SKIN and IMMUNE EXAM

A CD4+ lymphocyte count is performed in a client with human immunodeficiency virus (HIV) infection. When providing education about the testing, what should the nurse tell the client? "It establishes the stage of HIV infection." "It confirms the presence of HIV infection." "It identifies the cell-associated proviral DNA." "It determines the presence of HIV antibodies in the bloodstream."

"It determines the presence of HIV antibodies in the bloodstream." Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A CD4+ lymphocyte count is performed to establish the stage of HIV infection, to help with decisions regarding the timing of initiation of antiretroviral therapy and prophylaxis for opportunistic infections and to monitor treatment effectiveness. The remaining options are unrelated to the CD4+ lymphocyte count. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Immunity, Infection

The nurse iscaring for a patient with aquired immunodeficiency syndrome (AIDS). To evaluate forearly signs of Kaposi's sarcoma, the nurse assesses the patient for lesions that are 1. Flat, nonpruritic, and red or violet 2. Flat, pruritic, and brown 3. Papular, painful, and pink, brown, or violet 4. Papular, painless, and red or violet

4. Papular, painless, and red or violet Cutaneous lesions associated with Kaposi's sarcoma may be cosmetically disfiguring and are usually papular (but may be macular or nodular), nonpruritic, painless, and deep red or violet. Early on they appear on the skin and mucous membranes. Diagnosed with skin biopsy . Causes tumors that affect internal organs.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA? Anemia Anorexia Amenorrhea Night sweats

Anorexia Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early clinical manifestations of RA include complaints of fatigue, generalized weakness, anorexia, and weight loss. Anemia, amenorrhea, and night sweats are not early manifestations of RA. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Strategic Words Priority Concepts: Clinical Judgment, Immunity

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? a. Scale b. Crust c. Ulcer d. Scar

Answer A. A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't accompany psoriasis.

The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? Run a dehumidifier in the home. Apply astringents to the skin twice daily. Apply emollients to the skin after bathing. Take baths twice daily using a dilute solution of alcohol and water.

Apply emollients to the skin after bathing.

A nurse is performing a skin assessment on a client diagnosed with a malignant melanoma. The nurse would expect to note which characteristic of this type of skin lesion? a) a small papule with a dry, rough scale b) a firm nodular lesion topped with crust c) a pearly papule with a central crater and a waxy border d) an irregularly shaped lesion

D. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue tone. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with dry, rough adherent yellow or brown scale.

Ten days after receiving a bone marrow transplant, a patient develops a skin rash on his palms and soles, jaundice, and diarrhea. What is the most likely etiology of these clinical manifestations? A. The patient is experiencing a type I allergic reaction. B. An atopic reaction is causing the patient's symptoms. C. The patient is experiencing rejection of the bone marrow. D. Cells in the transplanted bone marrow are attacking the host tissue.

D. Cells in the transplanted bone marrow are attacking the host tissue. The patient's symptoms are characteristic of graft-versus-host-disease (GVHD) in which transplanted cells mount an immune response to the host's tissue. GVHD is not a type I allergic response or an atopic reaction, and it differs from transplant rejection in that the graft rejects the host rather than the host rejecting the graft.

A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms? Purpura Petechiae Ecchymosis Erythema

Ecchymosis

The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? Brown-red macules with scales Pustules on the trunk of the body White patches noted on the elbows and knees Multiple straight or wavy threadlike lines underneath the skin

Multiple straight or wavy threadlike lines underneath the skin Rationale: Scabies can be identified by the multiple straight or wavy threadlike lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Integumentary Strategy(ies): Subject Priority Concepts: Infection, Tissue Integrity

What is a firm, elevated flat rough superficial papule greater than 1 cm in diameter; may be joined (e.g. psoriasis or seborrhea)?

Plaque

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? Swelling in the genital area Swelling in the lower extremities Positive punch biopsy of the cutaneous lesions Appearance of reddish-blue lesions noted on the skin

Positive 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 gastrointestinal tract. 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 gastrointestinal lesions. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Evidence, Immunity

A 14-year-old female and her mother come to see their nurse practitioner for treatment of the daughter's acne. What should the nurse assess the patient for to support the existence of acne? Ulcers Wheals Vesicles Pustules

Pustule

A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? Provide large, nutritious meals. Serve foods while they are hot. Add spices to food for added flavor. Remove dairy products and red meat from the meal.

Remove dairy products and red meat from the meal. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The client with AIDS who has nausea and vomiting should avoid fatty products such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. The client should avoid spices and odorous foods because they aggravate nausea. Foods are best tolerated cold or at room temperature. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immune Strategy(ies): Subject, Data in the Question Priority Concepts: Immunity, Nutrition

A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE? Fever Fatigue Skin lesions Elevated red blood cell count

Skin lesions Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. The major skin manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Clinical Judgment, Immunity

What skin disorder is characterized by a well-demarcated, usually disseminated, eruption that is evanescent over minutes to about 24 hours with an asymmetrical distribution?

Urticaria

What is a chronic relapsing inflammatory condition that can take several forms, i.e. atopic, nummular or dyshidrotic, and is characterized by erythematous macules, papules, and vesicles that weep or crust?

Eczema

On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient's mouth. How should the nurse document this finding? Scar Fissure Atrophy Excoriation

Fissure

A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions. The nurse expects that these lesions will appear to be: Ring-shaped Shaped like an arc Net-like appearance Linear

Net-like appearance

If a patient presents with a flat non-palpable irregular shaped macule that is greater than 1 cm in diameter? (port wine stain, Mongolian spot)

Patch

What is a chronic, relapsing autoimmune disorder characterized by well-demarcated erythematous plaques, patches and papules, which typically present with silvery scales?

Psoriasis

What is a vasomotor instability disorder characterized by sebaceous gland hypertrophy, papules, pustules, persistent erythema and telangiectasias?

