exam 2

Of the following, which drug is not used in the treatment of rheumatoid arthritis? a) Allopurinol (Zyloprim) b) Adalimumab (Humira) c) Methotrexate (Rheumatrex) d) Etanercept (Enbrel

a) Allopurinol (Zyloprim) Explanation: Allopurinol (Zyloprim) is used in the treatment of gout. Etanercept (Enbrel), adalimumab (Humira), and methotrexate (Rheumatrex) are all used in the treatment of rheumatoid arthritis. pg.1079

A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and heaviness. During the admission process, the client presents her advance directive, which states that she doesn't want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse respond?

"It's important for us to have this information. You should review the document with your physician at every admission."

A client with lymphedema is struggling with negative emotions related to her appearance. Which of the following suggestions from the nurse would be most effective in helping the client address the problem?

"Let's discuss some clothing styles that can help conceal the problem while you are being treated.

A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?

"MS symptoms may be worse after the pregnancy." rational: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

Your HIV positive patient has been prescribed enfuvirtide (Fuzeon) 90 mg SC bid. The pharmacy dispenses the product pictured above. You will educate the patient that he has been prescribed enough for _______ days of treatment? Pic: 90mg, 60 single use vials

30 bid means 2 a day

A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?

A cell-mediated response

A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring? A) Delayed hypersensitivity response B) Anaphylactic reaction C) Sensitization D) An immediate hypersensitivity response

A) Delayed hypersensitivity response

The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestation? a) an exaggerated sense of well-being b) slurring of words when excited c) visual hallucinations d) inappropriate laughter

A) an exaggerated sense of well-being Explanation: A client with multiple sclerosis may have a sense of optimism and euphoria, particularly during remissions. Euphoria is characterized by mood elevation with an exaggerated sense of well-being. Inappropriate laughter, slurring of words, and visual hallucinations are uncharacteristic of euphoria

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patients skin rash? a. The donor T cells are attacking the patients skin cells. b. The patients antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection

ANS:A The patients history and symptoms indicate that the patient is experiencing graft-versus-host disease, inwhich the donated Tcells attack the patients tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.

What should you make sure to discuss with someone who has multiple sclerosis?

Advanced directives because patient will eventually end up on vent and the use of a peak flow meter.

A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client?

Anemia and granulocytopenia

What intervention is a priority when treating a client with HIV/AIDS?

Assessing fluid and electrolyte balance

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent: a) fluid overload. b) contractures. c) dry mouth. d) ascites.

B) contractures. Explanation: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial? a) weekly visits by another person with MS b) regular exercise c) psychotherapy d) day care for the granddaughter

B) regular exercise Explanation: An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients

The nurse caring for a client with systemic lupus erythematosus (SLE) provides teaching about measures to avoid fatigue. The nurse recognizes that the client needs additional teaching if the client states he or she should: a. Avoid long periods of rest. b. Perform activities sitting whenever possible. c. Take a hot shower. d. Engage in low-impact exercise when well rested.

C To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, to avoid hot baths, to schedule moderate low-impact exercises when not fatigued, and to maintain a balanced diet. The client is instructed not to rest for long periods, because it promotes joint stiffness

A nurse is monitoring the client's progression of human immunodeficiency virus (HIV). What debilitating gastrointestinal condition found in up to 90% of all AIDS clients should the nurse be aware of? Anorexia Chronic diarrhea Nausea and vomiting Oral candida

Chronic diarrhea Explanation: Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of acquired immune deficiency syndrome (AIDS) can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.

Which of the following is not a stage of Multiple Sclerosis? A. Acute Attack B. Remission-Exacerbation C. Chronic progressive D. Chronic Attack

D. Chronic Attack

Mycobacterium avium complex (MAC)

Early symptoms may be minimal and can precede detectable mycobacteremia by several weeks and include fever, night sweats, weight loss, fatigue, diarrhea, and abdominal pain

The nurse is reviewing the medical record of a client who is positive for human immunodeficiency virus (HIV). The nurse notes that the client is classified as HIV asymptomatic based on which CD4+ T lymphocyte count?

Greater than 500/mm3

Which condition is an early manifestation of HIV encephalopathy?

Headache Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.

A nurse is addressing a group of nursing students about gamma globulins. What is the best response to the nursing students about the function of IgA? Stimulates complement activity Functions as an antigen receptor Protects the fetus before birth against antitoxins, viruses, and bacteria Helpful in defense against invasion of microbes via nose, eyes, lungs, and intestines

Helpful in defense against invasion of microbes via nose, eyes, lungs, and intestines Explanation: IgA helps in defense against invasion of microbes via nose, eyes, lungs, and intestines. IgM stimulates complement activity. IgD functions as an antigen receptor. IgG protects the fetus before birth against antitoxins, viruses and bacteria.

Which of the following indicates that a client with HIV has developed AIDS?

Herpes simplex ulcer persisting for 2 months

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean that

His body has not produced antibodies to the AIDS virus

The nurse is performing a physical assessment for a patient at the clinic and palpates enlarged inguinal lymph nodes on the left. What should the nurse document? (Select all that apply.)

Location • Size • Consistency • Reports of tenderness

A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:

Lymphocytes migrate to areas of the lymph node

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

NK cells

Which type of cells is capable of recognizing and killing infected or stressed cells and producing cytokines?

Natural killer cells NK cells are a class of lymphocytes that recognize infected and stressed cells and respond by killing these cells and by secreting macrophage-activating cytokine. Natural killer cells defend against microorganisms and some type of malignant cells.

A majority of patients with CVID develop which type of anemia?

Pernicious

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements?

Primary immunodeficiencies develop early in life after protection from maternal antibodies decreases

Which stage of HIV infection is indicated when the results are more than 500 CD4+ lymphocytes/mm?

Primary infection (acute HIV infection or acute HIV syndrome)

A nurse caring for a client with multiple sclerosis notes that the client has mood swings. Which of the following can best explain this?

Psychological manifestation due to involvement of white matter of cerebral cortex.

Which diagnostic study is decreased in patient diagnosed with rheumatoid arthritis?

RBC

Which of the following adverse effects should the nurse closely monitor in a patient who has secondary immunodeficiencies due to immunosuppressive therapy?

Respiratory or urinary system infections

Which stage of the immune response occurs when the differentiated lymphocytes function in either a humoral or a cellular capacity?

Response stage

What intervention is appropriate before the patient starts on efavirenz (EFV, Sustiva) therapy?

Testing for Stevens-Johnson syndrome potential

The diagnosis of multiple sclerosis is based upon which of the following tests? a) MRI b) Evoked potential studies c) Neuropsychological testing d) CSF electrophoresis

a) MRI

A client diagnosed with HIV asks the nurse how the doctor can know what their viral load is. What should the nurse respond?

The doctor can have a polymerase chain reaction test run. The RT-PCR test, which measures viral load, is used along with the CD4+ count, which indicates the level of immune dysfunction, to assess the stage and severity of HIV infection

A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which of the following explanations about the cause of the disorder?

