Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 78: Management of Clients with Immune Disorders
MULTIPLE CHOICE
1. The nurse assesses an atopic client with many allergies for the development of a reaction to
medications administered during hospitalization. The nurse recognizes that the most severe
form of a type I hypersensitivity reaction is
a. anaphylaxis.
b. bronchial asthma.
c. dermatitis.
d. cell-mediated sensitivity.
ANS: a
Type I hypersensitivity reactions include anaphylaxis as the most severe form.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2318
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The client receiving a blood transfusion complains of headache and back pain. The most
appropriate initial intervention of the nurse is to
a. evaluate the nature of the headache.
b. call the physician.
c. monitor the client's vital signs.
d. stop the transfusion.
ANS: d
Manifestations of a transfusion reaction result from intravascular hemolysis of red blood cells.
They include headache and back pain (flank), chest pain similar to angina, nausea and vomiting,
tachycardia, hypotension, hematuria, and urticaria. Transfusions of more than 100 ml of
incompatible blood can result in severe permanent renal damage, circulatory shock, and death.
Therefore, if manifestations develop, stop the transfusion at once, maintain an open intravenous
line, check the client's vital signs, and notify the physician immediately.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
3. The nurse caring for a client with allergic rhinitis who is using a decongestant nasal spray
would include in the teaching plan that
a. the spray should be used on a round-the-clock, equally spaced interval basis for
maximal effectiveness.
b. overuse can result in nosebleeds and mucosal ulceration.
c. nasal sprays must be combined with an oral antihistamine to achieve relief.
Chapter 78: Management of Clients with Immune Disorders
2
d. rebound rhinitis (rhinitis medicamentosa) is common with continual use.
ANS: d
Because the prolonged use of topical nasal sprays can cause rhinitis medicamentosa (recurrence
of congestion), it is advisable to limit their use to no more than once a week.
DIF: Cognitive Level: Application
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
4. A nurse conducting an in-service on hypersensitivity disorders uses the term “haptens,”
which refers to
a. routes of transmission.
b. vectors that carry an allergen.
c. molecules that combine with proteins to form antibodies.
d. the type of hypersensitivity response.
ANS: c
Molecules that combine with proteins to produce antibodies are called haptens.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2316
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
5. The home health care nurse who is assessing the environment of a client reminds the client
that most allergens are
a. inhaled.
b. ingested.
c. transmitted by direct contact.
d. injected.
ANS: a
Most allergens are inhaled.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2316
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
6. A client develops a positive reaction to an injection of purified protein derivative, a screening
measure for exposure to tuberculosis. The nurse records this reaction as a
a. Type I reaction.
b. Type II reaction.
c. Type III reaction.
d. Type IV reaction.
ANS: d
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
3
Type IV reactions occur after the intradermal injection of tuberculosis antigen or purified protein
derivative. If the client has been sensitized to tuberculosis, sensitized T cells react with the
antigen at the injection site.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2318, 2319, Table 78-2;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
7. A nurse would observe the client for how long to determine whether there is an immediate
reaction to a skin test?
a. 1 to 2 minutes
b. 2 to 5 minutes
c. 5 to 10 minutes
d. 10 to 20 minutes
ANS: c
Nurses often administer skin tests and interpret test results. An immediate reaction (i.e.,
appearing within 10 to 20 minutes after the injection), marked by erythema and wheal formation
greater than 3 mm of the positive control (usually histamine) denotes a positive reaction.
DIF: Cognitive Level: Application
REF: Text Reference: 2320
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. Which remedy should a client be taught to avoid by a nurse who is counseling a client about
how to manage allergic reactions at a skin testing site?
a. Cool compresses
b. Heating pad
c. Topical steroid
d. Antihistamine cream
ANS: b
Itching and discomfort at the injection site are common and can be relieved by the application of
cool compresses, topical steroid or antihistamine creams, and oral antihistamines such as
diphenhydramine (Benadryl). Heat adds to the vasodilation and may cause a false-positive.
DIF: Cognitive Level: Application
REF: Text Reference: 2320
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
9.
a.
b.
c.
d.
The nurse warns a client about the drowsiness caused by
loratadine (Claritin).
fexofenadine (Allegra).
diphenhydramine (Benadryl).
cetirizine (Zyrtec).
ANS: c
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
4
Traditional antihistamines such as diphenhydramine cross the blood-brain barrier and can
produce significant drowsiness. Because newer agents (cetirizine, fexofenadine, and loratadine)
do not cross the blood-brain barrier (or do so poorly), they do not cause the drowsiness that
limits the use of older medications.
DIF: Cognitive Level: Application
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
10.
a.
b.
c.
d.
The nurse explains that the most effective type of drug for the treatment of rhinitis is a(n)
antihistamine.
decongestant.
corticosteroid.
anticholinergic.
ANS: c
Corticosteroids are the most effective drug for the treatment of rhinitis.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
11. The nurse instructs the client who has a new prescription for cromolyn sodium (NasalCrom)
that the most effective administration schedule is
a. at the start of allergy season, with once-a-day dosing.
b. 1 week before allergy season begins, with four to six doses per day.
c. just after manifestations begin, with twice daily dosing.
d. when manifestations peak only, with two or three doses per day.
ANS: b
Cromolyn sodium should be administered before allergen exposure. It should be started a week
before allergy season to be most effective in the treatment of seasonal allergic rhinitis. It must be
used on a regular basis and, unfortunately, dosing is required four to six times a day.
DIF: Cognitive Level: Application
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
12. A client is beginning treatment for asthma with an antileukotriene type of drug. The nurse
prepares written instructions for use of
a. zafirlukast (Accolate).
b. albuterol (Ventolin).
c. ipratropium (Atrovent).
d. budesonide (Rhinocort).
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
5
ANS: a
Antileukotrienes are used to treat manifestations of asthma and anaphylaxis. These drugs include
zafirlukast and zileuton (Zyflo).
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
13. A client with a history of type I hypersensitivity reaction is receiving immunotherapy (or
desensitization therapy). The nurse administering the allergen injection at 1:00 PM would ask
the client to remain in the office until
a. 1:10.
b. 1:20.
c. 1:40.
d. 2:15.
ANS: c
Clients are asked to wait at least 30 to 40 minutes after receiving the injections so that immediate
reactions can be treated.
DIF: Cognitive Level: Application
REF: Text Reference: 2321
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
14. The nurse teaches the client who will undergo testing for possible food allergy to chocolate,
to eliminate chocolate from the diet prior to the testing for
a. 1 to 2 days.
b. 3 to 5 days.
c. 5 to 10 days.
d. 10 to 14 days.
ANS: d
The suspected food is eliminated from the diet for 10 to 14 days.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2323
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
15.
a.
b.
c.
d.
The nurse would teach the client who has atopic dermatitis to avoid the practice of
bathing in hot water.
using gentle soaps.
applying a lubricant after bathing.
keeping fingernails trimmed.
ANS: a
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
6
Teach the client general skin care measures, such as how to maintain good skin hydration by
bathing in lukewarm water; to use gentle soaps; apply a lubricant like Alpha Keri, petroleum
jelly, Eucerin, or Aquaphor to the skin immediately after bathing; avoid scratching; and keep
fingernails trimmed to avoid infection.
DIF: Cognitive Level: Application
REF: Text Reference: 2324
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
16. The nurse instructs a client diagnosed with urticaria in the use of the most common remedy,
which is
a. warm oatmeal baths.
b. nonsteroidal anti-inflammatory drugs (NSAIDs).
c. antihistamines.
d. corticosteroids.