Rosacea

What is a viral exanthema similar to measles and starts as fine macules and papules on the face and progresses caudally?

Rubella

What is a fungal eruption that causes rashes at a variety of sites such as body, foot, beard, groin and scalp?

Tinea

What term refers to a superficial pustular, bullous, or non-bullous eruption, followed by crusting (often honey colored)?

impetigo

What is an infestation by a mite that deposits eggs in the epidermis of the skin?

scabies

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 instruction? 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."

1. "I should take hot baths because they are relaxing." 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. Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Immune Strategy(ies): Negative Event Query, Strategic Words, Subject Priority Concepts: Client Education, Immunity

Which of the following changes of aging skin increases the likelihood of skin breakdown in older adults who are confined to bed? SELECT ALL THAT APPLY. 1. Hair follicles become inactive 2. Decreased skin circulation 3. Loss of elasticity in the skin 4. Decreased melanocytes 5. Thinning of the subcutaneous tissue layer

2,3,5 Decreased circulation, loss of elasticity, and a thinner SQ fat layer all increase the risk of skin breakdown.

The nurse notices that a client being seen in the clinic for advancing upper lateral chest and back pain has a rash in a straight line. Which of the following would be appropriate for the nurse to document about this finding? A. The client has a zosteriform lesion. B. The client has a grouped lesion. C. The client has an annular lesion. D. The client has a polycyclic lesion.

A. The client has a zosteriform lesion.

When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care? a. Placing mitts on the client's hands b. Administering systemic antibiotics as prescribed c. Applying topical antibiotics as prescribed d. Continuing to administer antibiotics for 21 days as prescribed

Answer B. Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis, a dangerous complication. The client's nails should be kept trimmed to avoid scratching; however, mitts aren't necessary. Topical antibiotics are less effective than systemic antibiotics in treating impetigo.

Inspection of an obese, female patient reveals the presence of a foul odor that emanates from the patient's abdominal skin folds. What should the nurse suspect that is most likely causing the odor? Ecchymosis Colonization by yeast or bacteria Age-related integumentary changes Atrophy of the skin under the abdominal folds

Colonization by yeast or bacteria

During change-of-shift report, the outgoing nurse reports a new finding of petechiae in a new patient admitted with a yet-to-be diagnosed hematologic disorder. On assessment of this patient, what should the incoming nurse expect to find? 1. Tiny, purple spots on the skin 2. Large ecchymotic areas on the skin 3. Hyperkeratotic papules and plaques 4. Small, raised red areas on the soles of the feet

1. Tiny, purple spots on the skin

A patient has ptosis secondary to myasthenia gravis. Which of the following assessment findings would the nurse expect to see in this patient?, 1. redness and swelling of the conjunctiva 2. Dropping of the upper eyelid or both 3. Redness, swelling, and crusting along the lid margins 4. Small superficial white nodules along the lid margins

2. Dropping of the upper eyelid or both

A nursing assistant asked the nurse to look at a client's skin . The client has bright red areas in her axillae, under her breasts, and in her perineal area. The client states that the skin in these areas feels like it is burning, and she has a discharge that looks like cottage cheese. What is the best action by the nurse? 1. Call the physician and describe the signs and symptoms that probably indicate a bacterial infection. 2.Tell the medication nurse that this client should not be receiving an antibiotic 3. Tell the charge nurse the signs and symptoms that probably indicate a fungal infections. 4. Report too the care manager that the nursing assistant is not caring adequately for this clients skin

3 These are signs of a fungal infection which are common in a skin fold (like CANDIDIASIS) the HCP should be notified so that proper medication should be ordered. This is not indicative of a fungal infection.

Which vitamin is likely to be produced less in dark-skinned older adults than in elders with light skin? 1. Vit A 2. Vit B 3. Vit C 4. Vit D

4 Vit D amounts are less likely to be produced because of more productive melanin production in the skin that lighter skinned people.

What kind of protective caution should the nurse use when caring for a client with psoriasis? 1. None, because psoriasis is not contagious. 2. Wear gown and gloves when doing any client care to protect the nurse from exposure to client's lesions 3. Wear mask whenever in client's room to prevent contact with organisms that transmit psoriasis. 4. Wear gloves for contact with lesions to prevent possible contact with client's blood

4. Wear gloves for contact with lesions to prevent possible contact with client's blood

The nurse is assessing a client's degree of edema and writes +4 on the medical record. What amount of edema is this client demonstrating? A. Moderately deep B. Deep C. Mild D. Moderate

B. Deep

A patient's low hemoglobin and hematocrit have necessitated a transfusion of packed red blood cells (RBCs). Shortly after the first unit of RBCs starts to infuse, the patient develops signs and symptoms of a transfusion reaction. Which type of hypersensitivity reaction has the patient experienced? A. Type I B. Type II C. Type III D. Type IV

B. Type II Transfusion reactions are characterized as a type II (cytotoxic) reaction in which agglutination and cytolysis occur. Type I hypersensitivity reactions are IgE-mediated reactions to specific allergens (e.g., exogenous pollen, food, drugs, or dust). Type III reactions are immune-complex reactions that occur secondary to antigen-antibody complexes. Type IV reactions are delayed cell-mediated immune response reactions.

The nurse notices flat red minute hemorrhages over a client's hands, arms, and face. Which of the following might be an appropriate question for the nurse to make to this client? A. When was your last menstrual period? B. What did the physician tell you about your liver function? C. Are you still on anticoagulant therapy? D. Your blood pressure medication isn't working very well.

C. Are you still on anticoagulant therapy?

a nurse inspects the skin of a pt who is suspected of having scabies. Which of the following findings would the nurse note if this disorder was present? A. patchy hair loss and round, red macules with scales. B. the presence of wheal patches scattered about the trunk C. multiple straight or wavy threadlike lines beneath the skin D. The appearance of vesicles or pustules with a thick, honey-colored crust.

