1.

An older adult with no known cognitive impairment residing in a long-term care facility
suddenly becomes disoriented and confused. There are no signs of extremity weakness or other
neurological changes. Based on these observations, the nurse would focus the assessment in
which priority body systems?

a) pulmonary and renal systems

b) reproductive and endocrine system
c) integumentary and neurological systems
d) cardiovascular and gastrointestinal systems

2. A female client arrives at the health care clinic and tells the nurse that she was just bitten by a
tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the
tick and flushed it down the toilet. Which of the following nursing actions is most appropriate?

a) refer the client for blood test immediately

b) inform the client that there is no test available for Lyme disease
c) tell the client that testing is not necessary unless arthralgia develops
d) instruct the client to return in 4 to 6 weeks to be tested because testing before this time is not
reliable

3. Following diagnosis of stage I Lyme disease, the nurse would anticipate that which of the
following will be part of the treatment plan for the client?

a) no treatment unless symptoms develop

b) a 3-week course of oral antibiotic therapy
c) daily oatmeal baths for 2 weeks
d) treatment with intravenously administered antibiotics

4. A Cub Scout leader, who is a nurse preparing a group of Cub Scouts for an overnight camping
trip, instructs the scouts about the methods to prevent Lyme disease. Which statement by one of
the Cub Scouts indicates a need for further instructions?

a) I need to bring a hat to wear during the trip

b) I should wear long-sleeved tops and long pants
c) I should not use insect repellents because it will attract the ticks
d) I need to wear closed shoes and socks that can be pulled up over my pants

5. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's
sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of
the following?

a) swelling in the genital area

b) swelling in the lower extremities
c) punch biopsy of the cutaneous lesions
d) appearance of reddish-blue lesions noted on the skin
6. Which of the following individuals is least likely at risk for the development of Kaposis's
sarcoma?

a) A kidney transplant client

b) a male with a history of same-gender partners
c) a client receiving anti-neoplastic medications
d) an individual working in an environment in which he or she is exposed to asbestos

7. The nurse prepares to give a bath and change the bed linens on a client with cutaneous
Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid.
Which of the following would the nurse incorporate into the plan during the bathing of this
client?

a) wearing gloves
b) wearing a gown and gloves
c) wearing a gown, gloves, and a mask
d) wear a gown and gloves to change the bed linens and gloves only for the bath

8. A client is suspected of having systemic lupus erythematosus. The nurse monitors the client,
knowing that which of the following is one of the initial characteristic signs of systemic lupus
erythematosus?

a) weight gain
b) subnormal temperature
c) elevated red blood cell count
d) rash on the face across the bridge of the nose and on the cheeks

9. The nurse provides home care instructions to a client with systemic lupus erythematosus and
tells the client about methods to manage fatigue. Which statement by the client indicates a need
for further instructions?

a) I should take hot baths because they are relaxing

b) I should sit whenever possible to conserve my energy
c) I should avoid long periods of rest because it causes joint stiffness
d) I should do some exercises, such as walking, when I am not fatigued

10. The client with acquired immunodeficiency syndrome has raised, dark purplish-colored
lesions on the trunk of the body. The nurse anticipates that which of the following procedures
will be done to confirm whether these lesions are caused by Kaposi's sarcoma?

a) skin biopsy
b) lung biopsy
c) western blot
d) enzyme-linked immunosorbent assay

11. The client with acquired immunodeficiency syndrome has a respiratory infection from
Pneumocystis jiroveci and a nursing diagnosis of Impaired Gas Exchange written in the plan of
care. Which of the following indicates that the expected outcome of care has nor yet been
achieved?

a) client limits fluid intake

b) client has clear breath sounds
c) client expectorates secretions easily
d) client is free of complaints of shortness of breath

12. A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on
which of the following descriptions of this condition?

a) the presence of tiny red vesicles

b) an autoimmune disease that causes blistering in the epidermis
c) the presence of skin vesicles found along the nerve caused by a virus
d) the presence of red, raised papules and large plaques covered by silvery scales

