Chapter 53 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 53

Question 1

Type: MCSA

A patient with a history of latex allergy has developed itching and hives after being admitted for a fractured left femur. What initial nursing action is indicated?

1. Survey the patients room for possible latex-containing items.

2. Ask if the patient is experiencing any difficulty breathing.

3. Alert the patients health care provider concerning the symptoms.

4. Collect a detailed history from the patient regarding the allergy.

Correct Answer: 2

Rationale 1: Attempting to locate latex-containing items is not the nurses priority.

Rationale 2: A history of latex allergy in combination with the patients 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.

Rationale 3: The health care provider should be alerted, but this is not the nurses immediate priority.

Rationale 4: Conducting a nursing history is not the immediate priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-1

Question 2

Type: MCSA

A patient is suspected of having an allergic reaction to certain laundry detergents. The nurse recognizes that which diagnostic test result would best confirm a hypersensitivity reaction?

1. Rh antigen with negative results

2. Eosinophils of 2% of the total WBC

3. Prick test with 3 mm erythema

4. Indirect Coombs showing no agglutination

Correct Answer: 3

Rationale 1: Rh antigen results that are negative reflect the absence of the Rh factor in the blood. This result is not associated with hypersensitivity reaction.

Rationale 2: Eosinophils do increase with hypersensitivity reaction, but this result is within normal limits.

Rationale 3: Positive results from a prick test include wheal and flare of at least 3 mm.

Rationale 4: The indirect Coombs test detects the presence of circulating antibodies against RBCs. This result is not associated with hypersensitivity reaction.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-1

Question 3

Type: MCSA

A patient who believes he has a peanut allergy presents at the emergency department concerned because he has ingested a small amount

of commercially prepared food that may have contained peanut oil. Which nursing question best addresses the patients risk for injury?

1. Did you self-administer epinephrine?

2. What makes you think you are allergic to peanuts?

3. Have you every undergone testing for a peanut allergy?

4. Have you ever experienced an allergic reaction to peanuts before?

Correct Answer: 4

Rationale 1: Self-administration of epinephrine is directed more toward management of a reaction than confirming the possibility of a reaction.

Rationale 2: This question will elicit important information, but it is not the first question the nurse should ask.

Rationale 3: The nurse should ask about testing, but this is not the priority question.

Rationale 4: The priority is to determine whether the patient is allergic to peanuts and at risk for injury in the form of an allergic reaction. Confirming a past reaction to the ingestion of peanuts is the best way to determine that possibility at this time.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-1

Question 4

Type: MCMA

The nurse is providing discharge education for a patient who experienced an anaphylactic reaction to a bee sting. To ensure that the patient receives prompt, appropriate medical care in the event of another bee sting, the nurse encourages which actions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Carry oral antihistamines at all times.

2. Be aware of how quickly the symptoms occur and exacerbate.

3. Always have quick access to an epinephrine pen.

4. Wear a medical alert bracelet that identifies allergy to bee venom.

5. Be able to identify early symptoms of allergic reaction.

Correct Answer: 2,3,4,5

Rationale 1: Oral medications would not work rapidly enough in case of another episode of anaphylaxis.

Rationale 2: Being aware of symptoms and the speed with which anaphylactic shock can develop will be vital to the patients receiving prompt, appropriate medical care.

Rationale 3: Carrying a self-administered epinephrine kit to use in the event of an anaphylactic reaction is essential.

Rationale 4: The nurse can 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.

Rationale 5: The patient who can self-assess for symptoms of allergic reaction will be able to initiate treatment earlier.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-1

Question 5

Type: MCSA

A patient is admitted to receive a kidney transplant from a live sibling. The nurse understands that which condition has been met for this surgery to be planned?

1. The human leukocyte antigens between the patient and sibling are very similar.

2. The human leukocyte antigens between the patient and sibling are very different.

3. The human leukocyte antigens of patient and sibling are an exact match.

4. The recipients human leukocyte antigens have been eliminated.

Correct Answer: 1

Rationale 1: In organ transplants, matching the human leukocyte antigen type as closely as possible tends to reduce the chances of rejection.

Rationale 2: If the human leukocyte antigen types were different, the surgery would not be successful.

Rationale 3: An exact match of HLA antigens is desirable but not absolutely essential for transplant success.

