Exam #5
1. A nurse is caring for a client who asked about the functions of the thymus, spleen, and lymph nodes which
of the following respondes should the nurse make?
a. These organs support immunity
b. these organs are used in digestion
c. These organs regulate electronic balance
d. these organs assist vitamin absorbption
These organs support immunity
2. The nurse asked the client who is about to have a cardiac catheterization about any allergies. The client
states I always get a rash when I eat shellfish which of the following is the priority nursing action?
a. Notify the provider of the clients allergy
b. attach a wristband indicating the clients allergy
c. ask the client if any other foods cause such a reaction
d. Notify the dietary Department of the client allergy
Notify the provider of the clients allergy
3. A nurse is caring for a client who has had an anaphylactic reaction after a blood transfusion. The nurse
reviews the literature to further understand antibody mediated immunity. Which of the following should
the nurse confirm about AMI?
a. AMI is mediated by antibodies produced by the plasma cell
b. humoral immune response is mediated by the T lymphocytes
c. AMI involved phagocyte natural kill sellers
d. AMI defense only against viral infections
AMI is mediated by antibodies produced by the plasma cell
4. A nurse is assessing a client who has a history of HIV with phagocyte dysfunction. The nurse should
monitor this client for which of the following conditions?
a. Dehydration
b. Fungal infection
c. Compartment syndrome
d. pleural effusion
Fungal infection
5. A nurse is teaching a client who has a depressive disorder about fluoxetine name. Which of the following
information should the nurse include in the teaching?
a. You may experience a decrease sex drive while taking this medication
b. You may notice an improvement in your depression or symptoms in two to three days
c. you may notice that you have less appetite while taking this medication
d. You may experience drooling while taking this medication
You may experience a decrease sex drive while taking this medication
6. A charge nurse is planning to admit several clients to the medical unit. Which of the following clients
should the nurse assigned to a private room?
a. A client who has a fever of unknown origin
b. A client who has a total hip arthroplasty
c. a client who is HIV positive
d. a client who is neutropenic
client who is neutropenic
7. A nurse is providing teaching to the parents of an adolescent who has a depressive disorder and a new
prescription for Trazodone. Which will go following information should the nurse include in the teaching?
a. Trazodone can cause suicidal thoughts in adolescence
b. expect your child to lose weight while taking Trazodone
, c. Trazodone should be taken in the morning to prevent insomnia
d. your child symptoms of depression should improve within one week
Trazodone can cause suicidal thoughts in adolescence
8. A nurse is caring for a client who is taking am amitriptyline. The nurse should monitor for which of the
following adverse affects?
a. Orthostatic hypertension
b. Drooling
c. diarrhea
d. metabolic taste in mouth
Orthostatic hypertension
9. During the past six months, a client diagnosed with acquired immunodeficiency syndrome has a chronic
diarrhea an unwanted weight loss of 18 pounds. Additional assessment findings include nausea, vomiting ,
tinted skin turgor, dry mucous membrane, and listlessness. Which nursing diagnose focus attention on the
client’s immediate problem?
a. Deficient fluid volume related to abnormal fluid loss in stool and emesis
b. in balanced nutrition: Less than body requirements related to nausea and vomiting
c. disturbed thought process related to central nervous system effects of disease process
d. diarrhea related to disease process in acute infection
Deficient fluid volume related to abnormal fluid loss in stool and emesis
10. A patient is brought to the emergency Department by a friend. The patient is unresponsive, and
respirations are low and shallow. Which of the following is their priority intervention?
a. Check the patient's blood glucose level
b. Ask a friend about illicit drug use
c. administer naloxone in per protocol
d. administer 100% oxygen per nasal cannula
administer 100% oxygen per nasal cannula
11. A nurse is preparing a client who is to receive chemotherapy by treatment of ovarian cancer. Which of the
following action should the nurse plan to take?
a. Tell the client to expect dark stools following chemotherapy
b. have the client floss four times daily
c. have the client swish with commercial mouthwash before therapy
d. administer antiemetic prior to procedure
administer antiemetic prior to procedure
12. A patient that was stung by a bee is exhibiting redness an enema in the hand and forearm. The nurses
actions would it be based on which scientific rationale?
a. Baking soda is the best treatment for edema from a bee sting
b. Hypersensitivity is possible. This patient may need an anti-sting kit
c. the client should not worry because people cannot develop severe allergies to bee venom
d. the client needs regular checkups to obtain Immunotherapy
Hypersensitivity is possible. This patient may need an anti-sting kit
13. A nurse is caring for a client who has a depressive disorder. The client states I just can't feel my any
happiness or joy in my life. Which of the following terms should the nurse use in documenting this finding?
a. Anhedonia
b. Anergia
c. Anosognosia
Anhedonia
14. A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several
years period which of the following findings is should the nurse document as manifestations of tardive
dyskinesia?
