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Immune System Review/Questions Term III Ana H. Corona, MSN, FNP-C Nursing Instructor November 2007 More presentations at www.nurseana.com Mayo Clinic, Leukemia Society of America, CDC, NIH, 2007; ExamCram HIV HIV belongs to a class of viruses called retroviruses. Retroviruses: viruses that carry their genetic material in the form of RNA (ribonucleic acid) and that have the enzyme reverse transcriptase Retroviruses in order to replicate (duplicate), they must make a DNA (deoxyribonucleic acid) copy of their RNA. It is the DNA genes that allow the virus to replicate. HIV HIV can replicate only inside cells, commanding the cell's machinery to reproduce. Only HIV and other retroviruses once inside a cell use an enzyme called reverse transciptase to convert their RNA into DNA, which can be incorporated into the host cell's genes. HIV HIV belongs to a subgroup of retroviruses known as lentiviruses "slow" viruses. The course of infection with these viruses is characterized by a long interval between initial infection and the onset of serious symptoms. AIDS Acquired Immunodeficiency Syndrome (AIDS) is the final stage of HIV infection. The CDC establish the definition of AIDS, which occurs in HIV-infected persons with fewer than 200 CD4+T cells and/or persons with HIV who develop certain opportunistic infections. In 1992, the CDC redefined AIDS to include 26 CDC-defined AIDS indicator illnesses and clinical conditions that affect persons with advanced HIV. CD4+T cells CD4+T cells are the immune system's key infection fighters and the entity that allows HIV to enter, attach and infect the body's immune system. The CD4+T cells (also called T4 cells) are disabled and destroyed by the virus, often with no symptoms, causing a significant decrease in the blood levels of T4 cells. In the advanced stages of HIV, the body may have fewer than 200 T4 cells, while a healthy adult's count is 1,000 or more. In this way, the body's immune system is continuously weakened from the moment of infection and the inability of the immune system to fight infection opens the door to opportunistic infections. AIDS AIDS is a disease developed by a person living with HIV. The term AIDS applies to the most advanced stages of HIV infection. Although an HIV-positive test result does not mean that a person has AIDS, most people will develop AIDS as a result of their HIV infection. HIV/AIDS There are four main stages in the progression of an HIV infected person developing AIDS. The period following the initial HIV infection is called the window period. It is called this because this period reflects the window of time between infection with the virus and when HIV antibodies develop in the bloodstream. An HIV test that looks for antibodies taken during this time can result in a false negative, though antibodies usually appear within six months of the initial infection. Seroconversion Refers to the period of time during which your body is busy producing HIV antibodies, trying to protect itself against the virus. This is the period after the initial infection when many people experience flu-like symptoms and swollen lymph nodes – this is a highly infectious stage. Seroconversion After most people seroconvert, they usually experience a symptom-free period or asymptomatic period. This stage can last anywhere from 6 months to over 10 years, varying from person to person. Although the person with HIV is experiencing no symptoms, the virus is still replicating inside the body and weakening the immune system. After this period, severe CD4+T cell loss leads to the symptomatic period, in which the body experiences the symptoms associated to HIV This is the final stage before developing AIDS. Opportunistic Infections According to the CDC, AIDS-defining opportunistic illnesses are the major cause of morbidity and mortality among HIV infected persons. Opportunistic infections are a result of the weakened immune system present in persons with HIV/AIDS. An infection takes the "opportunity" provided by the weakened immune system to cause an illness that is usually controlled by a healthy immune system. Opportunistic Infections These infections are sometimes lifethreatening and require medical intervention to prevent or treat serious illnesses. Persons living with advanced HIV infection suffer opportunistic infections of the lungs, brain, eyes and other organs. HIV symptoms It is common during the first two to four weeks of infection that people experience flu-like symptoms and enlarged lymph nodes. This is because the virus migrates to various organs in the body, particularly the lymphoid organs. During this stage people are highly infectious and HIV is present in large quantities in genital secretions. According to the Centers for Disease Control and Prevention, the following are symptoms that may be warning signs of HIV infections: Rapid weight loss Dry cough Recurring fever or profuse night sweats Profound and unexplained fatigue Swollen lymph glands in the armpits, groin or neck Diarrhea that lasts for more than a week White spots on the tongue, mouth or in the throat Pneumonia Red, brown, pink or purplish blotches on or under the skin or inside the mouth, nose or eyelids Memory loss, depression and other neurological disorders Transmission of HIV HIV infection most commonly occurs through sexual contact. However, the virus