The immune system recognizes one's own tissues as "foreign."

The nurse is administering an infusion of gamma-globulin to a patient in the hospital. When should the nurse discontinue the infusion? (Select all that apply.) When the patient complains of flank pain When the patient begins to have shaking chills When the patient complains of tightness in the chest When the patient voids 30/mL an hour When the patient complains of nausea

When the patient complains of flank pain When the patient begins to have shaking chills When the patient complains of tightness in the chest When the patient complains of nausea Explanation: Stop the infusions at the first sign of reaction, and initiate the institutional protocol to be followed in this emergent situation. Reactions include complaints of flank and back pain, shaking chills, flushing, dyspnea, and tightness in the chest; headache, fever, muscle cramps, nausea/vomiting, and local reaction at the infusion site.

Which of the following assessment should be completed if suspecting immune dysfunction in the neurosensory system?

ataxia

A patient, with a history of peptic ulcer disease is diagnosed with RA. The nurse practitioner prescribes an anti-inflammatory drug that also protects the stomach lining. Which of the following is that medication? a) c. DMARD (Rheumatrex) b) a. NSAID (ibuprofen) c) d. Biologic agent (Enbrel) d) b. COX-2 inhibitor (Celebrex)

b. COX-2 inhibitor (Celebrex)

A patient reports weakness of the extremities and diplopia. The nurse knows that these symptoms are characteristic of which condition? a. Cerebral palsy (CP) b. Multiple sclerosis (MS) c. Myasthenia gravis (MG) d. Parkinson's disease (PD)

b. Multiple sclerosis (MS)

A nurse assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? a) Weight gain, hypervigilance, hypothermia, and edema of the legs b) Photosensitivity, polyarthralgia, and painful mucous membrane ulcers c) Hypothermia, weight gain, lethargy, and edema of the arms d) Facial erythema, pericarditis, pleuritis, fever, and weight loss

d) Facial erythema, pericarditis, pleuritis, fever, and weight loss

A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide? "You should take your medications only during times of relapse." "You will have a steady and gradual decline in function." "You must avoid stress and extreme fatigue, because these can trigger a relapse." "Your type of MS is the least common, making it difficult to manage."

"You must avoid stress and extreme fatigue, because these can trigger a relapse."

(SELECT ALL THAT APPLY) The nurse is planning care for a client with multiple sclerosis. Which problems should the nurse expect the client to experience?

(1) Visual disturbances, (3) Balance problems, (5) Mood disorders

During a primary response, (a) IgM is initially higher than the IgG titer (b) IgG titer is initially higher than the IgM titer (c) IgM titer and IgG titer rise in parallel (c) only the IgM titer is affected.

(a) IgM is initially higher than the IgG titer

T cells and B cells can be activated only by (a) pathogens (b) exposure to a specific antigen at a specific site in a plasma membrane (c) interleukins, interferons and colony stimulating factors (d) all of these.

(b) exposure to a specific antigen at a specific site in a plasma membrane

32. Which of these defense cells are NOT phagocytic? (a) neutrophils (b) lymphocytes (c) macrophages (d) eosinophils.

(b) lymphocytes

. Antibodies that normally cross the placenta are (a) IgM (b) IgA (c) IgG (d) IgD.

(c) IgG

Which of the following would the nurse expect to assess in a client with ataxia-telangiectasis? Select all that apply.

- Loss of muscle coordination - Vascular lesions - Immune deficiency

A client with chronic mucocutaneous candidiasis, an autosomal recessive disorder, asks the nurse, "Will my children have this disease?" Which response by the nurse is appropriate? -"Only your male children are at risk for developing this disease." -"Your female children will be carriers for the disease, but only male children will develop the disease." -"All of your children will be carriers of the recessive gene but may not develop the disease." -"All of your children will develop the disease."

-"All of your children will be carriers of the recessive gene but may not develop the disease." Chronic mucocutaneous candidiasis is a rare T-cell disorder, which is thought to be an autosomal recessive disorder that affects both males and females. In pedigrees, an autosomal recessive disorder is revealed by the appearance of the phenotype in the male and female progeny of unaffected individuals. Parents must both be heterozygotes, C/c. (That is, both must have a c allele in order to contribute one to create a homozygote affected child with a cc phenotype displaying the disease.) A child born with Cc will be phenotypically normal but carry the recessive trait.

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate? -"Your child does not have AIDS but this condition puts your child at risk for it later in life." -"Your child's condition is extremely serious. Like AIDS, it will most likely be fatal." -"Although AIDS is an immune deficiency, your child's condition is different from AIDS." -"We need to do some more testing before we will know if your child's condition is AIDS."

-"Although AIDS is an immune deficiency, your child's condition is different from AIDS." Primary immune deficiencies should be not be confused with AIDS. They are not the same condition. In addition, a primary immune disorder does not increase the child's risk for developing AIDS later in life. Primary immune deficiency diseases are serious, but they are rarely fatal and can be controlled. Testing will reveal the evidence of a primary immune disease, not AIDS. AIDS is classified as a seconary immunodeficiency.

The nurse is preparing a teaching plan for a client with an immunodeficiency. What aspect would the nurse emphasize as most important? -Frequent and thorough handwashing -Identifying the signs and symptoms of infection -Adherence to prophylactic medication administration -Incorporation of treatment regimens into daily patterns

-Frequent and thorough handwashing Although identifying the signs and symptoms of infection, adherence to medication prophylaxis, and incorporation of treatment regimens into daily patterns are important, the most important aspect is frequent and thorough handwashing to prevent infection. If infection is prevented, signs and symptoms will not develop and medications would not necessarily be needed

A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen? -IV gamma globulin administration -Platelet administration -Factor VIII administration -Thymus grafting

-IV gamma globulin administration Treatment for ataxia-telangiectasia includes IV gamma globulin, antimicrobial therapy, and bone marrow transplantation. It does not include platelet administration, factor VIII administration, or thymus grafting.

A secondary immunodeficiency is characterized by the following. Choose all that apply. -It usually occurs as a result of underlying disease processes. -It frequently is caused by certain autoimmune disorders. -It may be caused by certain viruses. -IgA deficiency is present in 40% of individuals. -It is less common than primary immunodeficiency.

-It usually occurs as a result of underlying disease processes. -It frequently is caused by certain autoimmune disorders. -It may be caused by certain viruses. Secondary immunodeficiencies are more common than primary immunodeficiencies and frequently result from underlying disease processes or their treatment. Common causes of secondary immunodeficiencies include chronic stress, burns, uremia, diabetes mellitus, certain autoimmune disorders, certain viruses, exposure to immunotoxic medications and chemicals, and self-administration of recreational drugs and alcohol.

