Unit III Immunity N114 SU21

A nurse is teaching with a client about taking high doses of oral glucocorticoids for an extended period of time to treat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching?

"Monitor for compression fractures of the back and neck." High-dose, long-term use of glucocorticoids can result in bone loss in the back and neck within weeks of starting the medication. Clients experience an increase in parathyroid hormone, which causes calcium to move out of the bones can result in fractures.

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

A dry, red rash across the bridge of the nose and on the cheeks. A "butterfly" rash that is dry, red, and raised is characteristic of SLE.

A nurse is assessing a client who is to have IV urography. Which of the following data should indicate to the nurse that this procedure is contraindicated for this client?

Allergy to shellfish Shellfish contain iodine and an allergy to iodine is a contraindication to this procedure.

A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm³ with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results?

An acute infectious process The white blood cell (WBC) count is greatly elevated; however, even more telling is the elevated neutrophil count, sometimes referred to as a "shift to the left." So, with the combined information from the elevated WBC count indicating infection or inflammation and the elevated neutrophil count indicating an acute process, the appropriate analysis is that the client has an acute infectious process.

A nurse is assessing a client after administering IV vancomycin. Which of the following findings is the nurse's priority to report to the provider?

Audible inspiratory stridor When using the airway, breathing, circulation approach to client care the nurse determines the priority finding is inspiratory strider. The client is at risk for bronchospasms, hypotension and circulatory collapse due to anaphylaxis. The nurse should contact the rapid response team, discontinue the vancomycin, and administer epinephrine.

A nurse is teaching a client who has a new prescription for aspirin to treat rheumatoid arthritis. The nurse should include to monitor for which of the following adverse effects of this medication?

Bleeding Aspirin can cause bleeding, tinnitus, gastric ulceration, nausea, and heartburn. The client should monitor and report manifestations of bleeding, such as black tarry stools.

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

CD4-T-cell count 180 cells/mm3 A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

Candidiasis Although oral candidiasis can affect anyone, it occurs most often in infants, toddlers, older adults, and clients whose immune systems have been compromised by illness, such as AIDS, or medications.

A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE) and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body?

Connective tissue SLE originates in the connective tissues of the body and affects all organ systems.

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention?

Count the respiratory rate. Checking the client's respiratory status is the priority action when following the nursing process approach to client care.

A nurse is teaching a client who has a new prescription for prednisone to treat rheumatoid arthritis. The nurse should inform the client that which of the following is a therapeutic effect of this medication?

Decreases inflammation Prednisone is used to treat rheumatoid arthritis because it produces anti-inflammatory and immunosuppressive effects, which reduces inflammation, decreases pain, and increases mobility.

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Epinephrine The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer epinephrine, a bronchodilator and vasopressor used for allergic reactions to reverse severe manifestations of anaphylactic shock.

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

Erythrocyte sedimentation rate (ESR) Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases.

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

Exercise Deconditioning and muscle atrophy occurs as a result of lack of mobility. The nurse should encourage client to engage in conditioning exercises alternated with periods of rest.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

Facial rash SLE affects the skin. A facial "butterfly" rash that is dry, scaly, red, and raised is a manifestation of SLE.

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?

Flu-like symptoms and night sweats The nurse should explain that the initial symptoms may include flu-like symptoms and night sweats in category A of HIV infection.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?

Presence of peripheral edema. The client who has SLE is at greatest risk for death from lupus nephritis. Therefore, according to the safety and risk reduction priority setting framework, findings that indicate an impairment of renal function are the highest priority to report.

A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy?

Quantitative RNA assay A quantitative RNA assay measures the viral load and is useful in monitoring HIV disease progression and treatment effectiveness.

A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?

Stop the infusion. When using the airway, breathing, circulation approach to client care, the nurse should place the priority on stopping the infusion. The client is exhibiting signs of penicillin anaphylaxis and the first action that should be taken is to withdraw the medication.

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme-linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

Western blot analysis The Western blot analysis is used to confirm seropositivity when the ELISA test has a positive result. ELISA is inexpensive and accurate with few false-positives. Western blot is expensive, so is done only for confirmation.