ANS: c
Antihistamines are the mainstay of therapy for urticaria.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
17. When assisting in the treatment of a client with anaphylaxis the nurse would avoid using
which measure?
a. Oxygen
b. Reverse Trendelenburg position
c. Normal saline intravenous (IV) infusion
d. Epinephrine
ANS: b
Anaphylaxis is treated by subcutaneous epinephrine injection, removing or discontinuing the
causative agent, administering emergency oxygen, maintaining an open airway, placing the client
in the Trendelenburg position, and giving supportive IV fluids, such as 0.9% normal saline or
lactated Ringer's solution as necessary.
DIF: Cognitive Level: Application
REF: Text Reference: 2325
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
18. The nurse explains that in step I (sensitization) of becoming allergic, the body,
upon exposure to an allergen,
a. forms mast cells.
b. reacts with rhinitis, urticaria , asthma, or gastrointestinal (GI) manifestations.
c. develops immunoglobulin E (IgE) antibodies.
d. produces basophils.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
7
ANS: c
In the first step of a two-step process the body reacts to the exposure to an allergen by the
production of IgE antibodies.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2315
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
19. The nurse reminds a client that a delayed inflammatory response can occur 2 to 8
hours after exposure to an allergen and is governed by
a. T cells.
b. mast cells.
c. eosinophils.
d. basophils.
ANS: a
T cells govern the delayed response that occurs about 2 to 8 hours after mast cells have been
activated by the initial allergen exposure.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
20.
a.
b.
c.
d.
The nurse explains that a type II hypersensitivity reaction results in
cell destruction.
mast cell production.
T-cell stimulation.
antibody formation.
ANS: a
In the type 2 hypersensitivity reaction the antigen-antibody binding results in activation of the
complement system and destroys the cell on which the antigen is bound.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
21. The nurse closely monitors a client receiving a blood transfusion because permanent damage
can occur with an infusion as small as
a. 50 cc.
b. 100 cc.
c. 300 cc.
d. 500 cc.
ANS: b
Permanent renal damage, circulatory shock, and death can occur with the infusion of as little as
100 cc of incompatible blood.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
DIF: Cognitive Level: Application
REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
22. The nurse instructs a group of allergic clients that a type III hypersensitivity reaction can
result in an Arthus reaction, which is
a. a sudden asthmalike attack.
b. a localized area of necrosis.
c. a severe gastrointestinal (GI) response.
d. a sudden, severe hypotensive episode.
ANS: b
An Arthus reaction is a localized area of tissue necrosis that results from immune complex
hypersensitivity.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2319
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
Elsevier items and derived items © 2005 by Elsevier Inc.
8
Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 78: Management of Clients with Immune Disorders
MULTIPLE CHOICE
1. The nurse assesses an atopic client with many allergies for the development of a reaction to
medications administered during hospitalization. The nurse recognizes that the most severe
form of a type I hypersensitivity reaction is
a. anaphylaxis.
b. bronchial asthma.
c. dermatitis.
d. cell-mediated sensitivity.
ANS: a
Type I hypersensitivity reactions include anaphylaxis as the most severe form.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2318
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The client receiving a blood transfusion complains of headache and back pain. The most
appropriate initial intervention of the nurse is to
a. evaluate the nature of the headache.
b. call the physician.
c. monitor the client's vital signs.
d. stop the transfusion.
ANS: d
Manifestations of a transfusion reaction result from intravascular hemolysis of red blood cells.
They include headache and back pain (flank), chest pain similar to angina, nausea and vomiting,
tachycardia, hypotension, hematuria, and urticaria. Transfusions of more than 100 ml of
incompatible blood can result in severe permanent renal damage, circulatory shock, and death.
Therefore, if manifestations develop, stop the transfusion at once, maintain an open intravenous
line, check the client's vital signs, and notify the physician immediately.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
3. The nurse caring for a client with allergic rhinitis who is using a decongestant nasal spray
would include in the teaching plan that
a. the spray should be used on a round-the-clock, equally spaced interval basis for
maximal effectiveness.
b. overuse can result in nosebleeds and mucosal ulceration.
c. nasal sprays must be combined with an oral antihistamine to achieve relief.
Chapter 78: Management of Clients with Immune Disorders
2
d. rebound rhinitis (rhinitis medicamentosa) is common with continual use.
ANS: d
Because the prolonged use of topical nasal sprays can cause rhinitis medicamentosa (recurrence
of congestion), it is advisable to limit their use to no more than once a week.
DIF: Cognitive Level: Application
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
4. A nurse conducting an in-service on hypersensitivity disorders uses the term “haptens,”
which refers to
a. routes of transmission.
b. vectors that carry an allergen.
c. molecules that combine with proteins to form antibodies.
d. the type of hypersensitivity response.
ANS: c
Molecules that combine with proteins to produce antibodies are called haptens.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2316
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
5. The home health care nurse who is assessing the environment of a client reminds the client
that most allergens are
a. inhaled.
b. ingested.
c. transmitted by direct contact.
d. injected.
ANS: a
Most allergens are inhaled.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2316
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
6. A client develops a positive reaction to an injection of purified protein derivative, a screening
measure for exposure to tuberculosis. The nurse records this reaction as a
a. Type I reaction.
b. Type II reaction.
c. Type III reaction.
d. Type IV reaction.
ANS: d
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
3
Type IV reactions occur after the intradermal injection of tuberculosis antigen or purified protein
derivative. If the client has been sensitized to tuberculosis, sensitized T cells react with the
antigen at the injection site.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2318, 2319, Table 78-2;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
7. A nurse would observe the client for how long to determine whether there is an immediate
reaction to a skin test?
a. 1 to 2 minutes
b. 2 to 5 minutes
c. 5 to 10 minutes
d. 10 to 20 minutes
ANS: c
Nurses often administer skin tests and interpret test results. An immediate reaction (i.e.,
appearing within 10 to 20 minutes after the injection), marked by erythema and wheal formation
greater than 3 mm of the positive control (usually histamine) denotes a positive reaction.
DIF: Cognitive Level: Application
REF: Text Reference: 2320
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. Which remedy should a client be taught to avoid by a nurse who is counseling a client about
how to manage allergic reactions at a skin testing site?
a. Cool compresses
b. Heating pad
c. Topical steroid
d. Antihistamine cream
ANS: b
Itching and discomfort at the injection site are common and can be relieved by the application of
cool compresses, topical steroid or antihistamine creams, and oral antihistamines such as
diphenhydramine (Benadryl). Heat adds to the vasodilation and may cause a false-positive.
DIF: Cognitive Level: Application
REF: Text Reference: 2320
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
9.
a.
b.
c.
d.
The nurse warns a client about the drowsiness caused by
loratadine (Claritin).
fexofenadine (Allegra).
diphenhydramine (Benadryl).
cetirizine (Zyrtec).
ANS: c
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
4
Traditional antihistamines such as diphenhydramine cross the blood-brain barrier and can
produce significant drowsiness. Because newer agents (cetirizine, fexofenadine, and loratadine)
do not cross the blood-brain barrier (or do so poorly), they do not cause the drowsiness that
limits the use of older medications.
DIF: Cognitive Level: Application
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
10.
a.
b.
c.
d.
The nurse explains that the most effective type of drug for the treatment of rhinitis is a(n)
antihistamine.
decongestant.
corticosteroid.
anticholinergic.
ANS: c
Corticosteroids are the most effective drug for the treatment of rhinitis.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
11. The nurse instructs the client who has a new prescription for cromolyn sodium (NasalCrom)
that the most effective administration schedule is
a. at the start of allergy season, with once-a-day dosing.
b. 1 week before allergy season begins, with four to six doses per day.
c. just after manifestations begin, with twice daily dosing.
d. when manifestations peak only, with two or three doses per day.
ANS: b
Cromolyn sodium should be administered before allergen exposure. It should be started a week
before allergy season to be most effective in the treatment of seasonal allergic rhinitis. It must be
used on a regular basis and, unfortunately, dosing is required four to six times a day.
