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Rasmussen Nursing 2 Winter 2015: Immune, HIV, Diabetes, Skin, and Eyes & Ears Flashcards | StudBud
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Rasmussen Nursing 2 Winter 2015: Immune, HIV, Diabetes, Skin, and Eyes & Ears
Rasmussen Nursing 2 Winter 2015: Immune, HIV, Diabetes, Skin, and Eyes & Ears
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Nursing 2 Winter 2015 NCLEX question review
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1
Client w/ type 2 insulin-requireddiabetes asks about having alcohol. What is the
best
response?
If you drink, BG may be high at night & youcan skip a snack
If you drink,it's best to consume alcohol on an emptystomach
You can have 1-2/day if you have something to eat with them
Alcohol is detoxified in the liver,so it's not good to drink
2
Client has SLE c/ofatigue, joint pain, swelling, diff. urinating. What labs? (all that apply)
2+ urine protein
elevated hemoglobin
+ ANA
elevated BUN
3
RN is giving dischargeinstructions to a client w/ AIDS. Which statement shows understanding?
" I will rinse raw fruits with water before eatingthem."
"I will wear gloves whilechanging the pet litter box."
"I will wear a maskwhen around family members who are ill."
"I will cook vegetables before eating them."
4
Pt with night sweats, fatigue, cough, nausea, diarrhea, 100.6, HIV? Do what? all that apply
Perform a physical assessment
determine when symptoms began
Obtain a complete sexual history
test for HIV
5
Pt has (HHNK) asks how to prevent of this illness. RN instructs client on? Select allthat apply
consult ppv with elevated fbs
Monitor for s/s infection and treat early
Use sliding -scale insulin to treat unplanned snacks
use stress mgt techniques as stress increases blood glucose
6
To promote comfort after and immunization, teach the client what? (select all that apply)
use the affected extremity
take acetomenophin or ibuprofen
massage the injection site
apply a cool compress to the injection site
7
Hypersensitivitydisorders are due to a (an):
Desensitization of humoral immune components
Autoimmune disorder, such as RA
Immunedeficiency disorder, such as HIV
Heightenedimmune response to an antigen
8
Which statement would indicate a need for further teachingregarding the use of topical meds?
Applyafter bathing or cleansing the area
Donot bandage or cover area unless directed by physician
Don't put on face, perinium or axillae unlessdirected by dr.
Apply to broken or irritated skin
9
Pt w/ diabetes says “If I avoid carbs in my diet, I'd be ok” Diabetes affects the metabolismof?
Proteins, fats, and carbohydrates
Protein and carbohydrates only.
Carbohydrates only.
Fats and carbohydrates only.
10
Pt w/ immediate type 1 hypersensitivitywill respond to a SPT with the appropriate antigen by:
A wheal and flare response 48 hours later
A whealand flare response within 5 to 10 minutes
A wheal and flare response immediately
An increased susceptibility to herpes zoster
11
Atopicpts have an inherited tendency to hyperproduce what antibodiesin response to allergens?
IgE
Prostaglandin
Histamine
Mast cells
12
Client complains of hearing loss. On examination the canal is blocked w/ cerumen. What is next?
Use an ear curette
Refer to an otologist for removal
Insert a cotton swab to remove debris
Gently irrigate the canal
13
RN teaching pt with new Rx for prednisone. Include in teaching? (all that apply)
Hypotension
Moon face may occur
Weight Gain is expected
Striae may appear on the abdomen
14
Client complains of difficulty hearing when at dinner w/ family. This type of hearing loss is:
Complete hearing loss
Conductive hearing loss
Sensorineural hearing loss
Mixed hearing loss
15
Whatis the preferred method of debridement when a pt is immunocompromised or risk for bleeding?
Maggot Therapy
Enzymatic
Autolytic
Mechanical
16
RN is providing info to a clientdiagnosed with RA. Which statement by the RN is appropriate?
“Youmay experience low blood sugar.”
“Youmay experience morning stiffness when you get out bed.”
“Youmay experience weight gain.”