Rationale 4: It is not possible to eliminate the human leukocyte antigens.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 53-2

Question 6

Type: MCSA

A patient comes into the emergency department with itching, swelling, and slight shortness of breath after being stung by a bee 20 minutes ago. The nurse bases care of this patient on the pathophysiology of which hypersensitivity reaction?

1. Type I IgE-mediated hypersensitivity

2. Type II cytotoxic hypersensitivity

3. Type III immune complex-mediated hypersensitivity

4. Type IV delayed hypersensitivity

Correct Answer: 1

Rationale 1: Common hypersensitivity reactions such as anaphylactic shock are typical of type I or IgE-mediated hypersensitivity. When a potent allergen such as bee or wasp venom is injected, resulting in widespread antibodyantigen reaction and response to these chemical mediators, a systemic response such as anaphylaxis, urticaria, or angioedema occurs.

Rationale 2: A hemolytic transfusion reaction to blood of an incompatible type is characteristic of a type II or cytotoxic hypersensitivity reaction.

Rationale 3: Type III hypersensitivity reactions result from the formation of IgG or IgM antibodyantigen immune complexes in the circulation, leading to tissue damage. Serum sickness is an example of a disorder secondary to type III immune complex-mediated hypersensitivity.

Rationale 4: Type IV delayed hypersensitivity reactions result from an exaggerated interaction between an antigen and normal cell-mediated mechanisms. Symptomology does not manifest for 24 to 48 hours after the exposure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-2

Question 7

Type: MCSA

A patient is diagnosed with a type IV delayed hypersensitivity reaction. Which patient reaction is an example of this type of reaction?

1. The patients hands are dry, red, swollen, and itchy after wearing a latex costume to a party 2 days ago.

2. The patient is light-headed and complains of nausea after being stung by a wasp.

3. The patient develops rash and joint pain a week after taking penicillin.

4. The patient goes into shock after receiving a unit of blood.

Correct Answer: 1

Rationale 1: Contact dermatitis is a classic example of a type IV reaction.

Rationale 2: A reaction to a wasp sting is an example of a type I reaction.

Rationale 3: Delayed rash and joint pain are associated with type III reactions.

Rationale 4: Autoimmune hemolytic anemia is an example of a type II reaction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-2

Question 8

Type: MCSA

A patient develops a fever, rash, joint and muscle pain, and swollen lymph nodes after receiving a sulfonamide for a urinary tract infection (UTI). The nurse anticipates providing care for which condition?

1. Serum sickness

2. Worsening of the infection

3. Respiratory involvement from systemic release of pathogens

4. Subacute rheumatoid arthritis from increased serum uric acid

Correct Answer: 1

Rationale 1: Manifestations of serum sickness include fever, urticaria or rash, arthralgias, myalgias, and lymphadenopathy. Serum sickness can occur in response to some drugs, such as penicillin and sulfonamides.

Rationale 2: These findings are not associated with a worsening of UTI symptoms.

Rationale 3: There is no indication that these symptoms are from systemic pathogen release.

Rationale 4: These symptoms are not related to increased uric acid in the serum.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-2

Question 9

Type: MCSA

A patient who had a bone marrow transplant 10 days ago develops a maculopapular rash on the palms of both hands and the soles of the feet. The patient complains of severe abdominal pain with bloody diarrhea. The nurse would anticipate providing care for which condition?

1. Graft-versus-host disease

2. Chronic graft rejection

3. Acute tissue rejection

4. Hyperacute tissue rejection

Correct Answer: 1

Rationale 1: Rash and gastrointestinal symptoms can be symptoms of graft-versus-host disease.

Rationale 2: Chronic tissue rejection occurs from 4 months to years after the transplant of new tissue. Transplanted organs slowly fail when chronic graft rejection occurs.

Rationale 3: Acute tissue rejection, the most common type of rejection, occurs between 4 days and 3 months after the transplant. Acute rejection is mediated primarily by the cellular immune response, resulting in transplant cell destruction. The patient demonstrates manifestations of the inflammatory process, with fever, redness, and swelling.

Rationale 4: Hyperacute rejection occurs when there is a preexisting antibody to the graft tissue. Manifestations are rapid, occurring

within minutes to hours.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-2

Question 10

Type: MCSA

A patient is diagnosed with valvular heart disease after having strep throat. The nurse would explain that this condition is the result of which pathophysiology?

