91Qw/exp-Saunders NCLEX Immune Disorders

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? 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

1. Protecting the client from infection Rationale: The client with immunodeficiency has inadequate or absence of 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.

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. 1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. 3. Estimate the size of the wheal and document the finding. 4. Tell the client to return to have the site inspected only if there is a reaction. 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. Rationale: Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected; a list of potential allergens is identified. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients only need to be monitored for about 30 minutes to assess for any adverse effects.

A client is suspected of having discoid lupus erythematosus (DLE). Which diagnostic test will primarily confirm the diagnosis? 1. Skin biopsy 2. Anti-Smith test 3. Extractable nuclear antigens 4. Anti-deoxyribonucleic acid (DNA)

1. Skin biopsy Rationale: Discoid lupus erythematosus (DLE) is one classification of lupus. Because DLE is not a systemic condition and affects only the skin; therefore, the only significant test is a skin biopsy. A microscopic evaluation of skin cell scrapings from the rash will reveal the characteristic lupus cell and a number of inflammatory cells. Other specific immunological tests, such as anti-SS-a (RO), anti-SS-b (La), anti-Smith, anti-DNA, and extractable nuclear antigens, may be performed. High titers of some of these antibodies are associated with lupus, but some can also be found in persons without the disease.

A client with human immunodeficiency virus (HIV) infection is diagnosed with herpes simplex virus (HSV). The nurse should prepare the client for which diagnostic test to determine the presence of herpesvirus infection? 1. Chest x-ray 2. Viral culture 3. Stool culture 4. Neurological exam

2. Viral culture Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. HSV in people with HIV or acquired immunodeficiency syndrome (AIDS) occurs in the perirectal, oral, and genital areas. Numbness of tingling at the site of infection occurs up to 24 hours before blisters form. Lesions are painful, with chronic open areas after blisters rupture. Diagnostic tests for herpes simplex include a viral culture and gross examination. The tests in the other options will not diagnosis herpes simplex.

A client is tested for human immunodeficiency virus (HIV) infection with an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. What should the nurse tell the client? 1. HIV infection has been confirmed. 2. The client probably has a gastrointestinal infection. 3. The test will need to be confirmed with a Western blot. 4. A positive test result is normal and does not mean that the client has acquired HIV.

3. The test will need to be confirmed with a Western blot. Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A negative result on an ELISA indicates that infection is absent or that not enough time has passed since exposure for seroconversion. A positive ELISA result must be confirmed with a Western blot. The other options are incorrect.

The nurse provides education to the client about the primary purpose of neutrophils. Which statement by the client indicates successful teaching? 1. "They open up blood vessels." 2. "They close up blood vessels." 3. "They increase fluids at the injury site." 4. "They engulf any potential foreign materials."

4. "They engulf any potential foreign materials." Rationale: Neutrophil function provides protection after invaders, especially bacteria, enter the body. In the inflammatory response, neutrophils appear in the area of injury in 30 to 60 minutes. Their primary purpose is to phagocytize (ingest and destroy) any potentially harmful agents, such as microorganisms. The remaining options are incorrect.

The nurse reviews the record of a client with acquired immunodeficiency syndrome (AIDS) and notes that the client has a diagnosis of Candida. When performing history-taking and assessment, which finding should the nurse anticipate? 1. Hyperactive bowel sounds 2. Complaints of watery diarrhea 3. Red lesions on the upper arms 4. Yellowish-white, curdlike patches in the oral cavity

4. Yellowish-white, curdlike patches in the oral cavity Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Candidiasis is caused by Candida albicans, which is a part of the intestinal tract's natural flora. Fungal infection occurs by overgrowth of normal body flora. In a person with AIDS, candidiasis (overgrowth of the Candida fungus) occurs because the immune system can no longer control fungal growth. Candida stomatitis or esophagitis occurs often in AIDS. On examination of the mouth and throat, the nurse would note cottage cheese-like, yellowish white plaques and inflammation. The remaining options are not findings in this disorder.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA? 1. Anemia 2. Anorexia 3. Amenorrhea 4. Night sweats

2. Anorexia Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early clinical manifestations of RA include complaints of fatigue, generalized weakness, anorexia, and weight loss. Anemia, amenorrhea, and night sweats are not early manifestations of RA.

A home care nurse is prescribing dressing supplies for a client who has an allergy to latex. Which item should the nurse ask the medical supply personnel to deliver? 1. Elastic bandages 2. Adhesive bandages 3. Brown Ace bandages 4. Cotton pads and silk tape

4. Cotton pads and silk tape Rationale: Latex allergy is a type I hypersensitivity reaction in which a specific allergen is a processed natural latex rubber protein. Cotton pads and plastic or silk tape are latex-free products. The items identified in the other options contain latex.

The nurse is assigned to care for a client with human immunodeficiency virus (HIV) infection. The nurse reviews the client's health care record and notes documentation of toxoplasmosis encephalitis. On the basis of this information, the nurse would assess for which manifestation? 1. Lesions on the skin 2. Mental status changes 3. Changes in bowel pattern 4. Lesions on the oral mucosa

2. Mental status changes Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Toxoplasmosis encephalitis, caused by Toxoplasma gondii, is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat. It manifests with signs and symptoms such as an altered mental status, neurological deficits, headaches, and fever. Additional manifestations include difficulties with speech, gait, and vision; and seizures.The other options are not associated with toxoplasmosis.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing fatigue. The nurse should plan to teach the client which strategy to conserve energy after discharge from the hospital? 1. Bathe before eating breakfast. 2. Sit for as many activities as possible. 3. Stand in the shower instead of taking a bath. 4. Group all tasks to be performed early in the morning.

2. Sit for as many activities as possible. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The client is taught to conserve energy by sitting for as many activities as possible, including dressing, shaving, preparing food, and ironing. The client also should sit in a shower chair instead of standing while bathing. The client needs to prioritize activities, such as eating breakfast before bathing, and should intersperse each major activity with a period of rest.

