Adult 2 exam 4
A patient received epinephrine in response to an anaphylactic reaction at 10:00 AM. The nurse knows to observe the patient for a "rebound" reaction that may occur as early as:
2:00 PM. Explanation: Rebound reactions can occur from 4 to 10 hours after an initial allergic reaction. Therefore the patient needs to be assessed from 2:00 PM to 8:00 PM.
Colchicine
Antigout
hydroxychloroquine
Antimalarial
Cyclophosphamide
Chemotherapy and immune suppressant drug
A client is administered foscarnet to treat a case of CMV retinitis. Which adverse effect should the nurse closely monitor in the client?
Electrolyte imbalances Explanation: Alterations in renal function, fever, nausea, electrolyte imbalances, and diarrhea are the most common adverse effects of foscarnet and should be closely monitored. The drug does not cause hypotension. On the other hand, peripheral neuropathy is an adverse effect of administering drugs such as didanosine and zalcitabine. Anemia is an adverse effect of administering zidovudine.
Penicillamine
Immune suppressant and treats heavy metal toxicity for copper
A nurse is visiting the home of a client with AIDS who is experiencing HIV encephalopathy. When developing the plan of care for the client and his caregiver, the nurse identifies the nursing diagnosis of disturbed thought processes related to confusion and disorientation secondary to HIV encephalopathy. Which expected outcome would be most appropriate for the nurse to document on the client's plan of care?
The client can state that he is at his home. Explanation: The most appropriate outcome for the nursing diagnosis would be that the client can state that he is in his home, which indicates that he is aware of his surroundings and location. Remaining free of injury when out of bed would be appropriate if the nursing diagnosis was risk for injury. Nodding by the client may or may not indicate that the client understands instructions. Although engaging in diversional activities would help the client focus, it would be a more appropriate outcome for social isolation or deficient diversional activity.
T-cell deficiency occurs when which gland fails to develop normally during embryogenesis?
Thymus Explanation: T-cell deficiency occurs when the thymus gland fails to develop normally during embryogenesis.
The nurse is teaching a client with allergic rhinitis about medications. What medication is a mast cell stabilizer used in the treatment of allergic rhinitis?
intranasal cromolyn sodium Explanation: Intranasal cromolyn sodium is a mast cell stabilizer. Tetrahydrozoline hydrochloride, oxymetazoline hydrochloride, and pseudoephedrine hydrochloride are adrenergic agents.
IVIG
intravenous immunoglobulin
Which immunity type becomes active as a result of infection by a specific microorganism?
naturally acquired active immunity Explanation: Naturally acquired active immunity occurs as a direct result of an infection by a specific microorganism.
The nurse is teaching a client about contact dermatitis. What type of contact dermatitis requires light exposure in addition to allergen contact?
photoallergic Explanation: Photoallergic contact dermatitis resembles allergic dermatitis, but it requires light exposure in addition to allergen contact to produce immunologic reactivity. Phototoxic contact dermatitis resembles the irritant type, but it requires sunlight in combination with the chemical to damage the epidermis. Allergic contact dermatitis results from contact of skin with a allergenic substance. Irritant contact dermatitis results from contact with a substance that chemically or physically damages the skin on a nonimmunologic basis.
giant cell arteritis
temporal artery granulomatous vasculitis; ipsilateral blindness (ophthalmic artery)
immunotherapy
use of immune cells, antibodies, or vaccines to treat or prevent disease
Methotrexate
Chemotherapy and immune suppressant drug
A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse?
"The full benefit of the medication may take up to 2 weeks to be achieved." Explanation: Patients must be aware that full benefit of corticosteroid nasal sprays may not be achieved for several days to 2 weeks.
Infection control practices
-wearing gloves -washing hands -spill disinfection -proper waste disposal -use sharp containers -disinfection -sterilization
The side effect of bone marrow depression may occur with which medication used to treat gout?
Allopurinol Explanation: A client taking allopurinol needs to be monitored for the side effects of bone marrow depression, vomiting, and abdominal pain.
Which of the following cell types are involved in humoral immunity?
B lymphocytes Explanation: B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.