DIF: Cognitive Level: Application
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
12. A client is beginning treatment for asthma with an antileukotriene type of drug. The nurse
prepares written instructions for use of
a. zafirlukast (Accolate).
b. albuterol (Ventolin).
c. ipratropium (Atrovent).
d. budesonide (Rhinocort).
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
5
ANS: a
Antileukotrienes are used to treat manifestations of asthma and anaphylaxis. These drugs include
zafirlukast and zileuton (Zyflo).
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
13. A client with a history of type I hypersensitivity reaction is receiving immunotherapy (or
desensitization therapy). The nurse administering the allergen injection at 1:00 PM would ask
the client to remain in the office until
a. 1:10.
b. 1:20.
c. 1:40.
d. 2:15.
ANS: c
Clients are asked to wait at least 30 to 40 minutes after receiving the injections so that immediate
reactions can be treated.
DIF: Cognitive Level: Application
REF: Text Reference: 2321
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
14. The nurse teaches the client who will undergo testing for possible food allergy to chocolate,
to eliminate chocolate from the diet prior to the testing for
a. 1 to 2 days.
b. 3 to 5 days.
c. 5 to 10 days.
d. 10 to 14 days.
ANS: d
The suspected food is eliminated from the diet for 10 to 14 days.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2323
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
15.
a.
b.
c.
d.
The nurse would teach the client who has atopic dermatitis to avoid the practice of
bathing in hot water.
using gentle soaps.
applying a lubricant after bathing.
keeping fingernails trimmed.
ANS: a
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
6
Teach the client general skin care measures, such as how to maintain good skin hydration by
bathing in lukewarm water; to use gentle soaps; apply a lubricant like Alpha Keri, petroleum
jelly, Eucerin, or Aquaphor to the skin immediately after bathing; avoid scratching; and keep
fingernails trimmed to avoid infection.
DIF: Cognitive Level: Application
REF: Text Reference: 2324
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
16. The nurse instructs a client diagnosed with urticaria in the use of the most common remedy,
which is
a. warm oatmeal baths.
b. nonsteroidal anti-inflammatory drugs (NSAIDs).
c. antihistamines.
d. corticosteroids.
ANS: c
Antihistamines are the mainstay of therapy for urticaria.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
17. When assisting in the treatment of a client with anaphylaxis the nurse would avoid using
which measure?
a. Oxygen
b. Reverse Trendelenburg position
c. Normal saline intravenous (IV) infusion
d. Epinephrine
ANS: b
Anaphylaxis is treated by subcutaneous epinephrine injection, removing or discontinuing the
causative agent, administering emergency oxygen, maintaining an open airway, placing the client
in the Trendelenburg position, and giving supportive IV fluids, such as 0.9% normal saline or
lactated Ringer's solution as necessary.
DIF: Cognitive Level: Application
REF: Text Reference: 2325
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
18. The nurse explains that in step I (sensitization) of becoming allergic, the body,
upon exposure to an allergen,
a. forms mast cells.
b. reacts with rhinitis, urticaria , asthma, or gastrointestinal (GI) manifestations.
c. develops immunoglobulin E (IgE) antibodies.
d. produces basophils.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
7
ANS: c
In the first step of a two-step process the body reacts to the exposure to an allergen by the
production of IgE antibodies.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2315
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
19. The nurse reminds a client that a delayed inflammatory response can occur 2 to 8
hours after exposure to an allergen and is governed by
a. T cells.
b. mast cells.
c. eosinophils.
d. basophils.
ANS: a
T cells govern the delayed response that occurs about 2 to 8 hours after mast cells have been
activated by the initial allergen exposure.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
20.
a.
b.
c.
d.
The nurse explains that a type II hypersensitivity reaction results in
cell destruction.
mast cell production.
T-cell stimulation.
antibody formation.
ANS: a
In the type 2 hypersensitivity reaction the antigen-antibody binding results in activation of the
complement system and destroys the cell on which the antigen is bound.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
21. The nurse closely monitors a client receiving a blood transfusion because permanent damage
can occur with an infusion as small as
a. 50 cc.
b. 100 cc.
c. 300 cc.
d. 500 cc.
ANS: b
Permanent renal damage, circulatory shock, and death can occur with the infusion of as little as
100 cc of incompatible blood.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders
DIF: Cognitive Level: Application
REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
22. The nurse instructs a group of allergic clients that a type III hypersensitivity reaction can
result in an Arthus reaction, which is
a. a sudden asthmalike attack.
b. a localized area of necrosis.
c. a severe gastrointestinal (GI) response.
d. a sudden, severe hypotensive episode.
ANS: b
An Arthus reaction is a localized area of tissue necrosis that results from immune complex
hypersensitivity.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2319
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
Elsevier items and derived items © 2005 by Elsevier Inc.
8
Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 79: Management of Clients with Rheumatic Disorders
MULTIPLE CHOICE
1. The nursing intervention that is most effective in preserving motor function in a client with
rheumatoid arthritis (RA) during periods when the affected joints are not inflamed is
a. the application of moist heat to joints.
b. encouraging moderate increase in activity.
c. promotion of a high-protein diet.
d. restriction of the client's activity.
ANS: b
The use of rest requires a fine balance; however, once inflammation subsides, the client should
begin activity again to preserve as much joint function as possible.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2341
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
2. A client with RA is anxious to perform all of her activities of daily living. The nurse can best
help the client by encouraging
a. a slow, progressive schedule of daily activities.
b. complete rest during periods of exacerbation.
c. performance of activities in the early morning.
d. the use of assistive devices for dressing.
ANS: a
Encourage the client to stay active. Maintaining function and mobility is necessary for clients to
take care of themselves. Progressive exercise, activity, and range-of-motion (ROM) exercises
help accomplish this goal.
DIF: Cognitive Level: Application
REF: Text Reference: 2348
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
3. The nurse cautions a client with RA that uninformed self-treatment that has the potential to
make her condition worse is
a. isometric exercises.
b. application of cold compresses.
c. the use of aspirin to mask pain.
d. use of deep heat.
ANS: d
Deep heat raises intra-articular joint spaces, increasing pain.
Chapter 79: Management of Clients with Rheumatic Disorders
2
DIF: Cognitive Level: Application
REF: Text Reference: 2345
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance
4. The caution the nurse should give the client who is taking nonsteroidal anti-inflammatory
drugs (NSAIDs) as a remedy for arthritis is to
a. avoid taking NSAIDs with milk.
b. take NSAIDs with food.
c. liberalize fluids while taking NSAIDs.
d. watch for manifestations of skin damage.
ANS: b
Because of the gastric irritation and possible gastritis, NSAIDs should be taken with food.
DIF: Cognitive Level: Comprehension
REF: Text Reference: 2342, Integrating Pharmacology Box - Medications Used in Treatment
of Rheumatoid Arthritis;
TOP:
Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
5. The nurse caring for a client with systemic lupus erythematosus (SLE) should warn the client
that the factor most likely to cause an exacerbation of this disorder is
a. changes in temperature.
b. exposure to the sun.
c. a diet high in saturated fats.
d. ingestion of aspirin.
ANS: b
Sunlight may trigger local dermatitis or more severe manifestations of the disease.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2354
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance
6. The nursing assessment of clients with SLE should focus most intensely on the presence of
the common and serious sequela of this disorder, which is
a. difficulty swallowing.
b. interruptions in skin integrity.
c. peripheral neuropathies.
d. renal failure.
ANS: d
The leading cause of death in clients with SLE is renal failure.There is some degree of kidney
involvement, causing progressive changes within the glomeruli in most clients with SLE.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2354
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 79: Management of Clients with Rheumatic Disorders
3
7. Clients being evaluated for SLE should be assessed carefully about drugs that they are
taking because a drug that can cause lupus is
a. aspirin.
b. digoxin (Lanoxin).
c. gentamicin (Garamycin).
d. procainamide (Pronestyl).