A client with human immunodeficiency virus (HIV) infection has a fever, and histoplasmosis is suspected. The nurse should prepare the client for which diagnostic test to confirm the presence of histoplasmosis? 1. Skin biopsy 2. Sputum culture 3. Western blot test 4. Upper gastrointestinal series

2. Sputum culture Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Histoplasmosis is an opportunistic infection that affects the lungs and can occur in the client with HIV infection. Diagnostic tests include chest x-ray, sputum culture, lung biopsy, and bronchoscopy. The other options are incorrect. A Western blot test is used to confirm a diagnosis of HIV. A skin biopsy may be done if the client had Kaposi's sarcoma. Gastrointestinal series are done for a client suspected to have a gastrointestinal disorder.

A fluorescent antinuclear antibody titer (FANA) is performed in a client suspected of having rheumatoid arthritis (RA). Which laboratory value is most consistent with RA? 1. 0:5 2. 0:8 3. 1:5 4. 1:20

4. 1:20 Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The antinuclear antibody test measures the titer of antibodies that destroy the nuclei cells and cause tissue death. When the fluorescent method is used, the test sometimes is referred to as FANA. If this test is positive, a value greater than 1:8 will be present. Therefore, the options below this value are incorrect.

A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention 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 14 to 21 day course of doxycycline

4. A 14 to 21 day course of doxycycline Rationale: Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. A 3- to 4-week course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with IV antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.

A complete blood cell (CBC) count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE? 1. Decreased platelets only 2. Increased red blood cell count 3. Increased white blood cell count 4. Decreased number of all cell types

4. Decreased number of all cell types Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. In the client with SLE, a CBC count commonly shows pancytopenia, a decrease in the number of all cell types. This finding is most likely caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.

The nurse is preparing to care for a client with immunodeficiency. The nurse should plan to address which problem as the priority? 1. Anxiety 2. Fatigue 3. Risk for infection 4. Need for social isolation

3. Risk for infection Rationale: The client with immunodeficiency has inadequate or no immune bodies and is at risk for infection. The priority concern would be risk for infection. The question presents no data indicating that the client is experiencing anxiety. Fatigue may be a problem and the client may need to be placed on protective isolation, but these are not the priority problems for this client. Infection can be life-threatening and is the priority.

The nursing student is describing the differences between specific and nonspecific immunity to a group of classmates. Which statement made by the student to the classmates indicates accurate knowledge of specific immunity? 1. "It is present and functioning at birth." 2. "It is the first line of defense against infection." 3. "It is the second line of defense against infection." 4. "It is the type of immunity that reacts in the same way to all antigens."

3. "It is the second line of defense against infection." Rationale: Specific immunity is the second line of defense against infection. The body uses this process to identify specific antigens. With this type of immunity, different reactions occur in response to different antigens, and the response must be learned and developed. The remaining options identify nonspecific immunity.

A CD4+ lymphocyte count is performed in a client with human immunodeficiency virus (HIV) infection. When providing education about the testing, what should the nurse tell the client? 1. "It establishes the stage of HIV infection." 2. "It confirms the presence of HIV infection." 3. "It identifies the cell-associated proviral DNA." 4. "It determines the presence of HIV antibodies in the bloodstream."

1. "It establishes the stage of HIV infection." Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A CD4+ lymphocyte count is performed to establish the stage of HIV infection, to help with decisions regarding the timing of initiation of antiretroviral therapy and prophylaxis for opportunistic infections and to monitor treatment effectiveness. The remaining options are unrelated to the CD4+ lymphocyte count.

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 instruction? 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."

1. "I should take hot baths because they are relaxing." 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

The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an immune disorder, and they discuss the classes of human antibodies. Which statement by the nursing student indicates a need for further teaching? 1. "Immunoglobulin G (IgG) is the minor serum antibody." 2. "Immunoglobulin M (IgM) is the first antibody produced in response to antigen." 3. "Immunoglobulin E (IgE) accounts for less than 1% of the total antibody level in the blood." 4. "The major serum antibody is IgG, which constitutes about 70% of the total circulating antibodies."

1. "Immunoglobulin G (IgG) is the minor serum antibody." Rationale: The major serum antibody is IgG, which constitutes about 70% of the total circulating antibodies. It is antiviral, antibacterial, and effective against toxins. IgM is the first antibody produced in response to antigen and makes up about 7% of the total serum antibodies. IgE accounts for only about 0.5% of the total antibody level in the blood.

The nurse is assigned to care for a client with acquired immunodeficiency syndrome (AIDS) suspected of having Kaposi's sarcoma. The nurse should prepare the client for which test to confirm this diagnosis? 1. Biopsy 2. Blood culture 3. Computerized tomography 4. Magnetic resonance imaging

1. Biopsy Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Kaposi's sarcoma is the most common AIDS-related malignancy. It manifests as small purplish brown, raised lesions if they occur on the skin. Dyspnea occurs if they occur in the lungs. Lymph node swelling occurs if they are located in the lymph nodes. Kaposi's sarcoma also can occur in the gastrointestinal (GI) tract and manifests as an altered bowel pattern, including diarrhea or constipation. Chest x-ray, bronchoscopy, upper GI exam, colonoscopy, and computed tomography scan may be used to aid the diagnosis, but whether Kaposi's sarcoma manifests as a skin lesion or in the lungs or GI tract, the diagnosis is confirmed with a biopsy.

A home care nurse is assigned to visit a client who has 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 instruction regarding crutch walking. On admission assessment, the nurse discovered that the client has an allergy to latex. Before providing instructions regarding crutch walking, what action should the nurse take? 1. Cover the crutch pads with cloth. 2. Contact the health care provider (HCP). 3. Call the local medical supply store and ask that a cane be delivered. 4. Tell the client that the crutches must be removed from the house immediately.

1. Cover the crutch pads with cloth. Rationale: Latex allergy is a type I hypersensitivity reaction in which a specific allergen is a processed natural latex rubber protein. The rubber pads used on crutches may contain latex. If the client requires crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. No reason exists to contact the HCP at this time. 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. Telling the client that the crutches must be removed from the house is inappropriate and may alarm the client.