1. Molecular mimicry

2. Release of hidden antigens into the circulation

3. Biologic changes that caused self-antigens to produce autoantibodies

4. An autoimmune response by slow-growing mycobacteria

Correct Answer: 1

Rationale 1: The introduction of an antigen whose properties closely resemble those of host tissue stimulates the production of antibodies that target not only the foreign antigen but also normal tissue. This is known as molecular mimicry. Heart damage after upper respiratory infection is an example of the development of antibodies against normal tissue.

Rationale 2: Hidden antigens are not the cause of this valvular damage.

Rationale 3: In this instance, antigens are attacking self-cells because they look like foreign cells.

Rationale 4: Mycobacteria are not involved in this process.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-2

Question 11

Type: MCSA

A patient who is immunosuppressed asks the nurse why she is experiencing so many illnesses. How should the nurse respond?

1. You are unable to develop immunity to common bacteria, so you will experience more illnesses.

2. Your body takes longer to develop an immune response.

3. Your body thinks everything is foreign matter and responds with an illness.

4. You are under severe stress, which is causing the illnesses.

Correct Answer: 1

Rationale 1: Patients with immunodeficiency disorders demonstrate an unusual susceptibility to infection. When the antibody-mediated response is primarily affected, the patient is at particular risk for severe and chronic bacterial infections.

Rationale 2: This patients altered immunity manifests as a reduced level of response, not a slower response.

Rationale 3: Immunosuppression does not result in the body thinking everything is foreign.

Rationale 4: The illnesses are not caused by the patients stress level.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-1

Question 12

Type: MCSA

A patient is experiencing symptoms of exposure to environmental ragweed. The nurse should instruct the patient on the use of which class of medications?

1. Antihistamines

2. Antibiotics

3. Antiviral medications

4. Antifungal medications

Correct Answer: 1

Rationale 1: Antihistamines alleviate the systemic effects of histamines such as urticaria and angioedema. They are also useful in relieving allergic rhinitis, drying respiratory secretions through an anticholinergic effect. The preferred route of administration is oral, and side effects include drowsiness and dry mouth.

Rationale 2: The patient is experiencing an allergic response and will not be prescribed an antibiotic.

Rationale 3: The patient is experiencing an allergic response and will not be prescribed an antiviral medication.

Rationale 4: The patient is experiencing an allergic response and will not be prescribed an antifungal medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-1

Question 13

Type: MCSA

A patient diagnosed with AIDS complains of nausea, fever, severe diarrhea, and anorexia. Which medication would be the most effective to relieve the anorexia and to stimulate the patients appetite?

1. Megestrol (Megace)

2. Ciprofloxacin (Cipro)

3. Zidovudine (Retrovir, AZT)

4. Abacavir (Ziagen)

Correct Answer: 1

Rationale 1: Megestrol (Megace) can be prescribed to increase the patients appetite and promote weight gain.

Rationale 2: Ciprofloxacin (Cipro) is an anti-infective medication. It would not have a positive effect on the patients appetite.

Rationale 3: Zidovudine (Retrovir, AZT) is an antiretroviral agent. It would not stimulate the patients appetite.

Rationale 4: Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-4

Question 14

Type: MCSA

The nurse is instructing a patient diagnosed with AIDS regarding food choices that will increase caloric intake. Which meal choice would indicate that the patient understands the dietary instruction?

1. Spaghetti and meat sauce, raisin salad, whole-grain roll with butter, vanilla milkshake (with Ensure), and a piece of pecan pie

2. Baked chicken (thigh), cabbage, small green salad, slice of white bread, dried prunes, and a soda

3. Red beans and rice, slaw, tomato, crackers, chocolate pudding, and iced tea

4. Vegetable soup, small piece of cornbread, banana pudding, and water

Correct Answer: 1

Rationale 1: A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. This meal provides more calories than do the other choices.

Rationale 2: A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. This meal does not provide the highest protein and calorie intake.

Rationale 3: A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. This meal does not provide the highest protein and calorie intake.

Rationale 4: A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. This meal may provide the least protein and the fewest calories.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 53-4

Question 15

Type: MCSA

Which statement by a patient who has HIV would the nurse evaluate as indicating additional health care teaching is necessary?

