Med-Surg Infection/Immunity

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?

"It is a hyperimmune response to something in the environment that is usually harmless."

A client comes to the clinic and states he has "broken out in hives and itching since eating strawberries this morning." The client states he has never had problems with strawberries before. What is the best response by the nurse?

"It is possible to develop an allergic reaction to something you have had prior exposure to previously.

A female client informs the nurse that she is considering beginning sexual relations and wants to know the best way to protect herself from a sexually transmitted infection and HIV. What is the best response by the nurse?

"Using a condom (latex) and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV."

The nurse has four clients that come to the clinic for healthcare. Which one of these clients has the highest risk factor for HIV infection?

A 26-year-old inmate who receives tattoos in prison

A client with AIDS is brought to the clinic by his family. The family tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?

AIDS dementia complex (ADC)

A public health nurse is giving an informational presentation on HIV/AIDS at a nearby college. How would the nurse best define AIDS?

Acquired immunodeficiency syndrome is a fatal infection that profoundly weakens the immune system.

The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?

Airway obstruction

A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?

Artificially acquired active immunity

When an attenuated toxin is administered to a client, the B lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this?

Artificially acquired active immunity

A client visits the nurse complaining of diarrhea every time he eats. The client has AIDS and wants to know what he can do to stop having diarrhea. What should the nurse advise?

Avoid fibrous foods, lactose, fat, and caffeine

A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications?

Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.

A client comes to the clinic to see the physician with the complaint of "I think I ate something that I am allergic to." What symptoms would be appropriate for the nurse to ask the questions about?

Diarrhea and abdominal cramping

A client is scheduled for diagnostic skin testing in 1 week. What should the nurse be sure to instruct the client prior to the scheduled appointment?

Do not take prescribed or over-the-counter antihistamines or cold preparations for at least 72 hours before testing.

A client calls the clinic and asks the nurse if using Afrin nasal spray would be alright to relieve the nasal congestion he is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications?

Do not use Afrin for longer than 3 to 5 days in a row or rebound congestion can occur.

You are caring for a client with chronic fatigue syndrome. What is a realistic nursing intervention when taking care of a client with this diagnosis?

Educate the client about the disease process.

A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have?

Passive immunity transferred by the mother

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells

A client with Crohn's disease, an autoimmune disorder, informs the nurse that he has not had any symptoms of the disease in 8 months. What does the nurse understand this asymptomatic period is referred to?

Remission

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply.

Semen, Breast milk, Blood, Vaginal secretions

A 64-year-old male client, who leads a sedentary lifestyle, and a 31-year-old female client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. As the nurse, you would know that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?

The male client because of his age

Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply.

polymerase chain reaction, p24 antigen test

A client has been having joint pain and swelling in the left foot and is diagnosed with rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and the client has significant joint destruction. What type of disease is this considered?

Autoimmune

A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection?

Follow the same sexual precautions as someone who has been diagnosed with AIDS.

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?

For their immunosuppressant effects

A client's immune system has the ability to protect itself from external invaders. What type of immune function is present when this occurs?

Immunocompetence

The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?

Lymphoid tissues

A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?

Naturally acquired active immunity

A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?

Stool specimen for ova and parasites

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?

T-cell lymphocytes survey proteins in the body and attack the invading antigens.

The nurse is collecting data from a client with the autoimmune disorder, endocarditis. What does the nurse recognize as symptom of an acute exacerbation?

Temperature of 100.9° F

A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have?

The nurse ensures a written consent is obtained prior to testing.

A client has an allergic reaction to seafood with generalized edema and informs the nurse that he is unable to get his wedding ring off and it is too tight. The client was unable to remove it with soap and water. What action by the nurse can facilitate removal of the ring without damaging it?

Use twine to wrap the finger and, when the tissue is compressed, pull the free end of the twine and remove the ring