The nurse has been assigned to care for a client with an immune disorder. In developing a plan of care for this client, the nurse incorporates knowledge that the immune system consists of specific major types of cells. Which types of cells are associated with the immune system? Select all that apply. 1. Dendritic cells 2. B lymphocytes 3. Red blood cells 4. Helper T lymphocytes 5. Cytolytic T lymphocytes

1. Dendritic cells 2. B lymphocytes 4. Helper T lymphocytes 5. Cytolytic T lymphocytes Rationale: Immunity is composed of many cell functions that protect against the effects of injury or invasion. The immune system has 5 major types of cells: dendritic cells, B lymphocytes or B cells, helper T lymphocytes or CD4+ cells, cytolytic T lymphocytes or CD8+ cells, and macrophages.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse should recognize that which are early clinical manifestations of this disorder? Select all that apply. 1. Fatigue 2. Anorexia 3. High fever 4. Weight loss 5. Generalized weakness

1. Fatigue 2. Anorexia 5. Generalized weakness Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early manifestations of RA include fatigue, anorexia, generalized weakness, low-grade fever, paresthesias. Weight loss is one of the late manifestations.

The community health nurse is conducting a research study and 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. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

1. Hairdressers Rationale: Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; or those who have had multiple surgeries, have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

The nurse works with high-risk clients in an urban outpatient setting. Which groups should be tested for human immunodeficiency virus (HIV)? Select all that apply. 1. Injection drug abusers 2. Prostitutes and their clients 3. People with sexually transmitted infections (STIs) 4. People who have had frequent episodes of pneumonia 5. People who recently received a blood transfusion for a surgical procedure

1. Injection drug abusers 2. Prostitutes and their clients 3. People with sexually transmitted infections (STIs) Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Injection drug abusers, those engaged in prostitution, and people with STIs are high-risk groups that should be tested for HIV per the Centers for Disease Control and Prevention's recommendations. Those who have had frequent episodes of pneumonia and those who recently received a blood transfusion for a surgical procedure are not at risk for HIV unless another compounding factor places them at risk. However, if a blood transfusion was received between 1978 and 1985, the client should be tested.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. 1. Keep liquids at the bedside. 2. Place a towel over the pillowcase. 3. Make sure the pillow has a plastic cover. 4. Keep a change of bed linens nearby in case they are needed. 5. Administer an antipyretic after the client has a spike in temperature.

1. Keep liquids at the bedside. 2. Place a towel over the pillowcase. 3. Make sure the pillow has a plastic cover. 4. Keep a change of bed linens nearby in case they are needed. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is profuse. The client should have liquids at the bedside to drink.

The nurse asks a nursing student to identify the locations of macrophages in the body. The student responds correctly if the student indicates which organs and tissues contain a large number of these cells? Select all that apply. 1. Liver 2. Tonsils 3. Spleen 4. Bone marrow 5. Intestinal tract

1. Liver 3. Spleen 5. Intestinal tract Rationale: Macrophage functions include phagocytosis, repair, antigen presenting/processing, and secretion of cytokines for immune system control. The liver, spleen, and intestinal tract contain large numbers of macrophages. Bone marrow and tonsils contain no macrophage

The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select all that apply. 1. Oliguria 2. Hypotension 3. Fluid retention 4. Temperature of 99.6°F (37.6°C) 5. Serum creatinine of 3.2 mg/dL (282 mcmol/L)

1. Oliguria 3. Fluid retention 5. Serum creatinine of 3.2 mg/dL (282 mcmol/L) Rationale: Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibiodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection is the most common type that occurs with kidney transplants and occurs 1 week to any time postoperatively. It occurs over days to weeks. Findings consistent with acute rejection include oliguria or anuria; temperature higher than 100°F (37.8°C); increased blood pressure; enlarged, tender kidney; lethargy; elevated serum creatinine, blood urea nitrogen, and potassium levels; and fluid retention.

A client is diagnosed with stage I Lyme disease, and the nurse assesses the client for disease manifestations. Which should the nurse expect to note as the hallmark characteristic of this stage? 1. Skin rash 2. Arthralgias 3. Neurological deficits 4. Enlarged and inflamed joints

1. Skin rash Rationale: Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. The hallmark finding in stage I is a skin rash that appears 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 bull's eye appearance (however, not all clients develop this characteristic). The lesion enlarges to up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. Not all persons exhibit a skin rash but in addition, in stage I, most infected persons experience flulike symptoms that last 7 to 10 days and may recur later in the disease course. Arthralgias, neurological deficits, and enlarged and inflamed joints develop in later stages of the disease.

A client with human immunodeficiency virus infection has signs and symptoms of cryptosporidiosis. The nurse should prepare the client for which test that will assist in confirming the diagnosis? 1. Stool culture 2. Bronchoscopy 3. Sputum culture 4. Chest x-ray study

1. Stool culture Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Cryptosporidiosis is an intestinal infection caused by Cryptosporidium organisms. The client with cryptosporidiosis will present with signs and symptoms of watery diarrhea, flatus, abdominal distention, pain, and fever. It is important for t he nurse to monitor for an electrolyte imbalance. Diagnostic tests include a stool culture with a bowel biopsy. The other options are incorrect.

A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas exchange. Which finding indicates that the expected outcome of care has yet to be 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.

1. The client limits fluid intake. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The status of the client with a problem concerning gas exchange would be evaluated against the standard outcome criteria for a P. jiroveci infection. These would include options 2, 3, and 4 where breath sounds are clear, the nurse notes that secretions are being coughed up effectively, and the client states that breathing is easier. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

A nursing instructor is reviewing information on the organs of the immune system. The instructor asks a nursing student to name the location of Kupffer cells. Which organ identified by the nursing student indicates successful teaching? 1. The liver 2. The spleen 3. The tonsils 4. Bone marrow

1. The liver Rationale: The liver contains a large number of macrophages called Kupffer cells. Kupffer cells are a part of the body's reticuloendothelial system and is a protective function of the liver.They help filter blood by phagocytizing microorganisms and other foreign particles passing through the liver. The organs in the remaining options are incorrect.

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1. Use nonlatex gloves. 2. Use medications from glass ampules. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex 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 vials with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

A client presents at the health care provider's office with complaints of a bulls-eye rash on his upper leg. Which question should the nurse ask first? 1. "Do you have any cats in your home?" 2. "Have you been camping in the last month?" 3. "Have you or close contacts had any flu-like symptoms within the last few weeks?" 4. "Have you been in physical contact with anyone who has the same type of rash?"