A client with a history of allergic rhinitis comes to the clinic for an evaluation. The client is prescribed triamcinolone. What will the nurse include when teaching the client about this drug?
Be aware that some nasal burning and itching may occur. Explanation: Triamcinolone is an inhaled corticosteroid administered by a metered-spray device. It may cause drying of the nasal mucosa and burning and itching sensations. The drug is not given orally and does not cause dry mouth. Adrenergic topical ophthalmic drops are used for symptomatic relief of eye irritations resulting from allergies.
Which blood test confirms the presence of antibodies to HIV?
Enzyme immunoassay (EIA) Explanation: EIA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.
prednisone
Corticosteroid
The nurse is caring for a client with myasthenia gravis. The nurse generates a plan of care for the client based on which type of hypersensitivity reaction?
Cytotoxic Explanation: Cytotoxic hypersensitivity occurs when the body mistakenly identifies a part of the body as foreign, as in myasthenia gravis, where the body mistakenly identifies normal nerve endings as foreign. Delayed hypersensitivity reactions occur 24 to 72 hours after exposure. Immune complex hypersensitivity involves immune complexes formed when antigens bind to antibodies. Anaphylactic hypersensitivity is an immediate reaction characterized by edema in many tissues, often with hypotension, bronchospasm, and cardiovascular collapse
The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find?
Elevated erythrocyte sedimentation rate Explanation: The erythrocyte sedimentation rate (ESR) may be elevated, particularly as the disease progresses. ESR shows inflammation associated with RA. Red blood cell count and C4 complement component are decreased. Serum protein electrophoresis may disclose increased levels of gamma and alpha globulin but decreased albumin.
A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen?
IV gamma globulin administration Explanation: Treatment for ataxia-telangiectasia includes IV gamma globulin, antimicrobial therapy, and bone marrow transplantation. It does not include platelet administration, factor VIII administration, or thymus grafting.
Which of the following indicates that a client with HIV has developed AIDS?
Herpes simplex ulcer persisting for 2 months Explanation: A diagnosis of AIDS cannot be made until the person with HIV meets case criteria established by the Centers for Disease Control and Prevention. The immune system becomes compromised. The CD4 T-cell count drops below 200 cells and develops one of the opportunistic diseases, such as Pneumocystis carinii pneumonia, candidiasis, cytomegalovirus, or herpes simplex.
A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not say when teaching the client and family information about managing the disease?
If you have problems with a medication, you may stop it until your next physician visit. Explanation: Take medications exactly as directed and do not stop the medication if symptoms are relieved unless advised to do so by the physician. Sunlight tends to exacerbate the disease. Because fatigue is a major issue, allow for adequate rest, along with regular activity to promote mobility and prevent joint stiffness. Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing.
The nurse is teaching a group of health care workers about latex allergies. What reaction will the nurse teach the workers to be most concerned about with laryngeal edema?
IgE-mediated hypersensitivity Explanation: A type I, IgE-mediated hypersensitivity can cause severe reaction symptoms such as laryngeal edema and bronchospasm. Irritant and allergic contact dermatitis result in more localized skin reactions. IgG antibodies are important in fighting viral and bacterial infections.
The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?
Lymphoid tissues Explanation: The immune system actually is a collection of specialized white blood cells and lymphoid tissues that cooperate to protect a person from external invaders and the body's own altered cells. The function of these structures is assisted and supported by the activities of natural killer cells, antibodies, and nonantibody proteins such as cytokines and the complement system. Red blood cells and stem cells are not part of the immune system.
HIV complications
Opportunistic infections; AIDS dementia complex; Malignancies; Wasting syndrome
The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following?
Serum, which depletes the body's store of immunoglobulins Explanation: Major burns cause impaired skin integrity and compromise the body's first line of defense. Loss of large amounts of serum occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. Loss of serum or plasma does not deplete the body of catecholamines (adrenal gland), calcitonin (thyroid gland), or glucagon (pancreas).
