Immunology ATI

A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about the skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of the following responses should the nurse give? "Keep the lesions covered with a light sterile dressing when going outdoors." "Rub lesions with a washcloth to dry after washing." "Apply moisturizer after bathing the lesions with warm water." "Apply antibiotic cream twice per day until scabs form on the lesions."

"Apply moisturizer after bathing the lesions with warm water." The nurse should instruct the client to clean, dry, and moisturize the skin using warm (not hot) water, along with an unscented lotion.

A nurse is providing teaching to a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses should the nurse make? "Take a cool bath in the evening" "Exercise every other day" "Use pillows to support your joints while in bed" "Ask a friend or a family member to help with household chores"

"Ask a friend or a family member to help with household chores"

A nurse is planning discharge teaching for a client who is receiving chemotherapy and has bone marrow suppression. Which of the following instructions should the nurse plan to include in the teaching? "Take aspirin for minor aches and pains." "Clean your toothbrush with warm water weekly." "Bathe with an antimicrobial soap twice per day." "Wear clothing that will minimize sun exposure."

"Bathe with an antimicrobial soap twice per day."

A nurse is teaching a client who has human immunodeficiency virus about how the virus is transmitted. Which of the following statements should the nurse include in the teaching? "HIV can be transmitted as soon as a person develops manifestations." "HIV can be transmitted to anyone who has had contact with the infected blood." "HIV is transmitted through the respiratory route through droplets." "HIV is transmitted only during the active phase of the virus."

"HIV can be transmitted to anyone who has had contact with the infected blood." The concentration of the virus is highest in blood but also has been isolated in other body fluids, including sputum, saliva, cerebrospinal fluid, urine, and semen. Clients who have HIV are cautioned to practice safe sex, avoid donating blood, and abstain from sharing needles with others

A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? "I should take this medication with food." "I need to take a B-complex vitamin while taking this medication." "I can expect this medication to turn my skin orange." "I can expect this medication to make my vision blurry."

"I can expect this medication to turn my skin orange."

A nurse in a provider's office is providing teaching to a client who has a recent diagnosis of rheumatoid arthritis and has a new prescription for naproxen tablets. Which of the following statements by the client requires further teaching? "This medication will take 4 weeks for me to notice relief in my joints." "I can take an antacid with this medication for indigestion." "I can take this medication with aspirin." "The naproxen goes down easier when I crush it and put it in applesauce."

"I can take this medication with aspirin." The nurse should instruct the client to avoid taking this medication with any other NSAIDs, such as aspirin, because this can increase the risk for bleeding and gastrointestinal ulceration.

A nurse is providing discharge teaching to a client who has HIV. Which of the following statements by the client indicates an understanding of the teaching? "I will clean the bathroom surfaces with full-strength bleach." "I should discard open beverages that have been unrefrigerated for 1 hr." "I should wash laundry that is soiled with a body fluid in cool water." "I will work in the garden for exercise."

"I should discard open beverages that have been unrefrigerated for 1 hr."

A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching? "I should limit my exposure to sunlight." "I should avoid drinking alcohol." "I should not smoke." "I should limit of intake of foods high in purine."

"I should not smoke." Raynaud's disease is a disorder of the blood vessels that supply blood to the skin and cause the distal extremities to feel numb and cool in response to cold temperatures or stress. During a Raynaud's attack, these arteries narrow, limiting blood circulation to affected areas. Strong emotion or exposure to the cold causes these areas to become white, due to a lack of blood flow in the area. They then turn blue, as tiny blood vessels dilate to allow more blood to remain in the tissues. When the flow of blood returns, the area becomes red and then later returns to normal color. This can cause tingling, swelling and painful throbbing. The attacks can last from minutes to hours. If the condition progresses, blood flow to the area could become permanently decreased, causing the fingers to become thin and tapered, with smooth, shiny skin and slow-growing nails. If an artery becomes blocked completely, gangrene or ulceration of the skin can occur. Smoking cessation, not just reduction, is an action the client should take to prevent the onset of the manifestations of Raynaud's disease

A nurse is providing teaching to a client who has a diagnosis of Hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? "I am unable to donate blood." "I will need to get a booster shot of immune serum globulin every year." "I should stop eating raw clams." "I can get this disease by getting a tattoo."