1. I will use an oil-based lubricant when I use condoms.

2. I know I should not donate blood anymore.

3. I know I have to assume responsibility when I have sex.

4. I will not share my toothbrush or razor with my partner.

Correct Answer: 1

Rationale 1: Oil-based lubricants can damage condoms. Water-based lubricants should be used.

Rationale 2: The patient with HIV should not donate blood.

Rationale 3: The patient with HIV must take personal responsibility for using safe sexual practices.

Rationale 4: The HIV-positive patient should not share any personal item that may be contaminated with blood. Examples are toothbrushes and razors.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-4

Question 16

Type: MCSA

The nurse is performing an admission assessment on a patient with AIDS. Which question would best evaluate the patients risk of contracting an opportunistic infection?

1. What were the results of your last CD4 and T cells test?

2. Have you had any fever, diarrhea, or chills over the last 48 hours?

3. Can you identify the signs and symptoms of a possible infection?

4. Are you sexually active with persons who also have AIDS?

Correct Answer: 1

Rationale 1: 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. The results of the patients most recent CD4 and T cells test would help the nurse assess the patients risk of contracting such a disease.

Rationale 2: Identifying symptoms of an opportunistic infection such as fever, diarrhea, or chills is important to the treatment, not to evaluating the risk of contracting such a disease.

Rationale 3: The ability to self-assess would be helpful once an opportunistic infection has occurred.

Rationale 4: The AIDS status of the patients sexual partners has no bearing on the risk of contracting an opportunistic infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-4

Question 17

Type: MCMA

A patient diagnosed with AIDS has developed oral candidiasis. The home health nurse would agree with which actions by the family to help manage this opportunistic infection?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Offer to quit smoking with the patient.

2. Plan meals that avoid salty, spicy, acidic, or abrasive foods.

3. Allow the patients foods to cool prior to serving.

4. Assist the patient with oral care three times a day.

5. Provide the patient with a variety of favorite beverages.

Correct Answer: 1,2,3,5

Rationale 1: By offering to quit smoking, the family is helping the patient to avoid smoking, thus reducing the drying and irritation to mucous membranes.

Rationale 2: Salty, spicy, acidic, or abrasive foods irritate the oral mucosa and should be avoided.

Rationale 3: Foods that are extreme in temperature should be avoided to reduce aggravation of oral lesions.

Rationale 4: Assisting with oral care every 2 hours by rinsing oral mucosa with saline and dilute hydrogen peroxide solution reduces the spread of lesions.

Rationale 5: The family should encourage the patient to maintain a fluid intake of >2,500 oz/day, if not contraindicated, to maintain hydration and keep mucous membranes moist.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-4

Question 18

Type: MCSA

A patient is demonstrating signs of anaphylactic shock. Which action should the nurse take first to assist this patient?

1. Administer subcutaneous epinephrine.

2. Maintain an airway.

3. Provide calm reassurance.

4. Place the patient on a cardiac monitor.

Correct Answer: 2

Rationale 1: Administering epinephrine is an important intervention but is not the first priority.

Rationale 2: Establishing and maintaining a patent airway is of primary importance when a patient demonstrates anaphylactic shock.

Rationale 3: The nurse should remain calm and try to calm the patient, but other interventions have greater priority.

Rationale 4: The patient will be placed on a cardiac monitor, but this is not the priority intervention.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-1

Question 19

Type: MCSA

A patient with an autoimmune disorder tells the nurse, My family keeps telling me I dont look sick. The nurse would choose which nursing diagnosis to help this patient?

1. Interrupted Family Processes

2. Ineffective Protection

3. Ineffective Coping

4. Social Isolation

Correct Answer: 1

Rationale 1: The patients family does not recognize a disease process based on the patients physical appearance. Some autoimmune diseases manifest with subjective symptoms such as fatigue or with symptoms that are not obvious, such as hypotension or decreased renal function. The best nursing diagnosis for this patient would be Interrupted Family Processes.

Rationale 2: The patients appearance of health indicates he or she is adequately protected.

Rationale 3: The question does not suggest a lack of coping by the patient or the family. Rather, the family does not recognize the patients illness.

