NCLEX Immune

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.

A client calls the office of his primary care health care provider and tells the nurse 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. The appropriate nursing action is to:

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 room. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs. Answer: 2 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 bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

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.

The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food item?

1. Eggs 2. Milk 3. Yogurt 4. Bananas Answer: 4 Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy.

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 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 client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse would focus on which of the following first until additional help arrives?

1. Preparing a dose of epinephrine (Adrenalin) 2. Preparing a dose of a corticosteroid 3. Maintaining a patent airway 4. Telling the client to obtain a Medic-Alert bracelet Answer: 3 Rationale: The initial priority of the nurse would be to maintain a patent airway. Once additional helps arrives, the client would likely receive epinephrine and corticosteroids. The topic of the Medic-Alert bracelet should be deferred until the client is stable.

The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that immunization provides which of the following?

1. Protection from all diseases 2. Innate immunity from disease 3. Natural immunity from disease 4. Acquired immunity from disease Answer: 4 Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases.

Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply.

1. Use non-latex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Do not puncture rubber stoppers with needles. 5. Keep a latex-safe supply cart available in the client's area. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure. Answer: 1 2 4 5 Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use non-latex 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 bottles with a rubber stopper that requires puncture with a needle. It is not necessary to place the client in a private room.

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.

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancy c. Antibody deficiency screening d. Screening for autoimmune disorders

ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.