“Youmay experience abdominal pain.”
17
After cataract surgery the pt complains of nausea and severe pain. The nurse should do what?
Administer and antiemetic
Notify the provider
Turn the patient to the operative side.
Administer an analgesic
18
Aclient with type 1 diabetes mellitus has influenza. The nurse should instructthe client to:
Discontinuethat dose of insulin if unable to eat.
Increasethe frequency of blood glucose testing
Takehalf the normal dose of insulin
Reducefood intake to diminish nausea.
19
Themost common dermatological problems encountered by health care professionalsare?
Malignancies
Sexually Transmitted Infections
Staphylococcalinfections
Tineas/fungal infections
20
How can RN improve communication with PTwith a hearing deficit? (select all that apply)
Get the pt attention before speaking
When asked to repeat, repeat same phrase more slowly
Speak very loudly
Keep your hands away from your mouth while talking
21
Early clinical manifestations of GVHD include:
Respiratoryproblems, for example interstitial pneumonitis
Skin rashand pruritus
Dry lacrimal ducts and oral mucosa
Taut,firm, leather-like skin
22
RN is caring for a pt w/ AIDS. Which activity should be reported to the employee health dep.?
RN is stabbed w/ sterile syringe used to drawthe pts meds
RN removes gloves when giving a backrub onintact skin.
When flushing the used bedpan fluid splashes in the RNs eyes
The nurse does not wear a mask while in the clients room.
23
RN should do what before a scratch test for food and environ. allergy testing? (all that apply)
Inform client to expect itching at one site
Ask about previous medication over last several days
Ask about previous reactions to allergens
Gather all emergency resuscitation equipment
24
Whichfindings would the nurse expect to note on a stage II pressure ulcer?
Intactskin
Full-thicknessskin loss
Exposedbone, tendon, or muscle
Partial-thicknessskin loss of the dermis
25
RN caring for a client following atrabeculectomy. Which should the nurse include for teaching?
"You may continue to drive to and from work"
" Tilt your head back when washing your hair"
" You may need to limit your housekeeping activities"
"Continue playing golf"
26
Client on high doses of ASA complains of tinnitus & difficulty hearing. RN responds by:
Directing the client to increase the volume on the receiver
Informing the client that tinnitus occurs with aging
Performing Rinne and Weber tests
Telling the client that tinnitus is a side effect of aspirin
27
A client who has conductive hearing loss will have the followingcharacteristics:
Hearing loss associated with higher pitch tones.
Sound perceived as distorted.
Louder speech to hear better.
Conversation can be heard in noisy environments.
28
Client is found after an accident with animpaled object in the eye. The nurse does what first?
Turn the client on his side to prevent aspiration
Placea cup over the impaled object and tape in place
Assess the client for priority injuries
Pullout the object and observe for bleeding
29
Which diagnostic tests and lab tests confirm HIV? (select all that apply)
Western Blot
CD4+ T lymphocyte percentage of totallymphocytes
CD4+ T lymphocyte count
indirect immunoflourescence assay
30
Cellulitiscan best be described as having which characteristics?
acutesuperficial infection of the dermis & lymphatics
inflammationof epidermis only
skin infection of dermis & underlyinghypodermis
epidermal& lymphatic infection caused bystaphylococcus
31
Client w/ type 1 diabetes is admitted to ER.Which respiratory patterns requires STAT attention?
Regular depth of respirations with frequent pauses.
Short expirations and inspirations.
Deep,rapid respirations with long expirations.
Shallow respirations alternating with long expirations.
32
Aclient with diabetes is taking Humalog injections. The nurseshould advise the client to eat:
2 hours before the injection
Any time because timing of meals w/ insulin is unnecessary
1 hour after the injection.
Within 10 to 15 minutes after the injection.
33
RN mgr is planning the clinical assignment. Who can't care for a patient w/ herpes zosters?
