NCLEX Immunity

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.

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Test-Taking Strategy: Recall the classic symptoms of herpes zoster: clear vesicles in groups, pain, and lesions that occur on one side of the body. This will assist in determining that the client has shingles. From this point, recall that this disorder is associated with the chicken pox virus. Review the manifestations of shingles if you had difficulty with this question.

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est-Taking Strategy: Use the process of elimination, noting the strategic word, "first." Focus on the subject, that the site of the bee sting is painful. Eliminate option 1 because this measure produces a systemic and not a local effect. Eliminate option 4 next because this measure will not directly assist in alleviating the pain at the site of injury. From the remaining options, recalling the effects of heat will assist in eliminating option 2 and direct you to option 3. Review the initial measures that will alleviate pain from a bee sting if you had difficulty with this question.

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se the process of elimination. Remember that organisms indicate infection, blood indicates trauma, and urates indicate gout. Review the characteristics of rheumatoid arthritis if you had difficulty with this question.

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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? Dairy products with each snack and meal Red meat daily Adding spices to food to make the taste more palatable Foods that are at room temperature

Foods that are at room temperature

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? Hairdressers The homeless Children in day care centers Individuals living in a group home

Hairdressers

Study Mode Question 23 of 64 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: 6 total months and at least 1 month after cultures convert to negative 6 total months and at least 3 months after cultures convert to negative 9 total months and at least 3 months after cultures convert to negative 9 total months and at least 6 months after cultures convert to negative

9 total months and at least 6 months after cultures convert to negative

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? Keep the call bell within reach for the client. Administer a sedative at bedtime. Administer an antipyretic at bedtime. Provide a back rub and comfort measures before bedtime.

Administer an antipyretic at bedtime.

Which client is at the highest risk for systemic lupus erythematous (SLE)? An Asian male A white female An African-American male An African-American female

An African-American female

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? The presence of tiny red vesicles An autoimmune disease that causes blistering in the epidermis The presence of skin vesicles found along the nerve caused by a virus The presence of red, raised papules and large plaques covered by silvery scales

An autoimmune disease that causes blistering in the epidermis

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: Take two acetaminophen (Tylenol). Place a heating pad to the site. Apply ice and elevate the site. Lie down and elevate the arm.

Apply ice and elevate the site.

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? Eggs Milk Yogurt Bananas

Bananas

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? Infection Inability to cope Lack of information about the disease Feeling uncomfortable about body changes

Infection

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? Diarrhea Tinnitus Burning with urination Numbness in the legs

Numbness in the legs

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:

Positive

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: Raw fruits and vegetables Hot soup Peanut butter Puddings

Puddings

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. Ulnar drift Rheumatoid nodules Swan neck deformity Boutonniere deformity

Ulnar drift

Pemphigus

emphigus 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 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? Provide supportive care with hygiene needs. Provide meals and snacks with high protein, high calorie, and high nutritional value. Provide small, frequent meals. Offer low microbial food.

√ Provide supportive care with hygiene needs.

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? The client limits fluid intake. The client has clear breath sounds. The client expectorates secretions easily. The client is free of complaints of shortness of breath.

√ The client limits fluid intake.

Focus on the data in the question. Recalling that nausea, vomiting, and abdominal pain are signs of pancreatitis and that pancreatitis is associated with the use of this medication should direct you to the correct option. Review the adverse effects of this medication if you had difficulty with this question.

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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.

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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.

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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.

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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? Cloudy synovial fluid Presence of organisms Bloody synovial fluid Presence of urate crystals

Cloudy synovial fluid

Test-Taking Strategy: Use the process of elimination to answer the question. Begin by eliminating options 2 and 3 because they are comparable or alike. Remembering that the client with HIV is immunosuppressed will assist in directing you to option 4, the correct option. Review the procedures for interpreting the results of this test if you had difficulty with this question.

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Test-Taking Strategy: Use the process of elimination, and focus on the subject of difficulty swallowing. Evaluate each of the foods listed in terms of how easily they are swallowed. The rough, hot, and sticky foods in options 1, 2, and 3, respectively, help you to choose option 4 as the correct option. Review nutritional concepts for the AIDS client if you had difficulty with this question.

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Test-Taking Strategy: Use the process of elimination, and note the strategic words, "expected outcome" and "has not yet been achieved." These words indicate a negative event query and ask you to select an option that is an incorrect statement. This will direct you to option 1. Review care to the client with acquired immunodeficiency syndrome if you had difficulty with this question.

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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.

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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.

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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.

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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.

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Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparable or alike. From the remaining options, recalling that antibodies do not appear immediately in the blood will assist in directing you to option 3. Review HIV testing procedures if you had difficulty with this question.

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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.

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Test-Taking Strategy: Use the process of elimination. Knowing that the client with HIV requires longer therapy helps you eliminate options 1 and 2 first. To select between the remaining options, it is necessary to recall that sputum cultures must be negative for 6 months before terminating medication therapy because of the immunosuppressed status of the client. Review the guidelines related to medication therapy in the client with TB if you had difficulty with this question.

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Study Mode Question 53 of 64 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? 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.