13. The nurse is providing dietary instructions to the client with systemic lupus erythematosus.
Which of the following dietary items would the nurse instruct the client to avoid?

a) steak
b) turkey
c) broccoli
d) cantaloupe

14. A client calls the nurse in the emergency room and tells the nurse that he was just stung by a
bee while gardening. The client is afraid of a severe reaction because the client's neighbor
experienced such a reaction just 1 week ago. The appropriate nursing action is to:

a) advise the client to soak the site in hydrogen peroxide

b) ask the client if ever sustained a bee sting in the past
c) tell the client to call an ambulance for transport to the emergency room
d) tell the client no to worry about the sting unless difficulty with breathing occurs

15. The nurse is assisting in administering immunizations at a health care clinic. The nurse
understands that an immunization will provide:

a) protection from all disease

b) innate immunity from disease
c) natural immunity from disease
d) acquired immunity from disease

16. The nurse is assigned to care for a client with systemic lupus erythematosus. The nurse plans
care, knowing that this disorder is a(n):

a) local rash that occurs as a result of allergy

b) disease caused by overexposure to sunlight
c) inflammatory disease of collagen contained in connective tissue
d) disease caused by the continuous release of histamine in the body

17. The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic
lupus erythematosus. The nurse reviews the physician's orders, expecting to note that which type
of medication is prescribed?

a) antibiotic
b) antidiarrheal
c) corticosteroid
d) opioid analgesic

18. The community health nurse is conducting a research study and is identifying clients in the
community at risk for latex allergy. Which client population is at most risk for developing this
type of allergy?

a) hairdressers
b) the homeless
c) children in day care centers
d) individuals living in a group home

19. The home care nurse is performing an assessment on a client who has been diagnosed with
an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse
questions the client about an allergy to which food item?

a) eggs
b) milk
c) yogurt
d) bananas

20. The home care nurse is assigned to visit a client who has returned home from the emergency
room following treatment for a sprained ankle. The nurse notes that the client as sent home with
crutches that have rubber axillary pads and needs instructions regarding crutch walking. On
admission assessment, the nurse discovers that the client has an allergy to latex. Before providing
instructions regarding crutch walking, the nurse should:

a) contact the physician

b) cover the crutch pads with cloth
c) call the local medical supply store and ask for a cane to be delivered
d) tell the client that the crutches must be removed from the house immediately

21. The home care nurse is ordering dressing supplies for a client who has an allergy to latex.
The nurse asks the medical supply personnel to deliver which of the following?

a) elastic bandages
b) adhesive bandages
c) brown ace bandages
d) cotton pads and silk tape

22. The camp nurse prepares to instruct a group of children about Lyme disease. Which of the
following information would the nurse include in the instructions?

a) Lyme disease is caused by tick carried by deer

b) Lyme disease is caused by contamination from cat feces
c) Lyme disease can be contagious through skin contact with an infected individual
d) Lyme disease can be caused by the inhalation of spores from bird droppings

23. The client is diagnosed with stage I Lyme disease. The nurse assesses the client for which
characteristic of this stage?

a) arthralgias
b) flu-like symptoms
c) enlarged and inflamed joints
d) signs of neurological disorders

24. Select the interventions that would apply in the care of a client at high risk for an allergic
response to a latex allergy. Select all that apply

a) use non-latex gloves

b) use medications from glass ampules
c) place the client in a private room only
d) do not puncture rubber stoppers with needles
e) keep a latex-safe supply cart available in the client's area
f) use a blood pressure cuff from an electronic device only to measure the blood pressure

25. Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs
the client to contact the physician immediately if which of the following occurs?

a) nausea
b) lethargy
c) hearing loss
d) muscle aches

26. The client who is human immunodeficiency virus seropositive has been taking zalcitabine
(ddC, Hivid) as a component of treatment. The nurse plans to monitor which of the following
most closely while the client is taking this medication?