Thenurse who never had German measles
Thenurse who never had mumps
Thenurse who never had roseola
The nurse who never had chickenpox
34
PT complains of vertigo, tinnitus, n/v, & intermittent hearing loss. These are signs of:
Meniére’s disease
Presbycusis
Mastoiditis
Otosclerosis
35
RN is admitting a client who has suspected SLE. Which clinical finding supports this diagnosis?
Weightloss
Petechiae on thighs
Increasedhair growth
Alopecia
36
Whenassessing a lesion diagnosed as malignant melanoma the RN most likelyexpects which finding?
apearly papule with a central crater and a waxy border
afirm, nodular lesion topped with crust
an irregularly shaped lesion
asmall papule with a dry, rough scale
37
Client w/ sensorineural hearing loss asks ifhearing aid will return hearing. Which is correct?
Hearing aids assist clients to hear sounds as normal.
Hearing aids increase volume but not clarity ofsounds
Hearing aids help only clients with conductive hearing loss.
Hearing aids eliminate background noises.
38
Pt- DM wants a med for h/a after am x-rayproc. ismad aboutthe h/a, no bfast, wethands. RN does?
Adm headache med and review the day’s lab test results
. Adm med for h/a & feed breakfast
Acknowledge dissatisfaction, offer to a snack, give the med
Check blood glucose level and be prepared to give 4 oz juice
39
70 yo admBG 750. tx for HHNK IVreg ins BG has dropped to 400.wants OOB, skin moist.Do what?
Interpret as hypoglycemia and check BS
Recognize feelingbetter and wants control of situation
Assess body temperature and bladder distention
ascultate breath sounds and O2 sat
40
RN assesses the skin of a pt w/ a dx of psoriasis. Whichsymptom is associated w/ this disorder?
Clear,thin nail beds
Silvery-white scaly lesions
Red-purplishscaly lesions
Oilyskin
41
A client has a visual problem that iscorrect with convex corrective lenses. It is most likely?
Corneal Abrasion
Astigmatism
Hyperopia
Myopia
42
Aclient has a latex allergy.The client needs to seekimmediate medical attention if what occurs:
He experiences swelling around the lips oreyes
He feels his heart pounding after strenuousexercise.
His medical alert bracelet falls off.
He accidentally ingests sunflower seeds.
43
Pt with RA and increase joint tenderness and swelling. Expect to find? (all that apply)
Decrease range of motion
Recent influenza
Pain at rest
Hyper salivation
44
Assessmentof the diabetic client for common complications should include examination ofthe:
Lymph Glands
Pharynx
Eyes
Abdomen
45
Passive immunity involves:
Developmentof sensitized lymphocytes within the host body
Vaccine containing live or killed infectious organism
Transfer of antibodies through the motherto the fetus
Responseof memory cells to entry of an infectious organism
46
Which suggestion would be helpful to a (HIV) + client who has altered taste perception?
Avoid using plastic eating utensils.
Try zinc supplementation to improve taste perception.
Drink salty broths and other fluids to stimulate taste buds
Increase intake of meat to at least one serving per day.
47
The goal of HAART is to:
Lower the CD4 cell levels.
Encourage client compliance to the medication schedule.
Avoid viral resistance of each drug
Minimize side affects of the drug.
48
Pt with DM for d/c home after angioplasty. Goes to BR without slippers yet in reach. Nsg Diag.
Risk impaired cerebral perfusion r/t potential hypoglycemia
Risk infection r/t impaired tissue perfusion d/t barefoot
Risk for injury r/t falls d/t barefoot
Deficit Knowledge r/t angioplasty care
49
RN is providing teaching about self-care to client w/ SLE.Whichstatement needs further teaching
“Iwill apply powder to any skin rash.”
“Ishould use a mild hair shampoo.”
“Iwill call my doctor if I have a cough.”
“Ishould avoid sun exposure.”
50
What lab tests are used to diagnose RA? (select all that apply)
WBC
ANA
Urinalysis
ESR
51
Whenteaching the diabetic client about foot care, the RN should include which of the following?
Cut toenails at angles.
Use heating pads for sore feet.
Avoid going barefoot
Buy shoes a half size larger.
52
Client with bilateral eye abnormality, usually more acute in one compared to the other. Name?
