Targeted Med-Surg: Immune Flashcards Preview

Nursing II > Targeted Med-Surg: Immune > Flashcards

Flashcards in Targeted Med-Surg: Immune Deck (30):
1

When should a male examine their testicles?

Examine testicles immediately after showing because it’s easier to palpate

2

A pt with viral pneumonia and a hx of COPD. What should the nurse report?
- Consolidation in lower lobes
- Left shift in WBC differential
- Oxygen sat 90%
- Orthostatic hypotension

Left shift in WBC differential b/c it indicates that the pneumonia is of bacterial origin, rather than viral

3

A pt with systemic lupus erthematosus (SLE). Which statement indicates an understanding of the teaching?
- I should use a sunscreen with an SPF of at least 20
- Long-term immunosuppressive therapy will cure the disease
- I should wear gloves in cold weather
- SLE will not affect my breathing or lungs

I should wear gloves in cold weather.
Raynaud’s Syndrome Commonly a companies SLE and can cause painful vasoconstriction in the fingers when they are exposed to cold temperatures.

4

What can place a pt at increased risk for contracting Hep B?
- Residing in institutional setting
- Engaging in unprotected sexual intercourse
- Working with hazardous chemical waste materials
- Traveling to a foreign country

Engaging in unprotected sexual intercourse because its transmitted by sexual contact

5

What should the nurse teach the pt about rheumatoid arthritis?
- Take cool bath in evening
- Exercise every other day
- Use pillow to support joints while in bed
- Ask family members to help with household chores

Ask family members to help with household chores b/c it gives the pt an opportunity to rest

6

Pt has Hodgkin’s lymphoma. Which finding should nurse expect?
- Overgrowth of B-lymphocyte plasma cells
- Reed-Sternberg cells
- Epstein-Barr virus
- Overproduction of blast phase cells

Reed-Sternberg cells are cancer cells specific to Hodgkin’s lymphoma and found in lymph nodes

7

Amoxicillin teaching is correct:
- Birth control less effective
- Take med on empty stomach
- Expect constipation
- Keep taking medication until I feel better

Birth control is less effective while on this med

8

Non-Hodgkin’s lymphoma priority assessment finding?
- Loos of body hair
- Report anorexia
- Mucositis of oral cavity
- Erythema at IV insertion site

Erythema at IV insertion site has greatest risk in injury to tissue due to extravasation and infection

9

Correct instruction about pt with Hodgkin’s lymphoma and undergoing external radiation tx:
- Use antibacterial soap to cleanse skin
- Was ink marking off when showering
- Rub skin with towel when drying
- Avoid direct sun exposure to skin

Avoid direct sun exposure to skin b/c it can be damaging to skin being exposed to additional radiation

10

Pt reports skin change. Nurse should report what to provider?
- Asymmetrical papule that is pigmented
- Patch of silvery-white scales with red epidermal base
- Collection of irregular dry papules that are black
- Elevated red lesion that arises from a scar

Asymmetrical papule that is pigmented can indicate malignant melanoma

11

Teaching about Lyme disease:
- If bitten by tick, get tested immediately
- If tick embedded in skin, apply a lit match to remove it
- Wear dark-colored clothing to deter ticks from biting
- If pain and stiffness in joins, see your doctor

Pain and stiffness in joints- Stage 1: bull’s eye, rash, muscle and joint pain and stiffness

12

Discharge teaching for pt who is HIV-positive:
-Clean bathroom surfaces with full-strength bleach
- Discard beverages that’s been unrefrigerated for 1 hr.
- Wash laundry soiled with body fluid in warm water
- Work in garden for exercise

Discard beverages because they can support bacteria

13

Expected finding for acute leukemia:
- WBC 21,000/mm3
- Hgb 14 g/dL
- Hct 40%
- Platelets 170,000/mm3

WBC 21,000
Typically have elevated WBC

14

Diagnosis to confirm bacterial pharyngitis:
- Indirect laryngoscopy
- Chest x-ray
- Throat culture
- Monospot test

Throat culture

15

Risk factor for skin cancer:
- Light skin pigmentation
- Psoriasis
- Hx of frostbite
- Immunodeficiency disorder