Rationale 4: The patient is interacting with family, and there is no data to suggest a lack of interaction with others.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 53-1

Question 20

Type: MCSA

An HIV-positive patient comes into the clinic complaining of increasing pain in the feet and legs. The nurse realizes that this patient is demonstrating which complication?

1. A reaction to the medication

2. An opportunistic infection

3. A secondary cancer

4. A nervous system manifestation of the disease

Correct Answer: 4

Rationale 1: Specific complaints of pain in the feet and legs are not likely to be related to medication reactions.

Rationale 2: Specific complaints of pain in the feet and legs are not likely to be associated with opportunistic infection.

Rationale 3: Specific complaints of pain in the feet and legs are not likely to be associated with cancer development.

Rationale 4: Peripheral nervous system changes are common in HIV-infected patients. These changes are often manifested as pain and numbness in the extremities.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-3

Question 21

Type: MCSA

An HIV-positive patient is not adhering to the prescribed medication therapy. Which action by the nurse would be most effective at improving patient compliance and the long-term treatment of the disease process?

1. Confront the patient about the noncompliant behavior.

2. Talk with the patient about not adhering to the medication schedule.

3. Remind the patient that not following the recommended regimen may result in earlier death.

4. Warn the patient that if the treatment plan is not followed, reimbursement for services is not assured.

Correct Answer: 2

Rationale 1: Confronting the patient may lead to alienation, which would not be helpful.

Rationale 2: The first step of the nursing process is assessment. The nurse should talk with the patient to determine the reasons the medication schedule is not being followed.

Rationale 3: The patient should have already been educated about the reasons for the medication regimen. Scare tactics, such as warning of an early death, are not useful in gaining patient compliance.

Rationale 4: The nurse has no knowledge of how noncompliance will affect reimbursement for services. This warning is a threat, which has no place in nursing interventions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 53-3

Question 22

Type: MCMA

The nurse is preparing to instruct a class of young adults about ways to perform safe sex. What should be included in the nurses presentation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use spermicidal agents to lubricate the condom.

2. Get HIV testing if entering a new monogamous relationship and have the test repeated in 6 months.

3. Avoid sexual activity until both partners are HIV negative for two tests.

4. Use a condom along with oral contraceptives.

5. Avoid using water-based lubricants.

Correct Answer: 2,4

Rationale 1: The spermicidal agent nonoxynol-9 may increase vaginal tissue damage and the risk of HIV infection.

Rationale 2: There is a window of up to 6 months before HIV antibody testing is positive after infection. When entering a new monogamous relationship, both partners should undergo HIV testing initially. If both are negative, they should practice abstinence or safe sex for 6 months, followed by retesting; if results are still negative for both, sexual activity can probably be considered safe.

Rationale 3: The number of tests is not as significant as the time between the tests.

Rationale 4: Oral contraceptives do not protect against sexually transmitted infections. Condoms should also be used.

Rationale 5: Water-based lubricants should be used. Oil-based lubricants can damage condoms.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-3

Question 23

Type: MCSA

Which patients findings would the nurse interpret as most consistent with a type II cytotoxic hypersensitivity reaction?

1. Patient A

2. Patient B

3. Patient C

4. Patient D

Correct Answer: 4

Rationale 1: Type I hypersensitivity reactions are IgE mediated. Histamine is released.

Rationale 2: Type III hypersensitivity reactions are complex-mediated and involve IgG and IgM antibody-antigen immune complexes. These complexes are released into circulation and can be deposited in extravascular tissue.

Rationale 3: Type IV hypersensitivity reactions differ from other types of hypersensitivity reactions in that the response is delayed, with onset 24 to 48 hours after antigen exposure.

Rationale 4: A hemolytic transfusion reaction to blood of an incompatible type is characteristic of a type II or cytotoxic hypersensitivity reaction. IgG- or IgM-type antibodies are formed to a cell-bound antigen such as the ABO or Rh antigen. When these antibodies bind with the antigen, the complement cascade is activated, resulting in destruction of the target cell.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-2

Question 24

Type: SEQ

When considering guidelines for teaching about safer sex, how would the nurse rank the risk for HIV transmission from highest to lowest?