C. multiple straight or wavy threadlike lines beneath the skin

What is a yeast-like fungus that produces rashes at a variety of sites on the body, e.g. groin, axilla and gluteal?

Candidiasis

An older client's physical examination reveals the presence of a number of bright red-colored lesions scattered on the trunk and tights. The nurse interprets that this indicates which of the following lesions due to alterations in blood vessels of the skin? Venous star Purpura Cherry angioma Spider angioma

Cherry angioma

What is a palpable, elevated, encapsulated liquid or semisolid filled lesion with distinct borders?

Cyst

The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action? A. Administer IV diphenhydramine (Benadryl). B. Administer nitroprusside as soon as possible. C. Anticipate tracheostomy with laryngeal edema. D. Place the patient recumbent and elevate the legs.

D. Place the patient recumbent and elevate the legs. In this emergency situation, the ABCs (airway, breathing, circulation) are being followed. For hypotension the patient should be placed in a recumbent position with the legs elevated, epinephrine will continue to be administered every 2-5 minutes, and fluids will be administered with vasopressors. Diphenhydramine is an antihistamine used to treat allergy symptoms. Anticipating a tracheostomy may occur with ongoing patient monitoring. Nitroprusside is a vasodilator and would not be used now.

The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? Ascites Emboli Facial rash Two hemoglobin S genes

Facial Rash Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A butterfly rash on the cheeks and bridge of the nose is an essential sign of SLE. Ascites and emboli are found in many conditions but are not associated with SLE. Two hemoglobin S genes are found in sickle cell anemia. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Clinical Judgment, Immunity

What is the term for a more extensive infection secondary to folliculitis and often called a "boil?"

Furuncle

What is a superficial skin infection caused most often by Staphylococcus aureus and most commonly found in toddlers and preschoolers?

Impetigo

What is a 1 to 2-cm elevated, firm, palpable mass deep in the dermis, with a distinct border?

Nodule

What is an elevated, superficial, distinct, serous fluid-filled lesion less than 1 cm in diameter (e.g. blister)?

Vesicle

The nurse assessed the patient's skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called a. wheals. b. papules. c. pustules. d. plaques.

Wheal

Individuals with dark skin are more likely to develop a. keloids. b. wrinkles. c. skin rashes. d. skin cancer.

a. keloids.

To assess the skin for temperature and moisture, the most appropri- ate technique for the nurse to use is a. palpation. b. inspection. c. percussion. d. auscultation.

a. palpation.

What is the term for a skin disorder which is a chronic eruption of the pilosbaceous unit with either non-inflammatory or inflammatory lesions, most commonly a problem of adolescents?

acne vulgaris

What is the term for an abscess of conjoined or adjacent furuncles?

carbuncles

On inspection of a patient's dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. This assessment finding is called a. vitiligo. b. intertrigo. c. telangiectasia. d. Nevus of Ota.

d. Nevus of Ota.

A female client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid exercise because it may: dislodge the autografts. decrease circulation to the fingers. increase edema in the arms. increase the amount of scarring.

dislodge the autografts.

What is the term for a superficial pustular infection of the hair follicles?

folliculitius

The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client? "Apply ice to the site to prevent swelling." "Clean the site with alcohol 3 times daily." "Apply a warm, damp washcloth if discomfort occurs." "Avoid showering or taking baths until seen by the health care provider in 1 week."

"Apply a warm, damp washcloth if discomfort occurs." Rationale: Cryotherapy involves the local application of liquid nitrogen to the lesion; this causes cell death and tissue destruction. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister formation; therefore, ice is not applied to the site. The application of a warm, damp washcloth intermittently to the site will provide relief of any discomfort. The nurse instructs the client to clean the site with the prescribed solution to prevent secondary infection. A topical antibiotic also may be prescribed. Alcohol would cause irritation to the skin. There is no reason for the client to avoid showering or bathing. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Integumentary Strategy(ies): Subject Priority Concepts: Client Education, Tissue Integrity

While providing discharge instructions to a patient with systemic lupus erythematosus (SLE), the nurse should include which of the following statements? "Exercise intensely 3 times per week." "Get adequate rest." "Wear sunblock." "Take the corticosteroids PRN." "Monitor your temperature."

"Get adequate rest." "Wear sunblock." "Monitor your temperature." Explanation • SLE is an autoimmune disease that can affect almost any organ. • People with SLE have an increased risk of infection, so any increase in temperature should be reported to the doctor. • People with SLE have persistent fatigue, and it's important that they have adequate sleep and make time for naps if needed. • Ultraviolet light can exacerbate symptoms leading to a flare-up. Sun block and covering the extremities can help. • Incorrect: Oral corticosteroids are not to be taken PRN or stopped abruptly. • Incorrect: Intense exercise may cause fatigue and increase muscle pain.

The nurse instructs a client with candidiasis (thrush) of the oral cavity on how to care for the disorder. Which client statement indicates the need for further instruction? "I need to eat foods that are liquid or pureed." "I need to eliminate spicy foods from my diet." "I need to eliminate citrus juices and hot liquids from my diet." "I need to rinse my mouth 4 times daily with a commercial mouthwash."

"I need to rinse my mouth 4 times daily with a commercial mouthwash." Rationale: Candidiasis is caused by Candida albicans, which is a part of the intestinal tract's natural flora. Fungal infection occurs by overgrowth of normal body flora. Candida stomatitis or esophagitis occurs often in in immunocompromised clients. On examination of the mouth and throat, the nurse would note cottage cheese-like, yellowish white plaques and inflammation. Clients with candidiasis cannot tolerate commercial mouthwashes because the high alcohol concentration in these products can cause pain and discomfort to the lesions. A solution of warm water or mouthwash formulas without alcohol are better tolerated and may promote healing. A change in diet to liquid or pureed food often eases the discomfort of eating. The client should avoid spicy foods, citrus juice, and hot liquids. Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Immune Strategy(ies): Negative Event Query, Strategic Words Priority Concepts: Client Education, Infection

The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? Select all that apply. "I need to sit whenever possible." "I need to be sure to eat a balanced diet." "I need to take a hot bath every evening." "I need to rest for long periods of time every day." "I should engage in moderate low-impact exercise when I am not tired."