Diclofenac
Voltaren NSAID
lupus
a chronic autoimmune disease characterized by inflammation of various parts of the body
The parents of a child with contact dermatitis are asking questions about the reaction within the immune system. What description regarding contact dermatitis as a type IV hypersensitivity reaction is accurate?
a delayed-type hypersensitivity that is mediated by T cells Explanation: Contact dermatitis is a delayed-type hypersensitivity response that can occur 24 to 72 hours after exposure to an allergen.
gout
a type of arthritis characterized by deposits of uric acid crystals in the joints
allergic rhinitis
an allergic reaction to airborne allergens that causes an increased flow of mucus
scleroderma
an autoimmune disorder in which the connective tissues become thickened and hardened, causing the skin to become hard and swollen
Which allergic reaction is potentially life threatening?
angioedema Explanation: Angioedema is potentially life threatening. Medical management would include intubation, subcutaneous epinephrine, and aminophylline in severe reactions.
Kaposi sarcoma (KS) is diagnosed through
biopsy. Explanation: KS is diagnosed by biopsy of the suspected lesions. Prognosis depends on the extent of the tumor, the presence of other symptoms of HIV infection, and the CD4+ count
fibromyalgia
chronic condition with widespread aching and pain in the muscles and fibrous soft tissue
The nurse is reviewing the medication administration record of the client. Which medication would lead the nurse to suspect that the client is suffering from an acute attack of gout?
colchicine Explanation: Colchicine is prescribed for the treatment of an acute attack of gout.
The nurse is gathering a health history for a client with osteoarthritis. What clinical manifestation will the nurse expect to find?
early morning stiffness Explanation: Osteoarthritis is characterized by early morning stiffness that decreases with activity. Large joints are usually involved with osteoarthritis. Joint pain is a constant with osteoarthritis. Clients with rheumatoid arthritis have subcutaneous nodules.
Azathioprine
Immunosuppressant for prevention of organ rejection
A client with systemic lupus erythematosus is prescribed belimumab. For which reason will the nurse question giving the client this medication?
Received a live vaccination a week ago Explanation: Belimumab is a monoclonal antibody that specifically recognizes and binds to BLyS. BLyS acts to stimulate B cells to produce antibodies against the body's own nuclei, which is an integral part of the disease process in SLE. This action then halts the production of unnecessary antibodies and decreases disease activity in SLE. Live vaccines are contraindicated for 30 days before taking this medication. There is no reason to withhold giving the medication for a report of constipation, discoid rash on the face, or bilateral knee joint swelling.
A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?
A cell-mediated response Explanation: A cell-mediated response occurs when T cells survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. An example of a cell-mediated response is one that occurs when an organ is transplanted. The complement system cooperates with antibodies to attract phagocytes and coat antigens to make them more recognizable for phagocytosis and stimulate inflammation and is not related to the surgery. Colony-stimulating factors prompt the bone marrow to produce, mature, and promote the functions of blood cells. Naturally acquired active immunity is a direct result of infection by a specific microorganism
A client is being treated for hyperuricemia. Part of the treatment strategy is for the client to avoid contributing factors whenever possible. Which activities might bring on an acute attack?
eating organ meats and sardines Explanation: During an acute attack, high-purine foods are avoided, including organ meats, gravies, meat extracts, anchovies, herring, mackerel, sardines, and scallops. The other listed factors do not worsen attacks.
A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to:
infection because the spleen removes bacteria from the blood. Explanation: One function of the spleen is to remove bacteria from circulation; therefore, the client will be more susceptible to infection.
A client with a history of anaphylactic reactions to insect stings has just been stung by a wasp. Place the steps in the correct order that the client will follow for self-administration of an EpiPen. Use all options.
Remove the gray safety-release cap Inject the black tip into the outer thigh Massage the injection area Call the emergency medical response number (911)
The nurse is assessing a client with decreased dexterity of the hands related to rheumatoid arthritis. The nurse knows that which process causes joint deformities?
Inflammation Explanation: In clients with chronic inflammation, the immune response can deviate from normal. Instead of resolution of swelling and joint pain once the triggering event has subsided, pannus, or proliferation of newly formed synovial tissue infiltrated with inflammatory cells, formation occurs. Destruction of the joint's cartilage and erosion of bone soon follow. Remission is a period when the symptoms of the condition are reduced or absent. Exacerbation is a period when the symptoms occur or increase. Autoimmunity causes tissue destruction which leads to pain.