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Heterosexual intercourse between partners using latex condoms

Choice 2. Abstinence

Choice 3. Monogamous sex between partners who are both EIA and Western Blot negative

Choice 4. Anal intercourse between partners using latex condoms

Correct Answer: 4,1,3,2

Rationale 1: Heterosexual intercourse between partners using latex condoms is the second riskiest behavior of these choices.

Rationale 2: Abstinence carries the lowest risk and is the safest practice.

Rationale 3: Monogamous sex between partners who are both EIA and Western Blot negative still carries some small risk.

Rationale 4: Anal intercourse is damaging to sensitive tissues, increasing trauma and the risk of transmission.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-3

Question 25

Type: MCMA

A patient had no skin reaction to a purified protein derivative (PPD) screen. When discussing this result, the patient tells the nurse that she is HIV positive. What information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. As this is the first PPD you have ever had, you should have it repeated in 2 weeks.

2. You have not contracted TB.

3. Your skin test may not be valid.

4. You should have a chest X-ray.

5. Additional laboratory tests are indicated.

Correct Answer: 3,4,5

Rationale 1: Two-step PPD tests are commonly done but are not indicated for this patient.

Rationale 2: In a patient diagnosed with HIV, the PPD test will likely be negative. The immune system must be intact for the classic response to occur.

Rationale 3: The patients immune system is involved in the response to a PPD. Patients diagnosed with HIV may not respond.

Rationale 4: A screening chest X-ray should be done for patients who are HIV positive and who are exposed to TB.

Rationale 5: Acid-fast bacillus testing or sputum, blood, or cerebral spinal fluid may be used to diagnose the presence of TB.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-4

Question 26

Type: FIB

A patient diagnosed with HIV/AIDS weighed 180 pounds when diagnosed. The patient has had intermittent fever, diarrhea, and anorexia for the last 30 days. The nurse would be concerned that HIV wasting is occurring if the patient has lost more than _______ pounds.

Standard Text:

Correct Answer: 18

Rationale : HIV wasting is diagnosed when the patient has had fever of unknown origin for over 30 days, anorexia, diarrhea, and weight loss of over 10% of body weight. In this patient, 10% of body weight is 18 pounds.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-4

Question 27

Type: MCMA

A patient who is HIV positive comes to the clinic with concerns about a new skin lesion. Which assessment findings would the nurse evaluate as indicating possible Kaposis sarcoma?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The lesion turns a whitish color when pressure is applied.

2. The lesion is flat.

3. The lesion is a purple-brown color.

4. The lesion is the size of a quarter.

5. The lesion is raised.

Correct Answer: 2,3,4,5

Rationale 1: The lesions associated with Kaposis sarcoma do not blanch.

Rationale 2: Lesions associated with Kaposis sarcoma can be flat.

Rationale 3: The lesions associated with Kaposis sarcoma are a purple-brown color.

Rationale 4: The lesions associated with Kaposis sarcoma are of varying sizes and shapes.

Rationale 5: The lesions associated with Kaposis sarcoma can be raised.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-4

Question 28

Type: MCMA

A patient presents to the emergency department after sustaining a minor laceration. The patient tells the staff that he may be HIV positive, but I dont know for certain. Which information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. You must go to the state health department to be tested.

2. We can do a test here if you like.

3. There is a test available that will quickly give us an idea of your HIV status.

4. If the results of the test we do are positive, additional testing will be necessary.

5. It will take at least 5 days for test results to return.

Correct Answer: 2,3,4

Rationale 1: Testing is done in many areas, including state health departments.

Rationale 2: The patient must give permission for testing.

Rationale 3: Rapid screening tests provide results within minutes.

Rationale 4: All positive test results must be confirmed with Western blot tests.

Rationale 5: Rapid tests are available for screening.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-3

Question 29

Type: MCMA

A patient has given permission for an enzyme immunoassay (EIA) test for HIV. Which information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. You will need to return to the clinic in 3 days to discuss the results of this test.

2. I will send you the results in the mail.

3. If the test is positive, we will immediately set up an appointment for you to receive medications to treat the HIV.

4. A Western blot test may also be necessary.

5. If the test is negative, it will be repeated.

Correct Answer: 1,4

Rationale 1: Results of the EIA take 2 or 3 days.

Rationale 2: The patient is required to receive counseling to discuss the results.