Cataract
Glaucoma
Keratoconis
Retinal Detachment
53
The test that measures eye pressure to diagnosis glaucoma is?
Ballottement
Intracranial Pressure
Trabeculectomy
Tonometry
54
Hearing impairment are categorized by decibels. Normal hearing is measured by?
26–40 dB
0–15 dB
16–25 dB
41–55 dB
55
What complication may occur from rubbing the eyes continuously over a few weeks?
Hyperopia
Keratoconus
Refraction
Corneal Ulceration
56
Sero-conversion is the presence of antibodies of HIV in the blood& found by studies within:
One month following thestart of antiretroviral drug therapy
One to three months or more after exposure to HIV
Six months, when immune-antibody complexes are formed.
One to two weeks after exposure to HIV
57
RN is assessing a client for HIV. Pick risk factors associated with this virus? all that apply
Perineal Exposure
Occupational Hazard
Pregnancy
Older adult women
58
What is the best site for insulin absorption on a client who jogs daily?
Abdomen
Arms
Iliac Crest
Legs
59
A client just underwent a tympanoplasty.Which of the following interventions is appropriate?
Encourage deep breathing and coughing.
Assist the client with ambulation until vertigo is resolved.
Place the client lying on his or her operative side.
Tell the client hearing will return to normal immediately.
60
Whichof the following is not a risk factor of pressure ulcers?
Skinshearing and friction
Incontinence
Immobility
Autoimmune disorder
61
Which medication may cause a complication w/ the treatment planof a client w/ diabetes?
Angiotensin-converting enzyme (ACE)
Steroids
Sulfonylureas
Aspirin
62
Criteria used to dx AIDS in an person with HIV includeat least one of the following conditions:
Development of an opportunistic cancer.
CD4+ cell count above 200 cells
Dysfunction of one or more organs.
Anemia due to diminished RBC count
63
Occupational RN uses OSHAguidelines if high noise levels present and include? select all apply
Mandatory hearing protectors on all employees
Monitoring sound levels in the work force
Baseline and annual hearing test of all workers
Biannual education and training of noise pollution
64
Client has SLE & is experiencing Raynaud’s phenomenon. Which findings should the RNanticipate?
Swellingof joints of the fingers
Pallorof toes with cold exposure
Feetbecome reddened with ambulation
Clientreport of intense feeling of heat in the fingers
65
Whichof the following indicates a potential complication of diabetes mellitus?
Inflamed, painful joints.
Hemoglobin of 9 g/dL.
Stooped appearance.
Blood pressure of 160/100 mm/Hg.
66
RN is giving an IM immunoglobin to a pt who was exposed to hep A.Which statement is appropriate
This medication offers permanent immunity tohepatitis A
This contains attenuated virus tohelp you create antibodies
This medication involves 3 injections over several months
“Thisprovides an immune response faster than your body
67
hx Type 1 DM Tx bronchitis/sinusitus. resp deep rapid fruity odor unlabored dry skin. Action?
Assess breath sounds for additional signs tx infection
Assess blood glucose for hypoglycemia
Encourage to rest and drink 8-10 oz fluid daily
Assess for hyperglycemia and assess for ketones
68
The nurse would assess forwhich electrolyte imbalance as common finding in a client with AIDS
Hyperkalemia
Hypernatremia
Hyponatremia
Hypocalcaemia
69
Pt c/o blurred vision,it is better in bright light, sees wavy lines on the Amslergrid. Why?
Diabetic Retinopathy
Age related Macular Degeneration
Glaucoma
Strabismus
70
What is the most common cause of ocular cancer?
Melanoma
Intracranial Pressure Problems
Diabetes Mellitus
Hypertension
71
RN caring for pt with DM. What is the client at risk for?
Closed-Angle Glaucoma
Macular Degeneration
Cataracts
Open-Angle Glaucoma
72
A client being treated for anaphylaxis will be givenwhat drug by intramuscular injection?
Theophylline
Hydrocortisone
Epinephrine
Captopril
