ATI LPN
Immune System Questions Questions
Question 1 of 5
A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client?
Correct Answer: A
Rationale: The correct answer is A: Splints. Splints help immobilize joints, reducing pain and preventing further damage in clients with joint pain due to DIC. Cool compresses (B) may provide temporary relief but won't address the underlying issue. Heat (C) can worsen inflammation in joints. Ice (D) is contraindicated in DIC as it can exacerbate clotting issues.
Question 2 of 5
Which of the following would be an appropriate nursing diagnosis for a child who is receiving chemotherapy?
Correct Answer: D
Rationale: The correct answer is D: Impaired oral mucous membrane. This is an appropriate nursing diagnosis for a child receiving chemotherapy because chemotherapy often causes mucositis, leading to pain, difficulty eating, and an increased risk of infection in the oral cavity. Nurses need to assess and monitor oral mucous membranes closely in these patients. Incorrect choices: A: Ineffective breathing pattern - Not directly related to chemotherapy in this scenario. B: Constipation - Not typically a common issue specifically related to chemotherapy. C: Impaired skin integrity - Not directly related to the side effects of chemotherapy on oral mucous membranes.
Question 3 of 5
A child who has nephrotic syndrome is admitted to the pediatric unit. Which of the following should the nurse expect to find? (Select one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A: Decreased urine specific gravity. In nephrotic syndrome, there is increased protein loss in the urine, leading to proteinuria and hypoalbuminemia. This results in a decrease in colloid osmotic pressure, causing fluid to leak into the interstitial spaces, leading to edema. Hyperlipidemia occurs due to the liver's response to low serum albumin levels. However, urine specific gravity is typically normal or even increased due to the concentrated urine caused by the loss of proteins and other solutes. Therefore, the nurse should not expect to find decreased urine specific gravity in a child with nephrotic syndrome.
Question 4 of 5
The client in end-stage of renal failure had undergone kidney transplant. Which of the following assessment findings indicate kidney transplant rejection?
Correct Answer: C
Rationale: The correct answer is C. Decreased urinary output and sudden weight gain indicate kidney transplant rejection. Decreased urinary output suggests decreased kidney function, while sudden weight gain can be due to fluid retention caused by rejection. Increased urinary output and normal BUN indicate proper kidney function. High HCT and Hgb levels indicate good oxygen-carrying capacity, ruling out rejection. Decreased urinary output and weight loss are not typical signs of rejection.
Question 5 of 5
A child with severe gastroenteritis is admitted to a semiprivate room on the pediatric unit. The charge nurse should place this client with which roommate?
Correct Answer: C
Rationale: The correct answer is C. Placing the child with another child with gastroenteritis is the best option to prevent transmission of the infection to other vulnerable patients. Choosing option A would risk exposing the child with meningitis to gastroenteritis. Option B involves a child with neutropenia who is immunocompromised and at high risk for infection. Option D may not be ideal as the child recovering from an appendectomy may have a weakened immune system and could be at risk for acquiring gastroenteritis. Placing the child with another case of gastroenteritis minimizes the risk of spreading the infection and ensures appropriate care and isolation measures are in place.