What severe complication does the nurse monitor for in a patient with ataxia-telangiectasia? -Acute kidney injury -Chronic lung disease -Neurologic dysfunction -Overwhelming infection

-Overwhelming infection Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination), telangiectasia (vascular lesions caused by dilated blood vessels), and immune deficiency. The immunologic defects reflect abnormalities of the thymus. The disorder is characterized by some degree of T-cell deficiency, which becomes more severe with advancing age. Immunodeficiency is manifested by recurrent and chronic sinus and pulmonary infections, leading to bronchiectasis.

A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed? -Gastric ulcer -Pernicious anemia -Hyperthyroidism -Sickle cell anemia

-Pernicious anemia More than 50% of clients with CVID develop pernicious anemia. Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy, which is detected by biopsy of the stomach, are common findings. Gastrointestinal malabsorption may occur.

A nurse is developing a teaching plan for a client with an immunodeficiency. What would the nurse need to emphasize? Select all that apply. -Signs and symptoms of bleeding -Prophylactic medication regimens -Need to interrupt therapy for short periods -Ways to manage stress -Maintenance of a well-balanced diet

-Prophylactic medication regimens -Ways to manage stress -Maintenance of a well-balanced diet Teaching for clients with immunodeficiency disorders should focus on the signs and symptoms that indicate infection, prophylactic medication regimens, the need for continued therapy without interruptions, ways to manage stress, and measures to ensure optimal nutritional status.

A client presents with an acute exacerbation of multiple sclerosis. Which drug will the nurse be prepared to administer?

.Methylprednisolone (Medrol) Methylprednisolone is the drug of choice for acute exacerbations of the disease.

The nurse would evaluate that a patient with systemic lupus erythematosus understands dietary teaching when the patient selects which food for breakfast? 1. Orange juice 2. Sausage, gravy, and biscuits 3. A doughnut 4. Toast

1 Rationale 1: The patient with SLE requires additional vitamin C. Rationale 2: Generally, the diet should be low in sodium. Rationale 3: Food choices should reflect a healthy, balanced diet. Rationale 4: There is no particular reason that toast is not a good choice, but it does not offer any special benefit, either. Another choice would be healthier for this patient.

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? 1. Observe the client demonstrating the transfer technique. 2. Start a restorative nursing program before an injury occurs. 3. Seize the opportunity to discuss potential nursing home placement. 4. Determine the number of falls that the client has had in recent weeks.

1. Observe the client demonstrating the transfer technique.

The nurse has chosen these nursing diagnoses for a patient who has systemic lupus erythematosus. Which NDX would be assigned the highest priority? 1. Skin Integrity: Impaired 2. Activity Intolerance 3. Anxiety 4. Fluid Volume Excess

2 Rationale 1: Impaired Skin Integrity is applicable to most patients with SLE, but this is not the NDX of highest priority. Rationale 2: Inability to tolerate activity is the highest priority of the NDX listed. Patients should be taught to balance rest and activity. Rationale 3: The patient with SLE is likely to be anxious about the disease process and its effect on daily life. This is not the NDX of highest priority. Rationale 4: The patient with SLE may have fluid volume problems if kidney function is impaired. This is not the NDX of highest priority.

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? 1. Annual influenza vaccination 2. Ingestion of increased fruits and vegetables 3. An established routine of walking 2 miles each evening 4. A recent period of extreme outside ambient temperatures

2. Ingestion of increased fruits and vegetables

A patient sees a physician for pain in the joints of fingers with significant swelling. X-rays reveal extensive joint damage from theumatoid arthritis (RA); laboratory results are definitive. Which medication does the nurse anticipate the patient will receive to decrease the extensive joint damage? A nonsteroidal anti-inflammatory medication, such as Ibuprofen A glucocorticoid steroid, such as prednisone An uricosuric medication, such as Allopurinol A disease-modifying antirheumatic drug (DMARD), such as methotrexate

A disease-modifying antirheumatic drug (DMARD), such as methotrexate Explanation: To decrease extensive joint damage that occurs with RA, treatment with DMARDS or other biologic agents is recommended within 3 months of diagnosis.

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? a) Establish a regular voiding schedule. b) Insert an indwelling urinary catheter. c) Limit fluid intake to 1,000 mL/day. d) Administer prophylactic antibiotics, as prescribed.

A) Establish a regular voiding schedule. Explanation: Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? a) limiting fluid intake to 1,000 mL/day b) setting a regular time for elimination c) using an elevated toilet seat d) eating a diet high in fiber

A) imiting fluid intake to 1,000 mL/day Explanation: Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position

During assessment of the patient diagnosed with systemic lupus erythematosus (SLE), which signs and symptoms would the nurse expect to find? (Select all that apply.) a. Hair loss b. Enlarged cervical lymph nodes c. Mouth sores d. Fatigue e. Rashes

A, C, D, E The patient with SLE does not typically have enlarged lymph nodes. Hair loss, mouth sores, fa-tigue, and rashes are just a few of the symptoms present in a patient with SLE.

Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who has graft-versus-host disease and severe diarrhea c. Patient who is sneezing after having subcutaneous immunotherapy d. Patient with multiple chemical sensitivities who has muscle stiffness

ANS:C Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications.

Thechargenurseisassigningroomsfornewadmissions.Whichpatientwouldbethemostappropriate roommateforapatientwhohasacuterejectionofanorgantransplant? a. Apatientwhohasviralpneumonia b. Apatientwithsecond-degreeburns c. Apatientwhoisrecoveringfromananaphylacticreactiontoabeesting d. Apatientwithgraft-versus-hostdiseaseafterarecentbonemarrowtransplant

ANS:C Treatmentforapatientwithacuterejectionincludesadministrationofadditionalimmunosuppressants,andthepatientshouldnotbeexposedtoincreasedriskforinfectionaswouldoccurfrompatientswithviralpneumonia,graft-versus-hostdisease,andburns.Thereisnoincreasedexposuretoinfectionfromapatientwhohadananaphylacticreaction

Apatientwhoisreceivingimmunotherapyhasjustreceivedanallergeninjection.Whichassessmentfindingismostimportanttocommunicatetothehealthcareprovider? a. ThepatientsIgGlevelisincreased. b. Theinjectionsiteisredandswollen. c. Thepatientsallergysymptomshavenotimproved. d. Thereisa2-cmwhealatthesiteoftheallergeninjection

ANS:D Alocalreactionlargerthanquartersizemayindicatethatadecreaseintheallergendoseisneeded.AnincreaseinIgGindicatesthatthetherapyiseffective.Rednessandswellingatthesitearenotunusual.Becauseimmunotherapyusuallytakes1to2yearstoachieveaneffect,animprovementinthepatientssymptomsisnotexpectedafterafewmonths

A patient who has been newly diagnosed with systemic lupus erythematosus has been admitted to your unit. You know that a typical diagnostic finding related to this disease is what? A) Thrombocytopenia B) Elevated hemoglobin level C) Negative antinuclear antibodies level

Ans: A Feedback: Blood testing reveals moderate to severe anemia, thrombocytopenia, leukocytosis, and positive antinuclear antibodies. Proteinuria is not diagnostic of systemic lupus erythematosus.