a) platelet count
b) glucose level
c) red blood cell count
d) liver function studies
27. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired
immunodeficiency syndrome who is receiving foscarnet (Foscavir), an antiviral. The nurse
checks the latest results of which of the following laboratory studies while the client is taking
this medication?

a) CD4 cell count

b) serum albumin level
c) serum creatinine level
d) lymphocyte count

28. The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection
has been receiving pentamidine (Pentam 300). The client develops a temperature of 101F. The
nurse does further monitoring of the client, knowing that his sign would most likely indicate that
the:

a) dose of the medication is too low

b) client is experiencing toxic effects of the medication
c) client has developed inadequacy of thermoregulation
d) result of another infection caused by leukopenic effects of the medication

29. Saquinavir (Invirase) is prescribed for the client who is seropositive for human
immunodeficiency virus. The nurse reinforces medication instructions and tells the client to:

a) avoid sun exposure

b) eat low-calorie foods
c) eat foods that are low in fat
d) take the medication on an empty stomach

30. The client who is human immunodeficiency virus seropositive has been taking Stavudine
(d4t, Zerit). The nurse monitors which of the following most closely while the client is taking
this medication?

a) gait
b) appetite
c) level of consciousness
d) gastrointestinal function

31. The client with acquired immunodeficiency syndrome has begun therapy with zidovudine
(Retrovir, azidothymidine, AZT, ZDV). The nurse carefully monitors which of the following
laboratory results during treatment with this medication?

a) blood culture
b) blood glucose level
c) blood urea nitrogen level
d) complete blood count
32. The nurse is reviewing the results of serum laboratory studies drawn on a client with
acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets
that he client may have the medication discontinued by the physician if which of the following
significantly elevated results is noted?

a) serum protein level

b) blood glucose level
c) serum amylase level
d) serum creatinine level

33. The nurse is caring for a post-renal transplantation client taking cyclosporin (Sandimmune,
Gengraf, Neoral). Th nurse notes an increase in one of he client's vital signs and the client is
complaining of a headache. What is the vital sign that is most likely increased?

a) pulse
b) respiration
c) blood pressure
d) pulse oximetry

34. Ketoconazole (Nizoral) is prescribed for a client with a diagnosis of candidiasis. Select the
interventions that the nurse includes when administering this medication. Select all that apply

a) restrict fluid intake

b) instruct the client to avoid alcohol
c) monitor liver function studies
d) administer the medication with a antacid
e) instruct the client to avoid exposure to the sun
f) administer the medication on an empty stomach

35. The nurse has an order to begin administering foscarnet (Foscavir) to the client with
cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS). The nurse assesses
the latest results of which laboratory study prior to administering the dose?

a) serum albumin level

b) serum creatinine level
c) CD4 count
d) lymphocyte count

ANSWERS AND RATIONALE

1) A
- Changes in mental status and confusion are commonly associated with infections in the older
adult. Assessments of the pulmonary and renal systems would be the priority. The older adult is
at risk for pneumonia. The lungs should be auscultated for decreased breath sounds and other
adventitious sounds. Urinary tract infections are also common in older adults, especially women.
Flank pain with frequency and urgency are symptoms. The urine should be monitored for
cloudiness, odor, and other changes indicating hematuria. Based on the data in the question, the
body systems identified in options B, C, and D are not the priority.

2) D
A blood test is available to detect Lyme disease; however, the test is not reliable if performed
before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following
manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8
weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after
infection and may remain elevated for years. Options A, B, and C are incorrect.

3) B
- Prevention, public education, and early diagnosis are vital to the control and treatment of Lyme
disease. A 3-week course of oral antibiotic therapy is recommended during stage I. Later stages
of Lyme disease may require therapy with intravenously administered antibiotics, such as
penicillin G. Options A and C are incorrect.

