Immune

The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which should be the appropriate nursing action?

Ask the client if they ever sustained a bee sting in the past.

The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. The nurse should determine that which client population is at risk for developing this type of allergy?

Hairdressers

The nurse is assisting with the administration of immunizations at a health care clinic. The nurse should understand that immunization provides which protection?

Acquired immunity from disease

The nurse is instructing the client with a diagnosis of systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which primary foods? Select all that apply.

Beef Cheese

The primary health care provider aspirates synovial fluid from a knee joint of a client diagnosed with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and should expect the results to best indicate which finding?

Cloudy synovial fluid

The nurse is assisting in the care of the client diagnosed with systemic lupus erythematosus (SLE). The nurse should most appropriately administer which prescribed medication to manage the condition?

Corticosteroid

The home care nurse is prescribing dressing supplies for the client who has an allergy to latex. The nurse should ask the medical supply personnel to deliver which items?

Cotton pads and silk tape

A complete blood cell count is performed on the client with a diagnosis of systemic lupus erythematosus (SLE). The nurse should suspect that which finding will most likely be reported from this blood test

Decrease of all cell types

The nurse should determine that which are risk factors for systemic lupus erythematous (SLE)? Select all that apply.

Female gender African-American origin Age between 60 to 75 years Being in the childbearing years

The client is diagnosed with stage I of Lyme disease. The nurse should check the client for which characteristic of this stage?

Flu-like symptoms

A client is diagnosed with stage I Lyme disease. In addition to the rash, the nurse should check the client for which manifestation?

Flulike symptoms

The nurse is assisting in preparing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure should the nurse most likely include in the plan?

Foods that are at room temperature

The nurse reinforces home care instructions to a client diagnosed with systemic lupus erythematosus and instructs the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching?

I should take hot baths because they are relaxing."

Which findings should cause the nurse to postpone administration of an immunization and do further data collection? Select all that apply.

Immune deficiency disease Familial history of severe allergic response to the immunization

The nurse is assisting with identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?

Individuals with spina bifida

The client is diagnosed with an immune deficiency. The nurse focuses on which nursing responsibility as the highest priority when providing care to this client?

Protecting the client from infection

The nurse is assisting with planning the care of a client with a diagnosis of immunodeficiency. The nurse should incorporate which intervention as a priority in the plan of care?

Protecting the client from infection

The client with a diagnosis of acquired immunodeficiency syndrome has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that which procedure will be done to confirm whether these lesions are due to Kaposi's sarcoma?

Skin biopsy

The client calls the health care clinic and tells the nurse that he was bitten by a tick. The client asks the nurse about the first signs of Lyme disease. The nurse should respond with which characteristic of stage 1 of Lyme disease?

Skin rash

The nurse is explaining about antigens and antibodies when the client asks where antibodies come from. The nurse should include which areas as the most appropriate response? Select all that apply.

Tears Spleen Saliva Blood serum Lymph nodes

The client prescribed zidovudine has been diagnosed with severe neutropenia. The nurse anticipates which intervention should be implemented?

The medication will be temporarily discontinued.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking didanosine. The nurse reinforces instructions to the client to watch for which signs/symptoms that the medication may have caused the adverse effect of pancreatitis?

Vomiting and abdominal pain

The nurse determines that the client diagnosed with neutropenia needs further teaching if which statement is made by the client?

"I will include plenty of fresh fruits in my diet."

The nurse is reviewing the medical record of the client who is suspected of having systematic lupus erythematosus (SLE). Which sign should the nurse expect to be documented in the record that is most related to this diagnosis?

Butterfly rash on cheeks and bridge of the nose

The nurse is assisting in developing a plan of care for the pregnant client diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse should determine that which is the priority concern for this client?

Development of an infection

The client recently diagnosed with toxoplasmosis asks the nurse, "What is toxoplasmosis? How did I get it, and what do I have to do to get rid of it"? Which information should the nurse include in the response? Select all that apply.

Toxoplasmosis is treated with sulfadiazine. Pregnant people should not empty litter boxes. Toxoplasmosis is an organism found in rare pork. Toxoplasmosis may cause a severe inflammatory response.

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse incorporate in the plan during the bathing of this client?

Wearing a gown and gloves

The clinic nurse periodically cares for the client diagnosed with acquired immunodeficiency syndrome. The nurse should assess for an early manifestation of Pneumocystis jiroveci infection by monitoring for which sign/symptom at each client visit?

Cough

The client diagnosed with stage I Lyme disease asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which treatment should be included in the care plan?

A 3- to 4-week course of oral antibiotic therapy

The client reports to the health care clinic to obtain testing regarding human immunodeficiency virus (HIV) status after being exposed to an individual who is HIV positive. The test results are reported as negative and the client tells the nurse that he feels so much better knowing that he has not contracted HIV. The nurse should explain the test results to the client, including which information?

A negative HIV test is not considered accurate during the first 6 months after exposure.

The nurse is assisting in developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. Which nursing intervention should be included in the plan of care to manage this symptom?

Administer an antipyretic at bedtime.

The client diagnosed with pemphigus is being seen in the clinic regularly. The nurse should plan care based on which description of this condition?

An autoimmune disease that causes blistering in the epidermis

Which individual is least at risk for the development of Kaposi's sarcoma?