Light skin pigmentation

16

Teaching for methotrexate:
- Avoid crowds
- Expect sx to subside in 1 - 2 weeks
- Increase intake of vit. D
- Anticipate constipation

Avoid crowds b/c it can decrease WBC and platelet levels, thus increasing risk for infection

17

Which finding should the nurse expect from a pt with systemic lupus erythematosus (SLE):
- Subcutaneous nodules
- Decreased urine output
- Renal calculi
- Butterfly rash
- Joint inflammation

Decreased urine output
Butterfly rash
Joint inflammation

18

What would cause the nurse to suspect that a pts HIV has progressed to AIDS?
-Small purple-colored skin lesions
- Fever and diarrhea lasting longer than 1 month
- Persistent, generalized lymphadenopathy
- CD4-T cells decreased to 750 cells/mm3

Small purple-colored skin lesions means acquired kaposi’s sarcoma, which is an AIDS-defining illness.

18

Guidelines for the human papilloma virus (HPV) vaccine:
- One dose given at birth and another at 5 years
- Vaccine does not protect males
- Vaccine protects against chlamydia
- 3 doses should be given starting at age 11 or 12

3 doses should be given starting at age 11 or 12

19

Who is at greatest risk for pneumonia?
- School-aged child who has a history of allergies and asthma
- Young adult living in a college dorm room
- Middle age adult using an incentive spirometer following surgery
- Older adult transferred from a long-term care facility who has dysphasia

Older adult who has dysphagia

20

Instructions in the teaching for a patient with bone marrow suppression:
- Take aspirin for minor aches and pains
- Rinse the toothbrush with warm water after each use
- Avoid eating fresh fruits and vegetables
- wear clothing that will minimize sun exposure

Avoid eating fresh fruits and vegetables because they contain bacteria

21

What procedure will the client undergo if they have elevated prostate-specific antigen levels:
- Palpation of testes and lymph nodes
- Human chronic gonadotropin lvls
- Digital rectal examination
- Pelvic ultrasound

Digital rectal examination determines size and consistency of the prostate

22

Teaching for a client who has an allergy to peanuts:
- Inform other healthcare professionals of the allergy
- Where a medical identification tag
- Carry an emergency anaphylaxis kit
- Read food labels

Carry emergency anaphylaxis kit b/c greatest risk is injury from an anaphylactic reaction

23

What is the papanicolaou (pap) test testing for?
- Uterine cancer
- Cervical cancer
- Ovarian cyst
- Hemorrhoids

Cervical cancer

24

What finding should the nurse report to the provider after a breast examination:
- Asymmetrical breast size
- Breast tissue with an orange-peel appearance
- Presence of Montgomery’s tubercles on the areola
- Movable mass in the left-lower breast quadrant

Breast tissue with an orange-peel appearance d/t lymph channels indicates advanced breast cancer

25

Which lab finding indicated the medication therapy is working with a pt who has HIV?
- WBC 4,000/mm3
- Lymphocyte 2,000/mm3
- Decreased viral load
- Low CD4/CD8 ratio

Decreased viral load

26

Pt had kidney transplant: what information regarding hyperacute rejection should the nurse include in teaching?
- Can occur during 1st few weeks after transplant
- Kidney can become enlarged
- Organ will need to be removed
- Immunosuppressive therapy is giving to reverse hyperacute rejection

Organ will need to be removed if hyperacute rejection occurs

27

What should the nurse expect with the patient who has systemic lupus erythematosus (SLE)?
- Subcutaneous nodules
- Decreased urine output
- Renal calculi
- Butterfly rash
- Joint inflammation

- Decreased urine output
- Butterfly rash
- Joint inflammation

28

Pt who has leukemia and platelet count of 48,000/mm3. What action should nurse take?
- Provide a diet low in vit K
- Please client on contact precaution
- Administer subcutaneous epoetin alpha
- Test urine and stool for occult blood

Test urine and stool for occult blood. Thrombocytopenia is at risk for occult bleeding

29

What should the nurse monitor and report from the patient on clindamycin to treat acute pelvic inflammatory disease?
- Watery diarrhea
- Vaginitis
- Fever
- N/V

Watery diarrhea. Antibiotics can cause C.diff and the nurse should immediately discontinue the medication