2. "Have you been camping in the last month?" Rationale: The nurse should ask questions to assist in identifying the cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ring-like rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

The nursing student conducted a clinical conference on the role of B lymphocytes in the immune system. Which statement by a fellow nursing student indicates successful teaching? 1. "They activate T cells." 2. "They produce antibodies." 3. "They initiate phagocytosis." 4. "They attack and kill the target cell directly."

2. "They produce antibodies." Rationale: B lymphocytes have the job of making antibodies and mediating humoral immunity. They do not activate T cells. T cells attack and kill target cells directly. The primary function of macrophages is phagocytosis.

A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? 1. No further diagnostic studies are needed. 2. A Western blot will be done to confirm these findings. 3. The client probably will have a bone marrow biopsy done. 4. A CD4+ cell count will be done to measure T helper lymphocytes.

2. A Western blot will be done to confirm these findings. Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. If the result of the ELISA is positive, the Western blot is done to confirm the findings. If the result of the Western blot is positive, the client is considered to be seropositive for the infection and to be infected with the virus. The remaining options are incorrect.

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night.

2. Administer corticosteroids as prescribed for inflammation. Rationale: Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present.

A client calls the nurse in the emergency department and states 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. Which action should the nurse take? 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 department. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

2. Ask the client if he ever sustained a bee sting in the past. Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever experienced 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 client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse should take? 1. Place the client on 100% oxygen and prepare for intubation. 2. Assess for anaphylaxis and prepare for emergency treatment. 3. Teach the client about the relationship between asthma and allergies. 4. Obtain an arterial blood gas and immunoglobulin E (IgE) blood level.

2. Assess for anaphylaxis and prepare for emergency treatment. Rationale: Hypersensitivity or allergy is excessive inflammation occurring in response to the presence of an antigen to which the person usually has been previously exposed. If a client is experiencing an allergic or hypersensitivity response, the nurse's initial action is to assess for anaphylaxis. Promptly notifying the health care provider and preparing emergency equipment, including medication such as epinephrine and possible corticosteroids, is essential in preventing progression of anaphylaxis. Laboratory work is not a priority in this situation. The nurse would expect the IgE level to be elevated; the client may be hypoxic. The nurse would give the client supplemental oxygen; however, 100% is not given unless prescribed, and based on the information in the question intubation is not the first thing the nurse would prepare this client for. Teaching the client is important; however, this is not the right time. When the client is stabilized, the nurse should teach or reinforce that allergies, including some medications, are common triggers for asthma attacks and that people with asthma are predisposed to more allergies than people without asthma.

A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication? 1. Western blot 2. CD4+ cell count 3. Enzyme-linked immunosorbent assay (ELISA) 4. Complete blood cell (CBC) count with differential

2. CD4+ cell count Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Zalcitabine slows the progression of acquired immunodeficiency syndrome (AIDS) by improving the CD4+ cell count. The Western blot and the ELISA are performed to diagnose the infection initially. A CBC count with differential may be done as part of ongoing monitoring of the status of the client with AIDS and to detect adverse effects of other medications.

The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation? 1. Fever 2. Cough 3. Dyspnea at rest 4. Dyspnea on exertion

2. Cough Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The client with P. jiroveci infection usually has a cough as the first sign. The cough begins as nonproductive and then progresses to productive. Later signs and symptoms include fever, dyspnea on exertion, and finally dyspnea at rest.

A client asks the nurse about obtaining a home test kit to test for human immunodeficiency virus (HIV) status. What should the nurse tell the client? 1. Home test kits are not available for testing at this time. 2. Home test kits may not be as reliable as laboratory blood tests. 3. Home test kits are most reliable immediately after a risk event occurs. 4. Home test kits should not be used; rather, it is important to contact the health care provider (HCP) with concerns about the HIV status.

2. Home test kits may not be as reliable as laboratory blood tests. Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Should a client wish to know his or her HIV status, testing is available from a HCP or a local public health clinic, or a home test kit can be used. Some test kits may not be as reliable as a laboratory blood test. It is also recommended that a home test be performed at least 3 months after a risk event occurs. If a positive result on a home test occurs then the individual requires additional testing.

The nurse is reviewing the diagnostic tests performed in an adult with a connective tissue disorder. The erythrocyte sedimentation rate (ESR) is reported as 35 mm/hr (35 mm/hr). How should the nurse interpret this finding? 1. Normal 2. Indicating mild inflammation 3. Indicating severe inflammation 4. Indicating moderate inflammation

2. Indicating mild inflammation Rationale: The ESR is a blood test that can confirm the presence of inflammation or infection in the body. The normal ESR range is less than or equal to 15 mm/hr in a male and less than or equal to 20 mm/hr in a female. Generally, an ESR value of 30 to 40 mm/hr indicates mild inflammation, 40 to 70 mm/hr indicates moderate inflammation, and 70 to 150 mm/hr indicates severe inflammation.

A CD4 T-cell count is measured in a client newly diagnosed with human immunodeficiency virus (HIV). In planning care, the nurse understands that which is accurate regarding the CD4 T-cell count? Select all that apply. 1. Falls in response to a declining viral load 2. Is a primary marker of immunocompetence 3. Plays a role in the cell-mediated immune response 4. Is a direct measure of the magnitude of HIV replication 5. Guides decision making regarding timing of initiation of treatment

2. Is a primary marker of immunocompetence 3. Plays a role in the cell-mediated immune response 5. Guides decision making regarding timing of initiation of treatment Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. CD4 T-cells are a subgroup of lymphocytes that play an important role in the cell-mediated immune response; as such, CD4 T-cells are a primary marker of immunocompetence. Viral load is the direct measure of the magnitude of HIV replication. The CD4 T-cell count rises in response to a declining viral load. CD4 T-cell counts also guide decision making regarding initiation of treatment, when to change medications when treatment is failing, and the need for initiation of treatment against opportunistic infections.

The nurse mentor is describing the phases of the immune response to a recent nursing graduate. The mentor determines that the graduate needs additional information if the graduate states that which is a phase of the immune response? 1. Effector phase 2. Memory phase 3. Activation phase 4. Recognition phase

2. Memory phase Rationale: Immunity is composed of many cell functions that protect against the effects of injury or invasion. The purpose of inflammation and immunity is to provide protection by neutralizing, eliminating, or destroying organisms that invade the body. Specific immune responses have 3 main phases: the recognition phase, the activation phase, and the effector phase. Memory is not a feature of an immune response.

