immune nclex
A nurse is collecting data on a client with rheumatoid arthritis. The nurse looks at the client's hands and notes these characteristic deformities. The nurse identifies this deformity as: Refer to figure. 1. Ulnar drift 2. Rheumatoid nodules 3. Swan neck deformity 4. Boutonniere deformity
Answer: 1 Rationale: All of the conditions identified in the options can occur in rheumatoid arthritis. Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints.
A health care provider aspirates synovial fluid from a knee joint of a client with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to indicate which finding? 1. Cloudy synovial fluid 2. Presence of organisms 3. Bloody synovial fluid 4. Presence of irate crystals
Answer: 1 Rationale: Cloudy synovial fluid is diagnostic of rheumatoid arthritis. Organisms present in the synovial fluid are characteristic of a septic joint condition. Bloody synovial fluid is seen with trauma. Urate crystals are found in gout.
A nurse determines that the neutropenic client needs further discharge teaching if which of the following statements is made by the client? 1. "I will include plenty of fresh fruits in my diet." 2. "If I develop a fever over 100° F, I will call my doctor." 3. "Petting my dog is fine as long as I wash my hands after doing so." 4. "My husband will just have to take over cleaning the cat's litter box."
Answer: 1 Rationale: Fresh fruits and vegetables are eliminated from the diet to avoid the introduction of pathogens. Fever of 100.4° F or greater should be reported immediately. Feeding and petting cats and dogs are fine as long as handwashing follows. Handling pet excrement must be avoided to avoid exposure to pathogens.
The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. Which client population is at most risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home
Answer: 1 Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; individuals having multiple surgeries; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts.
The camp nurse prepares to instruct a group of children about Lyme disease. Which of the following information would the nurse include in the instructions? 1. Lyme disease is caused by a tick carried by deer. 2. Lyme disease is caused by contamination from cat feces. 3. Lyme disease can be contagious by skin contact with an infected individual. 4. Lyme disease can be caused by the inhalation of spores from bird droppings.
Answer: 1 Rationale: Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by Ixodes ticks can be infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings.
A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse suggest to assist the client in performing activities of daily living? 1. Provide supportive care with hygiene needs. 2. Provide meals and snacks with high protein, high calorie, and high nutritional value. 3. Provide small, frequent meals. 4. Offer low microbial food.
Answer: 1 Rationale: Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options 2, 3, and 4 are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option 2 will assist the client in maintaining appropriate weight and proper nutrition. Option 3 will assist the client in tolerating meals better. Option 4 will decrease the client's risk of infection.
The nurse is assessing a 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? 1. "Did you have chicken pox as a child?" 2. "How many sexual partners have you had?" 3. "Did you use an electric blanket on your side?" 4. "Why don't you try docosanol cream (Abreva) on your lesions?"
Answer: 1 Rationale: The client has the symptoms of herpes zoster, or shingles, which is caused by the same organism as chicken pox. Asking about sexual partners is inappropriate for this disorder. An electric blanket use does not cause this type of lesions. Abreva is used on herpes simplex I (cold sores).
A nurse is doing discharge teaching with a client who has sickle cell disease. The nurse instructs the client to avoid which factor that could precipitate a sickle cell crisis? 1. Infection 2. Mild exercise 3. Fluid overload 4. Warm weather
Answer: 1 Rationale: The client should avoid infections, which can increase metabolic demand and cause dehydration, precipitating a sickle cell crisis. The client should also avoid dehydration from other causes. Warm weather and mild exercise do not need to be avoided, but the client should take measures to avoid dehydration during these conditions. Fluids are important to prevent dehydration. Finally, the client should avoid being in areas of high altitude, or flying in a nonpressurized aircraft because of lesser oxygen tension in these areas.
The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function
Answer: 1 Rationale: The client with immune deficiency has inadequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.
A nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse understands that which problem is a priority for the client? 1. Infection 2. Inability to cope 3. Lack of information about the disease 4. Feeling uncomfortable about body changes
Answer: 1 Rationale: The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority problem is infection. The question presents no data indicating that options 2, 3, or 4 are a problem.
A nurse is providing dietary instructions to a client with systemic lupus erythematosus. Which of the following dietary items would the nurse instruct the client to avoid? 1. Steak 2. Turkey 3. Broccoli 4. Cantaloupe
Answer: 1 Rationale: The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake.