ANS: d
About 25 drugs can produce a lupuslike reaction, but only a few (hydralazine, procainamide, and
isoniazid) can cause the disorder with any great frequency.
DIF: Cognitive Level: Application
REF: Text Reference: 2356
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. A client has just been admitted to the nursing unit with the diagnosis of CREST syndrome.
The findings the nurse would expect to note during the assessment are
a. spider angiomas, erythrocytosis, and rosacea.
b. esophageal dysfunction, Raynaud's phenomenon, and calcinosis.
c. rash, thrombocytopenia, and subcutaneous nodules.
d. edema, telangiectasia, and syncope.
ANS: b
CREST syndrome is a group of manifestations involving calcinosis, Raynaud's syndrome,
esophageal motility (decreased), sclerodactyly, and telangiectasia.
DIF: Cognitive Level: Application
REF: Text Reference: 2359
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
9. When the nurse is caring for a client with progressive systemic sclerosis (PSS), the highestpriority nursing diagnosis would be
a. Risk for Imbalanced Body Temperature.
b. Constipation.
c. Risk for Impaired Skin Integrity.
d. Disturbed Thought Processes.
ANS: c
Nursing interventions are directed at the control of manifestations. One of the major areas of
concern is skin care to prevent breakdown and ulceration.
DIF: Cognitive Level: Application
REF: Text Reference: 2360
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
10. The nurse caring for a client with PSS should include in the teaching plan the measure to
prevent pain, which is
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 79: Management of Clients with Rheumatic Disorders
a.
b.
c.
d.
4
exercise only moderately.
do not stand for longer than 30 minutes at a time.
wash the hands with plain water only.
wear gloves when removing food from the freezer.
ANS: d
The client must learn to avoid activities that trigger pain. This includes such actions as joint
protective behaviors, avoiding extreme cold, wearing gloves when hands are exposed to cold
(even when removing food from the freezer), eliminating smoking, and resting the painful part
when pain is acute.
DIF: Cognitive Level: Application
REF: Text Reference: 2361
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance
11. The nursing care plan should be modified for a client with RA who develops Sjögren's
syndrome to include
a. encouraging fluids to prevent constipation.
b. lubricating the eyes with artificial tears.
c. restricting activity in the late evening.
d. providing skin care daily.
ANS: b
Clients with Sjögren’s syndrome have diminished lacrimal secretions and complain of eyes that
feel gritty. Artificial tears are helpful for keeping the eyes moist and preventing corneal
abrasions.
DIF: Cognitive Level: Application
REF: Text Reference: 2335
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
12. The nurse will include in the care plan for a client with dermatomyositis provisions to meet
the problem of
a. difficulty speaking and swallowing.
b. difficulty with ambulation.
c. disorientation.
d. phlebitis.
ANS: a
The muscle weakness can lead to problems with speaking and swallowing.
DIF: Cognitive Level: Application
REF: Text Reference: 2369
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
13. The common complication of ankylosing spondylitis that the nurse should address in the plan
of care is
a. cardiac dysrhythmias.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 79: Management of Clients with Rheumatic Disorders
5
b. respiratory compromise.
c. renal failure.
d. weight gain.
ANS: b
Because stiffening of the spine is inevitable, the goals of management are to relieve pain,
maintain optimal posture, and prevent respiratory involvement from minimal chest movements.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2364
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
14.
a.
b.
c.
d.
A newly diagnosed client with SLE is instructed by the nurse to avoid self-medication with
over-the-counter sedatives.
antihistamines.
NSAIDs.
diet pills.
ANS: c
NSAIDs inhibit prostaglandin formation in the kidney and interfere with renal blood flow.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2355
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
15. A client with RA asks the nurse what the purpose of a synovectomy is. The most appropriate
response from the nurse is
a. “Pain relief.”
b. “Improvement in the appearance of a joint.”
c. “Removal of infected material in the joint.”
d. “Reduction of the amount of inflammation.”
ANS: d
Synovectomy (surgical removal of synovia, as in the elbows, wrists, fingers, or knees) may be
used in RA to help maintain joint function. Early synovectomy helps prevent recurrent
inflammation because it removes the synovia, which is the first part of the joint attacked by the
disease.
DIF: Cognitive Level: Application
REF: Text Reference: 2350
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
16. The nurse performing an assessment on a client with fibromyalgia syndrome asks about the
most common clinical manifestation, which is
a. fatigue, unrelieved by sleep.
b. migratory areas of numbness.
c. varying degrees of paresthesias.
d. deformities of the fingers and toes.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 79: Management of Clients with Rheumatic Disorders
ANS: a
Fatigue that is unrelieved by sleep or rest is the most commonly presented problem of
fibromyalgia.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2368
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
17. The nurse explains that one of the few rheumatic joint diseases about which we know the
infectious etiology is
a. RA.
b. Sjögren's syndrome.
c. ankylosing spondylitis.
d. Lyme disease.
ANS: d
Lyme disease is one form of rheumatic joint disease with a known cause. This complex
multisystem disease is caused by the tick-borne spirochete Borrelia burgdorferi.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2372
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
18. The nurse caring for a client who had an elbow arthroplasty yesterday will include in the
postoperative care provisions for
a. positioning the arm below the shoulder.
b. assessing the ability to pinch.
c. avoiding lifting objects heavier than 10 pounds.
d. limiting flexion and extension of the elbow.
ANS: b
Assessments for the ability to pinch indicate that function has not been impaired by the surgery.
Clients should be instructed not to lift more than 5 pounds, the arm should be positioned above
the shoulder for several days, and flexion and extension of the elbow are permitted.
DIF: Cognitive Level: Application
REF: Text Reference: 2351
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
19.
a.
b.
c.
d.
To help promote sleep for a client with RA, the nurse would recommend
sleeping in thermal underwear.
taking a cool shower before bedtime.
using a large pillow and warm heavy blankets.
exercising just prior to bedtime.
ANS: a
Elsevier items and derived items © 2005 by Elsevier Inc.
6
Chapter 79: Management of Clients with Rheumatic Disorders
Sleeping in warm clothing, taking a warm shower, warming the bed, using small pillows with
lighter blankets, and engaging in soothing activities prior to bedtime all will assist with sleep
problems.
DIF: Cognitive Level: Application
REF: Text Reference: 2348
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
20.
The nurse who is reviewing the drug that a client with RA is taking recognizes a drug that is no
longer has popular use because of its slow action, which is
a. aspirin.
b. corticosteroids.
c. NSAIDs.
d. gold salts.
ANS: d
Slow-acting antirheumatic drugs (SAARDs)—gold salts, antimalarials, immunosuppressive
agents, and D-penicillamine—seem to slow progression of RA by blocking the immunologic
aspects of inflammation. Because the disease-modifying antirheumatic drugs are generally slow
acting, they must be taken for several months before an effective response becomes noticeable.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2342, Integrating Pharmacology Box - Medications Used in Treatment
of Rheumatoid Arthritis;
TOP:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
21. The nurse would advise the client beginning therapy with hydroxychloroquine for RA that
the client should take the precaution of
a. avoid drinking red wine.
b. have eye examinations every 6 months.
c. avoid excessive sun exposure.
d. assess blood pressure daily.
ANS: b
Hydroxychloroquine has a tendency to maculopathy.
DIF: Cognitive Level: Application
REF: Text Reference: 2342, Integrating Pharmacology Box - Medications Used in Treatment
of Rheumatoid Arthritis;
TOP:
Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance
22. The nurse clarifies that a client can be diagnosed with RA when, out of the seven
criteria, the client exhibits
a. two.
b. three.
c. four.
Elsevier items and derived items © 2005 by Elsevier Inc.
7
Chapter 79: Management of Clients with Rheumatic Disorders
d. five.