6. Upon admission, the physician orders baclofen (Lioresal) for a patient diagnosed with multiple sclerosis. The nurse knows that which of the following is an expected outcome of this medication? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Limited severity and duration of exacerbations

Ans: B Feedback: Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Anticholinesterase agents increase muscle strength in the upper extremities. Corticosteroids limit the severity and duration of exacerbations.

A 37-year-old teacher is hospitalized with complaints of weakness, incoordination, dizziness, and loss of balance. The diagnosis is multiple sclerosis (MS). Which of the following signs and symptoms, revealed during the history and physical assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinski's reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

Ans: C Feedback: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski's reflex is found in MS. Abdominal reflexes are absent with MS.

The immune system is a complicated and intricate system that contains specialized cells and tissues that protect us from external invaders and our own altered cells. Which of the following is the term used to define any substance capable of inducing a specific immune response and of reacting with the products of that response?

Antigens Antigens, which are protein markers on cells, are substance capable of inducing a specific immune response and of reacting with the products of that response

While taking the health history of a newly admitted client, the nurse asks for a list of the client's current medications. Which of the following medication classifications would place the client at risk for impaired immune function?

Antimetabolites

A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?

Autoimmune disorders include connective tissue (collagen) disorders

A physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis? a) Negative lupus erythematosus cell test b) An above-normal anti-deoxyribonucleic acid (DNA) test c) Increased total serum complement levels d) Negative antinuclear antibody test

B. An above-normal anti-deoxyribonucleic acid (DNA) test Explanation: Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE

A nurse is monitoring a client who developed facial edema after receiving a medication. Which white blood cells stimulated the edema?

Basophils

A 44-year-old man has come to the clinic with an asthma exacerbation. He tells the nurse that his father and brother also suffer from asthma, as does his 15-year-old son. The nurse explains that this is an allergic response based on a genetic predisposition. The specific allergen initiated by immunological mechanisms is usually mediated by immunoglobulin: A. M. G. E.

E. Explanation: Allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions are found in diseases like asthma. IgG is the most common immunoglobulin and is found in intravascular and intercellular compartments. IgA and IgM are found in mucous secretions.

During the immune response, cytotoxic cells bind to invading cells, destroy the targeted invader, and release lymphokines to remove the debris. Which type of T-cell lymphocyte is cytotoxic?

Effector T cells

Which blood test confirms the presence of antibodies to HIV? Erythrocyte sedimentation rate (ESR) p24 antigen Reverse transcriptase Enzyme-linked immunosorbent assay (ELISA)

Enzyme-linked immunosorbent assay (ELISA) Explanation: ELISA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. The p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.

Which cells block the entry of microbes and destroy them by secreting antimicrobial enzymes, proteins, and peptides within the mucous membrane linings of the gastrointestinal, respiratory, and urogenital tract? Immune Lymphatic Leukocytes Epithelial

Epithelial Explanation: Epithelial cells line the body systems and are joined by tight junctions to protect from invasion. Lymphatic tissue underlies the epithelia as a secondary barrier. Immune cells are present everywhere but are not used to line tissues. Leukocytes are white blood cells.

T-cells can be either regulator T cells or effector T cells. Regulator T cells are made up of helper and suppressor cells. What function are helper T-cells important in?

Fighting infection

A 38-year-old client has been diagnosed with rheumatoid arthritis, an autoimmune disease. During the health history assessment. the nurse learns that the client works as an aide at a facility that cares for children infected with AIDS, does moderate cardiovascular exercises every other day, takes no medication, has no allergies, and eats mainly a vegetarian diet with fish and chicken one to two times each week. Which factor is the most important consideration in determining the status of the client's immune system? Age Diet Gender Environment

Gender Explanation: The immune system functions of men and women differ. For example, many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones. Autoimmune diseases tend to be more common in women because estrogen tends to enhance immunity. Androgen, on the other hand, tends to be immunosuppressive. Autoimmune diseases are a leading cause of death by disease in females of reproductive age.

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis?

Help the client perform range-of-motion (ROM) exercises every 8 hours.

DIfference between Humoral and Cellular Responses

Humoral Bacterial phagocytosis and lysis Anaphylaxis Allergic hay fever (Rhinitis) and asthma Immune complex disease Bacterial and some viral infections Cellular Transplant rejection Delayed hypersensitivity (tuberculin reaction) Graft-versus-host disease Tumor surveillance or destruction Intracellular infections Viral, fungal, and parasitic infections

A patient is prescribed a DMARD that is successful in the treatment of RA but has side effects, including retinal eye changes. What medication does the nurse anticipate educating the patient about?

Hydroxychloroquine (Plaquenil)

What type of immunoglobulin does the nurse recognize that promotes the release of vasoa ctive chemicals such as histamine when a client is having an allergic reaction? IgG IgA IgM IgE

IgE Explanation: IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reaction. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.

There are several types of reactions to latex. The nurse knows to be most concerned about laryngeal edema with the following reaction

IgE-mediated hypersensitivity.

Which immunoglobulin (Ig) is the most abundant of circulating antibodies? IgA IgE IgG IgM

IgG Explanation: IgG makes up about 75% of the immunoglobulins. IgA is about 15%, IgM 10%, and IgE 0.004% of the total.

Types of Immunoglobulins

IgG (75% of Total Immunoglobulin) Appears in serum and tissues (interstitial fluid) Assumes a major role in bloodborne and tissue infections Activates the complement system Enhances phagocytosis Crosses the placenta IgA (15% of Total Immunoglobulin) Appears in body fluids (blood, saliva, tears, and breast milk, as well as pulmonary, gastrointestinal, prostatic, and vaginal secretions) Protects against respiratory, gastrointestinal, and genitourinary infections interferes with the entry of pathogens through exposed structures or pathways Prevents absorption of antigens from food Passes to neonate in breast milk for protection IgM (10% of Total Immunoglobulin) Appears mostly in intravascular serum Appears as the first immunoglobulin produced in response to bacterial and viral infections agglutinates (firmly sticks) antigens and lyses cell walls Activates the complement system IgD (0.2% of Total Immunoglobulin) Appears in small amounts in serum Possibly influences B-lymphocyte differentiation, but role is unclear IgE (0.004% of Total Immunoglobulin) Appears in serum Takes part in allergic and some hypersensitivity reactions Combats parasitic infections promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reaction

A school-aged client was vaccinated against varicella several years ago according to the recommended immunization schedule. The client has now been exposed to the virus by a classmate with chickenpox. What immune response will prevent the client's infection? IgG will be released by B memory cells Hageman factor will be activated and IgM released CD4 (helper) T cells will release the necessary antibodies Circulating levels of IgA will form antigen-antibody complex

IgG will be released by B memory cells Explanation: Exposure to an antigen eventually causes memory B cells to produce IgG specific to that antigen, which can be released upon secondary exposure to the antigen. Hageman factor is involved with inflammation, not humoral immunity. CD4 T cells do not directly produce or release antibodies. IgA is a specific type of immunoglobulin that does not exist in general circulation.