"I need to take a hot bath every evening." "I need to rest for long periods of time every day." Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Hot baths may exacerbate the fatigue. To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, avoid hot baths, engage in moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness. Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Immune Strategy(ies): Negative Event Query, Strategic Words, Subject Priority Concepts: Client Education, Immunity

The nurse is assisting in administering immunizations as well as providing education to the clients who receive them at a health care clinic. Which statement by a client indicates that teaching was successful? "Immunizations protect against all diseases." "Immunizations can provide natural immunity." "Immunizations can provide innate immunity." "Immunizations are a way to acquire immunity to a specific disease."

"Immunizations are a way to acquire immunity to a specific disease." Rationale: Acquired immunity is immunity that can occur by receiving an immunization that causes antibodies to a specific pathogen to form. No immunization protects the client from all diseases. Natural (innate) immunity is present at birth. Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process: Evaluation Content Area: Adult Health: Immune Strategy(ies): Comparable or Alike Options, Closed-ended Word Priority Concepts: Health Promotion, Immunity

The nursing student conducted a clinical conference on the role of B lymphocytes in the immune system. Which statement by a fellow nursing student indicates successful teaching? "They activate T cells." "They produce antibodies." "They initiate phagocytosis." "They attack and kill the target cell directly."

"They produce antibodies." Rationale: B lymphocytes have the job of making antibodies and mediating humoral immunity. They do not activate T cells. T cells attack and kill target cells directly. The primary function of macrophages is phagocytosis. Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process: Evaluation Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Cellular Regulation, Immunity

Dr. Martinez prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond? "This prevents evaporation of water from the hydrated epidermis." "This prevents inflammation of the skin." "This minimizes cracking of the dermis." "This makes the skin feel soft."

"This prevents evaporation of water from the hydrated epidermis

The nurse is assessing a reddened area on the coccyx of a debilitated client. The nurse presses on the are, and it remains red when he releases the pressure. How would the nurse document this finding? 1. Non-blanchable erythema on coccyx indicates Stage 1 pressure ulcer 2. Client has redness on coccyx that indicates an early bedsore 3. Stage 2 pressure ulcer on bony prominence 4. Client requires more protein and vitamins in his diet, lotion on his dry skin, and turning every2 hours.

1 Nonblanchable erythema on coccyx indicates stage 1 pressure ulcers.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? 1. An inflammation of the epidermis only 2. A skin infection of the dermis and underlying hypodermis 3. An acute superficial infection of the dermis and lymphatics 4. An epidermal and lymphatic infection caused by Staphylococcus

2. Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the epidermis.

The nurse is infusing packed red blood cells into a patient with anemia when the patient reports a backache and chills. The nurse notes hypotension. Which type of hypersensitivity reaction is occurring? 1. Type I, anaphylactic 2. Type II, cytotoxic 3. Type III, immune complex 4. Type V, cell-mediated

2. Type II, cytotoxic The patient is suffering from an acute hemolytic reaction, a type II cytotoxic hypersensitivity. Patients may have a sharp rise in temp, chills, the feeling of heat in the transfusing vein. pain in the lumbar region, pain in the chest, tachycardia, and hypotension. Occurs from incompatible blood and results in cell lysis by neutrophils

Which of the following clinical manifestations would the nurse expect to find on assessment of a patient admitted with cellulitis of the left foot? 1. pallor and poor turgor 2. Cyanosis and coolness 3. Redness and swelling 4. Edema and brown skin discoloration

3. Redness and swelling

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. 1. Presence of striae 2. Palpable radial pulses 3. Absence of any ecchymosis on the extremities 4. Thinner and decrease in number of reddish papules 5. Scarce amount of silvery-white scaly patches on the arms

4, 5 Rationale: Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis. Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process: Evaluation Content Area: Adult Health: Integumentary Strategy(ies): Subject Priority Concepts: Clinical Judgment, Tissue Integrity

A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? No further diagnostic studies are needed. A Western blot will be done to confirm these findings. The client probably will have a bone marrow biopsy done. A CD4+ cell count will be done to measure T helper lymphocytes.

A Western blot will be done to confirm these findings. Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. If the result of the ELISA is positive, the Western blot is done to confirm the findings. If the result of the Western blot is positive, the client is considered to be seropositive for the infection and to be infected with the virus. The remaining options are incorrect. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Client Education, Immunity

The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder? An athlete An adolescent An older client A client who tans in an indoor tanning bed

A client who tans in an indoor tanning bed Rationale: Prolonged exposure to the sun (including indoor tanning), unusual cold, or other extreme conditions can damage the skin, posing the highest risk for skin disorders. An athlete would be at low risk of developing an integumentary problem. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. An older client may be at a higher risk than a younger person. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Integumentary Strategy(ies): Strategic Words Priority Concepts: Clinical Judgment, Tissue Integrity

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. An irregularly shaped lesion A small papule with a dry, rough scale A firm, nodular lesion topped with crust A pearly papule with a central crater and a waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight

A pearly papule with a central crater and a waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Integumentary Strategy(ies): Strategic Words Priority Concepts: Cellular Regulation, Tissue Integrity

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? A pink, edematous hand Fiery red skin with edema in the nail beds Black fingertips surrounded by an erythematous rash A white color to the skin, which is insensitive to touch

A white color to the skin, which is insensitive to touch Rationale: Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Integumentary Strategy(ies): Subject Priority Concepts: Clinical Judgment, Tissue Integrity

A nurse is performing a skin assessment on a client diagnosed with Actinic keratosis. The nurse would expect to note which characteristic of this type of skin lesion? a) a small papule with a dry, rough scale b) a firm nodular lesion topped with crust c) a pearly papule with a central crater and a waxy border d) an irregularly shaped lesion

A. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with dry, rough adherent yellow or brown scale. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue tone. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm nodular lesion topped with a crust or a central area of ulceration.