ANS: c
To be diagnosed with RA the client must have four of the seven criteria for several weeks.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2331, Table 79-1;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
Elsevier items and derived items © 2005 by Elsevier Inc.
8
Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
MULTIPLE CHOICE
1. A human immunodeficiency virus (HIV)–positive client is beginning therapy with
antiretroviral medications. The nurse will include in the teaching plan relative to the
medication that the client should
a. take the dose at any time after eating.
b. not skip a dose. If a dose is missed, double the next dose.
c. wait until the next visit before reporting significant side effects.
d. tell the prescriber if the decision is made to terminate treatment.
ANS: d
Instruct all clients taking retrovirals as follows. Take the drug at specified intervals. Do not skip
a dose. Do not increase or decrease the number of pills you take. If side effects occur, tell your
physician or nurse. If you do not want to take the drugs, tell your primary care provider. If you
take the drugs only periodically, it would be better not to take them at all.
DIF: Cognitive Level: Application
REF: Text Reference: 2388, 2389;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
2. The nurse participating in the evaluation of a client with a known HIV infection explains that
the laboratory study that will be of most significance during this process is
a. CD4+ cell count.
b. the total white blood cell count.
c. the enzyme-linked immunosorbent assay (ELISA) test.
d. the Western blot test.
ANS: a
The most recent classification system for HIV disease in adults and adolescents is based on two
monitoring parameters used to follow a client: (1) laboratory data (CD4+ cell count) and (2)
clinical presentation (the person's clinical manifestations of diseases).
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2380
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
3. A nurse with a small grant to increase knowledge of the transmission of HIV infection is
trying to determine the best expenditure of the funds. The nurse should recognize that the
group in which this problem of HIV infection is growing most rapidly is
a. adults older than the age of 50.
b. black teenagers.
c. gay white men.
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
2
d. blacks and Hispanics.
ANS: a
An overlooked population of rapidly growing HIV-positive people are those older than the age of
50.
DIF: Cognitive Level: Analysis
TOP: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity
REF: Text Reference: 2377
4. The nurse is counseling a woman who is HIV positive and has just given birth to a baby girl.
The nurse should advise the client to
a. avoid breast-feeding her infant.
b. seek professional counseling to deal with the guilt associated with the almost
certain passing of the disease to her child.
c. report all of her sexual partners to the infectious disease department in order to
break the chain of transmission of the disease.
d. anticipate the needs of her child immediately and make arrangements for
placement in a setting where her child's life will be comfortable.
ANS: a
Perinatal HIV exposure can occur during pregnancy, during vaginal delivery, and postpartum
through breast-feeding.
DIF: Cognitive Level: Application
REF: Text Reference: 2378
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
5. The nurse counseling a client who is afraid that HIV exposure has occurred would explain
that the period of time it takes before HIV antibodies can be detected by laboratory tests is
generally
a. 1 to 3 days.
b. 7 to 10 days.
c. 1 to 3 weeks.
d. 4 to 12 weeks.
ANS: d
There is a "window" for seroconversion (the time it takes for a newly infected person to develop
antibodies that can be detected in a laboratory specimen). On average, antibodies can be detected
in 4 to 12 weeks.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2382
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
6. The nurse teaching a client who is HIV positive should alert the client that the virus can be
transmitted
a. as soon as manifestations of illness appear.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
3
b. only to another susceptible host.
c. to anyone having contact with blood or semen.
d. once the diagnosis has been made.
ANS: c
Modes of transmission have remained constant throughout the course of the HIV pandemic. The
virus is spread through certain sexual practices, through exposure to blood, and through perinatal
transmission.
DIF: Cognitive Level: Application
REF: Text Reference: 2377
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance
7. The nurse caring for a client with acquired immunodeficiency syndrome (AIDS) whose
CD4+ cell count is 100 is aware that the most effective way to prevent Pneumocystis carinii
pneumonia in this client is to
a. administer prescribed oral trimethoprim-sulfamethoxazole.
b. encourage a high fluid intake.
c. place the client in protective isolation.
d. restrict the client's visitors.
ANS: a
Maintenance lifetime suppressive therapy for P. carinii is required with trimethoprimsulfamethoxazole, pentamidine aerosol, atovaquone, dapsone, or clindamycin-primaquine.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2387
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. An early manifestation that should alert the nurse to further evaluate a client with an HIV
infection for the opportunistic infection of toxoplasmosis is:
a. discoloration of the mucous membranes.
b. cardiac dysrhythmias.
c. headache.
d. lymphadenopathy.
ANS: c
Clinical manifestations of central nervous sytem (CNS) infections include headache, impaired
cognition, hemiparesis, aphasia, ataxia, vision loss, cranial nerve palsies, motor problems, and
seizures.
DIF: Cognitive Level: Application
REF: Text Reference: 2392
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
9. The problem the nurse should plan for when a client with AIDS is infected with the
Cryptosporidium parasite is
a. delirium.
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Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
b. painful open lesions.
c. profuse, watery diarrhea.
d. severe respiratory tract infection.
ANS: c
Clinical presentation includes profuse diarrhea, steatorrhea (1L/day), flatulence, abdominal
cramping and pain, anorexia, nausea, vomiting, profound weight loss, fever, fatigue, myalgia,
and electrolyte imbalance.
DIF: Cognitive Level: Application
REF: Text Reference: 2392
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
10. The nurse is assessing a client with AIDS for the presence of Kaposi's sarcoma (KS). The
manifestation the nurse should look for is
a. a thick, white exudate in the mouth.
b. a purple-red lesion on the body.
c. a crusty lesion on the back and groin.
d. a pustular lesion with yellow exudate.
ANS: b
Clinical presentation generally starts with an initial "patch" that is flat, pink, looks like a bruise,
and is symmetrical on both sides of the body. Later it turns into dark violet or black plaques.
DIF: Cognitive Level: Application
REF: Text Reference: 2393
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
11. A client with an HIV infection is receiving zidovudine (Retrovir). The nurse counsels the
client about the major problem with this medical protocol, which is
a. side effects.
b. noncompliance with its complex regimen.
c. cost.
d. long-term administration schedule.
ANS: b
Noncompliance relative to the complexity of the regimen is the major concern about the use of
this drug.
DIF: Cognitive Level: Application
REF: Text Reference: 2386, Integrating Pharmacology Box - Understanding HAART;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
12.
a.
b.
c.
The nurse explains that currently the drug that is best for treating HIV wasting syndrome is
human growth hormone.
megestrol acetate.
dronabinol.
Elsevier items and derived items © 2005 by Elsevier Inc.
4
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
d. thalidomide.
ANS: a
The drug used most successfully to treat wasting is human growth hormone.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2394
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
13. The suggestions a nurse could make to a client with AIDS who is experiencing night sweats
is
a. limit fluid intake after supper.
b. drink all liquids in the morning.
c. keep liquids at the bedside to drink.
d. take aspirin if awakened in the night.
ANS: c
Teach the client how to manage chronic recurrent night fever and night sweats by taking the
antipyretic of choice before going to sleep; having a change of bedclothes nearby; keeping a
plastic cover on the pillow; placing a towel over the pillow in case of profuse diaphoresis; and
keeping liquids at the bedside to drink.
DIF: Cognitive Level: Application
REF: Text Reference: 2395
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
14. In order to conserve energy, the nurse would encourage the client with AIDS who has a
nursing diagnosis of Fatigue to
a. bathe before eating breakfast.
b. sit down while showering.
c. use easy to clean forks and knives.
d. rest after every third major activity.
ANS: b
Promote rest and activity by developing a plan of daily activities that alternates short activities
with rest periods. Evaluate the client's needs and point out ways to conserve energy, such as
sitting down while dressing, shaving, or preparing food; sitting on a shower chair while bathing;
or using disposable items for eating so that no cleanup is needed.
