immune nclex

Which client is at the highest risk for systemic lupus erythematous (SLE)?

1. An Asian male 2. A white female 3. An African-American male 4. An African-American female Answer: 4 Rationale: SLE affects females more commonly than males. It is more common in African-American females than in white females.

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 instructions?

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." Answer: 1 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 nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is:

1. A local rash that occurs as a result of allergy 2. A disease caused by overexposure to sunlight 3. An inflammatory disease of collagen contained in connective tissue 4. A disease caused by the continuous release of histamine in the body Answer: 3 Rationale: SLE is an inflammatory disease of collagen contained in connective tissue. Options 1, 2, and 4 are not associated with this disease.

The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed?

1. Antibiotic 2. Antidiarrheal 3. Corticosteroid 4. Opioid analgesic Answer: 3 Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. The incorrect options are not standard components of medication therapy for this disorder.

A nurse is assisting in the care of a client diagnosed with systemic lupus erythematosus (SLE). The nurse should administer which of the following prescribed medications that is needed to manage the condition?

1. Antidiarrheal 2. Corticosteroid 3. Antibiotic 4. Opioid analgesic Answer: 2 Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory medications, corticosteroids, and immunosuppressants. The other options are not standard components of medication therapy for this disorder.

A nurse is providing information to a client with systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which of the following foods?

1. Chicken 2. Beef 3. Melons 4. Cauliflower Answer: 2 Rationale: The client with SLE is at risk for cardiovascular disorders, such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce intake of salt, fat, and cholesterol.

A nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse further checks for which of the following that is also indicative of the presence of SLE?

1. Emboli 2. Ascites 3. Two hemoglobin S genes 4. Butterfly rash on cheeks and bridge of nose Answer: 4 Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE. Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many conditions but are not associated with SLE.

A client is diagnosed with an immune deficiency. The nurse focuses on which of the following as the highest priority when providing care to this client?

1. Encouraging discussion about emotional impact of the disorder 2. Identifying historical factors that placed the client at risk 3. Providing emotional support to decrease fear 4. Protecting the client from infection Answer: 4 Rationale: The client with immune deficiency has inadequate immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. The other options are also part of the plan of care but are not the highest priority.

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse would suspect that which of the following findings will be reported from this blood test?

1. Increased red blood cell count 2. Decrease of all cell types 3. Increased white blood cell count 4. Increased neutrophils Answer: 2 Rationale: In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease of all cell types, probably caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.

A nurse is reviewing the medical record of a young female client who is suspected of having systematic lupus erythematosus (SLE). Which of the following would the nurse expect to note documented in the record that is related to this diagnosis?

1. Presence of two hemoglobin S genes in the blood cell report 2. Ascites noted in the abdomen 3. Recurrent emboli 4. Butterfly rash on cheeks and bridge of the nose Answer: 4 Rationale: SLE primarily occurs in females 10 to 35 years of age and is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE. Option 1 is found in sickle cell anemia. Options 2 and 3 are found in many conditions but are not usually noted in SLE.

The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care?

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 Answer: 1 Rationale: The client with immune deficiency has inadequate or absent 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.

A nurse is providing dietary instructions to a client with systemic lupus erythematosus. Which of the following dietary items would the nurse instruct the client to avoid?

1. Steak 2. Turkey 3. Broccoli 4. Cantaloupe Answer: 1 Rationale: The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake.

A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous?

1. Weight gain 2. Subnormal temperature 3. Elevated red blood cell count 4. Rash on the face across the bridge of the nose and on the cheeks Answer: 4 Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.