On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response increases with age? A. Autoimmune response B. Cell-mediated immunity C. Hypersensitivity response D. Humoral immune response

A. Autoimmune response With aging, autoantibodies increase, which lead to autoimmune diseases (e.g., systemic lupus erythematosus, acute glomerulonephritis, rheumatoid arthritis, hypothyroidism). Cell-mediated immunity decreases with decreased thymic output of T cells and decreased activation of both T and B cells. There is a decreased or absent delayed hypersensitivity reaction. Immunoglobulin levels decrease and lead to a suppressed humoral immune response in older adults.

A healthy 65-year-old man who lives at home is at the clinic requesting a "flu shot." When assessing the patient, what other vaccinations should the nurse ask the patient about receiving (select all that apply)? A. Shingles B. Pneumonia C. Meningococcal D. Haemophilus influenzae type b (Hib) E. Measles, mumps, and rubella (MMR)

A. Shingles B. Pneumonia The patient should receive the shingles (heres zoster) vaccine, Pneumovax, and influenza. The other options do not apply to this patient. Meningococcal vaccination is recommended for adults at risk (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies). Adults born before 1957 are generally considered immune to measles and mumps. Haemophilus influenzae type b (Hib) vaccination is only considered for adults with selected conditions (e.g., sickle cell disease, leukemia, HIV infection or for those who have anatomic or functional asplenia) if they have not been previously vaccinated.

a nurse is assigned to care for a client with herpes zoster. which of the following characteristics would the nurse expect to note when assessing the lesions of the infection? A. Clustered skin vesicles B. a generalized body rash C. small blue-white spots with red bases D. a fiery red edematous rash on the cheeks

A. clustered skin vesicles

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? Maintain bed rest as much as possible. Administer corticosteroids as prescribed for inflammation. Advise the client to remain supine for 1 to 2 hours after meals. Keep the room temperature warm during the day and cool at night.

Administer corticosteroids as prescribed for inflammation. Rationale: Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Caregiving, Immunity

While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is: a. "All family members will need to be treated." b. "If someone develops symptoms, tell him to see a physician right away." c. "Just be careful not to share linens and towels with family members." d. "After you're treated, family members won't be at risk for contracting scabies."

Answer A. When someone in a group of persons sharing a home contracts scabies, each individual in the home needs prompt treatment whether he's symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse should tell the client to take which measure? Maintain room humidity at less than 40%. Use very hot or very cold water for bathing. Apply emollients once the skin is thoroughly dry. Avoid bathing in the shower or tub more than once daily.

Avoid bathing in the shower or tub more than once daily. Rationale: Several things may be done to promote hydration of the skin. The client should limit tub or shower bathing to once daily or every other day and should sponge bathe on the other days. Room humidity should be maintained at greater than 40%. Bath water should be between 95°F and 100°F (35°C to 37.8°C) (tepid) and not very hot or very cold. Harsh soaps should be avoided, and emollients should be applied generously to skin while it is still damp. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Integumentary Strategy(ies): Subject Priority Concepts: Client Education, Tissue Integrity

A nurse is performing a skin assessment on a client diagnosed with a squamous cell carcinoma. The nurse would expect to note which characteristic of this type of skin lesion? a) a small papule with a dry, rough scale b) a firm nodular lesion topped with crust c) a pearly papule with a central crater and a waxy border d) an irregularly shaped lesion

B. Squamous cell carcinoma is a firm nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with dry, rough adherent yellow or brown scale. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue tone. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border.

A 58-year-old man who is waiting for a kidney transplant asks the nurse to explain the difference between a negative and positive cross match. Which statement by the nurse would be the most accurate response? A. "A negative cross match means that both the donor and recipient are Rh negative, and the transplant is safe." B. "A negative cross match means that no preformed antibodies are present and the transplant would be safe." C. "A positive cross match means the blood type is the same between donor and recipient, and the transplant is safe." D. "A positive cross match means that both the donor and the recipient have antigens that are similar, and the transplant would be safe."

B. "A negative cross match means that no preformed antibodies are present and the transplant would be safe." A cross match uses serum from the recipient mixed with donor lymphocytes to test for any preformed antibodies to the potential donor organ. A positive cross match indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation. A negative cross match indicates that no preformed antibodies are present and it is safe to proceed with transplantation.

Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? A. "You will need to get rid of your pets." B. "You should sleep in an air-conditioned room." C. "You would do best to stay indoors during the winter months." D. "You will need to dust your house with a dry feather duster twice a week."

B. "You should sleep in an air-conditioned room." Seasonal allergic rhinitis is most commonly caused by pollens from trees, weeds, and grasses. Airborne allergies can be controlled by sleeping in an air-conditioned room, daily damp dusting, covering the mattress and pillows with hypoallergenic covers, and wearing a mask outdoors.

The nurse notes that a client from a non-American culture has multiple bruises over the upper portion of her back. Which of the following should the nurse say to this client? A. If this is what your back looks like, I would hate to see what the other person looks like. B. Can you tell me how you received all of these bruises on your back? C. Adult abuse is very dangerous. Have you contacted the police? D. If you would like to talk about all of these bruises, please know that I can contact protective services for you.