A client has a serum study that is positive for the rheumatoid factor. What will the nurse tell the client about the significance of this test result?
It is suggestive of rheumatoid arthritis. Explanation: Rheumatoid factor is present in about 70% to 80% of patients with rheumatoid arthritis, but its presence alone is not diagnostic of rheumatoid arthritis, and its absence does not rule out the diagnosis. The antinuclear antibody (ANA) test is used to diagnose Sjögren's syndrome and systemic lupus erythematosus.
The nurse is caring for a client with ankylosing spondylitis (AS). Which medication will the nurse expect to be prescribed for this client?
Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: NSAIDs are the first-line therapy for treating all spondyloarthropathies. Antibiotics and anticoagulants are not used to treat AS. Corticosteroid injections may be used for periodic flares; however, oral and long-term use of steroids is not recommended.
Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues?
Scleroderma Explanation: Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.
A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include?
located over bony prominence Explanation: Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. The nodules are not reddened.
After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action?
Jabs the autoinjector into the outer thigh at a 90-degree angle Explanation: To self-administer epinephrine, the client should remove the autoinjector from its carrying tube, grasp the unit with the black tip (injecting end) pointed downward, form a fist around the device, and remove the gray safety release cap. Then the client should hold the black tip near the outer thigh and swing and jab firmly into the outer thigh at a 90-degree angle until a click is heard. Next, the client should hold the device firmly in place for about 10 seconds, remove the device, and massage the site for about 10 seconds.
Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?
Liquids Explanation: The nurse should encourage clients with AIDS to consume liquids in order to help replace fluid and electrolyte losses. Gluten and sucrose may increase the complication of malabsorption. Large doses of iron and zinc should be avoided because they can impair immune function.
A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching?
Caregiver cleans the client's anal area without wearing gloves Explanation: To prevent the risk of HIV transmission, standard precautions should be used. Cleaning the client's anal area without wearing gloves indicates that the nurse needs to reinstruct the caregiver in measures related to standard precautions. Handwashing before and after client care, disposing of sharps in a puncture-resistant container, and cleaning up spills with a dilute bleach solution are appropriate measures.
A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority?
Disturbed body image related to loss of fat in the face and arms Explanation: The client is experiencing lipoatrophy, which results in a localized loss of subcutaneous fat in the face (manifested as sinking of the cheeks, eyes, and temples), arms, legs, and buttocks. These changes as well as his statement about the side effects of the drug being worse than the disease indicate that he is concerned about how he appears to others. Therefore, the nursing diagnosis of disturbed body image would be the priority. Deficient knowledge, risk for infection, and risk for impaired liver function may be applicable; however, they are not concerns at this time.
A nurse is explaining treatment options to a client diagnosed with an immune dysfunction. Which statement by the client accurately reflects the teaching about current stem cell research?
"Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, and clinical trials using stem cells are underway in clients with a variety of disorders with an autoimmune component." Explanation: Research has shown that stem cells can restore an immune system that has been destroyed (Ko, 2012). Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, such as severe combined immunodeficiency; clinical trials using stem cells are underway in clients with a variety of disorders having an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis. Research with embryonic stem cells has enabled investigators to make substantial gains in developmental biology, gene therapy, therapeutic tissue engineering, and the treatment of a variety of diseases (Ko, 2012). However, along with these remarkable opportunities, many ethical challenges arise, which are largely based on concerns about safety, efficacy, resource allocation, and human cloning.
A client with human immunodeficiency virus (HIV) develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this client?
Pneumocystis pneumonia Explanation: The most common life-threatening infection in those living with acquired immune deficiency syndrome (AIDS) is Pneumocystis pneumonia (PCP), caused by P. jiroveci (formerly P. carinii) (Durham & Lashley, 2010). Without prophylactic therapy, most people infected with HIV will develop PCP. The clinical presentation of PCP in HIV infection is generally less acute than in people who are immunosuppressed as a result of other conditions. Clients with HIV infection initially develop nonspecific signs and symptoms, such as nonproductive cough, fever, chills, shortness of breath, dyspnea, and occasionally chest pain. Arterial oxygen concentrations in clients who are breathing room air may be mildly decreased, indicating minimal hypoxemia.