Rationale 3: If the first test is positive, it will be repeated.

Rationale 4: If two EIA tests are positive, a Western blot test is performed for confirmation.

Rationale 5: Positive results require a repeat test.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 53-3

Question 30

Type: MCMA

A patient who tested positive for HIV is started on antiretroviral medication. Which outcome would the nurse evaluate as indicating that the goals of this therapy are being met?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patients HIV RNA level has dropped from 100,000 copies/mL to 45,000 copies/mL.

2. The patients CD4 + T-cell count is 150 cells/mL.

3. The patient has not developed an opportunistic infection.

4. The patients viral load reveals that the disease is cured.

5. The patient has lost 10 pounds.

Correct Answer: 1,3

Rationale 1: The goal of antiretroviral therapy is to decrease the viral load to less than 55,000 copies/mL.

Rationale 2: The goal of antiretroviral therapy is to maintain CD4 + T-cell counts at greater than 200 cells/mL.

Rationale 3: The goal of antiretroviral therapy is to delay the onset of opportunistic infections.

Rationale 4: There is no cure for HIV infection.

Rationale 5: Weight loss may or may not be associated with HIV status.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 53-3

Question 31

Type: MCMA

A patient who is HIV positive comes to the clinic for a routine assessment. Which statement by the patient would the nurse evaluate as indicating a potential lack of adherence to the medication schedule?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. These medications are so expensive and my insurance doesnt pay very well.

2. One of the newer medications I am taking is a combination of two that I took previously.

3. One of the medications I am taking makes me nauseous.

4. I take so many pills at so many different times of the day.

5. Sometimes I feel I just cannot cope a single second longer.

Correct Answer: 1,3,4,5

Rationale 1: Some medications prescribed to treat HIV are very expensive. A lack of financial resources may adversely affect adherence to the medication schedule.

Rationale 2: Combination antiviral medications reduce the number of pills that must be taken and the complexity of the medication regimen. This helps to support adherence to the schedule.

Rationale 3: The adverse effects of antiviral medications include nausea, vomiting, diarrhea, fatigue, and loss of appetite. Adverse reactions increase the possibility that the patient will not adhere to the prescribed regimen.

Rationale 4: The dosing schedule for antiviral medications can be very complex. This complexity may adversely affect adherence.

Rationale 5: Inability to cope may manifest as inability to adhere to recommended therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 53-3

Question 32

Type: MCMA

A patient diagnosed with HIV/AIDS has developed pneumonia and is bedbound. Which nursing interventions should be planned?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Maintain fluid intake of 3 liters daily unless contraindicated.

2. Suction the oral cavity, but avoid tracheal suctioning.

3. Elevate the head of the patients bed at least 30 degrees.

4. Turn the patient every 2 hours.

5. Provide for periods of uninterrupted rest.

Correct Answer: 1,3,4,5

Rationale 1: Fluid intake helps to thin secretions.

Rationale 2: Suctioning tracheal secretions on an as-needed basis will help improve gas exchange. Suctioning should not be avoided.

Rationale 3: Elevating the head of the bed helps facilitate breathing.

Rationale 4: Frequent turning helps to prevent stasis of pulmonary secretions and protect skin integrity.

Rationale 5: Rest periods help to prevent excessive fatigue, which impairs ability to breathe.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 53-3

Question 33

Type: MCMA

A patient with HIV/AIDS has had diarrhea for 7 days. The nurse would evaluate that dietary teaching regarding diarrhea has been effective when the patient selects which foods for breakfast?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Coffee with cream but no sugar

2. Sliced bananas and cream of rice cereal

3. Applesauce and dry toast

4. Eggs scrambled with cheese and ham

5. Banana nut bread and cream cheese

Correct Answer: 2,3

Rationale 1: Coffee is a bowel stimulant and should be avoided.

Rationale 2: Bananas and rice are part of the BRAT diet used to help alleviate diarrhea.

Rationale 3: Applesauce and toast are part of the BRAT diet used to alleviate diarrhea.

Rationale 4: Fatty foods can stimulate diarrhea. Carbohydrates are easier to digest and cause less stimulation of the bowel.

Rationale 5: Bananas are part of the BRAT diet, but nuts should be avoided. Fatty foods such as cream cheese should be avoided.

Global Rationale:

 

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