B. Can you tell me how you received all of these bruises on your back?

An older adult recently diagnosed with a urinary tract infection displays sudden onset of confusion. She most likely is experiencing: A. Dementia B. Delirium C. Depression D. Social isolation

B. Delirium is a potentially reversible cognitive impairment that is often due to a physiological cause such as a urinary tract infection. Onset is typically sudden. Dementia is characterized by a gradual, progressive, irreversible cerebral dysfunction that leads to a decline in the ability to perform activities of daily living. Depression typically has an insidious onset where the person displays a lack of interest or pleasure in living. Thinking and perception remain intact except in severe cases. Social isolation is characterized by reduced interaction with others. It may be by choice or in response to conditions that inhibit the ability or the opportunity to interact with others.

A patient presents with small flat, non-palpable brown, freckles across both of their cheeks. They have irregular boarders and are <1cm in size. This is an example of what type of secondary skin lesion? A. Patch B. Macule C. Papule D. Stiae

B. Macule

An elderly client tells the nurse that she is worried about "all those dark spots on her hands" because she "can't wash them off and feels dirty." Which of the following can the nurse say to this client? A. This is a cherry angioma and you will need surgery to remove it. B. This is senile lentigines and is completely normal. C. This is a cutaneous tag and is something to tell the doctor about. D. This is a cutaneous horn and is completely normal.

B. This is senile lentigines and is completely normal.

The nurse is assigned to care for a client with acquired immunodeficiency syndrome (AIDS) suspected of having Kaposi's sarcoma. The nurse should prepare the client for which test to confirm this diagnosis? Biopsy Blood culture Computerized tomography Magnetic resonance imaging

Biopsy Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Kaposi's sarcoma is the most common AIDS-related malignancy. It manifests as small purplish brown, raised lesions if they occur on the skin. Dyspnea occurs if they occur in the lungs. Lymph node swelling occurs if they are located in the lymph nodes. Kaposi's sarcoma also can occur in the gastrointestinal (GI) tract and manifests as an altered bowel pattern, including diarrhea or constipation. Chest x-ray, bronchoscopy, upper GI exam, colonoscopy, and computed tomography scan may be used to aid the diagnosis, but whether Kaposi's sarcoma manifests as a skin lesion or in the lungs or GI tract, the diagnosis is confirmed with a biopsy. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Immunity, Tissue Integrity

The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? Clustered skin vesicles A generalized body rash Small blue-white spots with a red base A fiery-red edematous rash on the cheeks

Clustered skin vesicles Rationale: The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Options 2, 3, and 4 are incorrect descriptions. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Integumentary Strategy(ies): Subject Priority Concepts: Infection, Tissue Integrity

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? Determines the presence of antigens Identifies which additional tests need to be performed Confirms the diagnosis of a connective tissue disorder Confirms the presence of inflammation or infection in the body

Confirms the presence of inflammation or infection in the body Rationale: The ESR is a blood test that can confirm the presence of inflammation or infection in the body. It is particularly useful for the management of connective tissue disease because the rate measured directly correlates with the degree of inflammation and later with the severity of the disease. The other options are incorrect. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Infection, Inflammation

A nursing student is studying for a test on care of the client with endocrine disorders. Which of the following statements demonstrates an understanding of the difference between hyperthyroidism and hypothyroidism? a. "Deficient amounts of TH cause abnormalities in lipid metabolism, with decreased serum cholesterol and triglyceride levels." b. "Graves' disease is the most common cause of hypothyroidism." c. "Decreased renal blood flow and glomerular filtration rate reduces the kidney's ability to excrete water, which may cause hyponatremia." d. "Increased amounts of TH cause a decrease in cardiac output and peripheral blood flow."

Correct answer: c. "Decreased renal blood flow and glomerular filtration rate reduces the kidney's ability to excrete water, which may cause hyponatremia." Rationale: a. Is incorrect because deficient amounts of TH cause abnormalities in lipid metabolism with elevated serum cholesterol and triglyceride levels. b. Is incorrect because Graves' disease is the most common cause of hyperthyroidism, not hypothyroidism. d. Is incorrect because increased amounts of TH cause an increase in cardiac output and peripheral blood flow.

Which patient is at highest risk for developing graft-versus-host disease? A. A 65-year-old man who received an autologous blood transfusion B. A 40-year-old man who received a kidney transplant from a living donor C. A 65-year-old woman who received a pancreas and kidney from a deceased donor D. A 40-year-old woman who received a bone marrow transplant from a close relative

D. A 40-year-old woman who received a bone marrow transplant from a close relative Graft-versus-host disease occurs when an immunoincompetent patient is transfused or transplanted with immunocompetent cells. Examples include blood transfusions or the transplantation of bone marrow, fetal thymus, or fetal liver. An autologous blood transfusion is the collection and reinfusion of the individual's own blood or blood components. There is no risk for graft-versus-host disease in this situation.

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse suspects that which finding will be reported with this blood test? Increased neutrophils Increased red blood cell count Increased white blood cell count Decreased numbers of all cell type

Decreased numbers of all cell type Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. In the client with SLE, a complete blood cell count commonly shows pancytopenia, a decrease in all cell types. This probably is caused by a direct attack on all blood cells or bone marrow by immune complexes. The other options are incorrect. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Comparable or Alike Options Priority Concepts: Cellular Regulation, Immunity

A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? Monitor for signs of hyperglycemia. Administer the medication without food. Administer the medication with an antacid. Ensure that the client uses an electric razor for shaving.