The client with acquired immunodeficiency syndrome has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that which of the following procedures will be done to confirm whether these lesions are due to Kaposi's sarcoma? 1. Skin biopsy 2. Lung biopsy 3. Western blot 4. Enzyme-linked immunosorbent assay
Answer: 1 Rationale: The skin biopsy is the procedure of choice to diagnose Kaposi's sarcoma, which frequently complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay and Western blot are tests to diagnose human immunodeficiency virus status.
A client with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a nursing diagnosis of Impaired Gas Exchange written in the plan of care. Which of the following indicates that the expected outcome of care has not yet been achieved? 1. The client limits fluid intake. 2. The client has clear breath sounds. 3. The client expectorates secretions easily. 4. The client is free of complaints of shortness of breath.
Answer: 1 Rationale: The status of the client with a nursing diagnosis of Impaired Gas Exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include that the client breathes easier, coughs up secretions effectively, and has clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.
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 instructions? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."
Answer: 1 Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.
Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply. 1. Use non-latex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Do not puncture rubber stoppers with needles. 5. Keep a latex-safe supply cart available in the client's area. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure
Answer: 1 2 4 5 Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use non-latex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with a rubber stopper that requires puncture with a needle. It is not necessary to place the client in a private room.
A nurse is assisting in developing a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which of the following is the priority concern for this client? 1. Inability to care for self at home 2. Development of an infection 3. Lack of available support services 4. Isolation
Answer: 2 Rationale: Acquired immunodeficiency syndrome decreases the body's immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body's defense system. Opportunistic infections are a primary cause of death in people affected with AIDS. Therefore preventing infection is a priority of nursing care. Although the concerns in options 1, 3, and 4 may need to be addressed at some point in the care of the client, these are not the priority.
A nurse is providing instructions to a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. The nurse advises the client to do which of the following to increase comfort while minimizing symptoms? 1. Remove the plastic cover on the pillow. 2. Keep liquids on the nightstand at home. 3. Reduce fluid intake before bedtime. 4. Take an antipyretic after the fever spikes.
Answer: 2 Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to keep liquids on the nightstand at home. The client should keep a plastic cover on the pillow and place a towel over the pillowcase if needed also. The client should not decrease fluid intake, and the client should take an antipyretic before going to sleep and before the fever spikes.
The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate in the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wearing a gown and gloves to change the bed linens and gloves only for the bath
Answer: 2 Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.
A client with acquired immunodeficiency syndrome (AIDS) is taking zidovudine (Retrovir) 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. Which of the following would the nurse anticipate to be prescribed for the client? 1. Reduction in the medication dosage 2. Discontinuation of the medication 3. The administration of prednisone concurrent with the therapy 4. Administration of epoetin alfa (Epogen)
Answer: 2 Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.
A client calls the office of his primary care health care provider and tells the nurse that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction, because the client's neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to: 1. Advise the client to soak the site in hydrogen peroxide. 2.Ask the client if he ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency room. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.
Answer: 2 Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."
A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse would suspect that which of the following findings will be reported from this blood test? 1. Increased red blood cell count 2. Decrease of all cell types 3. Increased white blood cell count 4. Increased neutrophils
Answer: 2 Rationale: In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease of all cell types, probably caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.
A nurse is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1. Children in day care centers 2. Individuals with spina bifida 3. Individuals with cardiac disease 4. Individuals living in a group home
Answer: 2 Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work with manufacturing latex products; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, passion fruit, avocados, and chestnuts.
A client with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine (Videx) therapy. The clinic nurse emphasizes what instruction to this client? 1. Take crackers and milk with each dose of the medication. 2. Come to the health care clinic to be seen by the health care provider. 3. Decrease the dose of the medication until the next clinic visit. 4. This is an uncomfortable but expected side effect of the medication.
Answer: 2 Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine (Videx). The client should be seen by the health care provider and be monitored for indications of developing pancreatitis. The reported symptoms are not the primary subject, and so the options directed toward explaining or managing them are not correct. The nurse should not encourage the client to alter the medication dose without first notifying the health care provider.
A client with acquired immunodeficiency syndrome (AIDS) is taking didanosine (Videx). The client calls the nurse at the health care provider's office and reports nausea, vomiting, and abdominal pain. Which of the following instructions would the nurse provide to the client? 1. This is an expected side effect of the medication. 2. Come to the office to be seen by the health care provider. 3. Take crackers and milk with the administration of the medication. 4. Decrease the dose of the medication until the next health care provider's visit.
Answer: 2 Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of developing pancreatitis, which include increased serum amylase in association with increased serum triglycerides, decreased serum calcium, and nausea, vomiting, or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. The client should be seen by the health care provider.