A 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 actions are most appropriate? Select all that apply. 1. Tell the client that testing is not necessary unless arthralgia develops. 2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5. Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic.

2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 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. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic. Options 1 and 5 are incorrect.

A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding? 1. The histoplasmosis is resolving. 2. The client has disseminated histoplasmosis infection. 3. This is a side effect of the medications given to treat AIDS. 4. The client probably has another infection that is developing.

2. The client has disseminated histoplasmosis infection. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respiratory infection in the client with AIDS and then becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver. The client experiences dyspnea, fever, cough, and weight loss. The remaining options are incorrect.

The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 1. "My skin will have tiny red vesicles." 2. "The presence of the skin vesicles is caused by a virus." 3. "I have an autoimmune disease that causes blistering in the epidermis." 4. "The presence of red, raised papules and large plaques covered by silvery scales will be present on my skin."

3. "I have an autoimmune disease that causes blistering in the epidermis." 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 2 describes herpes zoster, and option 4 describes psoriasis.

The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? Select all that apply. 1. "I need to sit whenever possible." 2. "I need to be sure to eat a balanced diet." 3. "I need to take a hot bath every evening." 4. "I need to rest for long periods of time every day." 5. "I should engage in moderate low-impact exercise when I am not tired."

3. "I need to take a hot bath every evening." 4. "I need to rest for long periods of time every day." Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Hot baths may exacerbate the fatigue. To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, avoid hot baths, engage in moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness.

The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an altered immune system and the role of interferons is discussed. Which statement by the nursing student indicates a need for further teaching? 1. "They are produced by several types of cells." 2. "They are effective against a wide variety of viruses." 3. "They are effective against a wide variety of bacteria." 4. "They have been effective to some degree in the treatment of melanoma."

3. "They are effective against a wide variety of bacteria." Rationale: Interferon is produced by several types of cells and is effective against a wide variety of viruses (not bacteria). It works on the host cells to induce protection and differs from an antibody, which inactivates viruses found outside the cells. Interferons have been effective to some degree in the treatment of melanoma, hairy cell leukemia, renal cell carcinoma, ovarian cancer, and cutaneous T-cell lymphoma.

A client is suspected of having stage I Lyme disease. The nurse anticipates that which will be part of the treatment plan for the client? 1. Daily oatmeal baths for 2 weeks 2. No treatment unless symptoms develop 3. A 14 to 21 day course of oral antibiotic therapy 4. Treatment with intravenously administered antibiotics

3. A 14 to 21 day course of oral antibiotic therapy Rationale: Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Prevention, public education, and early diagnosis are vital to the control and treatment of Lyme disease. A 14 to 21 day course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with intravenously administered antibiotics, such as penicillin G. The remaining options are incorrect.

A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result should be most closely monitored? 1. Protein 2. Glucose 3. Amylase 4. Cholesterol

3. Amylase Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Didanosine is toxic to the pancreas and the liver. A serum amylase level that is increased by 1.5 to 2 times normal may signify pancreatitis and may be fatal in the client with AIDS. Therefore, the nurse should monitor the results of amylase and liver function studies closely. Alterations in protein, glucose, and cholesterol levels are unrelated to this medication.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has begun to experience multiple opportunistic infections. Which laboratory test would be most helpful in assessing the client's need for reassessment of treatment? 1. Western blot 2. B lymphocyte count 3. CD4+ cell or T lymphocyte count 4. Enzyme-linked immunosorbent assay (ELISA)

3. CD4+ cell or T lymphocyte count Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV),which destroys T cells, thereby increasing susceptibility to infection and malignancy. The T lymphocyte or CD4+ cell count indicates whether the client is responding to the medication treatment. The count should increase if the client is responding and should decrease if the client's response is poor. The Western blot and ELISA are tests to assist in diagnosing human immunodeficiency virus infection. The B lymphocyte count is not a priority marker to monitor with AIDS client

The clinic nurse reads the chart of a client just seen by the health care provider (HCP) and notes that the HCP has documented that the client has stage III Lyme disease. Which clinical manifestation should the nurse expect to note in this client? 1. Generalized skin rash 2. Cardiac dysrhythmia 3. Complaints of joint pain 4. Paralysis of the affected extremity

3. Complaints of joint pain Rationale: Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Stage III develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgias and enlargement or inflammation of joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage II. A rash occurs in stage I. Paralysis of the extremity on which the bite occurred is not a characteristic of Lyme disease.

A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? 1. Creatinine level 2. Potassium concentration 3. Complete blood cell (CBC) count 4. Blood urea nitrogen (BUN) level

3. Complete blood cell (CBC) count Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Common adverse effects of zidovudine are agranulocytopenia and anemia. The nurse should monitor the CBC count for these changes. Creatinine, potassium, and BUN are unrelated to this medication.

A client is admitted to the hospital with a diagnosis of parasitic worms. After reviewing the client's complete blood cell (CBC) count, the nurse should expect an increased laboratory value for which cells? 1. Basophils 2. Neutrophils 3. Eosinophils 4. Dendritic cells

3. Eosinophils Rationale: Eosinophils attack and destroy foreign particles that have been coated with antibodies of the immunioglobulin E (IgE) class. Their usual target is helminths (parasitic worms). Basophils mediate immediate hypersensitivity reactions. Dendritic cells perform the same antigen-presenting task as macrophages. Neutrophils phagocytize foreign particles such as bacteria.

A client is admitted to the hospital with a diagnosis of parasitic worms. By reviewing the client's complete blood cell (CBC) count results, which cells indicate attack by these foreign bodies? 1. Basophils 2. Neutrophils 3. Eosinophils 4. Dendritic cells

3. Eosinophils Rationale: Eosinophils attack and destroy foreign particles that have been coated with antibodies of the immunoglobulin E (IgE) class. Their usual target is helminths (parasitic worms). Basophils mediate immediate hypersensitivity reactions. Neutrophils phagocytize foreign particles such as bacteria. Dendritic cells perform the same antigen-presenting task as macrophages.

