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ATOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)MSC: Integrated Process: Caring43.

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Which characteristic is common to all types of hypersensitivity reactions?

The second stage occurs weeks or months after the appearance of the red rash.

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The client does not haveallergies, nor should he or she take antacids in the hope that they will reduce the problem.

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What kind of topical anesthetic was used on the client?

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ATOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC: Integrated Process: Nursing Process (Implementation)8.

Test again using the opposite side of the reflex (percussion) hammer and strike more firmly.

Determining the clients current medications, notifying next of kin, or measuring therate and depth of respirations is of less importance at this time.

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ANS: BThe circulating nurse should not leave the operating room to pick up fresh-frozen plasma andshould delegate the job to unlicensed personnel instead.

Highblood phosphate levels cause hypocalcemia and osteodystrophy; this makes a client prone tofracture.

Using this medicine with any of the following medicines is usually not recommended, but may be required in some cases.

Sounds like you took well over the the maximum amount recommended and took in too much sodium causing your thrist and possibly encountered some interference with digestive enzymes.


Creatinine is very high; this indicates renaldisease.

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ATOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-SpecificAssessments) MSC: Integrated Process: Nursing Process (Assessment)16.

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ANS: DHemorrhagic cystitis is a frequent side effect of cyclophosphamide therapy.

Diagnostic testing can also identify patients with a tumor or testicular torsion, but referral to a urologist should not be delayed to obtain imaging if testicular torsion is clinically suspected.

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Use sterile gloves and gowns whenever the nursing staff is in contactwith the client.

Which assessmentfinding could explain the clients weight gain and hunger?


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Any drug or condition that disrupts aldosterone secretion or release increases the clientsrisk for excessive water loss and increased potassium reabsorption.

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The client is scheduled for radiation therapy and states, I want to have childrensomeday, and this procedure will destroy my chances.

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Advise travelers that presumptive self-treatment of malaria is an interim measure and that they should seek medical evaluation as soon as possible.

Which assessment finding requires immediate action bythe nurse?

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ANS: CThe infection is spread through casual contact between cystic fibrosis clients, thus the need forisolation of these clients from each other.

ATOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for ComplicationsFrom Surgical Procedures and Health Alterations)MSC: Integrated Process: Nursing Process (Implementation)16.

The nurse works in a long-term care facility.

If too much urine output occurs, the clientmay be at risk for hypovolemia, which is a cause of prerenal kidney failure.

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ATOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations inBody Systems) MSC: Integrated Process: Nursing Process (Evaluation)24.

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ANS: A, D, EThe medical-surgical nurse can assess the clients response to the test results and encourage geneticcounseling for self and family.

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