A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which of the following descriptions of this condition? 1. The presence of tiny red vesicles 2. An autoimmune disease that causes blistering in the epidermis 3. The presence of skin vesicles found along the nerve caused by a virus 4. The presence of red, raised papules and large plaques covered by silvery scales
Answer: 2 Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.
A clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse assesses for an early manifestation of Pneumocystis jiroveci infection by monitoring for which of the following at each client visit? 1. Fever 2. Cough 3. Dyspnea on exertion 4. Dyspnea at rest
Answer: 2 Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.
A client is diagnosed with stage I of Lyme disease. In addition to the rash, the nurse would check the client for which manifestation? 1. Arthralgias 2. Flulike symptoms 3. Neurologic deficits 4. Enlarged and inflamed joints
Answer: 2 Rationale: The hallmark of stage I is the development of a skin rash at the tick bite site. The rash develops into a concentric ring that has a bullseye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. The other options listed occur in stage II (neurological deficits) or stage III (arthralgias and enlarged, inflamed joints).
The client is diagnosed with stage I of Lyme disease. The nurse assesses the client for which characteristic of this stage? 1. Arthralgias 2. Flu-like symptoms 3. Enlarged and inflamed joints 4. Signs of neurological disorders
Answer: 2 Rationale: The hallmark of stage I is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bullseye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Neurological deficits occur in stage II. Arthralgias and joint enlargements are most likely to occur in stage III.
A nurse is assigned to care for a client who returned home from the emergency department following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs 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: 1. Contact the health care provider (HCP). 2. Cover the crutch pads with cloth. 3. Call the local medical supply store, and ask for a cane to be delivered. 4. Tell the client that the crutches must be removed immediately from the house.
Answer: 2 Rationale: The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 4 is inappropriate and may alarm the client. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may not be appropriate, considering this client's injury. No reason exists to contact the HCP at this time.
A 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 of the following questions should the nurse ask next? 1. "Was the tick small or large?" 2. "When were you bitten by the tick?" 3. "Did you save the tick for inspection?" 4. "Did the tick bite anyone else in the family?"
Answer: 2 Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. The appropriate question by the nurse should elicit information related to when the tick bite occurred.
A nurse is assisting in the care of a client diagnosed with systemic lupus erythematosus (SLE). The nurse should administer which of the following prescribed medications that is needed to manage the condition? 1. Antidiarrheal 2. Corticosteroid 3. Antibiotic 4. Opioid analgesic
Answer: 2 Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory medications, corticosteroids, and immunosuppressants. The other options are not standard components of medication therapy for this disorder.
A 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 had not contracted HIV. The nurse explains the test results to the client, telling the client that: 1. There is no further need for testing. 2. A negative HIV test is considered accurate. 3. A negative HIV test is not considered accurate during the first 6 months after exposure. 4. The test should be repeated in 1 week.
Answer: 3 Rationale: A test done for HIV should be repeated. There might be a lag period after the infection occurs and before antibodies appear in the blood. Therefore a negative HIV test is not considered accurate during the first 6 months after exposure.
A nurse is assisting in developing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention should the nurse suggest including in the plan of care to manage this symptom? 1. Keep the call bell within reach for the client. 2. Administer a sedative at bedtime. 3. Administer an antipyretic at bedtime. 4. Provide a back rub and comfort measures before bedtime.
Answer: 3 Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer an antipyretic at bedtime. It is also helpful to keep a change of bed linens and night clothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Options 1, 2, and 4 are important interventions but they are unrelated to the subject of fever and night sweats.
A Cub Scout leader who is a nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellent because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants."
Answer: 3 Rationale: In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, one should avoid heavily wooded areas or areas with thick underbrush. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.
The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of the following? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions on the skin
Answer: 3 Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.
The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is: 1. A local rash that occurs as a result of allergy 2. A disease caused by overexposure to sunlight 3. An inflammatory disease of collagen contained in connective tissue 4. A disease caused by the continuous release of histamine in the body
Answer: 3 Rationale: SLE is an inflammatory disease of collagen contained in connective tissue. Options 1, 2, and 4 are not associated with this disease.
A client diagnosed with Lyme disease says to the nurse, "I heard this disease can affect the heart. Is this true?" The nurse should make which response to the client? 1. "Where did you get your information?" 2. "Yes, that's true but it rarely ever occurs." 3. "It can, but you will be monitored closely for cardiac complications." 4. "It primarily affects the joints with the occasional facial paralysis."