Proteins formed when cells are exposed to viral or foreign agents that are capable of activating other components of the immune system are referred to as Antibodies Antigens Interferons Complement

Interferons. Interferons are biologic response modifiers with nonspecific viricidal proteins. Antibodies are protein substances developed by the body in response to and interacting with a specific foreign substance. Antigens are substances that induce formation of antibodies. Complement refers to a series of enzymatic proteins in the serum that, when activated, destroy bacteria and other cells.

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders

A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand?

Neutrophils

A patient with rheumatoid arthritis is complaining of joint pain. What intervention is a priority to assist the patient? a) Ice packs b) Opioid therapy c) Surgery d) Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Which medication classification is known to inhibit prostaglandin synthesis or release?

Nonsteroidal anti-inflammatory drugs (in large doses) Nonsteroidal anti-inflammatory drugs (NSAIDs), in large doses, inhibit prostaglandin synthesis or release. NSAIDs include aspirin and ibuprofen. Antibiotics in large doses are known to cause bone marrow suppression. Adrenal corticosteroids and antineoplastic agents are known to cause immunosuppression.

An older adult has developed a sacral pressure ulcer. What should the nurse assess in order to ensure adequate wound healing and prevent poor outcomes for this client? Select all that apply. The client's ability to perform his or her own wound care Nutritional status Caloric intake Quality of food ingested The amount of carbohydrates the client ingests

Nutritional status Caloric intake Quality of food ingested Explanation: Nutritional intake that supports a competent immune response plays an important role in reducing the incidence of infections; clients whose nutritional status is compromised have a delayed postoperative recovery and often experience more severe infections and delayed wound healing. The nurse must assess the client's nutritional status, caloric intake, and quality of foods ingested.

A patient had unprotected sex with an HIV-infected person and arrives in the clinic requesting HIV testing. Results determine a negative HIV antibody test and an increased viral load. What stage does the nurse determine the patient is in?

Primary infection The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection, or stage 1. Initially, there is a period during which those who are HIV positive test negative on the HIV antibody blood test, although they are infected and highly infectious, because their viral loads are very high.

A client with human immunodeficiency virus (HIV) develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this client? Mycobacterium avium complex (MAC) Pneumocystis pneumonia Tuberculosis Community-acquired pneumonia

Pneumocystis pneumonia Explanation: The most common life-threatening infection in those living with acquired immune deficiency syndrome (AIDS) is Pneumocystis pneumonia (PCP), caused by P. jiroveci (formerly P. carinii) (Durham & Lashley, 2010). Without prophylactic therapy, most people infected with HIV will develop PCP. The clinical presentation of PCP in HIV infection is generally less acute than in people who are immunosuppressed as a result of other conditions. Clients with HIV infection initially develop nonspecific signs and symptoms, such as nonproductive cough, fever, chills, shortness of breath, dyspnea, and occasionally chest pain. Arterial oxygen concentrations in clients who are breathing room air may be mildly decreased, indicating minimal hypoxemia.

A client comes to the clinic with a rash. While inspecting the client's skin, the nurse determines that the rash is medication-related based on which finding? Rash has developed gradually. Rash is pale in color. Rash has several large raised areas. Rash is localized to a body area.

Rash has several large raised areas. Explanation: In general, drug reactions appear suddenly, have a particularly vivid color, and manifest with characteristics more intense than the somewhat similar eruptions of infectious origin. Therefore, the appearance of several large raised areas would suggest a drug reaction.

The patient presents with contracture deformities of the hand and complains of severe pain. What musculoskeletal disorder does this patient manifest? 1. Rheumatoid arthritis 2. Osteomyelitis 3. Osteoporosis 4. Ankylosing spondylitis

Rationale 1: The pattern of joint involvement in rheumatoid arthritis (RA) is typically polyarticular and symmetric. The proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints of the fingers, wrists, knees, ankles, and toes are most frequently involved, although RA can affect any joints.

A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has? a) Benign b) Primary progressive c) Relapsing-remitting (RR) d) Disabling

Relapsing-remitting (RR) Approximately 85% of patients with MS have a relapsing-remitting (RR) course. With each relapse, recovery is usually complete; however, residual deficits may occur and accumulate over time, contributing to functional decline.

A client with HIV will be started on a medication regimen of three medications. Which medication will be given that will interfere with the virus's ability to make a genetic blueprint. What drug will the nurse instruct the client about?

Reverse transcriptase inhibitors

1.ThenurseprovidesdischargeinstructionstoapatientwhohasanimmunedeficiencyinvolvingtheTlymphocytes.Whichscreeningshouldthenurseincludeintheteachingplanforthispatient? a. Screeningforallergies. Screeningformalignancy. Antibody deficiencyscreeningd. Screening forautoimmunedisorders

Screeningformalignancy.

A client with acquired immune deficiency syndrome (AIDS) is experiencing pain secondary to Kaposi's sarcoma. How would the nurse most likely expect the client to describe the pain? Dull cramping Sharp, throbbing pressure Burning numbness Crushing, widespread pressure

Sharp, throbbing pressure Explanation: The pain associated with Kaposi's sarcoma is typically described as sharp, throbbing pressure and heaviness. Pain related to peripheral neuropathy frequently is described as burning, numbness, and "pins and needles." Dull, cramping pain and crushing widespread pressure are not associated with Kaposi's sarcoma.

A client with rheumatoid arthritis has infiltration of the lacrimal and salivary glands with lymphocytes as a result of the disease. What does the nurse understand that this clinical manifestation is? a) Sicca syndrome b) Episcleritis c) Cataracts d) Glaucoma

Sicca syndrome Explanation: Sicca syndrome is a condition of dry eyes and dry mouth that can result from infiltration of the lacrimal and salivary glands with lymphocytes. Episcleritis is an inflammatory condition of the connective tissue between the sclera and conjunctiva. Glaucoma results from increased intraocular pressure, and cataracts are a clouding of the lens in the eye. pg.1072

A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis? Urine specimen for culture and sensitivity Blood specimen for electrolyte studies Stool specimen for ova and parasites Sputum specimen for acid fast bacillus

Stool specimen for ova and parasites Explanation: A stool specimen for ova and parasites will give a definitive diagnosis. The organism is spread by the fecal-oral route from contaminated water, food, or human or animal waste. Those infected can lose from 10 to 20 L of fluid per day. Losing this magnitude of fluid quickly leads to dehydration and electrolyte imbalances

Which of the following disorders is characterized by an increased autoantibody production? Systemic lupus erythematosus (SLE) Scleroderma Rheumatoid arthritis (RA) Polymyalgia rheumatic

Systemic lupus erythematosus (SLE) Explanation: SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

The nurse receives a phone call at the clinic from the family of a patient with AIDS. They state that the patient started "acting funny" after complaining of headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?

The patient may have cryptococcal meningitis and will need to be evaluated by the physician.

Which statement accurately reflects current stem cell research? Stem cell transplantation cannot restore immune system functioning. Stem cell transplantation has been performed in the laboratory only. Clinical trials are underway only in clients with acquired immune deficiencies. The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.