"I should stop eating raw clams." Hepatitis A is transmitted via the fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, or uncooked shellfish. Individuals who eat raw or steamed shellfish are at increased risk for acquiring hepatitis A

A nurse is providing teaching to a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? "I should use a sunscreen with an SPF of at least 15." "Long-term immunosuppressive therapy could cure this disease." "I should wear gloves when it is cold outside." "SLE should not affect my lungs or breathing."

"I should wear gloves when it is cold outside." Raynaud's phenomenon commonly accompanies SLE and can cause painful vasoconstriction in the client's fingers when exposed to cold temperatures

A nurse is teaching a client who has tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen when she states which of the following? "I will begin vacuuming once a week." "Carpeting the entire house will be very expensive, but it will be worth it." "I will apply a mattress cover to my bed." "Installing curtains on the windows will help control the dust in the house."

"I will apply a mattress cover to my bed."

A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following client statements indicates an understanding of the teaching? "I will avoid being in large crowds while taking this medication." "I should expect symptoms to subside in 1 to 2 weeks after starting this medication." "I will increase my intake of vitamin D while taking this medication." "I should expect to experience constipation while taking this medication."

"I will avoid being in large crowds while taking this medication." The nurse should instruct the client to avoid crowds when taking methotrexate. Methotrexate can cause leukopenia due to bone marrow suppression, which can increase the client's risk for infection.

A nurse is providing discharge instructions to a client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent transmission of the sexually transmitted infections (STI)? "I will bring my sexual partner in for treatment." "Now that I've had my first dose of medicine, I can resume sexual activity." "Once I have been treated, it is no longer necessary to use condoms." "Once treatment is completed and I am free of symptoms, I don't have to return to the clinic."

"I will bring my sexual partner in for treatment."

A nurse is providing teaching to a client who takes an oral contraceptive and has a new prescription for amoxicillin. Which of the following statements by the client indicates an understanding of the teaching? "I will use a backup method of birth control while I am taking this medication." "I should take this medication on an empty stomach." "I should expect to have constipation while taking this medication." "I will keep taking this medication until I feel better."

"I will use a backup method of birth control while I am taking this medication."

A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome. Which of the following statements by the clients' partner indicates the need for further teaching? "I will dispose soiled tissues in separate plastic bags." "I'll clean up blood spills immediately with hot water." "I know that hand washing is an important preventive measure." "I will wash soiled clothes in hot water."

"I'll clean up blood spills immediately with hot water."

A nurse is planning an education program for a group of high school teachers who will be taking students on a hike. Which of the following information should the nurse include regarding Lyme disease? "If bitten by a tick, you should be tested immediately." "If you have a tick embedded in your skin, apply a lit match to remove it." "You should wear dark-colored clothing to deter ticks from biting." "If you develop pain and stiffness in your joints, you should see your doctor."

"If you develop pain and stiffness in your joints, you should see your doctor." The nurse should inform the group that manifestations of stage 1 Lyme disease include influenza-like manifestations, a "bull's-eye" rash, muscle and joint pain, and stiffness. The nurse should instruct the group to report these findings to a provider.

A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse give? "That is your decision alone." "I would if I were you." "It sounds like you are unsure what to say to your partner." "Your provider is required by law to notify your partner."

"It sounds like you are unsure what to say to your partner." This response uses the therapeutic communication tools of clarifying and restatement. It identifies that the client is unsure about if or how to approach the issue of being HIV positive with his partner, a common concern of clients due to fear of rejection. This response shows that the nurse is open to further communication with the client and encourages his expression of feelings.