Answer: 3 Rationale: Stage 2 of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. The serious problems that occur in this stage include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. The remaining options are either untrue or do not effectively address the client's concern.
A nurse reads the chart of a client who has been diagnosed with stage 3 Lyme disease. Which clinical manifestation supports this diagnosis? 1. A generalized skin rash 2. A cardiac dysrhythmia 3. Complaints of joint pain 4. Paralysis of a facial muscle
Answer: 3 Rationale: Stage 3 develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage 2. A rash occurs in stage 1. Paralysis of the extremity where the tick bite occurred is not a characteristic of Lyme disease.
A client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse would focus on which of the following first until additional help arrives? 1. Preparing a dose of epinephrine (Adrenalin) 2. Preparing a dose of a corticosteroid 3. Maintaining a patent airway 4. Telling the client to obtain a Medic-Alert bracelet
Answer: 3 Rationale: The initial priority of the nurse would be to maintain a patent airway. Once additional helps arrives, the client would likely receive epinephrine and corticosteroids. The topic of the Medic-Alert bracelet should be deferred until the client is stable.
A 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. Which nursing action is appropriate? 1. Refer the client for a blood test immediately. 2. Inform the client that the tick is needed to perform a test. 3. Arrange for the client to return in 4 to 6 weeks to be tested. 4. Ask the client to describe the size, shape, and color of the tick.
Answer: 3 Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. Options 1, 2, and 4 are inaccurate.
Indinavir (Crixivan) is prescribed for a client with human immunodeficiency virus (HIV). The nurse has provided instructions to the client regarding ways to maximize absorption of the medication. Which of the following, if stated by the client, indicates an adequate understanding of the use of this medication? 1. "I need to take the medication with my large meal of the day." 2. "I need to store the medication in the refrigerator." 3. "I need to take the medication with water but on an empty stomach." 4. "I need to take the medication with a high-fat snack."
Answer: 3 Rationale: To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal such as cornflakes with skim milk and sugar. It is not to be administered with a large meal. The medication should be stored at room temperature and protected from moisture because moisture can degrade the medication.
The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed? 1. Antibiotic 2. Antidiarrheal 3. Corticosteroid 4. Opioid analgesic
Answer: 3 Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. The incorrect options are not standard components of medication therapy for this disorder.
A client calls the emergency department and tells the nurse that he received a bee sting to the arm while weeding a garden. The client states that he has received bee stings in the past and is not allergic to bees. The client states that the site is painful and asks the nurse for advice to alleviate the pain. The nurse tells the client to first: 1. Take two acetaminophen (Tylenol). 2. Place a heating pad to the site. 3. Apply ice and elevate the site. 4. Lie down and elevate the arm.
Answer: 3 Rationale: When a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. Pain may be alleviated by the application of an ice pack and elevating the site. A heating pad will increase discomfort at the site. Acetaminophen may be taken by the client to assist in alleviating discomfort, but this would not treat the injury at a local level. Lying down and elevating the arm may have some effect on reducing edema at the site but will not directly assist in alleviating the pain at the site of injury.
A client is positively diagnosed with stage 1 Lyme disease. The client asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which of the following will be part of the treatment plan? 1. Ultraviolet light therapy 2. No treatment unless symptoms develop 3. Treatment with intravenous (IV) penicillin G 4. A 3- to 4-week course of oral antibiotic therapy
Answer: 4 Rationale: A 3- to 4-week course of oral antibiotic therapy is recommended during stage 1. Later stages of Lyme disease may require therapy with intravenous antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.
A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which of the following nursing actions is appropriate? 1. Refer the client for a blood test immediately. 2. Inform the client that there is not a test available for Lyme disease. 3. Tell the client that testing is not necessary unless arthralgia develops. 4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.
Answer: 4 Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Options 1, 2, and 3 are incorrect.
The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that immunization provides which of the following? 1. Protection from all diseases 2. Innate immunity from disease 3. Natural immunity from disease 4. Acquired immunity from disease
Answer: 4 Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases.
The home care nurse is ordering dressing supplies for a client who has an allergy to latex. The nurse asks the medical supply personnel to deliver which of the following? 1. Elastic bandages 2. Adhesive bandages 3. Brown Ace bandages 4. Cotton pads and silk tape
Answer: 4 Rationale: Cotton pads and plastic or silk tape are latex-free products. The items identified in the incorrect options are products that contain latex.