DIF: Cognitive Level: Application
REF: Text Reference: 2395
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
15. A client with AIDS has a nursing diagnosis of Imbalanced Nutrition: Less Than Body
Requirements. The nurse should
a. encourage sweet foods and desserts that appeal to the taste.
b. encourage the client to dine alone to focus on food intake.
c. instruct the client to prepare meals, then divide and freeze them.
Elsevier items and derived items © 2005 by Elsevier Inc.
5
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
6
d. tell the client to eat large meals to result in greater intake.
ANS: c
Interventions include eating small meals frequently throughout the day; preparing meals ahead of
time so they can be divided into individual servings and frozen until ready to use; encouraging
the client to dine with family and friends; and consuming more nutrient-dense foods and
beverages rather than filling up on low-calorie items.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2396
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
16.
a.
b.
c.
d.
When a client with AIDS experiences pain while swallowing, the nurse could suggest
eating very cold foods.
drinking acidic juices such as orange juice.
increasing the intake of well-cooked eggs and noodle dishes.
avoiding the use of straws while drinking.
ANS: c
Encourage the client to eat foods at room temperature; choose mild foods and drinks, such as
apple juice rather than orange juice; eat nonabrasive foods that are easy to swallow (well-cooked
eggs, noodle dishes); use a straw while drinking.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2396
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
17. The situation that would be least helpful to manage pain in the AIDS client who is an
injecting drug user is
a. having multiple practitioners prescribing medications.
b. refusing to fill lost prescriptions.
c. carefully rationing narcotic prescriptions.
d. limiting rescue doses of narcotic analgesics on a monthly basis.
ANS: a
Helpful guidelines include having a single practitioner prescribe medications.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2397
TOP: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance
18. When the AIDs client refuses pain medication because he or she is not in pain presently, the
nurse should explain that
a. refraining from using the medication makes its effectiveness last longer.
b. taking the medication on schedule keeps the blood level constant.
c. skipping a dose will decrease diarrhea
d. using the drug will increase the appetite.
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Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
ANS: b
Taking pain medication on a schedule keeps the blood level constant and incidentally helps
control diarrhea by the side effect of constipation.
DIF: Cognitive Level: Application
REF: Text Reference: 2397
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
19.
a.
b.
c.
d.
The nurse counsels other co-workers that the suggested remedy for HIV exposure is
combination antiretrovirals for 4 weeks.
single antiretrovirals for 2 weeks.
combination antiretrovirals with CD4+ count every month.
single antiretrovirals for 2 months.
ANS: a
The current remedy for accidental exposure to HIV is combination antiretrovirals for 4 weeks.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2378
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
20. The client who has a positive enzyme immunoassay test asks the nurse if that means that he
is HIV positive. The nurse’s most helpful response would be
a. “Yes, you should seek medical care for antiretroviral drugs.”
b. “No, you need to have the Western blot test to confirm that you are positive.”
c. “Yes, but antiretrovirals will probably combat the infection now.”
d. “No, many people have positive enzyme immunoassays.”
ANS: b
If the enzyme immunoassay is positive, the Western blot test is needed to confirm an HIVpositive status.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2382
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
Elsevier items and derived items © 2005 by Elsevier Inc.
7
Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
MULTIPLE CHOICE
1. A human immunodeficiency virus (HIV)–positive client is beginning therapy with
antiretroviral medications. The nurse will include in the teaching plan relative to the
medication that the client should
a. take the dose at any time after eating.
b. not skip a dose. If a dose is missed, double the next dose.
c. wait until the next visit before reporting significant side effects.
d. tell the prescriber if the decision is made to terminate treatment.
ANS: d
Instruct all clients taking retrovirals as follows. Take the drug at specified intervals. Do not skip
a dose. Do not increase or decrease the number of pills you take. If side effects occur, tell your
physician or nurse. If you do not want to take the drugs, tell your primary care provider. If you
take the drugs only periodically, it would be better not to take them at all.
DIF: Cognitive Level: Application
REF: Text Reference: 2388, 2389;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
2. The nurse participating in the evaluation of a client with a known HIV infection explains that
the laboratory study that will be of most significance during this process is
a. CD4+ cell count.
b. the total white blood cell count.
c. the enzyme-linked immunosorbent assay (ELISA) test.
d. the Western blot test.
ANS: a
The most recent classification system for HIV disease in adults and adolescents is based on two
monitoring parameters used to follow a client: (1) laboratory data (CD4+ cell count) and (2)
clinical presentation (the person's clinical manifestations of diseases).
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2380
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
3. A nurse with a small grant to increase knowledge of the transmission of HIV infection is
trying to determine the best expenditure of the funds. The nurse should recognize that the
group in which this problem of HIV infection is growing most rapidly is
a. adults older than the age of 50.
b. black teenagers.
c. gay white men.
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
2
d. blacks and Hispanics.
ANS: a
An overlooked population of rapidly growing HIV-positive people are those older than the age of
50.
DIF: Cognitive Level: Analysis
TOP: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity
REF: Text Reference: 2377
4. The nurse is counseling a woman who is HIV positive and has just given birth to a baby girl.
The nurse should advise the client to
a. avoid breast-feeding her infant.
b. seek professional counseling to deal with the guilt associated with the almost
certain passing of the disease to her child.
c. report all of her sexual partners to the infectious disease department in order to
break the chain of transmission of the disease.
d. anticipate the needs of her child immediately and make arrangements for
placement in a setting where her child's life will be comfortable.
ANS: a
Perinatal HIV exposure can occur during pregnancy, during vaginal delivery, and postpartum
through breast-feeding.
DIF: Cognitive Level: Application
REF: Text Reference: 2378
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
5. The nurse counseling a client who is afraid that HIV exposure has occurred would explain
that the period of time it takes before HIV antibodies can be detected by laboratory tests is
generally
a. 1 to 3 days.
b. 7 to 10 days.
c. 1 to 3 weeks.
d. 4 to 12 weeks.
ANS: d
There is a "window" for seroconversion (the time it takes for a newly infected person to develop
antibodies that can be detected in a laboratory specimen). On average, antibodies can be detected
in 4 to 12 weeks.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2382
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
6. The nurse teaching a client who is HIV positive should alert the client that the virus can be
transmitted
a. as soon as manifestations of illness appear.
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Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
3
b. only to another susceptible host.
c. to anyone having contact with blood or semen.
d. once the diagnosis has been made.
ANS: c
Modes of transmission have remained constant throughout the course of the HIV pandemic. The
virus is spread through certain sexual practices, through exposure to blood, and through perinatal
transmission.
DIF: Cognitive Level: Application
REF: Text Reference: 2377
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance
7. The nurse caring for a client with acquired immunodeficiency syndrome (AIDS) whose
CD4+ cell count is 100 is aware that the most effective way to prevent Pneumocystis carinii
pneumonia in this client is to
a. administer prescribed oral trimethoprim-sulfamethoxazole.
b. encourage a high fluid intake.
c. place the client in protective isolation.
d. restrict the client's visitors.
ANS: a
Maintenance lifetime suppressive therapy for P. carinii is required with trimethoprimsulfamethoxazole, pentamidine aerosol, atovaquone, dapsone, or clindamycin-primaquine.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2387
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. An early manifestation that should alert the nurse to further evaluate a client with an HIV
infection for the opportunistic infection of toxoplasmosis is:
a. discoloration of the mucous membranes.
b. cardiac dysrhythmias.
c. headache.
d. lymphadenopathy.
ANS: c
Clinical manifestations of central nervous sytem (CNS) infections include headache, impaired
cognition, hemiparesis, aphasia, ataxia, vision loss, cranial nerve palsies, motor problems, and
seizures.