can also be spread through blood-to-blood contact -- such as sharing needles or blood transfusions involving unscreened blood. HIV is not transmitted through casual contact such as touching or sharing towels, bedding, utensils, telephones, swimming pools, or toilet seats. No evidence of transmission through kissing, sweat, tears, urine or feces. Sex does not transmit HIV, but certain bodily fluids: blood, semen (including "pre-cum"), vaginal secretions and breast milk. Transmission High-risk behaviors that can result in HIV transmission are sharing needles for drugs, tattoos, body piercing, vitamins or steroids with an HIV-infected person and/or engaging in unprotected anal, vaginal or oral sex with a person who is HIV infected. The virus also can be transmitted from an HIVinfected mother to her child through pregnancy, birth or breastfeeding. Mucous membranes are porous and viruses and other pathogens are able to pass through. When a person already has a sexually transmitted disease, sex organs may be flooded with CD4+T cells, making it much easier for HIV to infect. Transmission Mucous membranes are porous and viruses and other pathogens are able to pass through. When a person already has a sexually transmitted disease, sex organs may be flooded with CD4+T cells, making it much easier for HIV to infect. HIV Medications Twenty-nine medications have been approved by the U.S. government to fight HIV. View HIV medications by brand name at the following website: http://www.thebody.com/content/art40488.html Hodgkin's Lymphoma Is a cancer of the lymphatic system, which is part of your immune system. Cells in the lymphatic system grow abnormally and may spread beyond the lymphatic system. As Hodgkin's disease progresses, it compromises the body's ability to fight infection. Is one of two common types of cancers of the lymphatic system. Non-Hodgkin's lymphoma, the other type, is far more common. Advances in diagnosis, staging and treatment of Hodgkin's disease have helped to make this once uniformly fatal disease highly treatable with the potential for full recovery. Hodgkin's Lymphoma Signs & Symptoms Flu like symptoms Painless swelling of lymph nodes on the neck, armpits or groin Persistent fatigue Fever and chills Night sweats Unexplained weight loss as much as 10 percent or more of body weight Loss of appetite Itching Hodgkin's lymphoma etiology The exact cause is unknown. There are five types of Hodgkin's disease all among a group of cancers called lymphomas — cancers of the lymphatic system. Hodgkin's disease commonly begins in lymph nodes located in the upper part of your body. Some lymph nodes are in areas more readily noticed, such as in the neck, above the collarbone, under the arms or in the groin area. Enlarged lymph nodes in the chest cavity also are common. Eventually, Hodgkin's disease may spread outside your lymph nodes to virtually any part of your body. Risk Factors Age. Ages between 15 and 40, and those older than 55, are most at risk of Hodgkin's disease. Family history. Having a brother or a sister with the disease (may be due to environmental exposures rather than genetic factors). Sex. Males more likely to develop Hodgkin's. Past Epstein-Barr infection. People who have had illnesses caused by the Epstein-Barr virus, such as infectious mononucleosis, are more likely to develop Hodgkin's disease than people who haven't had a past Epstein-Barr infection. Compromised immune system. Having a compromised immune system, such as from HIV/AIDS or from having an organ transplant requiring medications to suppress immune response. Screenings Many people with Hodgkin's disease experience no classic symptoms. Sometimes, an abnormality found on a chest Xray done for nonspecific symptoms leads to an eventual diagnosis of Hodgkin's disease. Because the symptoms of Hodgkin's are similar to those of other disorders, such as influenza, the disease can be difficult to diagnose. Some distinctive characteristics help diagnose Hodgkin's disease, and these include: Orderly spread. The pattern of spread is orderly, progressing from one group of lymph nodes to the next. Diagnostic Pathology: presence of Reed-Sternberg cells. The affected lymph nodes may contain only a few of these malignant cells. X-ray CT scan Magnetic resonance imaging (MRI) Gallium scan, Positron emission tomography (PET) scan Bone marrow biopsy Blood tests If the disease is predominantly in the abdomen, you may need exploratory surgery to help define the extent of the disease. Staging Hodgkin's disease Staging likely affect treatment options. Stage I. The cancer is limited to one lymph node region or a single organ. Stage II. The cancer is in two different lymph nodes, but is limited to a section of the body either above or below the diaphragm. Stage III. When the cancer moves to lymph nodes both above and below the diaphragm, but hasn't spread from the lymph nodes to other organs. Stage IV. This is the most advanced stage of Hodgkin's disease. Stage IV Hodgkin's disease affects not only the lymph nodes but also other parts of your body, such as the bone marrow or your liver. Treatment Radiation Chemotherapy Chemotherapy drugs ABVD, which consists of doxorubicin (Adriamycin), bleomycin, vinblastine and dacarbazine (new regimen with less side effects and currently preferred treatment). BEACOPP, consists of bleomycin, etoposide, Adriamycin, cyclophosphamide, vincristine (Oncovin), procarbazine and prednisone COPP/ABVD, consists of cyclophosphamide, Oncovin, procarbazine, prednisone, Adriamycin, bleomycin, vinblastine and dacarbazine Stanford V, which consists of Adriamycin, vinblastine, mechlorethamine, etoposide, vincristine, bleomycin and prednisone MOPP, which consists of mechlorethamine, Oncovin, procarbazine and prednisone (had been the basic regimen, but it's very toxic). Bone Marrow Transplant If the disease recurs after an initial chemotherapy-induced remission, high-dose chemotherapy and transplantation of your own (autologous) bone marrow or peripheral stem cells may lead to prolonged remission. Peripheral stem cells are bone marrow cells mobilized from the bone marrow into the bloodstream. Because high doses of chemotherapy destroy bone marrow, the marrow or peripheral blood stem cells are collected before treatment and frozen. Following chemotherapy, the cells, which have been protected from the effects of the treatment, are injected back into the body. Leukemia Leukemia is the general term used to describe four different disease-types called: Acute Myelogenous Leukemia (AML) Acute Lymphocytic Leukemia (ALL) Chronic Myelogenous Leukemia (CML) Chronic Lymphocytic Leukemia (CLL) Terms The terms lymphocytic or lymphoblastic indicate that the cancerous change takes place in a type of marrow cell that forms lymphocytes. The terms myelogenous or myeloid indicate that the cell change takes place in a type of marrow cell that normally goes on to form red cells, some types of white cells, and platelets. Acute/Chronic Leukemias Acute lymphocytic leukemia and acute myelogenous leukemia are each composed of blast cells, known as lymphoblasts or myeloblasts. Acute leukemias progress rapidly without treatment. Chronic leukemias have few or no blast cells. Chronic lymphocytic leukemia and chronic myelogenous leukemia usually progress slowly compared to acute leukemias. Etiology The four types of leukemia each begin in a cell in the bone marrow. The cell undergoes a leukemic change and it multiplies into many cells. The leukemia cells grow and survive better than normal cells, over time, they crowd out normal cells. Normal stem cells in the marrow form three main cell-types: Red cells, platelets and white cells. There are two major types of white cells: germingesting cells (neutrophils and monocytes) and lymphocytes, which are part of the body's immune system and help to fight to infection. The rate at which leukemia progresses and how the cells replace the normal blood and marrow cells are different with each type of leukemia. Acute Leukemia In acute myelogenous leukemia (AML) and acute lymphocytic leukemia (ALL), the original acute leukemia cell goes on to form about a trillion more leukemia cells. These cells are described as "nonfunctional" because they do not work like normal cells. They also crowd out the normal cells in the marrow; in turn, this causes a decrease in the number of new normal cells made in the marrow. This further results in low red cell counts (anemia). Chronic Leukemia In chronic myelogenous leukemia (CML), the leukemia cell that starts the disease makes red cells, white cells and platelets that function almost like normal cells. The number of red cells is usually less than normal, resulting in anemia. Many WBCs and many platelets are still made. WBCs are nearly normal their counts are high and continue to rise. This can cause serious problems if the patient does not get treatment. If untreated, the WBC count can rise so high that blood flow slows down and anemia becomes severe Chronic Lymphocytic Leukemia The leukemia cell that starts the disease makes too many lymphocytes that do not function. These cells replace normal cells in the marrow and lymph nodes. They interfere with the work of normal lymphocytes, which weakens the patient's immune response. The high # of leukemia cells in the marrow may crowd out normal blood-forming cells and lead to anemia A very high # of leukemia cells building up in the marrow also can lead to low neutrophil and platelet counts. Patients with CLL may have disease that does not progress for a long time. Patient may remain in good health and do not need treatment for long periods of time. Most patients require treatment at the time of diagnosis or soon after. Etiology People can get leukemia at any age. It is most common in people over age 60. The most common types in adults are AML and CLL. ALL is the most common form of leukemia in children. Some risk factors for AML are: Certain chemotherapies used for lymphoma or other types of cancer Down syndrome and some other genetic diseases Chronic exposure to benzene (such as in the workplace) that exceeds federally approved safety limits Radiation therapy used to treat other types of cancer Tobacco smoke. Exposure to high doses of radiation therapy is also a risk factor for ALL and CML. Other possible risk factors for the four types of leukemia are continually under study. Symptoms for Acute Leukemia Tiredness or no energy Shortness of breath during physical activity Pale skin Mild fever or night sweats Slow healing of cuts and excess bleeding Black-and-blue marks (bruises) for no clear reason Pinhead-size red spots under the skin Aches in bones or joints (for example, knees, hips or shoulders) Low white cell counts, especially monocytes or neutrophils. CLL or CML May not have any