Which assessment finding(s) are likely to cause noncompliance with antiretroviral treatment?
Active substance abuse
A health care provider orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?
An above-normal anti-deoxyribonucleic acid (DNA) test Explanation: Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE.
Which response is a humoral immune response?
Anaphylaxis Explanation: Anaphylaxis is an example of a humoral response. Cellular responses include transplant rejection, intracellular infections, and delayed hypersensitivity.
While taking the health history of a newly admitted client, the nurse reviews general lifestyle behaviors. What strategies would have a positive effect on the immune system?
Biofeedback, relaxation, and hypnosis Explanation: Growing evidence indicates that strategies such as relaxation, imagery techniques, biofeedback, humor, hypnosis, and conditioning can positively influence a measurable immune system response. Intense or rigorous competitive exercise can cause negative effects on the immune system, especially if the environment is stressful while undergoing exercise.
A client with acquired immune deficiency syndrome (AIDS) informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the client has developed?
Candidiasis Explanation: Candidiasis, a fungal infection, occurs in almost all clients with AIDS and immune depression (Durham & Lashley, 2010). Oral candidiasis is characterized by creamy-white patches in the oral cavity and, if left untreated, can progress to involve the esophagus and stomach. Associated signs and symptoms include difficult and painful swallowing and retrosternal pain.
A nurse is taking the health history of a newly admitted client and asks for a list of the client's current medications. Which medication classification would NOT place the client at risk for impaired immune function?
Inotropics Explanation: Antimetabolites, antineoplastic agents, and adrenal corticosteroids all can cause immunosuppression. Inotropics do not directly affect the immune system.
A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed?
Pernicious anemia Explanation: More than 50% of clients with CVID develop pernicious anemia. Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy, which is detected by biopsy of the stomach, are common findings. Gastrointestinal malabsorption may occur.
A client comes to the clinic with a rash. While inspecting the client's skin, the nurse determines that the rash is medication-related based on which finding?
Rash has several large raised areas. Explanation: In general, drug reactions appear suddenly, have a particularly vivid color, and manifest with characteristics more intense than the somewhat similar eruptions of infectious origin. Therefore, the appearance of several large raised areas would suggest a drug reaction.
The result of which diagnostic study is decreased in the client diagnosed with rheumatoid arthritis?
Red blood cell count Explanation: Clients diagnosed with rheumatic diseases have a decreased red blood cell count. ESR is increased in inflammatory connective tissue disease. Uric acid is increased in gout. Increased creatinine may indicate renal damage in SLE, scleroderma, and polyarteritis.
The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction?
Symptoms are localized to the area of exposure, usually the back of the hands. Explanation: Clinical manifestations of a delayed hypersensitivity reaction are localized to the area of exposure. Clinical manifestations of an irritant contact dermatitis can be eliminated by changing glove brands or using powder-free gloves. With an irritant contact dermatitis, avoid use of hand lotion before donning gloves; this may worsen symptoms, as lotions may leach latex proteins from the gloves. When clinical manifestations occur within minutes after exposure to latex, which is described as a latex allergy, an immediate hypersensitivity (type I) allergic reaction has occurred.
The nurse is gathering data from laboratory studies for a client who has HIV. The client's CD4+ cell count is 200/mm³, and the client has been diagnosed with pneumocystis pneumonia. What does this indicate to the nurse?
The client has converted from HIV infection to AIDS. Explanation: AIDS is the end stage of HIV infection. Certain events establish the conversion of HIV infection to AIDS: a markedly decreased CD4+ cell count from a normal level of 500 to 1000/mm³ and the development of certain cancers and opportunistic infections. The client does not have advanced HIV; they meet the criteria for the development of AIDS. The CD4+ cell count is not decreasing due to an infection.
A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection?
