ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 33 : Introduction to the Immune System Questions
Question 1 of 5
The nurse is beginning the physical examination of a client who has reported fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
Correct Answer: A
Rationale: The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then perform a more comprehensive examination.
Question 2 of 5
The nurse is obtaining medication history information from a client with Crohn's disease. What medication would the nurse include when asking what medications the client has taken for suppression of the inflammatory and immune response?
Correct Answer: D
Rationale: The nurse obtains a history of immunizations, recent and past infectious diseases, and recent exposure to infectious diseases. The nurse reviews the client's drug history because certain drugs, such as corticosteroids, suppress the inflammatory and immune responses. Nonsteroidal anti-inflammatory medication does not suppress the inflammatory and immune responses of Crohn's disease. An ACE-I prevents the conversion of angiotensin I to angiotensin II and does not suppress the inflammatory or immune response. Diuretics also do not suppress the immune response but help reduce excess fluid from the kidneys.
Question 3 of 5
Why would it be important for the nurse to question the client about sexual practices, history of substance use disorder, and lifestyle during the interview process?
Correct Answer: B
Rationale: The nurse investigates the client's allergy history and asks about practices that put the client at risk for AIDS. The interview will not determine the client's ability to be compliant. The physician would make the determination if a counseling referral should be made. It is irrelevant to determine the personality traits in the initial interview.
Question 4 of 5
A client asks the nurse about the importance of taking supplements to maximize immune function. The client is healthy and does not have any medical problems. What is the best information to give to the client?
Correct Answer: D
Rationale: Until more is known about nutrient interactions, the best dietary advice to maximize immune function in healthy people is to eat a moderate diet that is balanced and varied. Eating fruits and vegetables and a vegetarian lifestyle may be healthy choices but do not maximize immune function as a balanced diet will.
Question 5 of 5
The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis?
Correct Answer: B
Rationale: The injection area swells if the client has developed antibodies against the antigen. The client is not necessarily actively infectious if the test results are positive. Although a productive cough is one of the symptoms of active tuberculosis, it may also indicate other diseases and disorders. The area should not be painful, and the client should not break out with a rash.