symptoms. CLL may notice enlarged lymph nodes in the neck, armpit or groin. Tired or short of breath or have frequent infections, If CLL is more severe, a blood test may show an increase in the lymphocyte count. CML signs and symptoms tend to develop slowly. People with CML may feel tired and short of breath while doing everyday activities; they may also have an enlarged spleen "dragging" feeling on the upper left side of the belly, night sweats and weight loss. Diagnosis A CBC is used to diagnose leukemia. This blood test may show high or low levels of white cells and show leukemic cells in the blood. Sometimes, platelet counts and red cell counts are low. Bone marrow tests are often done to confirm the diagnosis and to look for chromosome abnormalities. These tests identify the leukemia cell-type. A complete blood exam and a number of other tests are used to diagnose the type of leukemia. These tests can be repeated after treatment begins to measure how well the treatment is working. Treatment Patients with an acute leukemia begin induction therapy with chemotherapy in the hospital. Consolidation therapy or post induction therapy. This part of treatment may include chemotherapy with or without allogeneic stem cell transplantation (bone marrow transplantation). Patients with CML need to begin treatment once they are diagnosed. They usually begin treatment with imatinib mesylate (Gleevec®). This drug is taken by mouth. Gleevec® does not cure CML. But it keeps CML under control for many patients for as long as they take it. Other drugs, such as dasatinib (Sprycel®), are used for certain patients instead of Gleevec®. Treatments Allogeneic stem cell transplantation is the only treatment that can cure CML at this time. This treatment is most successful in younger patients. But patients up to 60 years of age who have a matched donor may be considered for this treatment. Allogeneic transplantation can be a high-risk procedure. Studies are under way to see whether CML patients have better long term outcomes with drug therapy or with transplantation. Some CLL patients do not need treatment for long periods of time after diagnosis. 1 A 43-YEAR-OLD AFRICAN AMERICAN MALE IS ADMITTED WITH SICKLE CELL ANEMIA. THE NURSE PLANS TO ASSESS CIRCULATION IN THE LOWER EXTREMITIES EVERY 2 HOURS. WHICH OF THE FOLLOWING OUTCOME CRITERIA WOULD THE NURSE USE? A. BODY TEMPERATURE OF 99°F OR LESS B. TOES MOVED IN ACTIVE RANGE OF MOTION C. SENSATION REPORTED WHEN SOLES OF FEET ARE TOUCHED D. CAPILLARY REFILL OF < 3 SECONDS 1 Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect. 2 A 30-YEAR-OLD MALE FROM HAITI IS BROUGHT TO THE EMERGENCY DEPARTMENT IN SICKLE CELL CRISIS. WHAT IS THE BEST POSITION FOR THIS CLIENT? A. SIDE-LYING WITH KNEES FLEXED B. KNEE-CHEST C. HIGH FOWLER'S WITH KNEES FLEXED D. SEMI-FOWLER'S WITH LEGS EXTENDED ON THE BED 2 Answer D is correct. Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the kneechest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect. 3 A 25-YEAR-OLD MALE IS ADMITTED IN SICKLE CELL CRISIS. WHICH OF THE FOLLOWING INTERVENTIONS WOULD BE OF HIGHEST PRIORITY FOR THIS CLIENT? A. TAKING HOURLY BLOOD PRESSURES WITH MECHANICAL CUFF B. ENCOURAGING FLUID INTAKE OF AT LEAST 200ML PER HOUR C. POSITION IN HIGH FOWLER'S WITH KNEE GATCH RAISED D. ADMINISTERING TYLENOL AS ORDERED 3 Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis. 4 Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? A. PEACHES B. COTTAGE CHEESE C. POPSICLE D. LIMA BEANS 4 Answer C is correct. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect. 5 A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention. A. ADJUST THE ROOM TEMPERATURE B. GIVE A BOLUS OF IV FLUIDS C. START O2 D. ADMINISTER MEPERIDINE (DEMEROL) 75MG IV PUSH 5 Answer C is correct. The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling. 6 THE NURSE IS INSTRUCTING A CLIENT WITH IRON-DEFICIENCY ANEMIA. WHICH OF THE FOLLOWING MEAL PLANS WOULD THE NURSE EXPECT THE CLIENT TO SELECT? A. ROAST BEEF, GELATIN SALAD, GREEN BEANS, AND PEACH PIE B. CHICKEN SALAD SANDWICH, COLESLAW, FRENCH FRIES, ICE CREAM C. EGG SALAD ON WHEAT BREAD, CARROT STICKS, LETTUCE SALAD, RAISIN PIE D. PORK CHOP, CREAMED POTATOES, CORN, AND COCONUT CAKE 6 Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect. 7 CLIENTS WITH SICKLE CELL ANEMIA ARE TAUGHT TO AVOID ACTIVITIES THAT CAUSE HYPOXIA AND HYPOXEMIA. WHICH OF THE FOLLOWING ACTIVITIES WOULD THE NURSE RECOMMEND? A. A FAMILY VACATION IN THE ROCKY MOUNTAINS B. CHAPERONING THE LOCAL BOYS CLUB ON A SNOW-SKIING TRIP C. TRAVELING BY AIRPLANE FOR BUSINESS TRIPS D. A BUS TRIP TO THE MUSEUM OF NATURAL HISTORY 7 Answer D is correct. Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect. 8 THE NURSE IS CONDUCTING AN ADMISSION ASSESSMENT OF A CLIENT WITH VITAMIN B12 DEFICIENCY. WHICH OF THE FOLLOWING WOULD THE NURSE INCLUDE IN THE PHYSICAL ASSESSMENT? A. PALPATE THE SPLEEN B. TAKE THE BLOOD PRESSURE C. EXAMINE THE FEET FOR PETECHIAE D. EXAMINE THE TONGUE 8 Answer D is correct. The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur, making answers A, B, and C incorrect. 9 AN AFRICAN AMERICAN FEMALE COMES TO THE OUTPATIENT CLINIC. THE PHYSICIAN SUSPECTS VITAMIN B12 DEFICIENCY ANEMIA. BECAUSE JAUNDICE IS OFTEN A CLINICAL MANIFESTATION OF THIS TYPE OF ANEMIA, WHAT BODY PART WOULD BE THE BEST INDICATOR? A. CONJUNCTIVA OF THE EYE B. SOLES OF THE FEET C. ROOF OF THE MOUTH D. SHINS 9 Answer C is correct. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect. 10 THE NURSE IS CONDUCTING A PHYSICAL ASSESSMENT ON A CLIENT WITH ANEMIA. WHICH OF THE FOLLOWING CLINICAL MANIFESTATIONS WOULD BE MOST INDICATIVE OF THE ANEMIA? A. BP 146/88 B. RESPIRATIONS 28 SHALLOW C. WEIGHT GAIN OF 10 POUNDS IN 6 MONTHS D. PINK COMPLEXION 10 Answer B is correct. When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect. 11 THE NURSE IS TEACHING THE CLIENT WITH POLYCYTHEMIA VERA ABOUT PREVENTION OF COMPLICATIONS OF THE DISEASE. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES A NEED FOR FURTHER TEACHING? A. "I WILL DRINK 500ML OF FLUID OR LESS EACH DAY." B. "I WILL WEAR SUPPORT HOSE WHEN I AM UP." C. "I WILL USE AN ELECTRIC RAZOR FOR SHAVING." D. "I WILL EAT FOODS LOW IN IRON." 11 Answer A is correct. The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation. 12 A 33-YEAR-OLD MALE IS BEING EVALUATED FOR POSSIBLE ACUTE LEUKEMIA. WHICH OF THE FOLLOWING WOULD THE NURSE INQUIRE ABOUT AS A PART OF THE ASSESSMENT? A. THE CLIENT COLLECTS STAMPS AS A HOBBY. B. THE CLIENT RECENTLY LOST HIS JOB AS A POSTAL WORKER. C. THE CLIENT HAD RADIATION FOR TREATMENT OF HODGKIN'S DISEASE AS A TEENAGER. D. THE CLIENT'S BROTHER HAD LEUKEMIA AS A CHILD. 12 Answer C is correct. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings. 13 AN AFRICAN AMERICAN CLIENT IS ADMITTED WITH ACUTE LEUKEMIA. THE NURSE IS ASSESSING FOR SIGNS AND SYMPTOMS OF BLEEDING. WHERE IS THE BEST SITE FOR EXAMINING FOR THE PRESENCE OF PETECHIAE? A. THE ABDOMEN B. THE THORAX C. THE EARLOBES D. THE SOLES OF THE FEET 13 Answer D is correct. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin might be too dark to make an assessment. 14 A CLIENT WITH ACUTE LEUKEMIA IS ADMITTED TO THE ONCOLOGY UNIT. WHICH OF THE FOLLOWING WOULD BE MOST IMPORTANT FOR THE NURSE TO INQUIRE? A. "HAVE YOU NOTICED A CHANGE IN SLEEPING HABITS RECENTLY?" B. "HAVE YOU HAD A RESPIRATORY INFECTION IN THE LAST 6 MONTHS?" C. "HAVE YOU LOST WEIGHT RECENTLY?" D. "HAVE YOU NOTICED CHANGES IN YOUR ALERTNESS?" 14 Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect. 15 WHICH OF THE FOLLOWING WOULD BE THE PRIORITY NURSING DIAGNOSIS FOR THE ADULT CLIENT WITH ACUTE LEUKEMIA? A. ORAL MUCOUS MEMBRANE, ALTERED RELATED TO CHEMOTHERAPY B. RISK FOR INJURY RELATED TO THROMBOCYTOPENIA C. FATIGUE RELATED TO THE DISEASE PROCESS D. INTERRUPTED FAMILY PROCESSES RELATED TO LIFE-THREATENING ILLNESS OF A FAMILY MEMBER 15 Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect. 16 A 21-YEAR-OLD MALE WITH HODGKIN'S LYMPHOMA IS A SENIOR AT THE LOCAL UNIVERSITY. HE IS ENGAGED TO BE MARRIED AND IS TO BEGIN A NEW JOB UPON GRADUATION. WHICH OF THE FOLLOWING DIAGNOSES WOULD BE A PRIORITY FOR THIS CLIENT? A. SEXUAL DYSFUNCTION RELATED TO RADIATION THERAPY B. ANTICIPATORY GRIEVING RELATED TO TERMINAL ILLNESS C. TISSUE INTEGRITY RELATED TO PROLONGED BED REST D. FATIGUE RELATED TO CHEMOTHERAPY 16 Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority. 17 A CLIENT HAS AUTOIMMUNE THROMBOCYTOPENIC PURPURA. TO DETERMINE THE CLIENT'S RESPONSE TO TREATMENT, THE NURSE WOULD MONITOR: A. PLATELET COUNT B. WHITE BLOOD CELL COUNT C. POTASSIUM LEVELS D. PARTIAL PROTHROMBIN TIME (PTT) 17 Answer A is correct. Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect. 18 THE HOME HEALTH NURSE IS VISITING A CLIENT WITH AUTOIMMUNE THROMBOCYTOPENIC PURPURA (ATP). THE CLIENT'S PLATELET COUNT CURRENTLY IS 80, IT WILL BE MOST IMPORTANT TO TEACH THE CLIENT AND FAMILY ABOUT: A. BLEEDING PRECAUTIONS B. PREVENTION OF FALLS C. OXYGEN THERAPY D. CONSERVATION OF ENERGY 18 Answer A is correct. The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance. 19 A CLIENT WITH HEMOPHILIA HAS A NOSEBLEED. WHICH NURSING ACTION IS MOST APPROPRIATE TO CONTROL THE BLEEDING? A. PLACE THE CLIENT IN A SITTING POSITION WITH THE HEAD HYPEREXTENDED B. PACK THE NARES TIGHTLY WITH GAUZE TO APPLY PRESSURE TO THE SOURCE OF BLEEDING C. PINCH THE SOFT LOWER PART OF THE NOSE FOR A MINIMUM OF 5 MINUTES D. APPLY ICE PACKS TO THE FOREHEAD AND BACK OF THE NECK 19 Answer C is correct. The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed. 20 A CLIENT WITH VAGINAL CANCER IS BEING TREATED WITH A RADIOACTIVE VAGINAL IMPLANT. THE CLIENT'S HUSBAND ASKS THE NURSE IF HE CAN SPEND THE NIGHT WITH HIS WIFE. THE NURSE SHOULD EXPLAIN THAT: A. OVERNIGHT STAYS BY FAMILY MEMBERS IS AGAINST HOSPITAL POLICY. B. THERE IS NO NEED FOR HIM TO STAY BECAUSE STAFFING IS ADEQUATE. C. HIS WIFE WILL REST MUCH BETTER KNOWING THAT HE IS AT HOME. D. VISITATION IS LIMITED TO 30 MINUTES WHEN THE IMPLANT IS IN PLACE. 20 Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect. 21 A CLIENT WITH LEUKEMIA IS RECEIVING TRIMETREXATE. AFTER REVIEWING THE CLIENT'S CHART, THE PHYSICIAN ORDERS WELLCOVORIN (LEUCOVORIN CALCIUM). THE RATIONALE FOR ADMINISTERING LEUCOVORIN CALCIUM TO A CLIENT RECEIVING TRIMETREXATE IS TO: A. TREAT IRON-DEFICIENCY ANEMIA CAUSED BY CHEMOTHERAPEUTIC AGENTS B. CREATE A SYNERGISTIC EFFECT THAT SHORTENS TREATMENT TIME C. INCREASE THE NUMBER OF CIRCULATING NEUTROPHILS D. REVERSE DRUG TOXICITY AND PREVENT TISSUE DAMAGE 21 Answer D is correct. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect. 22 A client with a diagnosis of HPV is at risk for which of the following? A. HODGKIN'S LYMPHOMA B. CERVICAL CANCER C. MULTIPLE MYELOMA D. OVARIAN CANCER 22 Answer B is correct. The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect. 23 A CLIENT HAS CANCER OF THE PANCREAS. THE NURSE SHOULD BE MOST CONCERNED ABOUT WHICH NURSING DIAGNOSIS? A. ALTERATION IN NUTRITION B. ALTERATION IN BOWEL ELIMINATION C. ALTERATION IN SKIN INTEGRITY D. INEFFECTIVE INDIVIDUAL COPING 23 Answer A is correct. Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern; thus, answers B, C, and D are incorrect. 24 THE HOME HEALTH NURSE IS VISITING AN 18-YEAR-OLD WITH OSTEOGENESIS IMPERFECTA. WHICH INFORMATION OBTAINED ON THE VISIT WOULD CAUSE THE MOST CONCERN? THE CLIENT: A. LIKES TO PLAY FOOTBALL B. DRINKS SEVERAL CARBONATED DRINKS PER DAY C. HAS TWO SISTERS WITH SICKLE CELL TRACT D. IS TAKING ACETAMINOPHEN TO CONTROL PAIN 24 Answer A is correct. The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition. Answers B, C, and D are not factors for concern. 25 The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take? A. ALLOW THE CLIENT TO KEEP THE FRUIT B. PLACE THE FRUIT NEXT TO THE BED FOR EASY ACCESS BY THE CLIENT C. OFFER TO WASH THE FRUIT FOR THE CLIENT D. TELL THE FAMILY MEMBERS TO TAKE THE FRUIT HOME 25 Answer D is correct. The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible. Answers A, B, and C will not help prevent bacterial invasions. 26 A 6-YEAR-OLD CLIENT IS ADMITTED TO THE UNIT WITH A HEMOGLOBIN OF 6G/DL. THE PHYSICIAN HAS WRITTEN AN ORDER TO TRANSFUSE 2 UNITS OF WHOLE BLOOD. WHEN DISCUSSING THE TREATMENT, THE CHILD'S MOTHER TELLS THE NURSE THAT SHE DOES NOT BELIEVE IN HAVING BLOOD TRANSFUSIONS AND THAT SHE WILL NOT ALLOW HER CHILD TO HAVE THE TREATMENT. WHAT NURSING ACTION IS MOST APPROPRIATE? A. ASK THE MOTHER TO LEAVE WHILE THE BLOOD TRANSFUSION IS IN PROGRESS B. ENCOURAGE THE MOTHER TO RECONSIDER C. EXPLAIN THE CONSEQUENCES WITHOUT TREATMENT D. NOTIFY THE PHYSICIAN OF THE MOTHER'S REFUSAL 26 Answer D is correct. If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences, so answers B and C are incorrect. 27 THE NURSE IS CARING FOR THE CLIENT RECEIVING AMPHOTERICIN B. WHICH OF THE FOLLOWING INDICATES THAT THE CLIENT HAS EXPERIENCED TOXICITY TO THIS DRUG? A. CHANGES IN VISION B. NAUSEA C. URINARY FREQUENCY D. CHANGES IN SKIN COLOR 27 Answer D is correct. Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of liver toxicity and is not specific to the use of Amphotericin B. Changes in vision are not related, and nausea is a side effect, not a sign of toxicity; nor is urinary frequency. Thus, answers A, B, and C are incorrect. 28 A CLIENT WITH PNEUMACYSTIS CARINI PNEUMONIA IS RECEIVING TRIMETREXATE. THE RATIONALE FOR ADMINISTERING LEUCOVORIN CALCIUM TO A CLIENT RECEIVING METHOTREXATE IS TO: A. TREAT ANEMIA. B. CREATE A SYNERGISTIC EFFECT. C. INCREASE THE NUMBER OF WHITE BLOOD CELLS. D. REVERSE DRUG TOXICITY. 28 Answer D is correct. Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron-deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers A, B, and C are incorrect 29 A CLIENT WITH BLADDER CANCER IS BEING TREATED WITH IRIDIUM SEED IMPLANTS. THE NURSE'S DISCHARGE TEACHING SHOULD INCLUDE TELLING THE CLIENT TO: A. STRAIN HIS URINE B. INCREASE HIS FLUID INTAKE C. REPORT URINARY FREQUENCY D. AVOID PROLONGED SITTING 29 Answer A is correct. Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect. 30 A CLIENT HOSPITALIZED WITH MRSA (METHICILLIN-RESISTANT STAPH AUREUS) IS PLACED ON CONTACT PRECAUTIONS. WHICH STATEMENT IS TRUE REGARDING PRECAUTIONS FOR INFECTIONS SPREAD BY CONTACT? A. THE CLIENT SHOULD BE PLACED IN A ROOM WITH NEGATIVE PRESSURE. B. INFECTION REQUIRES CLOSE CONTACT; THEREFORE, THE DOOR MAY REMAIN OPEN. C. TRANSMISSION IS HIGHLY LIKELY, SO THE CLIENT SHOULD WEAR A MASK AT ALL TIMES. D. INFECTION REQUIRES SKIN-TO-SKIN CONTACT AND IS PREVENTED BY HAND WASHING, GLOVES, AND A GOWN. 30 Answer D is correct. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negativepressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask, so answer C is incorrect. 31 THE PHYSICIAN HAS ORDERED A MINIMAL-BACTERIA DIET FOR A CLIENT WITH NEUTROPENIA. THE CLIENT SHOULD BE TAUGHT TO AVOID EATING: A. FRUITS B. SALT C. PEPPER D. KETCHUP 31 Answer C is correct. Pepper is not processed and contains bacteria. Answers A, B, and D are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed 32 THE NURSE IS PROVIDING DISCHARGE TEACHING FOR THE CLIENT WITH LEUKEMIA. THE CLIENT SHOULD BE TOLD TO AVOID: A. USING OIL- OR CREAM-BASED SOAPS B. FLOSSING BETWEEN THE TEETH C. THE INTAKE OF SALT D. USING AN ELECTRIC RAZOR 32 Answer B is correct. The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor; therefore, answers A, C, and D are incorrect. 33 A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC’s last in my body? The correct response is. A: The life span of RBC is 45 days. B: The life span of RBC is 60 days. C: The life span of RBC is 90 days. D: The life span of RBC is 120 days. 33 (D) RBC’s last for 120 days in the body. 34 Which of the following conditions would a nurse not administer erythromycin? A: Campylobacterial infection B: Legionnaire’s disease C: Pneumonia D: Multiple Sclerosis 34 (D) Erythromycin is used to treat conditions A-C. 35 A patient’s chart indicates a history of meningitis. Which of the following would you not expect to see with this patient if this condition were acute? A: Increased appetite B: Vomiting C: Fever D: Poor tolerance of light 35 (A) Loss of appetite would be expected 36 A nurse if reviewing a patient’s chart and notices that the patient suffers from conjunctivitis. Which of the following microorganisms is related to this condition? A: Yersinia pestis B: Helicobacter pyroli C: Vibrio cholera D: Hemophilus aegyptius 36 (D) Choice A is linked to Plague, Choice B is linked to peptic ulcers, Choice C is linked to Cholera 37 A nurse if reviewing a patient’s chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition? A: Borrelia burgdorferi B: Streptococcus pyrogens C: Bacilus anthracis D: Enterococcus faecalis 37 A) Choice B is linked to Rheumatic fever, Choice C is linked to Anthrax, Choice D is linked to Endocarditis. 