, a. shuffling gait
b. constant tapping of the feet when sitting
c. sudden onset of high fever
d. twisting tongue movements
twisting tongue movements
15. A nurse is teaching a group of clients about tick borne illnesses. Which of the following information should
the nurse include in the teaching regarding tick removal from the skin?
a. Grab the tick as close to the skin as possible
b. use a twisting motion when removing the tick
c. apply a pediculicide lotion to the area surrounding the tick
d. use a hot ember from the tip of the match to remove the stick
Grab the tick as close to the skin as possible
16. The nurse is assisting in planning care for a client who is diagnosed with immune deficiency and should
incorporate which action as a priority in the plan?
a. Identify factors that decrease the immune function
b. Provide emotional support to decrease fear
c. protecting the client from infection
d. Encourage decisions about life changes
protecting the client from infection
17. A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements
should the nurse include in the teaching?
a. Decrease your fluid intake to one liter per day
b. notify your provider if you experience vomiting or diarrhea
c. you might produce extra saliva while taking this medication
d. Take this medication on an empty stomach
Decrease your fluid intake to one liter per day
18. A nurse is teaching a group of clients about first aid care for beta sing which of the following information
should the nurse include in the teaching?
a. Remove this Stinger by scraping it off with a knife blade
b. apply a tourniquet
c. apply a warm pack
d. suck the wound
Remove this Stinger by scraping it off with a knife blade
19. The nurse is preparing a group of cub scouts for an overnight camping trip and instruct scouts about the
methods to prevent Lyme disease. Which statement by one of the scouts indicates a need for further
instructions?
a. I need to bring a hat to wear during the trip
b. I should wear long sleeve tops and long pants
c. I should not use insect repellent because they attract ticks
d. I need to wear clothes shoes and socks that will pull over my pants
I should not use insect repellent because they attract ticks
20. A nurse is reviewing medication for a newly admitted client who has bipolar disorder and expect the
experiencing mania which of the following client prescriptions should the nurse realize is expected to
reduce the clients mania?
a. Fluvastatin
b. carbamazepine
c. Lorazepam
d. Propranolol
carbamazepine
1. A nurse is caring for a client who asked about the functions of the thymus, spleen, and lymph nodes which
of the following respondes should the nurse make?
a. These organs support immunity
b. these organs are used in digestion
c. These organs regulate electronic balance
d. these organs assist vitamin absorbption
These organs support immunity
2. The nurse asked the client who is about to have a cardiac catheterization about any allergies. The client
states I always get a rash when I eat shellfish which of the following is the priority nursing action?
a. Notify the provider of the clients allergy
b. attach a wristband indicating the clients allergy
c. ask the client if any other foods cause such a reaction
d. Notify the dietary Department of the client allergy
Notify the provider of the clients allergy
3. A nurse is caring for a client who has had an anaphylactic reaction after a blood transfusion. The nurse
reviews the literature to further understand antibody mediated immunity. Which of the following should
the nurse confirm about AMI?
a. AMI is mediated by antibodies produced by the plasma cell
b. humoral immune response is mediated by the T lymphocytes
c. AMI involved phagocyte natural kill sellers
d. AMI defense only against viral infections
AMI is mediated by antibodies produced by the plasma cell
4. A nurse is assessing a client who has a history of HIV with phagocyte dysfunction. The nurse should
monitor this client for which of the following conditions?
a. Dehydration
b. Fungal infection
c. Compartment syndrome
d. pleural effusion
Fungal infection
5. A nurse is teaching a client who has a depressive disorder about fluoxetine name. Which of the following
information should the nurse include in the teaching?
a. You may experience a decrease sex drive while taking this medication
b. You may notice an improvement in your depression or symptoms in two to three days
c. you may notice that you have less appetite while taking this medication
d. You may experience drooling while taking this medication
You may experience a decrease sex drive while taking this medication
6. A charge nurse is planning to admit several clients to the medical unit. Which of the following clients
should the nurse assigned to a private room?
a. A client who has a fever of unknown origin
b. A client who has a total hip arthroplasty
c. a client who is HIV positive
d. a client who is neutropenic
client who is neutropenic
7. A nurse is providing teaching to the parents of an adolescent who has a depressive disorder and a new
prescription for Trazodone. Which will go following information should the nurse include in the teaching?