The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? 1. Ascites 2. Emboli 3. Facial rash 4. Two hemoglobin S genes

3. Facial rash Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A butterfly rash on the cheeks and bridge of the nose is an essential sign of SLE. Ascites and emboli are found in many conditions but are not associated with SLE. Two hemoglobin S genes are found in sickle cell anemia.

The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? 1. Fever, hypotension, and polyuria 2. Hypertension, polyuria, and thirst 3. Fever, hypertension, and graft tenderness 4. Hypotension, graft tenderness, and hypothermia

3. Fever, hypertension, and graft tenderness Rationale: Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibiodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection usually occurs within 3 months after transplantation, although it can occur up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment with corticosteroids, and possibly also with monoclonal antibodies and antilymphocyte agents, is begun immediately.

A client is diagnosed with Goodpasture's syndrome. The nurse determines that this client's renal disease is caused by a type II hypersensitivity response. Which laboratory results would be most important for the nurse to evaluate? 1. Urinalysis 2. Electrolytes 3. Glomerular filtration rate (GFR) 4. Partial thromboplastin time (PTT)

3. Glomerular filtration rate (GFR) Rationale: In the autoimmune disease known as Goodpasture's syndrome, autoantibodies attack the glomerulular basement membrane and neutrophils. As a result, the affected person will begin to experience decreased GFR with development of signs of chronic kidney disease. There will be an increased blood urea nitrogen (BUN) and creatinine but decreased GFR due to declining kidney function. Therefore, the remaining options are incorrect.

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? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3. Positive punch biopsy of the cutaneous lesions 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.

A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE? 1. Fever 2. Fatigue 3. Skin lesions 4. Elevated red blood cell count

3. Skin lesions Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. The major skin manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE.

The nurse is caring for a client with human immunodeficiency virus (HIV) infection and notes a diagnosis of cryptococcosis in the client's medical record. The nurse understands that this opportunistic infection most likely was diagnosed by which test? 1. Skin biopsy 2. Viral culture 3. Sputum culture 4. Bone marrow biopsy

3. Sputum culture Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Cryptococcosis is a fungal infection caused by Cryptococcus neoformans. It usually affects the lungs of central nervous system (brain and spinal cord) but it can also affect other parts of the body. Symptoms of lung involvement include cough, shortness of breath, chest pain, and fever. When it spreads to the brain manifestations include headache, fever, neck pain, nausea and vomiting, sensitivity to light, confusion, or changes in behavior. Diagnostic tests to confirm its presence in the lungs include chest x-ray studies and a sputum culture.

The nurse is reviewing the diagnostic tests prescribed for an assigned client and notes that an "LE cell prep" has been prescribed. Which immune disorder should the nurse primarily anticipate? 1. Histoplasmosis 2. Progressive systemic sclerosis 3. Systemic lupus erythematosus (SLE) 4. Human immunodeficiency virus infection

3. Systemic lupus erythematosus (SLE) Rationale: Lupus erythematosus (LE) cell test is a blood test that measures the presence of a special cell found mostly in individuals with systemic lupus erythematosus. The LE cell prep (lupus erythematosus cell preparation) may be performed in a client suspected of having SLE. It also may be used to screen for progressive systemic sclerosis but is used primarily to screen for SLE. The other options are not associated with this diagnostic test.

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. The client reports that he removed the tick and flushed it down the toilet. The nurse should take which nursing action? 1. Refer the client for a blood test immediately. 2. Ask the client about the size and color of the tick. 3. Tell the client to return to the clinic in 4 to 6 weeks. 4. Inform the client that the tick is needed to perform a test.

3. Tell the client to return to the clinic in 4 to 6 weeks. Rationale: Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. A blood test is available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks after the tick bite. Antibody formation takes place in the following manner: Immunoglobulin M (IgM) is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, then gradually disappears; IgG is detected 2 to 3 months after infection and may remain elevated for years. The actions in the remaining options are inaccurate.

The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity? 1. Sunlight 2. Going to parties 3. The use of latex condoms 4. Outdoor activities as much as possible

3. The use of latex condoms Rationale: Latex allergy is a type I hypersensitivity reaction in which a specific allergen is a processed natural latex rubber protein. Mucosal exposure to latex can occur on contact with latex condoms. The nurse most appropriately would provide instructions to the client about the need to avoid the use of condoms unless they are latex-free. No reason exists for the client to avoid outdoor activities or sunlight or to avoid parties; however, the client should be informed that certain forms of balloons are made of latex.

The nurse provided education about the tetanus toxoid and administered it to the client via injection after stepping on a nail while walking on the beach. Which statement by the client indicates successful teaching? 1. "The tetanus toxoid is caused by viruses." 2. "The tetanus toxoid is caused by parasites." 3. "The tetanus toxoid is an optional treatment so I really don't have to have this." 4. "The tetanus toxoid are toxins that have been altered so that they are no longer toxic."

4. "The tetanus toxoid are toxins that have been altered so that they are no longer toxic." Rationale: Toxoids are toxins produced by bacteria that have been altered so that they are no longer toxic. Their important antigenic receptor sites remain intact, enabling antibodies to the antigen-producing toxin to be produced. The remaining options are incorrect statements.

The nursing student enrolled in an anatomy and physiology course is studying the immune system. The nursing instructor determines that the student understands the chemical barriers against a nonspecific immune response if which statement is made? 1. "The skin is considered a chemical barrier." 2. "The mucous membranes act as chemical barriers." 3. "The cilia lining the respiratory tract are chemical barriers." 4. "Acids and enzymes found in body fluids function as chemical barriers."

4. "Acids and enzymes found in body fluids function as chemical barriers." Rationale: Chemical barriers include various acids and enzymes found in body fluids. The skin, the mucous membranes, and the action of cilia lining the respiratory tract are physical barriers

The nursing student conducting a clinical conference on immunity places an emphasis on active immunity. Which statement by fellow nursing students indicates successful teaching? 1. "Passive immunity can last for years." 2. "Active immunity only lasts from days to months." 3. "Active immunity provides protection immediately and forever." 4. "Active immunity lasts for years and can be easily reactivated by a booster dose of antigen."