An individual working in an environment where exposure to asbestos exists

The nurse is assisting in developing a plan of care for the client with immunodeficiency. The nurse should determine that which problem is a priority for the client?

Infection

The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate?

Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding this diagnosis?

It is an inflammatory disease of collagen contained in connective tissue.

Which symptoms should the nurse anticipate and monitor for in clients diagnosed with stage 4 human immunodeficiency virus (HIV) infection? Select all that apply.

Lymphoma Kaposi's sarcoma Candidiasis of the esophagus

A client is diagnosed with stage II Lyme disease. The nurse should check the client for which characteristic of this stage?

Nervous system disorders

The nurse should interpret that the client prescribed zalcitabine is experiencing an adverse effect of this medication when which event is reported by the client?

Numbness in the legs

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse implement to assist the client in performing activities of daily living?

Provide supportive care with hygiene needs.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client verbalizes the intent to increase intake of which food(s)?

Puddings

The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should determine that this has been confirmed by which finding?

Punch biopsy of the cutaneous lesions

The client is suspected of having systemic lupus erythematous (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of SLE?

Rash on the face across the nose and on the cheeks

A client diagnosed with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a client problem of impaired gas exchange written in the plan of care. Which indicates that the expected outcome of care has not yet been achieved?

The client limits fluid intake.

The nurse is collecting data on the client with a diagnosis of rheumatoid arthritis. The nurse looks at the client's hands and notes characteristic deformities. The nurse should identify this as which deformity? Refer to figure.

Ulnar drift

The nurse is assessing the client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection?

"Did you have chicken pox as a child?"

Indinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV). The nurse has reinforced instructions to the client regarding ways to maximize absorption of the medication. Which statement by the client indicates an adequate understanding of the use of this medication?

"I need to take the medication with water but on an empty stomach."

The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching

"I should not use insect repellent because it will attract the ticks."

The primary health care provider prescribes fluconazole for the client. When administering this medication the nurse should explain to the client that it is prescribed to treat which opportunistic infection?

Candidiasis

The client diagnosed with Lyme disease tells the nurse, "I heard this disease can affect the heart. Is this true?" The nurse should make which response to the client?

"It can, but you will be monitored closely for cardiac complications.

The client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which question should the nurse ask next?

"When were you bitten by the tick?"

The client diagnosed with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine therapy. The clinic nurse should reinforce which instruction to this client?

Come to the health care clinic to be seen by the primary health care provider.

The nurse is caring for the client diagnosed with systemic lupus erythematosus (SLE) that is affecting the hematopoietic system. Which data regarding signs and symptoms should the nurse anticipate collecting? Select all that apply.

Anemia Splenomegaly Lymphadenopathy

The client calls the emergency department and tells the nurse that he received a bee sting to the arm. The client states that he has received bee stings in the past and is not allergic to bees but the site is painful and asks the nurse how to alleviate the pain. Which primary action should the nurse instruct the client to take?

Apply ice and elevate the site.

The client arrives at the health care clinic requesting to be tested for Lyme disease. The client tells the nurse that he removed the tick and flushed it down the toilet. The nurse should respond with which most appropriate action?

Arrange for the client to return in 4 to 6 weeks to be tested.

The nurse reads the chart of the client who has been diagnosed with stage III Lyme disease. The nurse should determine that which sign/symptom best supports this diagnosis?

Complaints of joint pain

The nurse is collecting data on a client complaining of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse should further check for which manifestation that is also indicative of the presence of SLE?

Butterfly rash on the cheeks and bridge of the nose

The home care nurse is assigned to care for the client who returned home following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs to reinforce instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should do which action?

Cover the crutch pads with cloth.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking zidovudine 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results indicate severe neutropenia. Which should the nurse next anticipate to be prescribed for the client?

Discontinuation of the medication

Which signs/symptoms should indicate to the nurse that the client is experiencing an anaphylactic reaction? Select all that apply.

Hives Stridor Dyspnea Urticaria Wheezing

The nurse is assigned to care for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the primary health care provider's prescriptions. Which medication should the nurse expect to be prescribed to aid in long-term control?

Hydroxychloroquine

The client who is diagnosed positive for human immunodeficiency virus (HIV) has had a tuberculin skin test. The results show a 7-mm area of induration. The nurse should interpret the test results as which response?

It is positive.

The nurse is providing instructions to the client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. The nurse should advise the client to do which action to best increase comfort while minimizing symptoms?

Keep liquids on the nightstand at home.

The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse should question the client about an allergy to which food items? Select all that apply.

Kiwi Bananas

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?

Lyme disease is caused by a tick carried by deer.

Which medications should the nurse expect to be prescribed to effectively reduce nasal edema and rhinorrhea (thin watery discharge from the nose)? Select all that apply.

Oxymetazoline Pseudoephedrine

The nurse is reinforcing dietary instructions to a client diagnosed with systemic lupus erythematosus. Which dietary items should the nurse most instruct the client to avoid?

Steak

Which interventions should be implemented in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

Use nonlatex gloves. Use medications from glass ampules. Do not puncture rubber stoppers with needles. Keep a latex-safe supply cart available in the client's area.

The nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse should inform the students that which behavior is most unsafe?

Use of natural skin condoms