a. Trazodone can cause suicidal thoughts in adolescence
b. expect your child to lose weight while taking Trazodone
, c. Trazodone should be taken in the morning to prevent insomnia
d. your child symptoms of depression should improve within one week
Trazodone can cause suicidal thoughts in adolescence
8. A nurse is caring for a client who is taking am amitriptyline. The nurse should monitor for which of the
following adverse affects?
a. Orthostatic hypertension
b. Drooling
c. diarrhea
d. metabolic taste in mouth
Orthostatic hypertension
9. During the past six months, a client diagnosed with acquired immunodeficiency syndrome has a chronic
diarrhea an unwanted weight loss of 18 pounds. Additional assessment findings include nausea, vomiting ,
tinted skin turgor, dry mucous membrane, and listlessness. Which nursing diagnose focus attention on the
client’s immediate problem?
a. Deficient fluid volume related to abnormal fluid loss in stool and emesis
b. in balanced nutrition: Less than body requirements related to nausea and vomiting
c. disturbed thought process related to central nervous system effects of disease process
d. diarrhea related to disease process in acute infection
Deficient fluid volume related to abnormal fluid loss in stool and emesis
10. A patient is brought to the emergency Department by a friend. The patient is unresponsive, and
respirations are low and shallow. Which of the following is their priority intervention?
a. Check the patient's blood glucose level
b. Ask a friend about illicit drug use
c. administer naloxone in per protocol
d. administer 100% oxygen per nasal cannula
administer 100% oxygen per nasal cannula
11. A nurse is preparing a client who is to receive chemotherapy by treatment of ovarian cancer. Which of the
following action should the nurse plan to take?
a. Tell the client to expect dark stools following chemotherapy
b. have the client floss four times daily
c. have the client swish with commercial mouthwash before therapy
d. administer antiemetic prior to procedure
administer antiemetic prior to procedure
12. A patient that was stung by a bee is exhibiting redness an enema in the hand and forearm. The nurses
actions would it be based on which scientific rationale?
a. Baking soda is the best treatment for edema from a bee sting
b. Hypersensitivity is possible. This patient may need an anti-sting kit
c. the client should not worry because people cannot develop severe allergies to bee venom
d. the client needs regular checkups to obtain Immunotherapy
Hypersensitivity is possible. This patient may need an anti-sting kit
13. A nurse is caring for a client who has a depressive disorder. The client states I just can't feel my any
happiness or joy in my life. Which of the following terms should the nurse use in documenting this finding?
a. Anhedonia
b. Anergia
c. Anosognosia
Anhedonia
14. A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several
years period which of the following findings is should the nurse document as manifestations of tardive
dyskinesia?
, a. shuffling gait
b. constant tapping of the feet when sitting
c. sudden onset of high fever
d. twisting tongue movements
twisting tongue movements
15. A nurse is teaching a group of clients about tick borne illnesses. Which of the following information should
the nurse include in the teaching regarding tick removal from the skin?
a. Grab the tick as close to the skin as possible
b. use a twisting motion when removing the tick
c. apply a pediculicide lotion to the area surrounding the tick
d. use a hot ember from the tip of the match to remove the stick
Grab the tick as close to the skin as possible
16. The nurse is assisting in planning care for a client who is diagnosed with immune deficiency and should
incorporate which action as a priority in the plan?
a. Identify factors that decrease the immune function
b. Provide emotional support to decrease fear
c. protecting the client from infection
d. Encourage decisions about life changes
protecting the client from infection
17. A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements
should the nurse include in the teaching?
a. Decrease your fluid intake to one liter per day
b. notify your provider if you experience vomiting or diarrhea
c. you might produce extra saliva while taking this medication
d. Take this medication on an empty stomach
Decrease your fluid intake to one liter per day
18. A nurse is teaching a group of clients about first aid care for beta sing which of the following information
should the nurse include in the teaching?
a. Remove this Stinger by scraping it off with a knife blade
b. apply a tourniquet
c. apply a warm pack
d. suck the wound
Remove this Stinger by scraping it off with a knife blade
19. The nurse is preparing a group of cub scouts for an overnight camping trip and instruct scouts about the
methods to prevent Lyme disease. Which statement by one of the scouts indicates a need for further
instructions?
a. I need to bring a hat to wear during the trip
b. I should wear long sleeve tops and long pants
c. I should not use insect repellent because they attract ticks
d. I need to wear clothes shoes and socks that will pull over my pants
I should not use insect repellent because they attract ticks
20. A nurse is reviewing medication for a newly admitted client who has bipolar disorder and expect the
experiencing mania which of the following client prescriptions should the nurse realize is expected to
reduce the clients mania?
a. Fluvastatin
b. carbamazepine
c. Lorazepam
d. Propranolol
carbamazepine
