Allergic, Immune, and Autoimmune Disorders - Saunders & ATI

A nurse is reviewing strategies to promote comfort with a client who received an immuniation. Which of the following informaiton should the nurse include? (Select all that apply.) (3)

1. Apply a cool compress to the injection 2. Take acetaminophen or ibuprofen 3. Use the affected extremity

A nurse is reviewing the plan of care for a client who has systemic lupus erthemastosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse expect? (Select all that apply) (3)

1. Positive ANA titer 2. 2+ urine protein 3. Elevated BUN

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse should monitor for which side/adverse effects of the medicaiton? (Select all that apply) (2)

1. Rash 2. Hepatoxocity

A nurse is collecting data from a client who has SLE. Which of the following findings should the nurse expect?

Alopecia Alopecia (hair loss) is an expected finding of SLE

A nurse is preparing to adminsiter a varicella immunization to a client. Which of the following questions should the nurse ask?

"Are you pregnant?"

The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which should be the appropriate nursing action?

Ask the client if they ever sustained a bee sting in the past

Saquinavir is prescribed for the client who is diagnosed with human immunodeficiency virus (HIV) seropositive. The nurse should reinforce medication instructions about which health care measure to the client?

Avoid sun exposure

The client is diagnosed with stage 1 of Lyme disease. The nurse should check the client for which characteristic of this stage?

Flu-like symptoms

The client who is diagnosed with human immunodeficiency virus (HIV) seropositive has been taking stavudine. The nurse should monitor which parameter closely while the client is taking this medication?

Gait

Amikacin is prescribed for a client with a diagnosed bacterial infeciton. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs?

Hearing loss

ATI - A nurse is caring for a client who has a WBC count of 20,000/mm3. Which of the following WBC abnormalities is consistent with this finding?

Leukocytosis

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?

Lyme disease is caused by a tick carried by deer

A nurse is revieiwng the laboratory findings of a client who has measles. The nurse should expect an increase in which of the following types of WBCs?

Lymphocytes

The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should determine that this has been confirmed by which finding?

Punch biopsy of the cutaneous lesions

The nurse is assigned to care for the client diagnosed with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet. The nurse should monitor the results of which laboratory study while the client is taking this medication?

Serum creatinine level

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse incorporate in the plan during the bathing of this client?

Wearing a gown and gloves.

The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate?

Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable

The nurse is assigned to care for a cleint diagnosed with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding this diagnosis?

It is an inflammatory disease of collagen contained in connective tissue

The client brought to the emergency department is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action?

Maintaining a patent airway

The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching?

"I should not use insect repellent because it will attract the ticks"

A nurse is reinforcing teaching about self-care with a client who has SLE. Which of the following statements by the client indicates understanding?

"I should use a mild hair shampoo" A client who has SLE should use a mild hair shampoo that does not irritate the scalp

A nurse in a clinic is caring for a client who is to receive an immunization. The client asks baout contraindications to immunizations. Which of the following responses should the nurse make?

"The provider will weigh the risks if you have experienced any adverse effects"

A nurse is preparing to adminsiter an IM injection of immune globulin to a client following exposure to hepatitis A. Which of the following statements should the nurse make?

"This medication provides an immune response more quickly than the body can produce it."

A nurse is preparing to administer a scratch test to a client who has possible food and environmental allergies. Which of the following actions should the nurse perform prior to the procedure? (Select all that apply) (4)

1. Ask the client about previous reactions to allergens 2. Ask the client about medications taken the past several days 3. Inform the client to expect itching at one site 4. Obtain emergency resuscitation equipment

Which individual is least at risk for the development of Kaposi's sarcoma?

An individual working in an environment where exposure to asbestos exists

A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors? (Select all that apply.) (3)

1. Diuretic use 2. Obesity 3. Cardiovascular disease

Ketoconazole is prescribed for a client with a diagnosis of candidiases. Which interventions should the nurse include when administering this medicaiton? (Select all that apply (3)

1. Monitor liver function studies 2. Instruct the client to avoid alcohol 3. Instruct the client to avoid exposure to the sun

Which interventions should be implented 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. Do not puncture rubber stoppers with needles 4. Keep a latex-safe supply cart available in the client's area

The client with diagnosed acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temeprature of 101 F (38.3 C). The nurse continues to monitor the client, knowing that this sign would most likely indicate which condition

A result of another infection caused by the leukopenic effects of the medication

The client diagnosed with pemphigus is being seen in the clinic regularly. The nurse should plan care based on which description of this condition?

An autoimmune disease that causes blistering in the epidermis

The client diagnosed with acquired immunodeficiency syndrome (AIDS) has begun therapy with zidovudine. The nurse should montior which laboratory result during treatment with this medication.

Complete blood count

A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

Pallor of toes with cold exposure

The nurse is assisting with planning the care of a client with a diagnosis of immunodeficiency. The nurse should incorporate which intervention as a priority in the plan of care?

Protecting the client from infection

A client is suspected of having systemic lupus erythematosus (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of systemic lupus erythematosus (SLE)?

Rash on the face across the nose and on the cheeks

The nurse is reviewing the results of serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which significantly elevated result is noted?

Serum amylase

The nurse is assisting with the administration of immunizations at a health care clinic. The nurse should understand that immunization provides which protection?

Acquired immunity from disease

A nurse is preparing to document administration of a meningococcal vaccine to a client. Which of the following informaiton should the nurse include in the documentation? (Select all that apply) (3)

1. Name of vaccine manufacturer 2. Vaccine expiration date 3. Date of administration

The nurse is caring for a postrenal transplantation client with prescription for cyclosporine. If the nurse notes an increase in one of the client's vital signs and the client is complaining of a headache, which vital sign is most likely increased?

Blood pressure