A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse plan to include? "Avoid the use of NSAIDS." "Stop taking the corticosteroids when your symptoms resolve." "Exposure to ultraviolet light will help control the skin rashes." "Monitor your body temperature and report any elevations promptly."

"Monitor your body temperature and report any elevations promptly." SLE is a chronic autoimmune disorder that can affect any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack tissues and organs, including the skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation and remissions. The nurse should teach the client to monitor body temperature and report any elevations promptly, as fever can suggest either an exacerbation or a potentially life-threatening infection

A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following information should the nurse include in the teaching? "PCP is sexually transmitted from person to person." "You were most likely exposed to a contaminated surface, such as a drinking glass." "PCP results from an impaired immune system." "You may have contracted PCP from a family pet."

"PCP results from an impaired immune system."

A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching? "Wash your genitalia using an antimicrobial soap." "Rinse your dishes with cold water." "Clean your toothbrush once per month." "Incorporate raw fruits and vegetables into your diet."

"Wash your genitalia using an antimicrobial soap." The nurse should instruct the client to bathe daily using an antimicrobial soap to prevent the spread of infection. If bathing is not possible, washing the genitalia using an antimicrobial soap is recommended.

A nurse is teaching a client who has human immunodeficiency virus about the early manifestations of acquired immune deficiency syndrome. Which of the following statements should the nurse include in the teaching? "You can expect a persistent fever and swollen glands." "You can expect an elevated white blood cell count." "You can expect an increase in blood pressure and edema." "You can expect weight gain."

"You can expect a persistent fever and swollen glands." Clients who have AIDS can have persistent fever, swollen glands, diarrhea, weight loss, and fatigue. These manifestations indicate the onset of AIDS.**

A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client? A diffuse maculopapular rash Dyspnea Double vision A progressive, circular rash

A progressive, circular rash Early Lyme disease is characterized by fever, influenza-like manifestations, and erythema migrans, a distinct progressive circular or bulls-eye rash that often develops at the bite site, but can also develop at other sites, such as the thighs and knees

A nurse is caring for 4 clients. Which of the following clients is at the greatest risk for pneumonia? A school-age child who has a history of asthma A young adult client who is living in a college dormitory A middle adult client who is using an incentive spirometer following surgery An older adult client who has dysphagia

An older adult client who has dysphagia An older adult client who has dysphagia is at the greatest risk for pneumonia due to the increased risk for aspiration when eating

A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching? Use an alcohol-based soap to clean lesions. Wear a condom during sexual activity when lesions are present. Take a sitz bath once per day. Apply a warm compress to the lesions.

Apply a warm compress to the lesions. The nurse should instruct the client to apply a warm compress to the lesions to relieve discomfort.

A nurse is providing teaching to a client who has Hodgkin's lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include? Use an antibacterial soap to cleanse the skin. Wash the ink marking off when showering. Rub the skin with a towel when drying. Avoid direct sun exposure to the skin.

Avoid direct sun exposure to the skin. The nurse should instruct the client to avoid sun exposure because the client's skin is sensitive to sunburn due to the external radiation.

A nurse is performing a breast examination on a female client who is pregnant. Which of the following findings should the nurse report to the provider? Slight asymmetrical breast size Breast tissue with an orange-peel appearance Nipple inversion of one breast since puberty Elevated Montgomery's glands

Breast tissue with an orange-peel appearance

A nurse is providing teaching to a client who has an allergy to peanuts. Which of the following instructions is the priority to include in the teaching? Inform other health care professionals of the allergy. Wear a medical identification tag. Carry an emergency anaphylaxis kit. Keep a food diary.

Carry an emergency anaphylaxis kit. The greatest risk to the client is injury or death from an anaphylactic reaction. Therefore, the priority instruction for the client is to be prepared for emergency treatment by carrying an emergency anaphylaxis kit

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? (select all that apply) Subcutaneous nodules Decreased urine output Renal calculi Butterfly rash Joint inflammation

Decreased urine output Butterfly rash Joint inflammation Decreased urine output, due to kidney damage, is a manifestation of SLE. A scaly rash on the face, commonly known as the "butterfly rash," is a common manifestation of SLE. Joint inflammation is a common manifestation of SLE. Subcutaneous nodules are manifestations of rheumatoid arthritis. Lupus nephritis, not renal calculi, is a manifestation of SLE.