Trimethoprim-sulfamethoxazole Explanation: To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole (Bactrim, Septra) is prescribed. The other medications are antifungals and used to treat candidiasis.
A client has been living with rheumatoid arthritis (RA) for several years. Which diagnostic test will the nurse prepare the client for to determine the progression of the disease?
X-ray Explanation: Plain x-ray is the most common radiographic study used to track disease progression as it is inexpensive, reliable, and reproducible. MRI may be used to detect erosions not visible on x-ray or ultrasound. CT scan is not routinely used to track the progression of RA. Ultrasound might be used to establish a baseline for joint evaluation however is not used to track progression of the condition.
A client has a known allergy to peanuts, meaning that the client's immune system has identified peanuts as a foreign invader and has produced specific cells to attack if the client should come in contact with peanuts again. The formation of these specific cells is known as:
humoral response. Explanation: The B-cell lymphocytes mature in the bone marrow and migrate to the spleen and other lymphoid tissues such as the lymph nodes. When stimulated by T cells, the B cells become either plasma or memory cells. Plasma cells produce antibodies. Formation of antibodies is called a humoral response.
The nurse is aware that the most prevalent cause of immunodeficiency worldwide is
Malnutrition Explanation: The most prevalent cause of immunodeficiency worldwide is severe malnutrition.
A client with human immunodeficiency virus undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. What accurate conclusion can the nurse make?
The client is immunodeficient and won't have a skin response. Explanation: Anergy testing determines the level of immune response an individual has to common microbes. A normal response is a local skin reaction to all the antigens injected intradermally. Absence of a response within 3 days suggests the individual is immunodeficient and can't produce a normal immune response. It doesn't imply nonexposure to the antigens, which are environmentally prevalent. A positive skin reaction demonstrates presence of antibodies to the antigens. An expected reaction to the antigens isn't considered an allergic or hypersensitive reaction.
A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses, including the steps in the process of HIV entering the host cell. What would the nurse describe as the first step?
Attachment Explanation: Once HIV enters the host cell, attachment occurs in which the glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors. This is followed by uncoating, in which HIV's viral core is emptied into the CD4+ T cell. Cleavage and budding occur as the last steps.
Which of the following cells destroy antigens already coated with antibody?
Null lymphocytes Explanation: Null lymphocytes, a subpopulation of lymphocytes, destroy antigens already coated with antibody. Memory cells are responsible for recognizing antigens from previous exposure and mounting an immune response. Suppressor T cells have the ability to decrease B cell production, thereby keeping the immune response at a level compatible with health. NK cells are lymphocytes that assist in combating organisms.
A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"?
Only use the nasal spray for 3 to 4 days once every 12 hours. Explanation: Adrenergic agents, which are vasoconstrictors of mucosal vessels, are used topically in nasal (oxymetazoline [Afrin]) and ophthalmic (brimonidine [Alphagan P]) formulations in addition to the oral route (pseudoephedrine [Sudafed]). The topical route (drops and sprays) causes fewer side effects than oral administration; however, the use of drops and sprays should be limited to a few days to avoid rebound congestion.
What intervention is a priority for a client diagnosed with osteoarthritis?
Physical therapy and exercise Explanation: Clients with osteoarthritis need to maintain joint mobility. To preserve joint function, individuals need to learn appropriate activities. Colchicine and allopurinol are used for gout, not osteoarthritis. Hydrotherapy is not a priority for care.
The nurse is teaching a client who has been diagnosed with Hashimoto's thyroiditis. Which statement correctly describes the process of autoimmunity?
The normal protective immune response attacks the body, damaging tissues. Explanation: Autoimmunity happens when the normal protective immune response paradoxically turns against or attacks the body, leading to tissue damage. It is not an immune deficiency. An exaggerated immune response describes a hypersensitivity. An overproduction of immunoglobulins is the definition of gammopathies.
The nurse explains to a client that immunotherapy initially starts with injections at which interval?
Weekly Explanation: Typically, immunotherapy begins with very small amounts and gradually increases, usually at weekly intervals until a maximum tolerated dose is attained. Then maintenance booster injections are administered at 2- to 4-week intervals, frequently for a period of several years.