4. "Active immunity lasts for years and can be easily reactivated by a booster dose of antigen." Rationale: Active immunity lasts for years and is natural by infection or artificial by stimulation of the body's immune defenses for example by vaccination. It can be easily reactivated by a booster dose of antigen. Protection from active immunity takes 5 to 14 days to develop after the first exposure to the antigen and 1 to 3 days after subsequent exposures. Active immunity lasts much longer and is more effective at preventing subsequent infections than passive immunity however it does not last forever. Passively received human antibodies have a half-life of about 30 days. Passive immunity provides protection immediately.

The nurse instructs a client with candidiasis (thrush) of the oral cavity on how to care for the disorder. Which client statement indicates the need for further instruction? 1. "I need to eat foods that are liquid or pureed." 2. "I need to eliminate spicy foods from my diet." 3. "I need to eliminate citrus juices and hot liquids from my diet." 4. "I need to rinse my mouth 4 times daily with a commercial mouthwash."

4. "I need to rinse my mouth 4 times daily with a commercial mouthwash." Rationale: Candidiasis is caused by Candida albicans, which is a part of the intestinal tract's natural flora. Fungal infection occurs by overgrowth of normal body flora. Candida stomatitis or esophagitis occurs often in in immunocompromised clients. On examination of the mouth and throat, the nurse would note cottage cheese-like, yellowish white plaques and inflammation. Clients with candidiasis cannot tolerate commercial mouthwashes because the high alcohol concentration in these products can cause pain and discomfort to the lesions. A solution of warm water or mouthwash formulas without alcohol are better tolerated and may promote healing. A change in diet to liquid or pureed food often eases the discomfort of eating. The client should avoid spicy foods, citrus juice, and hot liquids.

The nurse is assisting in administering immunizations as well as providing education to the clients who receive them at a health care clinic. Which statement by a client indicates that teaching was successful? 1. "Immunizations protect against all diseases." 2. "Immunizations can provide natural immunity." 3. "Immunizations can provide innate immunity." 4. "Immunizations are a way to acquire immunity to a specific disease."

4. "Immunizations are a way to acquire immunity to a specific disease." Rationale: Acquired immunity is immunity that can occur by receiving an immunization that causes antibodies to a specific pathogen to form. No immunization protects the client from all diseases. Natural (innate) immunity is present at birth.

The nursing instructor is evaluating a nursing student for knowledge of antibody classes. Which statement by the nursing student indicates that teaching has been effective? 1. "Immunoglobulin G (IgG) is the first antibody produced in response to antigen." 2. "Immunoglobulin A (IgA) is the last antibody produced in response to antigen." 3. "Immunoglobulin D (IgD) is the last antibody produced in response to antigen." 4. "Immunoglobulin M (IgM) is the first antibody produced in response to antigen."

4. "Immunoglobulin M (IgM) is the first antibody produced in response to antigen." Rationale: IgM is the first antibody produced in response to antigen. IgM composes about 10% to 15% of the circulating antibody population. IgM is especially effective at the antibody actions of agglutination and precipitation because of having 10 potential binding sites per molecule. Because of their size, these antibodies are confined to the bloodstream. The remaining options are incorrect.

The nursing instructor asks a nursing student to identify the components of natural resistance as it relates to the immune system. Which statement by the nursing student indicates a need for further research? 1. "It also is called inherited immunity." 2. "It is the immunity with which a person is born." 3. "It does not require previous exposure to the antigen." 4. "It includes all antigen-specific immunities a person develops during a lifetime."

4. "It includes all antigen-specific immunities a person develops during a lifetime." Rationale: Natural resistance, also called innate inherited or innate-native immunity, is the immunity with which a person is born. It does not require previous exposure to the antigen. Acquired immunity includes all antigen-specific immunities that a person develops during a lifetime.

The nursing instructor asks a nursing student to define the process of phagocytosis. The nursing instructor determines that the student has an accurate understanding if which statement is made? 1. "It is the initial reaction in the inflammatory response." 2. "Phagocytosis is required for the production of antibodies." 3. "It is when a is protein is produced in response to a viral infection." 4. "It is a process by which a particle is ingested and digested by a cell."

4. "It is a process by which a particle is ingested and digested by a cell." Rationale: Phagocytosis, an important nonspecific immune response, is a process by which a particle is ingested and digested by a cell. The statements made in the remaining options are incorrect.

The nurse provides education to the student about the process of phagocytosis. Which statement by the student indicates successful teaching? 1. "It is the first stage of inflammation." 2. "It is a process of blood cell production." 3. "It is a process of blood cell destruction." 4. "It is a process of ingesting and destroying any potentially foreign materials, such as germs."

4. "It is a process of ingesting and destroying any potentially foreign materials, such as germs." Rationale: Phagocytosis, an important nonspecific immune response, is a process in which the particle is ingested and digested by a cell. This rids the body of debris after tissue injury. The other options are incorrect.

The nursing student is reviewing information related to the primary purpose of neutrophils in the inflammatory response. The nursing instructor determines that understanding is accurate when which statement is made by the student? 1. "Neutrophils dilate the blood vessels." 2. "Neutrophils increase fluids at the site of injury." 3. "Neutrophils allow permeability of the blood vessels." 4. "Neutrophils phagocytize any potentially harmful agents."

4. "Neutrophils phagocytize any potentially harmful agents." Rationale: In the inflammatory response, neutrophils appear in the area of injury within 30 to 60 minutes. Their primary purpose is to phagocytize (ingest and destroy) any potentially harmful agents, such as microorganisms. The remaining options are not actions of the neutrophils.

A client reports to the health care clinic for testing for human immunodeficiency virus (HIV) immediately after being exposed to HIV. The test results are negative, and the client expresses relief about not contracted HIV. What should the nurse emphasize when explaining the test results to the client? 1. No further testing is needed. 2. The test should be repeated in 1 month. 3. A negative HIV test result is considered accurate. 4. A negative HIV test result is not considered accurate immediately after exposure.

4. A negative HIV test result is not considered accurate immediately after exposure. Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A test for HIV should be repeated if results are negative. Seroconversion is the point at which antibodies appear in the blood. The average time for seroconversion is 2 months, with a range of 2 to 10 months. For this reason, a negative HIV test result is not considered accurate immediately after exposure. The remaining options are incorrect.