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Test-Taking Strategy: Focus on the subject, performing activities of daily living. Options 2, 3, and 4 are important interventions for the client with AIDS but do not address the subject. Option 1 is the only option that addresses the subject of the question. Also note that options 2, 3, and 4 are comparable or alike and relate to nutrition. Review care to the client with AIDS if you had difficulty with this question.

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Test-Taking Strategy: Knowledge regarding the adverse effects related to the administration of zidovudine is required to answer this question. Focus on the strategic words, "severe neutropenia," to assist in directing you to the correct option. Review the adverse effects of this medication if you had difficulty with this question.

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Test-Taking Strategy: Note the strategic word, "priority." Use Maslow's Hierarchy of Needs theory to eliminate options 1, 3, and 4. Also, recalling that AIDS affects the body's immune system will direct you to option 2. Review the priority concerns related to the client with AIDS if you had difficulty with this question.

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Test-Taking Strategy: Use Maslow's Hierarchy of Needs theory to answer the question. Recall that physiological needs are the priority. This will easily direct you to option 1. Review the care of a client with immunodeficiency if you had difficulty with this question.

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Test-Taking Strategy: Use knowledge related to the effects of AIDS on the gastrointestinal system to assist in answering the question. Additionally, general principles related to nutrition in a client with an immunosuppressive disorder will assist in directing you to option 4. Review dietary measures for the client with AIDS if you had difficulty with this question.

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Test-Taking Strategy: Use the process of elimination and knowledge regarding the alternative resources for a client with an allergy to latex. No data in the question support the need to contact the HCP. The nurse should not prescribe assistive devices for the client. Option 4 is not a therapeutic action. Review care to the client with a latex allergy if you had difficulty with this question.

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Test-Taking Strategy: Use the process of elimination and knowledge regarding the food items related to a latex allergy. Eliminate the incorrect options because they are comparable or alike and relate to dairy products. Review the food items that are associated with a risk for latex allergy if you had difficulty with this question.

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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.

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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.

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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.

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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.

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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? Elastic bandages Adhesive bandages Brown Ace bandages Cotton pads and silk tape

Cotton pads and silk tape

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.

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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.

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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.

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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.

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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.

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Test-Taking Strategy: Use the process of elimination and knowledge regarding the products that contain latex to answer this question. Eliminate options 1 and 3 first because they are comparable or alike. Noting the strategic words, "cotton" and "silk," in option 4 will assist you in answering correctly from the remaining options. Review the list of products that contain latex if you had difficulty with this question.

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Test-Taking Strategy: Use the process of elimination and note the strategic words "characteristic sign." Recalling the characteristic butterfly rash associated with SLE will direct you to the correct option. If you are unfamiliar with this disorder, review this content.

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Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because SLE is a systemic disorder, not a local one. Next eliminate option 2 because of its similarity to option 1. From the remaining options, select option 3 because of its systemic characteristic. If you are unfamiliar with this disorder, review its characteristics.

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ationale: 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).

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The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is: A local rash that occurs as a result of allergy A disease caused by overexposure to sunlight An inflammatory disease of collagen contained in connective tissue A disease caused by the continuous release of histamine in the body

An inflammatory disease of collagen contained in connective tissue

est-Taking Strategy: Focus on the subject of the question, which is night fever and night sweats. Options 1, 2, and 4 are helpful and important interventions but do not address the subject of the question. Because night fever and sweats occur serially, it is helpful to give the antipyretic before sleep as a prophylactic measure. Review nursing measures for the client with AIDS if you had difficulty with this question.

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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: There is no further need for testing. A negative HIV test is considered accurate. A negative HIV test is not considered accurate during the first 6 months after exposure. The test should be repeated in 1 week.

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

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? Emboli Ascites Two hemoglobin S genes Butterfly rash on cheeks and bridge of nose

Butterfly rash on cheeks and bridge of nose

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? Weight gain Subnormal temperature Elevated red blood cell count Rash on the face across the bridge of the nose and on the cheeks

Rash on the face across the bridge of the nose and on the cheeks

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.

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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.

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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.

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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? This is an expected side effect of the medication. Come to the office to be seen by the health care provider. Take crackers and milk with the administration of the medication. Decrease the dose of the medication until the next health care provider's visit.

Come to the office to be seen by the health care provider.

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: Contact the health care provider (HCP). Cover the crutch pads with cloth. Call the local medical supply store, and ask for a cane to be delivered. Tell the client that the crutches must be removed immediately from the house.

Cover the crutch pads with cloth.

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? Inability to care for self at home Development of an infection Lack of available support services Isolation

Development of an infection

Study Mode Question 31 of 64 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? Did you have chicken pox as a child?" "How many sexual partners have you had?" "Did you use an electric blanket on your side?" "Why don't you try docosanol cream (Abreva) on your lesions

Did you have chicken pox as a child?"

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? Reduction in the medication dosage Discontinuation of the medication The administration of prednisone concurrent with the therapy Administration of epoetin alfa (Epogen)

Discontinuation of 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? Antibiotic Antidiarrheal Corticosteroid Opioid analgesic

Corticosteroid