Rheumatoid arthritis
a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked
A client is prescribed a disease-modifying antirheumatic drug that is successful in the treatment of rheumatoid arthritis but has side effects, including retinal eye changes. What medication will the nurse anticipate educating the client about?
hydroxychloroquine Explanation: The DMARD hydroxychloroquine is associated with visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. The nurse should emphasize the need for ophthalmologic examinations every 6-12 months. Azathioprine, diclofenac, and cyclophosphamide do not have visual changes as a side effect.
The nurse is teaching a client about histamine release during an anaphylactic reaction. What does histamine release in anaphylaxis cause?
nasal congestion Explanation: Histamine release causes sweating, sneezing, shortness of breath, and nasal congestion. Feelings of impending doom are related to activation of IgE and subsequent release of chemical mediators. Urinary urgency and stomach cramps occur from smooth muscle contractions of intestines and bladder.
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:
neutrophils and monocytes. Explanation: Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.
The nurse is teaching a client about allergic rhinitis and its triggers. What is the most common trigger for the respiratory allergic response?
plant pollen Explanation: Plant pollen (from trees, grass, and other plants) causes the most common form of allergic rhinitis, which is known as hay fever. Animal dander, dust mites, and mold spores can be triggers, but are not the most common causes.
The nurse is teaching a newly diagnosed client about systemic lupus erythematosus(SLE). What statement by the client indicates the teaching was successful?
"The belief is that it is an autoimmune disorder with an unknown trigger." Explanation: Systemic lupus erythematosus is believed to be an autoimmune disorder but the triggering mechanism is not known. The disorder is more common in women than in men, most with the disorder in the 3rd or 4th decade of life. The disease is considered the "great imitator" because the clinical signs resemble many other conditions. SLE is a diffuse connective tissue disease that affects multiple body systems.
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Explanation: Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells-those cells that are "self." Autoantibodies, antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder.
A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?
AIDS Explanation: AIDS, the most common secondary disorder, is perhaps the best-known secondary immunodeficiency disorder. It results from infection with the human immunodeficiency virus (HIV). DAF refers to lysis of erythrocytes due to lack of decay-accelerating factor (DAF) on erythrocytes. CVID is a disorder that encompasses various defects ranging from IgA deficiency (in which only the plasma cells that produce IgA are absent) to severe hypogammaglobulinemia (in which there is a general lack of immunoglobulins in the blood). Severe combined immunodeficiency disease (SCID) is a disorder in which both B and T cells are missing.
Activation of a natural immunity response is enhanced by physical and chemical barriers. Which of the following is a physical barrier, which the nurse knows can be altered by illness, nutrition, or lifestyle?
Cilia of the respiratory tract Explanation: Cilia are considered a physical barrier, along with intact skin and mucous membranes.
A client is given a nursing diagnosis of social isolation related to withdrawal of support systems and stigma associated with AIDS. Which outcomes would indicate that the nurse's plan of care was effective? Select all that apply.
Client demonstrates beginning participation in events and activities. Client identifies appropriate sources of assistance and support. Client verbalizes feelings related to the changes imposed by the disease.
An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated?
Cytotoxic T cells Explanation: Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis (disintegration) and by releasing cytolytic enzymes and cytokines. Lymphokines can recruit, activate, and regulate other lymphocytes and white blood cells. These cells then assist in destroying the invading organism.
Which is an appropriate nursing intervention in the care of the client with osteoarthritis?
Encourage weight loss and an increase in aerobic activity Explanation: Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening, are important approaches to pain management. Clients should be assisted to plan their daily exercise at a time when the pain is least severe, or plan to use an analgesic, if appropriate, before an exercise session. Gastrointestinal complications, especially bleeding, are associated with the use of nonsteroidal anti-inflammatory drugs. Topical analgesics such as capsaicin and methyl salicylate may be used for pain management.
Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?
Histamine Explanation: When cells are damaged, histamine is released. Bradykinin is a polypeptide that stimulates nerve fibers and causes pain. Serotonin is a chemical mediator that acts as a potent vasoconstrictor and bronchoconstrictor. Prostaglandins are unsaturated fatty acids that have a wide assortment of biologic activities.
