nclex book ch 62 immune problems

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? SATA 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 4-6 wks after bite to detect the presence of disease 5) Tell client that if this happens again, to never remove the tick but vigorously scrub the area w/ 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 4-6 wks after bite to detect the presence of disease

The nurse prepares to give a bath and change the bed linens of a client w/ cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan of care during the bathing of this client? 1) Wearing gloves 2) Wearing a gown and gloves 3) Wearing a gown, gloves, and mask 4) Wearing a gown and gloves to change linens and gloves only for bath

2) Wearing a gown and gloves

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? SATA 1) Admin O2 2) Quickly assess client's respiratory status 3) Document the event, interventions, and client's response 4) Leave the client briefly to contact primary HCP 5) Keep client supine regardless of BP readings 6) Start an IV infusion of D5W and admin a 500 mL bolus

1) Admin O2 2) Quickly assess client's respiratory status 3) Document the event, interventions, and client's response

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) Homeless 3) Day care center children 4) Individuals in group homes

1) Hairdressers

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? SATA 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 1-2 hr after injection

1) Record site, date, and time of the test 2) Give the client a list of potential allergens if identified

The nurse provides home care instructions to a client w/ 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 bc they are relaxing. 2) I should sit whenever possible to conserve energy. 3) I should avoid long periods of rest bc it causes joint stiffness. 4) I should do some exercises, such as walking, when I am not fatigued.

1) I should take hot baths bc they are relaxing.

The nurse is assisting in planning care for a client w/ a dx 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

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? SATA 1) Use nonlatex gloves 2) Use meds 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 use of med vials w/ rubber stoppers 6) Use a blood pressure cuff from an electronic device only to measure the BP

1) Use nonlatex gloves 2) Use meds from glass ampules 4) Keep a latex-safe supply cart available in the client's area 5) Avoid use of med vials w/ rubber stoppers

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

2) Admin corticosteroids as prescribed for inflammation

A client calls the nurse in the ER and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction bc the client's neighbor experienced such a reaction just a 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 ER 4) Tell the client not to worry about the sting unless difficulty w/ breathing occurs

2) Ask the client if he ever sustained a bee sting in the past

A client presents at the primary HCP office w/ complaints of a ring-like 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 w/in the last few weeks? 4) Have you been in physical contact w/ anyone who has the same type of rash?

2) Have you been camping in the last month?

The nurse is conducting a teaching session w/ a client on their dx of pemphigus. Which statement by the client indicates they understand the dx? 1) My skin will have tiny red vesicles. 2) The presence of skin vesicles is caused by a virus. 3) I have an autoimmune disease that causes blistering of the skin. 4) 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 of the skin.

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs them about methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction? 1) I need to bring a hat to wear during the trip. 2) I should wear long-sleeved tops and long pants. 3) I should not use insect repellents bc it will attract the ticks. 4) I need to wear closed shoes and socks that can be pulled up over my pants.

3) I should not use insect repellents bc it will attract the ticks.

The client w/ AIDS is diagnosed w/ cutaneous Kaposi's sarcoma. Based on this dx, the nurse understands that this has been confirmed by which finding? 1) Swelling in the genital area 2) Swelling in the LE 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

The nurse is performing an assessment on a client who has been dx w/ a latex allergy. 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