chapter 66 immune disorder

A client arrives at the healthcare clinic and tells the nurse that she was bitten by a tick and would like to be retested for lymes. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate ? SATA A)twll the client testng is unnecessary unless arthralgia develops B)tell client to avoid any woody,grassy areas that may contain ticks C)instruct client to take antibiotic immediately D)inform client to plan to have a blood test 4-6 weeks after a bite to detect presence of the disease E)tell the client that if this happens again to never remove the tick but vigorously scrub the area with an antiseptic

b,c,d

the nurse is performing as assessment on a client who has been diagnosed with an allergy to latex. in determining the clients risk factors , the nurse should question the client about an allergy to food items ? A)eggs B)milk C)yogurt D)bananas

4

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 daycare D)people in group homes

A

the nurse is assisting in planning of care for a client diagnosed of immunodeficiency and should incorporate which action as a priority in the plan ? A)protecting client from infection B)providing emotional support to decrease fear C)encouraging discussions about lifestyle changes D)identifying factors that decreased immune function

A

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 instruction? 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 exercise such as walking when i am not fatigued.

A ) i should take hot baths b/c they are relaxing

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? A) administer oxygen B) assess respiratory status C)document events,interventions, clients response D)leave the client briefly to contact HCP E)Keep client supine regardless of the blood pressure readings F)Start an IV of D5W, administer 500ml bolus

A, B,C

the nurse is conducting allergy testing on a client .Which post procedure interventions are most appropriate?SATA A)record site, date and time of test B)give the client a list of the wheal and document finding C)estimate the size of the wheal and document the finding D)tell the client to return to have the site inspected only if theres a reaction E)have client wait in the waiting room for at least 1-2 hours after injection

A,B

A client calls the nurse in the ER and states that he was stung by a bee while gardening. The client is afraid of a severe reaction b/c the clients neighbor experienced a reaction 1 week ago. Which action should the nurse take ? A)Advise the client to soak the site in hydrogen peroxide B)Ask the client if he ever sustained a bee sting in the past. C)Tell the client to call an ambulance for transport D)tell the client to not worry about the sting unless breathing occurs

B

A client is diagnosed with scleroderma. Which interventions should the nurse anticipate to be prescribed ? A) maintain bed rest as much as possible B)administer corticosteroids as prescribed for inflammation C)Advise the client to remain supine for 1 -2 hours after meals D)keep the room temperature warm during the day and cool at night

B

A client presents at the health care provider office with complaints of a ring like rash on his upper leg. Which question should the nurse ask first ?A) do you have any cats in your home B)have you been camping last month C) Have you or close contacts had any flu like symptoms within the last few weeks D) Have you been in physical contact with anyone who has the same type of rash

B

The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. which statement by the client indicates that the client that the client understand the diagnosis? A)my skin will have tiny red vesicles B)The presence of the skin vesicles is caused by a virus C)I have an autoimmune disease that causes blistering in the epidermis D) The presence of red, raised papules and large plaques covered by silvery scales will be present on my skin

C

the client with AIDs is diagnosed with cutaneous kaposis sarcoma. Based on the diagnosis nurse understands that this has been diagnosed by which finding? A) swelling in the genital area B)swelling in lower extremities C)positive punch biopsy of the cutaneous lesions D)appearance of reddish bluish lesions noted on skin

C

Which interventions apply in care of a client at high risk for an allergic response to a latex allergy?SATA a)use nonlatex gloves B)use medications from glass amplules C)place client in private room only D)keep latex safe supply cart available E)avoid use of meds vial that have rubber stoppers F)use a blood pressure cuff from the election device only to measure the blood pressure

a,b,D, e

the nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? a)wearing gloves b)gown,gloves c)gown, gloves, mask d)gown, gloves to change the bed linens,gloves only for the bed

b)gown, gloves

the nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent lymes. Which statements by one of the scouts indicates a need for further a need for further instruction ? A)i need to bring a hat to wear during the trip B)i should wear long sleeved tops, long pants C)i should not use insect repellents because it will attract ticks D)i need to wear closed shoes ,socks, that can be pulled over my pants

c