The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Explanation: The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Stem cells comprise only a small portion of all types of bone marrow cells. Research conducted with mouse models has demonstrated that once the immune system has been destroyed experimentally, it can be completely restored with the implantation of just a few purified stem cells. Stem cell transplantation has been carried out in human subjects with certain types of immune dysfunction, such as severe combined immunodeficiency. Clinical trails are underway in clients with a variety of disorders with an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis.

The nursing instructor is discussing the development of human immunodeficiency disease (HIV) with the students. What should the instructor inform the class about helper T cells? They are activated on recognition of antigens and stimulate the rest of the immune system. They attack the antigen directly by altering the cell membrane and causing cell lysis. They have the ability to decrease B-cell production. They are responsible for recognizing antigens from previous exposure and mounting an immune response.

They are activated on recognition of antigens and stimulate the rest of the immune system. Explanation: Helper T cells are activated on recognition of antigens and stimulate the rest of the immune system.

A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately? Mouth sores Sneezing Constipation Tickle in the throat

Tickle in the throat Explanation: Continually assess the client for adverse reactions; be especially aware of complaints of a tickle or lump in the throat, which could be the precursor to laryngospasm that precedes bronchoconstriction.

A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection?

Trimethoprim-sulfamethoxazole (Bactrim, Septra)

Tyler Harris, a 5-year-old male, is a client in the pediatric unit of the hospital where you practice nursing. Tyler is recovering from an anaphylactic reaction to an allergen which brought him to the ED. In your first assessment of Tyler for your shift, he presents with a periorbital accumulation of blood, a common occurrence in children. What type of allergic reaction presents "allergic shiners"?

Type I

A client is prescribed epinephrine for the treatment of anaphylaxis. This client is experiencing what type of hypersensitivity reaction? type I type II type III type IV

Type I (also called immediate hypersensitivity because it occurs within minutes of exposure to the antigen) is an immunoglobulin E (IgE)-induced response triggered by the interaction of antigen with antigen-specific IgE bound on mast cells, causing mast cell activation. Hives, atopic dermatitis, Anaphylaxis is a type I response, which can be mild or life threatening. Type II responses are mediated by IgG or IgM, generating direct damage to the cell surface. These cytotoxic reactions include blood transfusion reactions, hemolytic disease of newborns, autoimmune hemolytic anemia, Myasthenia Gravis , and some drug reactions. Type III is an IgG- or IgM-mediated reaction characterized by formation of antigen-antibody complexes that induce an acute inflammatory reaction in the tissues. Serum sickness is the prototype of these reactions. The classic type IV hypersensitivity reaction is the tuberculin test, but similar reactions occur with contact dermatitis and some graft rejection.

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the: Upper mediastinum. Lower right abdomen. Upper left quadrant of the abdomen. Lower margin around the liver.

Upper left quadrant of the abdomen. Explanation: The spleen is located to the left of the stomach, in the upper left of the abdomen. It plays an important role in the immune system.

in MS

Urinary tract infection may be superimposed on the underlying neurologic dysfunction. Ascorbic acid (vitamin C) may be prescribed to acidify the urine, making bacterial growth less likely. Antibiotic agents are prescribed when appropriate.

The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply. Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Food labels on baked items are the only labels that need to be read. Carry EpiPen autoinjector at all times.

Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Carry EpiPen autoinjector at all times. Explanation: Wearing a medic alert bracelet allows others to be alerted of the allergy. Listing symptoms of the allergy makes the client aware of the allergic reaction if symptoms are being experienced. Identifying ways to manage allergies while dining out allows the client to be safe from a potential reaction. All food labels should be read not only baked items. The EpiPen autoinjector should be carried at all times in case it needs to be administered because of an allergic reaction.

(see full question) A nurse practitioner working in a dermatology clinic explained to a group of nursing students that the pathophysiology of an allergic response involves a chain of events that includes responses from lymphocytes, IgE, mast cells, and basophils. The nurse mentioned that the most important chemical mediator involved in the response is:

You selected: Histamine. Correct Explanation: All chemical mediators are participants in the response cycle, but histamine is the most important protein involved. Activated by a mast cell, it increases vessel permeability

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: a) rest in an air-conditioned room. b) avoid naps during the day. c) take a hot bath. d) increase the dose of muscle relaxants

a) rest in an air-conditioned room. Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity

Which measure should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? a. Vigilant infection control and adherence to standard precautions b. Careful monitoring of neurologic assessment and frequent reorientation c. Maintenance of a calorie count and hourly assessment of intake and output d. Assessment of blood pressure and monitoring for signs of orthostatic hypotension

a. Vigilant infection control and adherence to standard precautions Infection control is a priority in the care of patients with MS, since infection is the most common cause of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in malnutrition, hypotension, or fluid volume excess or deficit.

When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should inquire about: Urinary tract problems Chest pain skin rashes increase in libido

any urinary tract problems. rational: Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

Which of the following is the most common clinical manifestation of multiple sclerosis? a) Ataxia b) Fatigue c) Pain d) Spasticity

b) Fatigue

A nursing student asks the instructor how to identify rheumatoid nodules in a client with rheumatoid arthritis. Which of the following characteristics would the instructor include? a) Reddened b) Located over bony prominence c) Nonmovable d) Tender to touch

b) Located over bony prominence

The immune abnormalities that characterize systemic lupus erythematosus (SLE) include which of the following? Select all that apply. a) Autoantibodies immune complexes b) Susceptibility c) Damage d) Abnormal innate and adaptive immune responses e) Inflammation

b) Susceptibility d) Abnormal innate and adaptive immune responses a) Autoantibodies immune complexes e) Inflammation c) Damage Explanation: The immune abnormalities that characterize SLE occur in five phases: susceptibility, abnormal innate and adaptive immune responses, autoantibodies immune complexes, inflammation, and damage.

When establishing a diagnosis of MS, the nurse should teach the patient about what diagnostic studies (select all that apply)? a. EEG b. CT scan c. Carotid duplex scan d. Evoked response testing e. Cerebrospinal fluid analysis

b. CT scan d. Evoked response testing e. Cerebrospinal fluid analysis There is no definitive diagnostic test for MS. CT scan, evoked response testing, cerebrospinal fluid analysis, and MRI along with history and physical examination are used to establish a diagnosis for MS. EEG and carotid duplex scan are not used for diagnosing MS.

A hospice nurse has been providing care for a man who has AIDS. Among the manifestations of the man's disease has been a profound weight loss over the past several weeks. Consequently, the nurse is adjusting the patient's plan of care to reprioritize this problem. When planning interventions for the patient's weight loss, the nurse should be aware that: a. The patient should simultaneously receive total parenteral nutrition (TPN) and oral nutritional supplements. b. Nutritional interventions may not necessarily resolve the patient's weight loss. c. The patient's weight loss is a sign of the progression of AIDS but is not a direct threat to his health. d. The patient's weight loss is attributable to psychological factors rather than pathophysiological factors.

b. Nutritional interventions may not necessarily resolve the patient's weight loss.