A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine. The nurse assesses the complete blood cell (CBC) count, knowing that which is an adverse effect of this medication? 1. Polycythemia 2. Leukocytosis 3. Thrombocytosis 4. Agranulocytopenia

4. Agranulocytopenia Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Zidovudine is a neucloside-nucleotide reverse transcriptase inhibitor used to the virus. An adverse effect of this medication is agranulocytopenia with anemia. The nurse carefully monitors CBC count results for changes that could indicate this occurrence. With early infection and in the client who is asymptomatic, the CBC count is monitored monthly for 3 months and then every 3 months thereafter. In clients with advanced disease, the CBC count is monitored every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. The remaining options are not side or adverse effects of the medication.

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

4. Bananas Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen. Options 1, 2, and 3 are unrelated to latex allergy.

Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage? 1. Arthralgias 2. Joint enlargement 3. Erythematous rash 4. Cardiac conduction deficits

4. Cardiac conduction deficits Rationale: Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Stage II of Lyme disease develops within 1 to 6 months in a majority of untreated persons. The most serious problems include cardiac conduction deficits and neurological disorders such as Bell's palsy and paralysis. Arthralgias and joint enlargement are noted in stage III. A rash appears in stage I.

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? 1. Determines the presence of antigens 2. Identifies which additional tests need to be performed 3. Confirms the diagnosis of a connective tissue disorder 4. Confirms the presence of inflammation or infection in the body

4. Confirms the presence of inflammation or infection in the body Rationale: The ESR is a blood test that can confirm the presence of inflammation or infection in the body. It is particularly useful for the management of connective tissue disease because the rate measured directly correlates with the degree of inflammation and later with the severity of the disease. The other options are incorrect

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse suspects that which finding will be reported with this blood test? 1. Increased neutrophils 2. Increased red blood cell count 3. Increased white blood cell count 4. Decreased numbers of all cell types

4. Decreased numbers of all cell types Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. In the client with SLE, a complete blood cell count commonly shows pancytopenia, a decrease in all cell types. This probably is caused by a direct attack on all blood cells or bone marrow by immune complexes. The other options are incorrect

A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? 1. Monitor for signs of hyperglycemia. 2. Administer the medication without food. 3. Administer the medication with an antacid. 4. Ensure that the client uses an electric razor for shaving.

4. Ensure that the client uses an electric razor for shaving. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach or without food and should not be taken with an antacid

A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102°F (38.9°C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition? 1. Inadequate thermoregulation 2. Insufficient medication dosing 3. Toxic nervous system effects from the medication 4. Infection caused by leukopenic effects of the medication

4. Infection caused by leukopenic effects of the medication Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. Adverse effects of pentamidine include leukopenia, thrombocytopenia, and anemia. The client should be routinely assessed for signs and symptoms of infection. The remaining options are inaccurate interpretations.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? 1. Provide large, nutritious meals. 2. Serve foods while they are hot. 3. Add spices to food for added flavor. 4. Remove dairy products and red meat from the meal.

4. Remove dairy products and red meat from the meal. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The client with AIDS who has nausea and vomiting should avoid fatty products such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. The client should avoid spices and odorous foods because they aggravate nausea. Foods are best tolerated cold or at room temperature.

A client seen in an ambulatory clinic has a facial rash that is present on both cheeks and across the bridge of the nose. The nurse interprets that this finding is consistent with manifestations of which disorder? 1. Hyperthyroidism 2. Pernicious anemia 3. Cardiopulmonary disorders 4. Systemic lupus erythematosus (SLE)

4. Systemic lupus erythematosus (SLE) Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A major skin manifestation of SLE is the appearance of a rash on both cheeks and across the nose. It is known as a "butterfly rash." Hyperthyroidism is associated with moist skin and increased perspiration. Pernicious anemia causes pallor of the skin. Cardiopulmonary disorders may lead to clubbing of the fingers.

A rheumatoid factor assay is performed in a client with a suspected diagnosis of rheumatoid arthritis (RA). Which laboratory result should the nurse anticipate? 1. The presence of inflammation 2. The presence of infection in the body 3. The presence of antigens of immunoglobulin A (IgA) 4. The presence of unusual antibodies of the IgG and IgM types

4. The presence of unusual antibodies of the IgG and IgM types Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The rheumatoid factor assay tests for the presence of unusual antibodies of the IgG and IgM types, which develop in a number of connective tissue diseases. The test result in a person without RA would be negative or <60 units/mL by nephelometric method of laboratory testing. The other options are incorrect.

The nursing instructor asks a nursing student to identify the location of Peyer's patches. The nursing instructor determines that the student has understanding of the location if which organ is identified? 1. The liver 2. The spleen 3. The tonsils 4. The small intestine

4. The small intestine Rationale: Peyer's patches are lymphoid nodules located in the small intestine, where T cells congregate. Peyer's patches are most important in the secondary immune response, although they play a role in the primary immune response as well. These organs may enlarge as they become highly active in the immune response. The organs noted in the remaining options are incorrect.

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this disease? 1. Neutropenia 2. Hyperglycemia 3. Antigens of immunoglobulin A (IgA) 4. Unusual antibodies of the IgG and IgM type

4. Unusual antibodies of the IgG and IgM type Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type, which develop in a number of connective tissue diseases. The other options are incorrect.

The nurse is assigned to care for a client with human immunodeficiency virus (HIV) infection. The nurse notes recent documentation of herpes simplex in the client's medical record. On assessment, the nurse would expect to note which type of lesion? 1. Macular lesions 2. Ecchymotic lesions 3. Creamy white patches 4. Vesicular lesions that rupture

4. Vesicular lesions that rupture Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. HSV in people with HIV or acquired immunodeficiency syndrome (AIDS) occurs in the perirectal, oral, and genital areas. Numbness of tingling at the site of infection occurs up to 24 hours before blisters form. Lesions are painful, with chronic open areas after blisters rupture. The nurse should assess for fever, pain, bleeding, and enlarged lymph nodes in the affected area. The nurse should also assess for headache, myalgia, and malaise. The other options are not characteristic of herpesvirus infection.