Ensure that the client uses an electric razor for shaving. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach or without food and should not be taken with an antacid. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immune Strategy(ies): Strategic Words Priority Concepts: Clotting, Infection

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse should recognize that which are early clinical manifestations of this disorder? Select all that apply. Fatigue Anorexia High fever Weight loss Generalized weakness

Fatigue Anorexia Generalized weakness Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early manifestations of RA include fatigue, anorexia, generalized weakness, low-grade fever, paresthesias. Weight loss is one of the late manifestations. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Strategic Words Priority Concepts: Clinical Judgment, Immunity

The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? Fever, hypotension, and polyuria Hypertension, polyuria, and thirst Fever, hypertension, and graft tenderness Hypotension, graft tenderness, and hypothermia

Fever, hypertension, and graft tenderness Rationale: Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibiodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection usually occurs within 3 months after transplantation, although it can occur up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment with corticosteroids, and possibly also with monoclonal antibodies and antilymphocyte agents, is begun immediately. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Clinical Judgment, Immunity

A client is diagnosed with Goodpasture's syndrome. The nurse determines that this client's renal disease is caused by a type II hypersensitivity response. Which laboratory results would be most important for the nurse to evaluate? Urinalysis Electrolytes Urinalysis Electrolytes Glomerular filtration rate (GFR) Partial thromboplastin time (PTT) Partial thromboplastin time (PTT)

Glomerular filtration rate (GFR) Rationale: In the autoimmune disease known as Goodpasture's syndrome, autoantibodies attack the glomerulular basement membrane and neutrophils. As a result, the affected person will begin to experience decreased GFR with development of signs of chronic kidney disease. There will be an increased blood urea nitrogen (BUN) and creatinine but decreased GFR due to declining kidney function. Therefore, the remaining options are incorrect. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Strategic Words, Subject Priority Concepts: Cellular Regulation, Immunity

A CD4 T-cell count is measured in a client newly diagnosed with human immunodeficiency virus (HIV). In planning care, the nurse understands that which is accurate regarding the CD4 T-cell count? Select all that apply. Falls in response to a declining viral load Is a primary marker of immunocompetence Plays a role in the cell-mediated immune response Is a direct measure of the magnitude of HIV replication Guides decision making regarding timing of initiation of treatment

Is a primary marker of immunocompetence Plays a role in the cell-mediated immune response Guides decision making regarding timing of initiation of treatment Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. CD4 T-cells are a subgroup of lymphocytes that play an important role in the cell-mediated immune response; as such, CD4 T-cells are a primary marker of immunocompetence. Viral load is the direct measure of the magnitude of HIV replication. The CD4 T-cell count rises in response to a declining viral load. CD4 T-cell counts also guide decision making regarding initiation of treatment, when to change medications when treatment is failing, and the need for initiation of treatment against opportunistic infections. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Immunity, Infection

The nurse provides home care instructions to a client diagnosed with impetigo. Which statement by the client indicates the need for further instruction? "I need to continue with the antibiotics as prescribed." "I need to wash my hands thoroughly and frequently throughout the day." "I should wash my dishes separately from those of other household members." "It is not necessary to separate my linens and towels from those of other household members."

It is not necessary to separate my linens and towels from those of other household members." Rationale: The client needs to separate his or her linens and towels from those of other household members. Thorough hand washing, separating linens and towels, and separate washing of the client's dishes are required because the infection is contagious so long as skin lesions are present. Antibiotics are administered and should be continued as prescribed. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Adult Health: Integumentary Strategy(ies): Negative Event Query, Strategic Words Priority Concepts: Infection, Safety

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. Lesion is painful to touch. Lesion is highly metastatic. Lesion is a nevus that has changes in color. Skin under the lesion is reddened and warm to touch. Lesion occurs in body area exposed to outdoor sunlight.

Lesion is highly metastatic. Lesion is a nevus that has changes in color. Rationale: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions are most commonly found on the upper back and legs and on the soles and palms of persons with dark skin. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Integumentary Strategy(ies): Subject Priority Concepts: Cellular Regulation, Tissue Integrity

The nurse is assessing a patient with systemic lupus erythematosus (SLE). Which of the following would the nurse expect to note? Muscle pain and weakness Alopecia Excessive hair growth Hyperthyroidism Recurrent deep vein thrombosis Butterfly rash on the face

Muscle pain and weakness Alopecia Butterfly rash on the face Explanation • SLE is a systemic autoimmune disease that more common in women. There is no cure, but it is treated with immunosuppression. • A butterfly rash over the cheeks and bridge of the nose is a classic sign of SLE. Other signs include chest pain with inspiration, fatigue, fever, general discomfort, alopecia (hair loss), mouth dryness and sores, photosensitivity, and muscle pain and weakness. • Incorrect: Hyperthyroidism is not associated with SLE. Sometimes an autoimmune thyroid dysfunction (hypothyroidism) can be more common in individuals with SLE. • Incorrect: Hair loss, not hair growth, is commonly seen in patients with SLE. • Incorrect: Recurrent DVTs are not commonly associated with SLE.

The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select all that apply. Oliguria Hypotension Fluid retention Temperature of 99.6°F (37.6°C) Serum creatinine of 3.2 mg/dL (282 mcmol/L)

Oliguria Fluid retention Serum creatinine of 3.2 mg/dL (282 mcmol/L) Rationale: Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibiodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection is the most common type that occurs with kidney transplants and occurs 1 week to any time postoperatively. It occurs over days to weeks. Findings consistent with acute rejection include oliguria or anuria; temperature higher than 100°F (37.8°C); increased blood pressure; enlarged, tender kidney; lethargy; elevated serum creatinine, blood urea nitrogen, and potassium levels; and fluid retention. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Analysis Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Cellular Regulation, Immunity

If a patient presents with a firm, elevated, palpable, brown, red, purple, white or tan area with distinct regular border less than a centimeter in diameter (such as warts or a mole). What secondary skin lesion are you identifying? 1. Plaque 2. Nodule 3. Vesicle 4. Papule

Papule

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? Intact skin Full-thickness skin loss Exposed bone, tendon, or muscle Partial-thickness skin loss of the dermis

Partial-thickness skin loss of the dermis Rationale: In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Integumentary Strategy(ies): Subject Priority Concepts: Clinical Judgment, Tissue Integrity

The nurse is examining a patient with systemic lupus erythematosus (SLE). Which of the following symptoms would the nurse expect? Butterfly rash, fatigue, diarrhea Proteinuria, fatigue, butterfly rash Weight gain, fatigue, butterfly rash Butterfly rash, edema, hypothermia

Proteinuria, fatigue, butterfly rash Explanation • Symptoms commonly caused by SLE include chest pain with inspiration, fatigue, fever, general discomfort, hair loss, mouth sores, photosensitivity, and weakness. • Proteinuria is due to autoimmune kidney damage. • Edema, weight gain, hypothermia, and diarrhea are not commonly caused by SLE.