4) C
- In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent
on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and
long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or
areas with thick underbrush should be avoided. Socks can be pulled up and over the pant legs to
the prevent ticks from entering under clothing.

5) C
- Kaposi’s sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that
change into plaques. These large plaques ulcerate or open and drain. The lesions spread by
metastasis through the upper body and then to the face and oral mucosa. They can move to the
lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in
the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous
lesions and biopsy of pulmonary and gastrointestinal lesions

6) D
- Kaposi’s sarcoma is a vascular malignancy that presents as a skin disorder and is a common
acquired immunodeficiency syndrome indicator. Malignancy is seen most frequently in men with
a history of same-gender partners. Although the cause of Kaposi’s sarcoma is not known, it is
considered to be caused by an alteration or failure in the immune system. The renal
transplantation client and the client receiving antineoplastic medications are at risk for
immunosuppression. Exposure to asbestos is not related to the development of Kaposi’s sarcoma.

7) B
- Gowns and gloves are required if the nurse anticipates contact with soiled items such as those
with wound drainage or is caring for a client who is incontinent with diarrhea or a client who has
an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are
necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

8) D
- Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial
characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also
occur. Anemia is most likely to occur later in SLE.

9) A
- To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should
instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue),
schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The
client is instructed to avoid long periods of rest because it promotes joint stiffness.

10) A
- The skin biopsy is the procedure of choice to diagnose Kaposi’s sarcoma, which frequently
complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung
biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay
and Western blot are tests to diagnose human immunodeficiency virus status.

11) A
- The status of the client with a diagnosis of Impaired gas exchange would be evaluated against
the standard outcome criteria for this nursing diagnosis. These would include the client stating
that breathing is easier and is coughing up secretions effectively, and has clear breath sounds.
The client should not limit fluid intake because fluids are needed to decrease the viscosity of
secretions for expectoration.

12) B
- Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has
large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering
of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may
have crusting areas instead of intact blisters. Option A describes eczema, option C describes
herpes zoster, and option D describes psoriasis.

13) A
- The client with systemic lupus erythematosus (SLE) is at risk for cardiovascular disorders such
as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce
these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The
client is advised to reduce salt, fat, and cholesterol intake.

14) B
- In some types of allergies, a reaction occurs only on second and subsequent contacts with the
allergen. The appropriate action, therefore, would be to ask the client if he ever received a bee
sting in the past. Option A is not appropriate advice. Option C is unnecessary. The client should
not be told “not to worry.”

15) D
- Acquired immunity can occur by receiving an immunization that causes antibodies to a specific
pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the
client from all diseases.
16) C
- Systemic lupus erythematosus is an inflammatory disease of collagen in connective tissue.
Options A, B, and D are not associated with this disease.

17) C
- Treatment of systemic lupus erythematosus is based on the systems involved and symptoms.
Treatment normally consists of anti-inflammatory drugs, corticosteroids, and
immunosuppressants. Options A, B, and D are not standard components of medication therapy.

18) A
- Individuals at risk for developing a latex allergy include health care workers, individuals who
work in the rubber industry or those who have had multiple surgeries, have spina bifida, wear
gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to
kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water
chestnuts.

19) D
- Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados,
potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought
to be to the result of a possible cross-reaction between the food and the latex allergen. Options A,
B, and C are unrelated to latex allergy.

20) B
- The rubber pads used on crutches may contain latex. If the client requires the use of crutches,
the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 4 is inappropriate
and may alarm the client. The nurse cannot order a cane for a client. Additionally, this type of
assistive device may not be appropriate, considering this client’s injury. No reason exists to
contact the physician at this time.

21) D
- Cotton pads and plastic or silk tape are latex-free products. The items identified in options A,
B, and C are products that contain latex.

22) A
- Lyme disease is a multisystem infection that results from a bite by a tick carried by several
species of deer. Persons bitten by the Ixodesscapularis or I. pacificus tick can become infected
with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to
another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings.
Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces.