DIF: Cognitive Level: Application
REF: Text Reference: 2392
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
9. The problem the nurse should plan for when a client with AIDS is infected with the
Cryptosporidium parasite is
a. delirium.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
b. painful open lesions.
c. profuse, watery diarrhea.
d. severe respiratory tract infection.
ANS: c
Clinical presentation includes profuse diarrhea, steatorrhea (1L/day), flatulence, abdominal
cramping and pain, anorexia, nausea, vomiting, profound weight loss, fever, fatigue, myalgia,
and electrolyte imbalance.
DIF: Cognitive Level: Application
REF: Text Reference: 2392
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
10. The nurse is assessing a client with AIDS for the presence of Kaposi's sarcoma (KS). The
manifestation the nurse should look for is
a. a thick, white exudate in the mouth.
b. a purple-red lesion on the body.
c. a crusty lesion on the back and groin.
d. a pustular lesion with yellow exudate.
ANS: b
Clinical presentation generally starts with an initial "patch" that is flat, pink, looks like a bruise,
and is symmetrical on both sides of the body. Later it turns into dark violet or black plaques.
DIF: Cognitive Level: Application
REF: Text Reference: 2393
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
11. A client with an HIV infection is receiving zidovudine (Retrovir). The nurse counsels the
client about the major problem with this medical protocol, which is
a. side effects.
b. noncompliance with its complex regimen.
c. cost.
d. long-term administration schedule.
ANS: b
Noncompliance relative to the complexity of the regimen is the major concern about the use of
this drug.
DIF: Cognitive Level: Application
REF: Text Reference: 2386, Integrating Pharmacology Box - Understanding HAART;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
12.
a.
b.
c.
The nurse explains that currently the drug that is best for treating HIV wasting syndrome is
human growth hormone.
megestrol acetate.
dronabinol.
Elsevier items and derived items © 2005 by Elsevier Inc.
4
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
d. thalidomide.
ANS: a
The drug used most successfully to treat wasting is human growth hormone.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2394
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
13. The suggestions a nurse could make to a client with AIDS who is experiencing night sweats
is
a. limit fluid intake after supper.
b. drink all liquids in the morning.
c. keep liquids at the bedside to drink.
d. take aspirin if awakened in the night.
ANS: c
Teach the client how to manage chronic recurrent night fever and night sweats by taking the
antipyretic of choice before going to sleep; having a change of bedclothes nearby; keeping a
plastic cover on the pillow; placing a towel over the pillow in case of profuse diaphoresis; and
keeping liquids at the bedside to drink.
DIF: Cognitive Level: Application
REF: Text Reference: 2395
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
14. In order to conserve energy, the nurse would encourage the client with AIDS who has a
nursing diagnosis of Fatigue to
a. bathe before eating breakfast.
b. sit down while showering.
c. use easy to clean forks and knives.
d. rest after every third major activity.
ANS: b
Promote rest and activity by developing a plan of daily activities that alternates short activities
with rest periods. Evaluate the client's needs and point out ways to conserve energy, such as
sitting down while dressing, shaving, or preparing food; sitting on a shower chair while bathing;
or using disposable items for eating so that no cleanup is needed.
DIF: Cognitive Level: Application
REF: Text Reference: 2395
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
15. A client with AIDS has a nursing diagnosis of Imbalanced Nutrition: Less Than Body
Requirements. The nurse should
a. encourage sweet foods and desserts that appeal to the taste.
b. encourage the client to dine alone to focus on food intake.
c. instruct the client to prepare meals, then divide and freeze them.
Elsevier items and derived items © 2005 by Elsevier Inc.
5
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
6
d. tell the client to eat large meals to result in greater intake.
ANS: c
Interventions include eating small meals frequently throughout the day; preparing meals ahead of
time so they can be divided into individual servings and frozen until ready to use; encouraging
the client to dine with family and friends; and consuming more nutrient-dense foods and
beverages rather than filling up on low-calorie items.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2396
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
16.
a.
b.
c.
d.
When a client with AIDS experiences pain while swallowing, the nurse could suggest
eating very cold foods.
drinking acidic juices such as orange juice.
increasing the intake of well-cooked eggs and noodle dishes.
avoiding the use of straws while drinking.
ANS: c
Encourage the client to eat foods at room temperature; choose mild foods and drinks, such as
apple juice rather than orange juice; eat nonabrasive foods that are easy to swallow (well-cooked
eggs, noodle dishes); use a straw while drinking.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2396
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
17. The situation that would be least helpful to manage pain in the AIDS client who is an
injecting drug user is
a. having multiple practitioners prescribing medications.
b. refusing to fill lost prescriptions.
c. carefully rationing narcotic prescriptions.
d. limiting rescue doses of narcotic analgesics on a monthly basis.
ANS: a
Helpful guidelines include having a single practitioner prescribe medications.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2397
TOP: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance
18. When the AIDs client refuses pain medication because he or she is not in pain presently, the
nurse should explain that
a. refraining from using the medication makes its effectiveness last longer.
b. taking the medication on schedule keeps the blood level constant.
c. skipping a dose will decrease diarrhea
d. using the drug will increase the appetite.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 80: Management of Clients with Acquired Immunodeficiency Syndrome
ANS: b
Taking pain medication on a schedule keeps the blood level constant and incidentally helps
control diarrhea by the side effect of constipation.
DIF: Cognitive Level: Application
REF: Text Reference: 2397
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
19.
a.
b.
c.
d.
The nurse counsels other co-workers that the suggested remedy for HIV exposure is
combination antiretrovirals for 4 weeks.
single antiretrovirals for 2 weeks.
combination antiretrovirals with CD4+ count every month.
single antiretrovirals for 2 months.
ANS: a
The current remedy for accidental exposure to HIV is combination antiretrovirals for 4 weeks.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2378
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
20. The client who has a positive enzyme immunoassay test asks the nurse if that means that he
is HIV positive. The nurse’s most helpful response would be
a. “Yes, you should seek medical care for antiretroviral drugs.”
b. “No, you need to have the Western blot test to confirm that you are positive.”
c. “Yes, but antiretrovirals will probably combat the infection now.”
d. “No, many people have positive enzyme immunoassays.”
ANS: b
If the enzyme immunoassay is positive, the Western blot test is needed to confirm an HIVpositive status.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2382
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
Elsevier items and derived items © 2005 by Elsevier Inc.
7
Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 81: Management of Clients with Leukemia and Lymphoma
MULTIPLE CHOICE
1.
a.
b.
c.
d.
The nurse explains that acute leukemia is caused by
undifferentiated blast cells entering bone marrow.
accumulation of immature blast cells.
excessively rapid mitosis of leukemic cells.
proliferation of neutrophils.
ANS: b
Leukemia is caused by an accumulation of immature and useless blast cells in the marrow that
undergo a clonal change and ultimately “crowd out” and interfere with the production of other
blood cells. The cell division of leukemic cells is much slower than other normal cells.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2402, 2403;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
2. The nurse reviewing a hematology report recognizes the ominous indicator of pancytopenia,
which is
a. platelets that are immature.
b. white cells that are undifferentiated.
c. cellular components of the blood are reduced.
d. red cells that have become polymorphic.
ANS: c
Pancytopenia is a condition in which the leukemic process has reduced or obliterated all other
cellular components of the blood.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2403
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse reviewing a hematology report of a client with chronic leukemia brings to the
attention of the physician a change that may indicate a blast crisis may be occurring, which is
a. thrombocytic proliferation.
b. myeloid cell precursors in excess of 20%.
c. hemoglobin drop to 9 g/dl.
d. drastic decrease in monocytes.
