telangiectasia. Purpura are small hemorrhages on the skin or mucous membranes resulting in a rash of purple, red, or brown spots. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is reviewing laboratory data for an older-adult client. Which of the following results should be of most concern? a. White blood cell (WBC) count of 3.5 ´ 109/L b. Hematocrit of 37% c. Platelet count of 400 ´ 109/L d. Hemoglobin of 118 g/L ANS: A The total WBC count is not usually affected by aging, and the low WBC here would indicate that the client’s immune function may be compromised. The platelet count is normal. The slight decrease in hemoglobin and hematocrit is not unusual for an older client. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 MSC: NCLEX: Physiological Integrity 4. The health care provider performs a bone marrow aspiration from the left posterior iliac crest on a client with pancytopenia. Which of the following actions should the nurse implement following the procedure? a. Elevate the head of the bed to 45 degrees. b. Apply a sterile Band-Aid at the aspiration site. c. Use half-inch sterile gauze to pack the wound. d. Apply a pressure dressing on the aspiration site. ANS: D A pressure dressing is used to cover the aspiration site. The wound after bone marrow biopsy is small and will not be packed with gauze. There is no indication that the head needs to be elevated for this client. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a client with a chronic iron-deficiency anemia. Which of the following assessment findings should the nurse anticipate? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Numbness of the extremities d. Gum bleeding and tenderness ANS: B Loss of the papillae of the tongue occurs with chronic iron deficiency. Scleral jaundice is associated with hemolysis, gum bleeding and tenderness occur with thrombo-cytopenia or neutropenia, and extremity numbness is associated with vitamin B12 deficiency or pernicious anemia. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 6. A client’s complete blood count shows a hemoglobin of 200 g/L and a hematocrit of 54%. Which of the following questions should the nurse ask to determine possible causes of this finding? a. “Has there been any recent weight loss?” b. “Do you have any problems with your vision?” c. “What is your intake of fruits and vegetables?” d. “Have you noticed any dark or bloody stools?” ANS: B The hemoglobin and hematocrit results indicate polycythemia and polycythemia may cause visual abnormalities. The other questions will be appropriate for clients who are anemic. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a client who is receiving heparin. Which of the following laboratory tests should the nurse monitor? Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 a. Prothrombin time (PT) b. Fibrin degradation products (FDP) c. International normalized ratio (INR) d. Activated partial thromboplastin time (aPTT) ANS: D aPTT testing is used to determine whether heparin is at a therapeutic level. FDP is useful in diagnosis of problems such as disseminated intravascular coagulation (DIC). PT and INR are most commonly used to test for therapeutic levels of warfarin. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse is evaluating the red cell indices result of a client’s laboratory report. Which of the following interpretations is correct related to a low mean corpuscular volume (MCV)? a. Hypochromic red blood cells (RBCs) b. Inadequate numbers of RBCs c. Low hemoglobin in the RBCs d. Small size of the RBCs ANS: D The MCV is low when the RBCs are smaller than normal. Inadequate numbers of RBCs are an indication of anemia. Low levels of hemoglobin in the RBCs and hypochromic RBCs result in a low mean corpuscular hemoglobin (MCH). DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. While examining the lymph nodes during physical assessment, the nurse would be most concerned about which of the following findings? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a client with an infected foot ANS: A Enlarged and nontender nodes are most suggestive of malignancy such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5–1 cm and nontender. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a client who had an intraoperative hemorrhage 12 hours ago. Which of the following laboratory results should the nurse anticipate? a. Hematocrit of 45% b. Hemoglobin of 132 g/L c. Decreased white blood cell (WBC) count d. Elevated reticulocyte count ANS: D Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 Hemorrhage causes the release of more immature RBCs from the bone marrow into the circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. The nurse is caring for a client whose complete blood count (CBC) and differential indicate that the client is neutropenic. Which of the following actions should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods. ANS: C Neutropenic clients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. The other actions would not address the client’s neutropenia. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a newly admitted client whose complete blood count (CBC) shows a “shift to the left.” Which of the following assessments should the nurse monitor in the plan of care? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation ANS: C The term shift to the left indicates that the number of immature polymorphonuclear neutrophils, or bands, is elevated and is a sign of severe infection. There is no indication that the client is at risk for hypoxemia, pallor or weakness, or cool extremities. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. The health care provider orders an ultrasound of the spleen for a client who has been in a car accident. Which of the following actions should the nurse take before this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Place the client on NPO status. d. Assist the client to a flat position. ANS: D The client is placed in a flat position before splenic ultrasound. The client does not have to be NPO or have an IV line. No iodine-containing materials are used for ultrasound. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity Downloaded by Nurse Lizzo ([email protected])  lOMoARcPSD|14578492 14. The nurse is caring for a client with pancytopenia of unknown origin who is confused and is scheduled for the following diagnostic tests. Which of the following tests should the nurse contact the client’s family member to obtain a signed consent form? a. ABO blood typing b. Bone marrow biopsy c. Abdominal ultrasound d. Complete blood count (CBC) ANS: B Bone marrow biopsy is a minor surgical procedure that requires the client or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the client or family. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is reviewing the complete blood count (CBC) for a client admitted with abdominal pain. Which of the following information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 116 g/L c. Platelet count 145 ´ 109/L d. White blood cells 13.5 ´ 109/L ANS: D The elevation in WBCs indicates that an abdominal infection may be the cause of the client’s pain and that further diagnostic testing is needed. The monocytes are at a normal level. The slight decreases in hemoglobin and platelet count also would be reported but would not require any immediate action. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is reviewing the laboratory results of clotting study tests for the client. Which of the following findings should the nurse identify as abnormal? (Select all that apply.) a. Activated clotting time 118 seconds b. Activated partial thromboplastin time 40 seconds c. D-dimer 200 mcg/L d. Fibrinogen 5 g/L e. Prothrombin time 21 seconds ANS: B, D, E The activated partial thromboplastin time is elevated (normal: 25–35 seconds); fibrinogen is elevated (normal: 2–4 g/L); and, the prothrombin time is elevated (normal: 11–16 seconds). The activated clotting time is within normal limits (70–120 seconds). The D-dimer is within normal limits (