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 questions the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas
Answer: 4 Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy.
Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma? 1. A kidney transplant client 2. A male with a history of same-sex partners 3. A client receiving antineoplastic medications 4. An individual working in an environment where exposure to asbestos exists
Answer: 4 Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It is seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma.
The nurse interprets that the client who is prescribed zalcitabine (Hivid) is experiencing an adverse effect of this medication when which event is reported by the client? 1. Diarrhea 2. Tinnitus 3. Burning with urination 4. Numbness in the legs
Answer: 4 Rationale: Peripheral neuropathy is an adverse effect associated with the use of zalcitabine, which manifests initially as numbness and burning sensations in the extremities. They may progress to sharp shooting pains or severe continuous burning if the medication is not withdrawn. The other options are not associated with use of this medication.
Which client is at the highest risk for systemic lupus erythematous (SLE)? 1. An Asian male 2. A white female 3. An African-American male 4. An African-American female
Answer: 4 Rationale: SLE affects females more commonly than males. It is more common in African-American females than in white females.
A nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse further checks for which of the following that is also indicative of the presence of SLE? 1. Emboli 2. Ascites 3. Two hemoglobin S genes 4. Butterfly rash on cheeks and bridge of nose
Answer: 4 Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE. Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many conditions but are not associated with SLE.
A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous? 1. Weight gain 2. Subnormal temperature 3. Elevated red blood cell count 4. Rash on the face across the bridge of the nose and on the cheeks
Answer: 4 Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.
A client 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 verbalized to increase intake of foods such as: 1. Raw fruits and vegetables 2. Hot soup 3. Peanut butter 4. Puddings
Answer: 4 Rationale: The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables. The client is encouraged to take in foods that are mild, nonabrasive, and easy to swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs, and desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating.
A nurse is assisting in preparing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure should the nurse include in the plan? 1. Dairy products with each snack and meal 2. Red meat daily 3. Adding spices to food to make the taste more palatable 4. Foods that are at room temperature
Answer: 4 Rationale: The client with AIDS experiencing nausea should avoid fatty products, such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous foods should be avoided because they aggravate nausea. Foods are best tolerated either cold or at room temperature.
A client who is human immunodeficiency virus (HIV) positive has had a Mantoux skin test. The results show a 7-mm area of induration. The nurse evaluates that this result is: 1. Negative 2. Borderline 3. Uncertain 4. Positive
Answer: 4 Rationale: The client with HIV is considered to have positive results on Mantoux skin testing with an area of 5 mm of induration or greater. The client without HIV is positive with induration greater than 10 or 15 mm if the client is at low risk. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is also possible for the client infected with HIV to have false negative readings because of the immunosuppression factor.
A client is diagnosed with an immune deficiency. The nurse focuses on which of the following as the highest priority when providing care to this client? 1. Encouraging discussion about emotional impact of the disorder 2. Identifying historical factors that placed the client at risk 3. Providing emotional support to decrease fear 4. Protecting the client from infection
Answer: 4 Rationale: The client with immune deficiency has inadequate immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. The other options are also part of the plan of care but are not the highest priority.
A client with human immunodeficiency virus (HIV) who has contracted tuberculosis (TB) asks the nurse how long the medication therapy lasts. The nurse responds that the duration of therapy would likely be for at least: 1. 6 total months and at least 1 month after cultures convert to negative 2. 6 total months and at least 3 months after cultures convert to negative 3. 9 total months and at least 3 months after cultures convert to negative 4. 9 total months and at least 6 months after cultures convert to negative
Answer: 4 Rationale: The client with tuberculosis who is coinfected with HIV requires that antitubercular therapy last longer than usual. The prescription is usually for a total of 9 months and at least 6 months after sputum cultures convert to negative.
A client is diagnosed with stage 1 Lyme disease. The nurse checks the client for which hallmark characteristic of this stage? 1. Signs of neurological disorders 2. Enlarged and inflamed joints 3. Headache 4. Skin rash
Answer: 4 Rationale: The hallmark of stage 1 is the development of a skin rash that occurs within 2 to 30 days of infection, generally at the site of the tick bite. The remaining options are not initially related to this pathology.
A nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse would inform the students that which of the following is an unsafe behavior? 1. Abstinence 2. Mutual monogamy 3. Use of latex condoms 4. Use of natural skin condoms
Answer: 4 Rationale: The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through. Abstinence is the safest way to avoid HIV infection. The next most reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of the HIV virus as long as the condom is used properly and remains in place and intact.