23) B
- The hallmark of stage I Lyme disease is the development of a rash within 2 to 30 days of
infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it
a bull’s-eye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop
farther away from the original tick bite. In stage I, most infected persons develop flu-like
symptoms that last 7 to 10 days; these symptoms may reoccur later. Neurological deficits occur
in stage II. Arthralgias and joint enlargements are most likely to occur in stage III.
24) A, B, D, E
- If a client is allergic to latex and is at high risk for an allergic response, the nurse would use
nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the
client’s area. Any supplies or materials that contain latex would be avoided. These include blood
pressure cuffs, medications with a rubber stopper that requires puncture with a needle, latex-safe
syringes, and latex-safe intravenous tubing. It is not necessary to place the client in a private
room.

25) C
Amikacin (Amikin) is an aminoglycoside. Adverse effects of aminoglycosides include
ototoxicity (hearing problems) confusion, disorientation, gastrointestinal irritation, palpitations,
blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to
report hearing loss to the physician immediately. Lethargy and muscle aches are not associated
with the use of this medication. It is not necessary to contact the physician immediately if nausea
occurs. If nausea persists or results in vomiting, the physician should be notified.

26) D

- Zalcitabine (ddC, Hivid) is an antiretroviral (nucleoside reverse transcriptase inhibitor) used to

manage human immunodeficiency virus infection in combination with other antiretrovirals.
Zalcitabine also has been used as a single agent in clients who are intolerant of other regimens.
Zalcitabine can cause serious liver damage, and liver function studies should be monitored
closely. Options A, B, and C are not associated specifically with the use of this medication.

27) C
- Foscarnet (Foscavir) is toxic to the kidneys. The serum creatinine level is monitored before
therapy, two or three times per week during induction therapy, and at least weekly during
maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium,
phosphorus, and potassium. Thus, these levels also are measured with the same frequency.

28) D
- Frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia.
The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and
3 are inaccurate interpretations.

29) A
- Saquinavir is an antiretroviral (protease inhibitor) used with other antiretroviral medications to
manage human immunodeficiency virus infection. Saquinavir is administered with meals and is
best absorbed if the client consumes high-calorie, high-fat meals. Saquinavir can cause
photosensitivity, and the nurse should instruct the client to avoid sun exposure.

30) A
- Stavudine (d4t, Zerit) is an antiretroviral used to manage human immunodeficiency virus
infection in clients who do not respond to or who cannot tolerate conventional therapy. The
medication can cause peripheral neuropathy, and the nurse should monitor the client’s gait
closely and ask the client about paresthesia.
31) D
- Common side effects of this medication therapy are leukopenia and anemia. The nurse
monitors the complete blood count results for these changes. Options A, B, and C are unrelated
to the use of this medication.

32) C
- Didanosine (Videx) can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2
times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome
and is potentially fatal. The medication may have to be discontinued. The medication is also
hepatotoxic and can result in liver failure.

33) C
- Hypertension can occur in a client taking cyclosporine (Sandimmune, Gengraf, Neoral) and,
because this client is also complaining of a headache, the blood pressure is the vital sign to be
monitoring most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism.
Options A, B, and D are unrelated to the use of this medication.

34) B, C, E
- Ketoconazole (Nizoral) is an antifungal medication. It is administered with food (not on an
empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure
absorption. The medication is hepatotoxic and the nurse monitors liver function studies. The
client is instructed to avoid exposure to the sun because the medication increases
photosensitivity. The client is also instructed to avoid alcohol. There is no reason for the client to
restrict fluid intake. In fact, this could be harmful to the client.

35) B
- Foscarnet (Foscavir) is very toxic to the kidneys. The serum creatinine level is monitored prior
to therapy, two or three times weekly during induction therapy, and at least weekly during
maintenance therapy. It also may cause decreased levels of calcium, magnesium, phosphorus,
and potassium. Thus, these levels are also measured with the same frequency.