The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses?
Immunosenescence Explanation: Immunosenescence is the term for age-related changes in the immune system. These changes have been linked to the increased rates of illness and mortality in older adults, and an increased incidence of infections. There is no evidence that polypharmacy has caused an increase in infections in the older adult. The development of infections is not directly linked to vitamin intake or self-care activities.
A nurse is preparing an in-service presentation about primary immunodeficiencies. When describing these conditions, what would the nurse need to integrate into the presentation?
Most cases are typically diagnosed in infancy. Explanation: Most primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1. A large fraction of primary immunodeficiencies are not diagnosed until adolescence or early adulthood when the gender distribution equalizes. Secondary immunodeficiencies are more common than primary immunodeficiencies.
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as the form of the genetic viral material?
Ribonucleic acid (RNA) Explanation: HIV is a retrovirus that carries its genetic material in the form of RNA rather than DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding glycoproteins.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Risk for injury Explanation: In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.
A nurse knows to advise a patient who is taking Atarax, an over-the-counter (OTC) antihistamine, to be aware of the serious potential side effect of:
Seizures. Explanation: Atarax is the only OTC antihistamine that has the potential serious side effect of tremors and seizures.
The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (HIV). Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications?
Side effects of drug therapy Explanation: Describing the side effects of drug therapy is essential, with the admonition to refrain from discontinuing any of the prescribed drugs without first consulting the prescribing physician. Although the client may want to know how the drugs work in general, the specific action of each antiretroviral drug is not essential information. Teaching about condoms and vaccinations may be appropriate, but these topics are not directly related to the client's HIV medications.
A client who is has been HIV positive for 10 years has a CD4+T-lymphocyte count of 2600 cells/L. For which stage of the virus will the nurse provide care when the client is diagnosed with invasive cervical cancer?
Stage 3 because an opportunistic infection has occurred Explanation: There are five stages of HIV infection based on clinical history, physical examination, laboratory evidence, signs and symptoms, and associated infections and malignancies. If a stage 3-defining opportunistic illness has been diagnosed, the client is identified as being in stage 3 regardless of the CD4+ T-lymphjocyte test. The client does not qualify for stage 0 regardless of the length of time having the virus. The client was in stage 1 until cervical cancer was diagnosed. Stage 2 is not defined by the number of opportunistic infections that develop.
T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do?
T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person. Explanation: T-cell and B-cell lymphocytes are the primary participants in the immune response. They distinguish harmful substances and ignore those natural and unique to a person. Options B, C, and D are incorrect.
Which statement accurately reflects current stem cell research?
The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Explanation: The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Stem cells comprise only a small portion of all types of bone marrow cells. Research conducted with mouse models has demonstrated that once the immune system has been destroyed experimentally, it can be completely restored with the implantation of just a few purified stem cells. Stem cell transplantation has been carried out in human subjects with certain types of immune dysfunction, such as severe combined immunodeficiency. Clinical trails are underway in clients with a variety of disorders with an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis.
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:
Western blot test for confirmation of diagnosis. Explanation: The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.
Fibromyalgia is a common condition that involves
chronic fatigue, generalized muscle aching, and stiffness. Explanation: Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. The cause is unknown, and no pathological characteristics specific for the condition have been identified. Treatment consists of attention to the specific symptoms reported by the client. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals.
The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care?
increased fatigue Explanation: Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen. The client is reporting being able to do ADLs and decreased joint pain. The client's weight gain of 2 pounds does not correlate with self-care problems.
A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often." Which nursing action is the priority for this client?
Offer information on human immunodeficiency virus (HIV) testing. Explanation: In women, gynecologic problems may be the focus of the chief complaint for clients who are HIV positive but not yet diagnosed. Abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may also correlate with HIV infection. Based on this information, the priority nursing action is to offer information on HIV testing to the client. Although recommending abstinence or safer-sex practices, providing a prescribed topical antifungal agent to treat the client's vaginal infection, and referring to a support group may be appropriate, the priority is to determine the source of the client's symptoms.