ANS: b
Chapter 81: Management of Clients with Leukemia and Lymphoma
2
When the myeloid cell precursors rise in excess of 20% in the circulating volume and 30% in the
marrow, it is a strong suggestion that blast crisis may be occurring. This condition usually brings
on death within 6 months of the onset.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2404
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The nurse preparing a client with acute leukemia for the induction phase of chemotherapy
explains that the objective of this phase is to
a. “shock” the marrow into producing normal stem cells.
b. decrease the number of monocytes.
c. reduce long bone pain and splenomegaly.
d. induce complete remission.
ANS: d
The induction phase is a period of time in which there is an intense course of chemotherapy
designed to bring about complete remission.
DIF: Cognitive Level: Application
REF: Text Reference: 2405
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
5. A client with acute leukemia is receiving chemotherapy along with the administration of
allopurinol (Zyloprim). The laboratory study the nurse monitors regularly is
a. serum cholesterol.
b. cardiac enzymes.
c. urine cultures.
d. uric acid level.
ANS: d
If the white blood cell count is high when chemotherapy is initiated, rapid cell lysis can lead to
increased serum uric acid, phosphate, and potassium levels and decreased serum calcium. Acute
tumor lysis syndrome can be prevented by increasing intravenous (IV) hydration, alkalizing the
urine, and administering allopurinol (Zyloprim).
DIF: Cognitive Level: Application
REF: Text Reference: 2406
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. When the nurse records a platelet count of 20,000 mm3, the most appropriate nursing action
is to
a. encourage iron-rich foods.
b. institute bleeding precautions.
c. place in protective isolation.
d. increase fluid intake.
ANS: b
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Chapter 81: Management of Clients with Leukemia and Lymphoma
Teach the client and significant others to institute bleeding precautions during periods of
thrombocytopenia.
DIF: Cognitive Level: Application
REF: Text Reference: 2408, 2409;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
7.
a.
b.
c.
d.
A client with acute leukemia develops a neutrophil count of 450/mm3. The nurse should
allow no visitors at this time.
place the client on bleeding precautions.
allow no plants or live flowers in the room.
place the client on complete bed rest.
ANS: c
When the count is below 500, protective isolation should be instituted: bacteria-free diet, no
fresh flowers or plants in the room, and visitors screened for the presence of an infection.
DIF: Cognitive Level: Application
REF: Text Reference: 2408
TOP: Nursing Process Step: Application
MSC: NCLEX: Physiological Integrity
8. A client contemplating chemotherapy for acute leukemia tells the nurse that he is concerned
that he will be sterile as a result. The nursing action most appropriate is to explain
a. reproductive alternatives such as sperm banking or artificial insemination.
b. the effect on reproductive functions is only temporary.
c. sperm production is not affected by chemotherapy
d. chemotherapy will not cause sterility but will cause the development of abnormal
sperm.
ANS: b
Describe to the client the normal cellular destruction that might lead to temporary or permanent
destruction of reproductive function. In appropriate cases, inform the client of reproductive
alternatives, such as sperm banking and artificial insemination.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2410
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity
9. The nurse caring for a client who had a bone marrow transplant this morning should observe
the client for manifestations of
a. acute graft-versus-host disease (GVHD).
b. hemorrhage.
c. pulmonary complications.
d. Sjögren's syndrome.
ANS: c
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Chapter 81: Management of Clients with Leukemia and Lymphoma
4
Potential immediate adverse reactions are allergic (urticaria, chills, fever), volume overload, and
pulmonary complications secondary to fat emboli. GVHD does occur but not so early in the
postprocedure period.
DIF: Cognitive Level: Analysis
REF: Text Reference: 2419
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
10. After a bone marrow transplant, a client develops stage I GVHD. The laboratory study the
nurse assesses to monitor the progression of this complication is
a. bilirubin level.
b. white blood cell count.
c. platelet count.
d. cardiac enzymes.
ANS: a
Maculopapular rash involving less than 25% of the body surface area, bilirubin levels of 2 to 3
mg/dl, and diarrhea 500 to 1000 ml/day are classified as stage I GVHD.
DIF: Cognitive Level: Application
REF: Text Reference: 2420, Table 81-5;
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
11. A client with stage I GVHD following a bone marrow transplant is very depressed because
he has developed this complication. The nurse should base interactions with this client on the
fact that stage I GVHD is
a. usually fatal.
b. beneficial in preventing leukemic relapse.
c. likely to prevent successful engraftment.
d. treatable with steroids.
ANS: b
Whereas severe GVHD is usually fatal, researchers believe that a complete absence of this
immune reaction increases the risk of leukemic relapse.
DIF: Cognitive Level: Application
REF: Text Reference: 2421
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity
12.
a.
b.
c.
d.
A client with Hodgkin’s disease is staged at III2. The nurse knows this means there
are two or more nodes on the same side of the diaphragm.
is involvement of a single lymphoid structure.
are nodes on both sides of the diaphragm with portal involvment.
are nodes on both sides of the diaphragm with para-aorta involvement.
ANS: d
Classification III2 indicates that there are nodes on both sides of the diaphragm with involvement
of para-arotic, iliac, or mesenteric nodes.
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Chapter 81: Management of Clients with Leukemia and Lymphoma
5
DIF: Cognitive Level: Application
REF: Text Reference: 2413, Table 81-2;
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
13. A client has been receiving MOPP (mechlorethamine, vincristine [Oncovin], procarbazine,
prednisone) therapy for treatment of Hodgkin's disease. The treatment has changed to a
protocol of ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine and dacarbazine).
When the client asks the nurse for clarification about the change in protocol, the nurse’s
response will include that ABVD
a. prevents hypercalcemia.
b. reduces the risk of leukemia.
c. negates the need for radiation therapy.
d. can frequently produce a remission after only 1 cycle.
ANS: b
The primary advantages of ABVD are its ease of delivery in full doses, fewer side effects, and
less risk of development of leukemia.
DIF: Cognitive Level: Application
REF: Text Reference: 2413
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
14. A client is scheduled to begin ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine,
dacarbazine) chemotherapy as treatment for Hodgkin's disease. The nurse should relate to the
client that ABVD has the benefit of
a. fewer side effects.
b. being less costly.
c. not requiring radiation to achieve full remission.
d. blood transfusion.
ANS: a
ABVD has fewer side effects.
DIF: Cognitive Level: Application
REF: Text Reference: 2413
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
15. The nurse offers a large glass of iced lemonade to an anorexic leukemic client, who takes one
sip and sets it aside. The nurse belatedly remembers that leukemic clients
a. are unable to drink cold beverages without pain.
b. have increased nausea from citrus drinks.
c. have difficulty holding large items.
d. lose sensitivity to sour and sweet tastes.
ANS: d
Leukemic clients lose their sensitivity to the tastes of sweet and sour.
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Chapter 81: Management of Clients with Leukemia and Lymphoma
6
DIF: Cognitive Level: Comprehension REF: Text Reference: 2404
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
16. When a teenager laughs off his present infection of mononucleosis as a silly “kissing
disease,” the nurse cautions him that mononucleosis is a risk factor for
a. acute lymphoblastic leukemia.
b. Hodgkin’s disease.
c. chronic lymphocytic leukemia.
d. severe bone marrow depression.
ANS: b
People who have had mononucleosis have a threefold propensity toward Hodgkin’s disease.
DIF: Cognitive Level: Application
REF: Text Reference: 2411
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
17. The nurse records the absolute neutrophil count (ANC) of a client who has bands of 4%, segs
of 42%, and white blood cell (WBC) count of 1450 as
a. 638 mm3.
b. 718 mm3.
c. 801 mm3.
d. 930 mm3.
ANS: a
(4% + 42%) × 1450 – 638 mm3.
The ANC is calculated by adding the segs and bands and multiplying by the WBC. A count of
less than 500 indicates the need for protective isolation.
DIF: Cognitive Level: Application
REF: Text Reference: 2408, Box 81-1;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
Elsevier items and derived items © 2005 by Elsevier Inc.