Thenurseteachesapatientdiagnosedwithsystemiclupuserythematosus(SLE)aboutplasmapheresis.Whatinstructionsaboutplasmapheresisshouldthenurseincludeintheteachingplan? a.Plasmapheresiswilleliminateeosinophilsandbasophilsfromblood. b. Plasmapheresiswillremoveantibody-antigencomplexesfromcirculation .c. Plasmapheresiswillpreventforeignantibodiesfromdamagingvariousbodytissues. d. PlasmapheresiswilldecreasethedamagetoorganscausedbyattackingTlymphocytes.

b. Plasmapheresiswillremoveantibody-antigencomplexesfromcirculation

A client who is HIV positive has been prescribed antiretroviral drugs. The nurse explains the action of each antiretroviral drug and develops a schedule for the client's self-administration, including strong emphasis about rigidly adhering to the dosage, time and frequency of the administration of the drugs. Why is it important to adhere to the schedule of drug dosing developed for this client? a. To avoid overdosing on the drugs b. To avoid resistance to the drugs c. To maintain appropriate blood levels of the drugs d. To get the most benefit from the drugs

b. To avoid resistance to the drugs

a patient with HIV has been on antiretroviral therapy (ART) for 6 months. the patient comes to the clinic with home medications and the nurse observes that there are too many pills in the container. what does the nurse know about the factors associated with non-adherence to ART? (select all the apply) a. lives alone b. active substance abuse c. taking other medication d. depression e. lack of social support

b. active substance abuse d. depression e. lack of social support

A nurse is caring for a client with human immunodeficiency virus (HIV). To determine the effectiveness of treatment the nurse expects the physician to order: a. E-rosette immunofluorescence. b. quantification of T-lymphocytes. c. enzyme-linked immunosorbent assay (ELISA). d. ELISA with Western blot test.

b. quantification of T-lymphocytes.

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis? a) "I have pain in my hands." b) "I have trouble with my balance." c) "My finger joints are oddly shaped." d) "My legs feel weak."

c) "My finger joints are oddly shaped."

The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform? a) Avoid swimming and any weight-bearing activity. b) Exercise following a circuit training regimen. c) Apply warm packs to the affected area. d) Relax in a hot bath.

c) Apply warm packs to the affected area.

The nursing instructor is teaching the senior nursing class about neuromuscular disorders. When talking about Multiple Sclerosis (MS) what diagnostic finding would the instructor list as being confirmatory of a diagnosis of MS? a) An elevated acetylcholine receptor antibody titer b) Episodes of muscle fasciculations c) Oligoclonal bands d) IV administration of edrophonium

c) Oligoclonal bands

A client is diagnosed with systemic lupus erythematosus (SLE). Which of the following would be most appropriate for the nurse to use to evaluate the client's stage of disease? a) Auscultate the client's lung sounds. b) Observe the client's gait. c) Review the client's medical record. d) Inspect the client's mouth.

c) Review the client's medical record. Explanation: The nurse evaluates the stage of SLE and plans appropriate interventions by reviewing the medical record and diagnostic findings of the client. The stage of the disease cannot be established by observing the client's gait, inspecting the client's mouth, or auscultating the client's lung sounds. pg.1070

A patient with MS has a nursing diagnosis of self-care deficit related to muscle spasticity and neuromuscular deficits. In providing care for the patient, it is most important for the nurse to a. Teach the family members how to care adequately for the patient's needs. b. Encourage the patient to maintain social interactions to prevent social isolation. c. Promote the use of assistive devices so the patient can participate in self-care activities. d. Perform all activities of daily living (ADLs) for the patent to conserve the patient's energy.

c. Promote the use of assistive devices so the patient can participate in self-care activities.

A patient with an acute exacerbation of arthritis is temporarily confined to bed. What position can the nurse recommend to prevent flexion deformities? a) Supine with pillows under the knees b) Semi-Fowler's c) Side-lying with pillows supporting the shoulders and legs d) Prone

d) Prone Explanation: It is best for the patient with rheumatoid arthritis to lie prone several times daily to prevent hip flexion contracture.

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene, 25 mg P.O. daily. Which assessment finding indicates the medication is effective? a) Increased ability to sleep b) Relief from pain c) Relief from constipation d) Reduced muscle spasticity

d) Reduced muscle spasticity Dantrolene reduces muscle spacticity. It doesn't increase the ability to sleep or relieve constipation or pain.

A patient comes to the clinic with an inflamed wrist. How should the nurse splint the joint to immobilize it? a) Extension b) Internal rotation c) Hyperextension d) Slight dorsiflexion

d) Slight dorsiflexion Explanation: Devices such as braces, splints, and assistive devices for ambulation (e.g., canes, crutches, walkers) ease pain by limiting movement or stress from putting weight on painful joints. Acutely inflamed joints can be rested by applying splints to limit motion. Splints also support the joint to relieve spasm. pg.1056

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? a) Padded tongue blade b) Nasal cannula and oxygen c) Sphygmomanometer d) Suction machine with catheters

d) Suction machine with catheters

The nurse is performing a health history on a patient who has multiple sclerosis. The patient reports episodes of muscle spasticity and recurrence of muscle weakness and diplopia. The nurse will expect this patient to be taking which medication? a. Adrenocorticotropic hormone (ACTH) b. Cyclophosphamide (Cytoxan) c. Cyclobenzaprine (Flexeril) d. Interferon-B (IFN-B)

d. Interferon-B (IFN-B)

A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:

fluid replacement

A patient is receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS). This patient should be closely monitored for a) hypoxia. b) renal insufficiency. c) mood changes and fluid and electrolyte alterations. d) leukopenia and cardiac toxicity.

leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lymphoma but is also used to treat secondary progressive MS. Patients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity. Patients receiving corticosteroids are monitored for side effects related to corticosteroids such as mood changes and fluid and electrolyte alterations. Patients receiving mitoxantrone are closely monitored for leukopenia and cardiac toxicity.

A client with multiple sclerosis is being discharged. The nurse understands that living with chronic conditions imposes many challenges, including the need to accomplish the following. Choose all that apply. a) Validate family functioning b) Validate individual self-worth c) Die without comfort d) Ignore threats to identity e) Alleviate and manage symptoms

• Alleviate and manage symptoms • Validate family functioning • Validate individual self-worth

A nurse is developing a teaching plan for a community presentation on smoking cessation. Based on current research regarding the effects of cigarette smoking on the immune system, which of the following alterations in immune function can be attributed to smoking and should be included in the teaching presentation? Select all that apply

• Increased white blood cell (WBC) count • Decreased T cell function • Decreased natural killer (NK) cells • Increased risk of infection

A patient diagnosed with rheumatoid arthritis (RA) is reluctant to start some recommended therapies. The nurse tells the patient that early intervention is crucial for long-term health. What rationales would the nurse provide for this statement? Select all that apply. 1. Early intervention is instrumental in bringing about long-term remission of symptoms. 2. Beginning treatment early can help control pain generated by the disorder. 3. If the disease is not treated, tissue and joint damage can be extreme. 4. Early and aggressive exercise will help keep joints mobile. 5. If treatment is started early, joint deformity can be avoided.

