Nokea
The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis?
- A. The client will have a productive cough.
- B. The injection area swells if the client has developed antibodies against the antigen.
- C. The injection area will become painful with induration if the client has antibodies against the antigen.
- D. The injection area will break out in a fine macular rash.
Correct Answer: B
Rationale: The injection area swells if the client has developed antibodies against the antigen. The client is not necessarily actively infectious if the test results are positive. Although a productive cough is one of the symptoms of active tuberculosis, it may also indicate other diseases and disorders. The area should not be painful, and the client should not break out with a rash.
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A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse of having several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications?
- A. Administer the medications that the physician ordered.
- B. Call the pharmacy and let them know the client has several drug allergies.
- C. Consult drug references to make sure the medicines do not contain substances to which the client is hypersensitive.
- D. Give the client one medicine at a time and observe for allergic reactions.
Correct Answer: C
Rationale: Clear identification of any substances to which the client is allergic is essential. The nurse must consult drug references to verify that prescribed medications do not contain substances to which the client is hypersensitive. Administering the medications or giving one at a time may cause the client to have an allergic reaction. The nurse may call the pharmacy but still maintains responsibility for the medications administered.
The nurse is caring for a client on tube feedings. The physician has ordered Osmolite HN as the feeding formula for the client. The family asks why the physician has ordered Osmolite HN instead of another formula to feed their family member. What is an important reason that tube-feeding formulas, such as Impact, Immun-Aid, or Perative, be recommended to clients?
- A. To suppress immune system function
- B. To block tumor necrosis factor
- C. To enhance the production of T-cell lymphocytes and NK cells
- D. To stimulate the immune system to attack tumor cells
Correct Answer: C
Rationale: Immune-enhancing tube-feeding formulas enhance the production of lymphocytes and NK cells, resulting in increased cell-mediated immunity. Drugs such as azathioprine, cyclosporine, and muromonab-CD3 suppress immune system function, whereas infliximab and etanercept minimize inflammation by blocking tumor necrosis factor. Aldesleukin is used as biologic therapy for clients who do not respond to conventional cancer treatment. Aldesleukin stimulates the immune system's ability to attack tumor cells.
The nurse is obtaining medication history information from a client with Crohn's disease. What medication would the nurse include when asking what medications the client has taken for suppression of the inflammatory and immune response?
- A. Nonsteroidal anti-inflammatory
- B. Angiotensin-converting enzyme inhibitors (ACE-I)
- C. Diuretics
- D. Corticosteroids
Correct Answer: D
Rationale: The nurse obtains a history of immunizations, recent and past infectious diseases, and recent exposure to infectious diseases. The nurse reviews the client's drug history because certain drugs, such as corticosteroids, suppress the inflammatory and immune responses. Nonsteroidal anti-inflammatory medication does not suppress the inflammatory and immune responses of Crohn's disease. An ACE-I prevents the conversion of angiotensin I to angiotensin II and does not suppress the inflammatory or immune response. Diuretics also do not suppress the immune response but help reduce excess fluid from the kidneys.
The nurse is beginning the physical examination of a client who has reported fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
- A. The client appears mildly ill, listless, and disheveled.
- B. The client has a blood pressure of 120/72 mm Hg.
- C. The client is alert and oriented to all spheres.
- D. The client has palpable peripheral pulses in the upper extremities.
Correct Answer: A
Rationale: The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then perform a more comprehensive examination.
Why would it be important for the nurse to question the client about sexual practices, history of substance use disorder, and lifestyle during the interview process?
- A. To find out if the client will be compliant with therapeutic treatments
- B. To determine if the client has practices that are risk factors for acquired immunodeficiency syndrome (AIDS)
- C. To determine if the client needs a referral to counseling services
- D. To determine what type of personality the client has
Correct Answer: B
Rationale: The nurse investigates the client's allergy history and asks about practices that put the client at risk for AIDS. The interview will not determine the client's ability to be compliant. The physician would make the determination if a counseling referral should be made. It is irrelevant to determine the personality traits in the initial interview.