A nurse is caring for a client who has HIV. Which of the following lab findings should suggest to the nurse that medication therapy is effective? WBC count 3,500/mm3 Lymphocyte 1,400/mm3 Decreased viral load Low CD4/CD8 ratio

Decreased viral load The nurse should recognize that a client who has HIV and is receiving medication therapy should display a decreasing viral protein amount in the blood, indicating a positive response to the medication therapy

A nurse in an emergency department is assessing a newly admitted client. Which of the following actions places the client at increased risk for contracting hepatitis B? Residing in an institutional setting Engaging in unprotected sexual intercourse Working with hazardous chemical waste materials Traveling to a foreign country

Engaging in unprotected sexual intercourse

A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding? Loss of body hair Report of anorexia Mucositis of the oral cavity Erythema at the IV insertion site

Erythema at the IV insertion site The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema at the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss. This is the priority assessment finding

A nurse is caring for a client who is 2 days postoperative. Which of the following findings should alert the nurse that the client is developing an infection? Temperature 37.8° C (100° F) Erythema at the incision site WBC count 9,000/mm3 Pain reported as 6 on a scale of 0 to 10

Erythema at the incision site

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE? Exercise Pregnancy Infection Sunlight

Exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and the manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with her provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active.

A nurse is teaching an assistive personnel about standard precautions when caring for a client who has vancomycin resistant Enterococcus of the urine. Which of the following PPE should the nurse recommend the AP to use when caring for this client? Mask and glasses Gloves Goggles Shoe covers

Gloves The nurse should don clean gloves when caring for a client who has vancomycin-resistant enterococcus of the urine. This protects the nurse from coming in contact with bodily fluids contaminated with the bacteria of the client.

A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest x-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? Have the client wear a surgical mask. Wear a gown for protection from the client's infection. Ask the radiology staff to perform a portable chest x-ray in the client's room. Place an N95 respirator on the client.

Have the client wear a surgical mask.

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments? An assistive device to use when the client is ambulating Heat paraffin therapy applied to the client's joints Gentle massage of the client's hands Active range-of-motion exercises on the client's affected joints

Heat paraffin therapy applied to the client's joints The nurse should anticipate the use of heat paraffin to be prescribed as a nonpharmacologic intervention. The elevated ESR indicates an acute inflammatory process due to client's rheumatoid arthritis. The use of the warm paraffin relives the stiffness of the client's joints and provides comfort

A nurse is preparing to administer a Mantoux skin test to a client. The nurse should inform the client that the purpose of a Mantoux skin test using purified protein derivative (PPD_ is to do which of the following actions? Identify if a client lacks immunity to TN Find out if a client has active TB Decrease the hypersensitivity of the client's reaction to PPD Identify if a client has been infected with mycobacterium tuberculosis.

Identify if a client has been infected with mycobacterium tuberculosis.

A nurse is caring for a client who had radioallergosorbent (RAST) testing completed due to seasonal allergies. The nurse should anticipate an elevation in which of the following lab tests? IgM IgA IgG IgE

IgE RAST testing involves measuring the quantity of IgE present in serum after exposure to specific antigens selected on a basis of the client's symptom history. An elevated IgE indicates a positive response and is common among clients who have a history of allergic manifestations, anaphylaxis, and asthma.**

A nurse is teaching a client about manifestations of an allergic reaction. The nurse should explain that histamine release causes which of the following reactions? Increased mucus secretion Bronchial dilation Bradycardia Vertigo

Increased mucus secretion The nurse should instruct that the client that increased mucus secretion is a manifestation of histamine release. Histamine is the neurotransmitter the body produces during an allergic reaction.