38 35. A 20 year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first? A: Blood sugar check B: CT scan C: Blood cultures D: Arterial blood gases 38 (C) Blood cultures would be performed to investigate the fever and rash symptoms. 39 What is the most common cancer among men? A: lung B: prostate C: brain D: pancreatic 39 A. Prostate cancer is also very common in males. 40 What is the most common transfusion reaction? A: coma B: nausea C: anxiety D: fever 40 D. The most common adverse reaction after a transfusion is fever 41 What is another name for the neoplastic disorder of the bone marrow in which there is an overproduction of white blood cells? A: bone density deficiency B: leukemia C: cystic fibrosis D: arthritis 41 B. Leukemia is a potentially fatal disease. 42 Which is the most common cancer among females? A: brain B: pancreatic C: lung D: breast 42 D.Breast cancer is by far the most common cancer among females. 43 Which of the following foods is NOT high in iron? A: meat B: black beans C: seafood D: green vegetables 43 B. It is important to get plenty of iron in the diet. 44 Which of the following are not treated with Methotrexate? A. Sarcomas B. Leukemias C. Ectopic pregnancy D. Rheumatic fever 44 The answer is D The right answer was Rheumatic fever. 45 Which of the following are not treated with Prednisone? A. Cushing’s disease B. Testicular cancer C. Lympthomas D. Chronic leukemias 45 The answer is B Testicular cancer 46 A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract? A. Thoroughly cooking all foods B. Offering yogurt and buttermilk between meals C. Forcing fluids D. Providing small, frequent meals 46 Answer D is correct. Providing small, frequent meals will improve the client’s appetite and help reduce nausea. Answer A is incorrect because it does not compensate for limited absorption. Foods and beverages containing live cultures are discouraged for the immune-compromised client; therefore, answer B is incorrect. Answer C is incorrect because forcing fluids will not compensate for limited absorption of the intestine. 47 The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetadine. The purpose of the cimetadine is to: Decrease the secretion of pancreatic enzymes Enhance the effectiveness of methotrexate Promote peristalsis Prevent a common side effect of prednisone 47 Answer D is correct. A common side effect of prednisone is gastric ulcers. Cimetadine is given to help prevent the development of ulcers. Answers A, B, and C do not relate to the use of cimetadine; therefore, they are incorrect. 48 Which diet is associated with an increased risk of colorectal cancer? A. Low protein, complex carbohydrates B. High protein, simple carbohydrates C. High fat, refined carbohydrates D. Low carbohydrates, complex proteins 48 Answer C is correct. A diet that is high in fat and refined carbohydrates increases the risk of colorectal cancer. High fat content results in an increase in fecal bile acids, which facilitate carcinogenic changes. Refined carbohydrates increase the transit time of food through the gastrointestinal tract and increase the exposure time of the intestinal mucosa to cancer-causing substances. Answers A, B, and D do not relate to the question; therefore, they are incorrect. 49 The nurse is providing dietary instructions for a client with irondeficiency anemia. Which food is a poor source of iron? A. Tomatoes B. Legumes C. Dried fruits D. Nuts 49 Answer A is correct. Tomatoes are a poor source of iron, although they are an excellent source of vitamin C, which increases iron absorption. Answers B, C, and D are good sources of iron; therefore, they are incorrect. 50 A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer? A. A family history of laryngeal cancer B. Chronic inhalation of noxious fumes C. Frequent straining of the vocal cords D. A history of alcohol and tobacco use 50 Answer D is correct. A history of frequent alcohol and tobacco use is the most significant factor in the development of cancer of the larynx. Answers A, B, and C are also factors in the development of laryngeal cancer, but they are not the most significant; therefore, they are incorrect. 51 The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia? A. Difficulty in breathing after exertion B. Numbness and tingling in the extremities C. A faster-than-usual heart rate D. Feelings of lightheadedness 51 Answer B is correct. Numbness and tingling in the extremities is common in the client with pernicious anemia, but not those with other types of anemia. Answers A, C, and D are incorrect because they are symptoms of all types of anemia. 