Immunity (Bilal, Sheila, Hannah)
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: a. Temperature 37.8 C (100 F) B. Erythema at incision site C. WBC of 9,500 /mm3 D. Pain reported as 9 on a scale of 0-10
ANSWER: b. Erythema at incision site RATIONALE: Redness or erythema indicates signs of infection at incision site of a wound.
A nurse is preparing to document administration of a flu vaccine for a client. Which of the following information should the nurse include in the documentation? (Select all that apply) a. Age of the client b. Name of the Vaccine manufacturer c. Vaccine expiration date d. Date of administration e. Serial Number of the vaccine
ANSWER: b. The nurse should document the vaccine manufacturer c. the nurse should document the vaccine expiration date d. the nurse should document the date of the vaccine was administered
Possible signs and symptoms of severe allergic reaction to influenza vaccine or medication includes: (Select all that apply) a. Headache and malaise b. Wheezing c. Throat, tongue, and/or lip swelling d. Dizziness, low BP, elevated heart rate e. Seizures
ANSWER: b. Wheezing c. Throat, tongue, and/or lip swelling d. Dizziness, low BP, elevated heart rate e. Seizures
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? a. Protecting the client from infection b. Providing emotional support to decrease fear c. Encouraging discussion about lifestyle changes d. Identifying factors that decreased the immune function
ANSWER: a. Protecting the client from infection
A working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect. Select all that apply. a. Recent influenza b. Decreased range of motion c. Hypersalivation d. Increased blood pressure e. Pain at rest
ANSWER: a. Recent influenza b. Decreased range of motion e. Pain at rest
A 25-year old man receives a knife wound to the leg in a hunting accident. Which of the following types of immunity was compromised? a. Passive immunity b. Natural immunity c. Adaptive immunity d. Specific immunity
ANSWER: b. Natural immunity
A nurse is assessing a patient with a primary immunodeficiency. Afterward she documents that the patient displayed ataxia. Which of the following statements explains the documentation? a. The patient has difficulty swallowing. b. The patient has uncoordinated muscle movements. c. The patient has vascular lesions caused by dilated blood vessels. d. The patient has an inability to understand the spoken word.
ANSWER: b. The patient has uncoordinated muscle movements.
A nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. The nurse further checks for which of the following that is also indicative of the presence of SLE? a. Emboli b. Ascites c. Two hemoglobin S genes d. Butterfly rash on cheeks and bridge of nose
ANSWER: d. Butterfly rash on cheeks and bridge of nose 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.
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 finding? a. Swelling in the genital area b. Swelling in the lower extremities c. Positive punch biopsy of the cutaneous lesions d. Appearance of reddish-blue lesions noted on the skin
ANSWER: c. Positive punch biopsy of the cutaneous lesions
A patient is scheduled to receive an intravenous immunoglobulin infusion. He asks the nurse about the infusion's administration and its adverse effects. Which of the following choices should the nurse instruct this patient to report immediately? a. Sneezing b. Constipation c. Mouth sores d. Tickle in the throat
ANSWER: d. Tickle in the throat