A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse report to the provider immediately? Negative blood culture Left shift in WBC differential Oxygen saturation 93% Crackles heard on auscultation

Left shift in WBC differential When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a left shift in the client's WBC differential, which indicates that the pneumonia is of bacterial origin, rather than viral. The left shift can be a manifestation of sepsis, and the nurse should report this finding to the provider

A nurse is teaching a client who has Raynaud's disease. Which of the following information should the nurse include in the teaching? Protect against the cold by wearing layers of clothing. Begin an exercise program of 2-mile walks once per week. Increase vitamin A in the diet. Elevate the hands above heart level when resting.

Protect against the cold by wearing layers of clothing. Clients who have Raynaud's disease are prone to attacks during cold weather. Extreme cold can lead to tissue damage. Therefore, the client needs to be protected with layers of clothing to promote warmth and increase circulation to the extremities.**

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A nonproductive cough, fever, and shortness of breath Lesions on the retina that produce blurred vision Onset of progressive dementia Reddish-purple skin lesions

Reddish-purple skin lesions. Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following biopsy, the lesions are treated with radiation and/or chemotherapy.

A nurse is reviewing the lab report for a client who has Hodgkin's lymphoma. Which of the following finding should the nurse expect? Overgrowth of B-lymphocyte plasma cells Reed-Sternberg cells Epstein-Barr virus Overproduction of blast phase cells

Reed-Sternberg cells

A nurse is reviewing the lab results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following lab tests can indicate arthritis? Reticulocyte count Rheumatoid factor Direct Coombs' test Platelet count

Rheumatoid factor An increase in the client's rheumatoid factor can indicate rheumatoid arthritis or other connective tissue diseases.

A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS? Small, purple-colored skin lesions Fever and diarrhea lasting longer than 1 month Persistent, generalized lymphadenopathy CD4-T-cells decreased to 750 cells/mm3

Small, purple-colored skin lesions The nurse should identify the presence of small, purple-colored skin lesions as an indication that the client has acquired Kaposi's sarcoma, which is an AIDS-defining illness.

A nurse is caring for a client who has human immunodeficiency virus. Which of the following types of isolation should the nurse implement to prevent transmission of HIV? Protective isolation Droplet precautions Standard precautions Airborne precautions

Standard precautions Standard precautions should be implemented with every client, to prevent the spread of infection transmitted by direct or indirect contact with infectious blood or body fluids. Because HIV is spread through blood and bodily fluids, standard precautions are appropriate.

A nurse is planning care for a client who has leukemia and a platelet count of 48,000/mm3. Which of the following interventions should the nurse include in the plan? Provide the client with a diet that is low in vitamin K. Place the client on contact precautions. Administer subcutaneous epoetin alfa. Test the client's urine and stool for occult blood.

Test the client's urine and stool for occult blood.

A nurse is caring for a client who has neutropenia. Which of the following findings indicates a need for intervention? The client's grandchild is visiting and telling the client about the first day of kindergarten. The client has a grilled ham and cheese sandwich, a banana, and yogurt on their lunch tray. The client's family brings in a silk flower arrangement. The client's assistive personnel places paper cups and plastic utensils in the client's room.

The client's grandchild is visiting and telling the client about the first day of kindergarten. The nurse should limit the client's visitors to healthy adults. A visit from a child who is attending school can place the client at risk for infection due to the client's immunocompromised status.

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? Confluent, honey-colored, crusted lesions Large, tender nodule located on a hair follicle Unilateral, localized, nodular skin lesions A fluid-filled vesicular rash in the genital region

Unilateral, localized, nodular skin lesions Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces unilateral, localized, nodular skin lesions.**

A nurse is reviewing the daily lab results for a female client who has acute leukemia. Which of the following values is an expected finding? WBC count 21,000/mm3 Hgb 14 g/dL Hct 40% Platelets 170,000/mm3

WBC count 21,000/mm3