NCLEX chpt 59 immune problems practice questions

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

1. Protecting the client from infection RATIONALE: The client with immune deficiency has an adequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection.

Which interventions would be implemented in the care of a client at high risk for an allergic response to a latex allergy?

1. Use non-latex gloves 2. Use medication's from glass ampules 4. Do not puncture rubber stoppers with needles 5. Keep a latex safe supply cart available in the clients area RATIONALE: any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

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

2. An auto immune disease that causes blistering in the epidermidis RATIONALE: The client has large flaccid blisters. Because the blisters are in the epidermidis, they have a thin covering of skin and break easily, leaving large denuded areas of skin.

A client is diagnosed with stage one of Lyme disease. The nurse would check the client for which characteristic of the stage?

2. Flu like symptoms RATIONALE:The hallmark of stage 1 is the development of a skin rash 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. The lesion enlarges up to 50 CM to 60 CM, and smaller lesions develop further away from the original tick bite. In stage 1 most infected persons develop flu like symptoms that last 7 to 10 days the symptoms may reoccur later.

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

2. Maintaining a patent airway RATIONALE: if the client experiences an anaphylactic reaction, the immediate action would be to maintain a patent airway. The client then would receive Epinephrine

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 would the nurse incorporate in the plan during the beating of this client?

2. Wearing a gown and gloves RATIONALE: gowns and gloves are required if the nurse anticipates contact with soil items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has ileostomy or colonostomy.

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

4. Acquired immunity from disease RATIONALE: acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural any immunity is present at birth. No immunization protect the client from all diseases.

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

4. An individual working in an environment where exposure to asbestos exists RATIONALE:Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It is seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system.

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

1. Lyme disease is caused by a tick carried by deer. RATIONALE: Lyme disease is a multi system infection that results from a bite by it take carried by several species of deer. Lyme disease cannot be transmitted from one person to another

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?

3. I will not use insect repellent because it will attract the ticks RATIONALE: in the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found.

A client with AIDS is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse would determine that this has been confirmed by which finding?

3. 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 G.I. track. 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 G.I. lesions.

The nurse is assigned to care for a client diagnosed with SLE. The nurse should plan care considering which factor regarding this diagnosis?

4. It is an inflammatory disease of collagen contained in connective tissue RATIONALE: SLE is an inflammatory disease a collagen contained in connective tissue.

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

4. Rash on the face across the nose and on the cheeks RATIONALE: skin lesions or a rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of SLE. Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

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

4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable RATIONALE: A blood test is available to detect Lyme disease, but the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: immuno globin M is detected 3 to 4 weeks after lyme disease onset, peaks at 6 to8 weeks, and then gradually disappears.

The client calls the office of the PHCP and states to the nurse that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because they're neighbor experience such a reaction just one week ago. Which would be the appropriate nursing action?

2. Ask the client if they 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. Therefore the appropriate action would be to ask the client if he ever received a beast thing in the past