52 A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should: A. Remove the unsightly markings with acetone or alcohol B. Cover the radiation site with loose gauze dressing C. Sprinkle baby powder over the radiated area D. Refrain from using soap or lotion on the marked area 52 Answer D is correct. The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Answer A is incorrect because it would remove the marking. Answers B and C are not necessary for the client receiving radiation; therefore, they are incorrect 53 A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid: A. Calcium-rich foods B. Canned or frozen vegetables C. Processed meat D. Raw fruits and vegetables 53 Answer D is correct. The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Answers A, B, and C are incorrect because they are permitted in the client’s diet. 54 A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for: A. Abdominal pain and anorexia B. Fatigue and bruising C. Bleeding and pallor D. Petechiae and mucosal ulcers 54 Answer C is correct. The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Answers A, B, and D, common in the child with leukemia, are not life-threatening. 55 The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in: A. The tail of the pancreas B. The head of the pancreas C. The body of the pancreas D. The entire pancreas 55 Answer B is correct. The Whipple procedure is performed for cancer located in the head of the pancreas. Answers A, C, and D are not correct because of the location of the cancer. 56 The primary cause of anemia in a client with chronic renal failure is: A. Poor iron absorption B. Destruction of red blood cells C. Lack of intrinsic factor D. Insufficient erythropoietin 56 Answer D is correct. Insufficient erythropoietin production is the primary cause of anemia in the client with chronic renal failure. Answers A, B, and C do not relate to the anemia seen in the client with chronic renal failure; therefore, they are incorrect. 57 While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should: A. Place the implant in a biohazard bag and return it to the lab B. Give the client a pair of gloves and ask her to reinsert the implant C. Use tongs to pick up the implant and return it to a lead-lined container D. Discard the implant in the commode and double-flush 57 Answer C is correct. The radioactive implant should be picked up with tongs and returned to the lead-lined container. Answer A is incorrect because radioactive materials are placed in lead-lined containers, not plastic ones, and are returned to the radiation department, not the lab. Answer B is incorrect because the client should not touch the implant or try to reinsert it. Answer D is incorrect because the implant should not be placed in the commode for disposal. 58 A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client: A. To drink additional fluids throughout the day B. To avoid contact sports for 1–2 months C. To have a snack twice a day to prevent hypoglycemia D. To continue antibiotic therapy for 6 months 58 Answer B is correct. The client recovering from mononucleosis should avoid contact sports and other activities that could result in injury or rupture of the spleen. Answer A is incorrect because the client does not need additional fluids. Hypoglycemia is not associated with mononucleosis; therefore, answer C is incorrect. Answer D is incorrect because antibiotics are not usually indicated in the treatment of mononucleosis. 59 A client with breast cancer is returned to the room following a right total mastectomy. The nurse should: A. Elevate the client's right arm on pillows B. Place the client's right arm in a dependent sling C. Keep the client's right arm on the bed beside her D. Place the client's right arm across her body 59 Answer A is correct. A total mastectomy involves removal of the entire breast and some or all of the axillary lymph nodes. Following surgery, the client’s right arm should be elevated on pillows, to facilitate lymph drainage. Answers B, C, and D are incorrect because they would not help facilitate lymph drainage and would create increased edema in the affected extremity 60 The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus. Which action by the nurse indicates an understanding regarding the care of clients with MRSA? A. The nurse leaves the stethoscope in the client's room for future use. B. The nurse cleans the stethoscope with alcohol and returns it to the exam room. C. The nurse uses the stethoscope to assess the blood pressure of other assigned clients. D. The nurse cleans the stethoscope with water, dries it, and returns it to the nurse's station. 60 Answer A is correct. The stethoscope should be left in the client’s room for future use. The stethoscope should not be returned to the exam room or the nurse’s station; therefore, answers B and D are incorrect. The stethoscope should not be used to assess other clients; therefore, answer C is incorrect 61 A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS? A. High calorie, high protein, high fat B. High calorie, high carbohydrate, low protein C. High calorie, low carbohydrate, high fat D. High calorie, high protein, low fat 61 Answer D is correct. The suggested diet for the client with AIDS is one that is high calorie, high protein, and low fat. Clients with AIDS have a reduced tolerance to fat because of the disease as well as side effects from some antiviral medications; therefore, answers A and C are incorrect. Answer B is incorrect because the client needs a high-protein diet.