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. Record site, date, and time of the test. Give the client a list of potential allergens if identified. Estimate the size of the wheal and document the finding. Tell the client to return to have the site inspected only if there is a reaction. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

Record site, date, and time of the test. Give the client a list of potential allergens if identified. Rationale: Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected; a list of potential allergens is identified. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients only need to be monitored for about 30 minutes to assess for any adverse effects. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immune Strategy(ies): Closed-ended Word, Strategic Words Priority Concepts: Client Education, Immunity

A client seen in an ambulatory clinic has a facial rash that is present on both cheeks and across the bridge of the nose. The nurse interprets that this finding is consistent with manifestations of which disorder? Hyperthyroidism Pernicious anemia Cardiopulmonary disorders Systemic lupus erythematosus (SLE)

Systemic lupus erythematosus (SLE) Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A major skin manifestation of SLE is the appearance of a rash on both cheeks and across the nose. It is known as a "butterfly rash." Hyperthyroidism is associated with moist skin and increased perspiration. Pernicious anemia causes pallor of the skin. Cardiopulmonary disorders may lead to clubbing of the fingers. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Data in the Question Priority Concepts: Immunity, Tissue Integrity

A patient is seen in the emergency department after a bee sting caused bronchospasm and severe pruritis. The nurse understands that this type of hypersensitivity reaction is known as: type I type IV type III type II

Type I Explanation • The patient is suffering from a type I reaction (anaphylaxis) due to IgE-mediated histamine release. Hypersensitivity reactions • A type I (anaphylactic): an immediate allergic reaction involving IgE. The reaction may involve skin (urticaria or itching), eyes (conjunctivitis), nasopharynx (rhinorrhea, rhinitis), dyspnea, and cramping or diarrhea. Examples include anaphylaxis, angioedema, allergic conjunctivitis, and hay fever. • A type II (cytotoxic): a process involving IgG and IgM as they bind to antigens, activating the complement pathway. Though primarily mediated by antibodies of the IgM or IgG classes and complement, phagocytes and K cells may also play a role. This leads to cell lysis. Examples include ABO incompatibility, drug-induced hemolytic anemia, Goodpasture's nephritis, granulocytopenia, and thrombocytopenia. Treatment involves anti-inflammatory and immunosuppressive agents. • A type III (immune complex): involves antigen-antibody complexes that are not adequately cleared, leading to an inflammatory response. The reaction may take 3-10 hours after exposure to the antigen. It is mediated by soluble immune complexes and complement (C3a, and 5a). They are mostly of the IgG class, although IgM may also be involved. The damage is caused by platelets and neutrophils. Neutrophils and deposits of immune complexes and complement are seen. Examples include lupus, aspergillosis, polyarteritis, and post-streptococcal glomerulonephritis. • A type IV (cell-mediated): also called a delayed hypersensitivity reaction, involves sensitized T-cells and takes several days to develop. The classical example of this hypersensitivity is tuberculin () reaction, which peaks 48 hours after the injection of antigen (PPD or old tuberculin). The lesion is characterized by induration and erythema. Type IV hypersensitivity is involved in the pathogenesis of many autoimmune and infectious diseases (tuberculosis, leprosy, histoplasmosis, toxoplasmosis) and granulomas, due to infections and foreign antigens. Another example is contact dermatitis (poison ivy).

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this disease? Neutropenia Hyperglycemia Antigens of immunoglobulin A (IgA) Unusual antibodies of the IgG and IgM type

Unusual antibodies of the IgG and IgM type Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type, which develop in a number of connective tissue diseases. The other options are incorrect. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Cellular Regulation, Immunity

The nurse is assigned to care for a client with human immunodeficiency virus (HIV) infection. The nurse notes recent documentation of herpes simplex in the client's medical record. On assessment, the nurse would expect to note which type of lesion? Macular lesions Ecchymotic lesions Creamy white patches Vesicular lesions that rupture

Vesicular lesions that rupture Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. HSV in people with HIV or acquired immunodeficiency syndrome (AIDS) occurs in the perirectal, oral, and genital areas. Numbness of tingling at the site of infection occurs up to 24 hours before blisters form. Lesions are painful, with chronic open areas after blisters rupture. The nurse should assess for fever, pain, bleeding, and enlarged lymph nodes in the affected area. The nurse should also assess for headache, myalgia, and malaise. The other options are not characteristic of herpesvirus infection. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Immunity, Infection

The nurse reviews the record of a client with acquired immunodeficiency syndrome (AIDS) and notes that the client has a diagnosis of Candida. When performing history-taking and assessment, which finding should the nurse anticipate? Hyperactive bowel sounds Complaints of watery diarrhea Red lesions on the upper arms Yellowish-white, curdlike patches in the oral cavity

Yellowish-white, curdlike patches in the oral cavity Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Candidiasis is caused by Candida albicans, which is a part of the intestinal tract's natural flora. Fungal infection occurs by overgrowth of normal body flora. In a person with AIDS, candidiasis (overgrowth of the Candida fungus) occurs because the immune system can no longer control fungal growth. Candida stomatitis or esophagitis occurs often in AIDS. On examination of the mouth and throat, the nurse would note cottage cheese-like, yellowish white plaques and inflammation. The remaining options are not findings in this disorder. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immune Strategy(ies): Subject Priority Concepts: Immunity, Infection