2,3 Rationale 1: RA is a chronic condition without a cure or long-term remission. Rationale 2: RA is a painful condition that requires a combination of therapeutic approaches to treatment. Early treatment of pain helps maintain joint function. Rationale 3: Treatment can help reduce the amount of tissue and joint damage. If treatment is started earlier, rather than later, tissue and joint damage can be minimized. Rationale 4: Exercise should be balanced with rest, and joints should be safeguarded. Rationale 5: Joint deformity is likely to occur despite early treatment.

A 24-year-old woman is admitted to the hospital for a complete medical examination. Her current complaints are indicative of systemic lupus erythematosus (SLE). Which of the fol-lowing symptoms would indicate this diagnosis? 1. Recent weight gain of 10 pounds 2. Difficulty breathing in the morning 3. Frequent episodes of diarrhea 4. Musculoskeletal pain in the hands

4 Musculoskeletal symptoms are experienced by 95% of SLE patients at some time during the course of their disease.

A child receives the measles, mumps, and rubella vaccine. What type of immunity does this represent? Passive Active Natural Innate

Active Explanation: Active immunity is produced by the person's own immune system in response to a disease caused by a specific antigen or administration of an antigen from a source outside the body, usually by injection. Passive immunity occurs when antibodies are formed by the immune system of another person or animal and transferred to the host. Innate or natural immunity, which is not produced by the immune system, includes monocytes, macrophages, dendritic cells, natural killer (NK) cells, basophils, eosinophils, and granulocytes.

An infant is suspected of having a severe combined T- and B-cell immunodeficiency disorder. Which effect on the infant makes early detection a priority? Administering live attenuated virus vaccines can be fatal. The infant may have developmental delays. The infant may develop food allergies. The infant is at risk for cardiovascular disease.

Administering live attenuated virus vaccines can be fatal. Explanation: For infants born with severe combined T- and B-cell immunodeficiency, early diagnosis is essential before the development of severe infections and the administration of live attenuated virus vaccines (e.g., measles, mumps, rubella, varicella, and bacillus Calmette-Guerin), which could have devastating and life-threatening complications. The infant may have developmental delays but these delays are not a priority related to this diagnosis. The infant is not at risk for cardiovascular disease any more so than other children of this age group.

A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes the patient has lost some of her ability to function since her last office visit. What might be an appropriate intervention for the nurse to make for this patient? A) Recommend to the physician that the patient be hospitalized. B) Ask the physician for a referral to an arthritis support group in the community. C) Make a referral for home health so the patient can be assessed in her own environment. D) Make referrals for occupational therapy and physical therapy.

Ans: C Feedback: Appropriate adaptive equipment needed for increased independence is often identified more readily when the nurse sees how the patient functions in the home. There is nothing in the scenario that indicates the patient needs to be hospitalized. The nurse could make the referral to the support group; the physician does not need to do this. The nurse could not make referrals for occupational therapy and physical therapy.

The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care?

Assist with chest physiotherapy every 2 to 4 hours.

An occupational therapist is treating a client with rheumatoid arthritis. Which assessment finding in the client does the nurse share with the occupational therapist? a. Difficulty sleeping because of pain in the knees and elbows b. Difficulty tying shoelaces and doing zip-pers on clothing c. Swollen knees with crepitus and limited range of motion d. Generalized joint stiffness that is worse in the early morning

B The functional assessment helps nurses and therapists measure how functional the client is with activities of daily living, including dressing. The occupational therapist can assist the client to explore clothing options that are easier to manage with arthritic fingers. The other findings would not necessarily need to be shared with the occupational therapist for the treatment plan.

(see full question) A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. Which of the following would the nurse identify as a common cause of anaplhylaxis? Select all that apply?

Correct response: • Milk • Eggs • Shrimp

Which intervention should the nurse implement to manage pain for the client with rheumatoid arthritis? Select all that apply. a) Provide assistive devices for self-feeding. b) Assist the client to develop a sleep routine. c) Provide diversional activities. d) Support joints with splints and pillows. e) Provide opportunities for the client to verbalize feelings.

D. Support joints with splints and pillows. C. Provide diversional activities. E. Provide opportunities for the client to verbalize feelings. Explanation: To manage pain, the nurse maintains normal alignment of extremities as much as possible by supporting the joints with splints and pillows. Diversional activities distract the client's focus from the pain. Providing opportunities for the client to verbalize feelings facilitates coping with pain. Assistive devices for self-feeding help the client meet nutritional needs independently. Assisting the client to develop a sleep routine promotes rest and minimizes fatigue.

Which of the following is a process in which the antigen-antibody molecule is coated with a sticky substance that facilitates phagocytosis? Apoptosis Agglutination Opsonization Immunoregulation

Opsonization in the process of opsonization, the antigen-antibody molecule is coated with a sticky substance that also facilitates phagocytosis. Apoptosis is programmed cell death that results from the digestion of DNA by endonucleases. Agglutination is the clumping effect occurring when an antibody acts as a cross-link between two antigens. Immunoregulation is a complex system of checks and balances that regulates or controls immune responses

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan? Wear only synthetic fabrics. Use a topical skin moisturizer daily. Bathe only three times per week. Keep the thermostat above 75° F (23.9° C).

Use a topical skin moisturizer daily. Explanation: The nurse should instruct the client to use a topical skin moisturizer daily to help keep the skin hydrated. Likewise, the client should be encouraged to bathe daily. To minimize irritation, the client should wear only cotton fabrics. The client should maintain a room temperature between 68° F (20° C) and 72° F (22.2° C).

The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what? Peripheral edema Uncoordinated muscle movement Vascular lesions caused by dilated blood vessels A condition marked by development of urticaria

Vascular lesions caused by dilated blood vessels Explanation: Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia refers to uncoordinated muscle movement and is a clinical manifestation of combined B-cell and T-cell deficiencies. Telangiectasia is not peripheral edema, vascular lesions, or urticaria.

A patient is seen in the office for complaints of joint pain, swelling, and a low-grade fever. What blood studies does the nurse know are consistent with a positive diagnosis of RA? (Select all that apply.) a) Positive antinuclear antibody (ANA) b) Positive C-reactive protein (CRP) c) Aspartate aminotransferase (AST) and alanine transaminase (ALT) levels of 7 units/L d) Red blood cell (RBC) count of <4.0 million/mcL e) Red blood cell (RBC) count of >4.0 million/mcL

a) Positive antinuclear antibody (ANA) b) Positive C-reactive protein (CRP) d) Red blood cell (RBC) count of <4.0 million/mcL Explanation: Several assessment findings are associated with RA: rheumatoid nodules, joint inflammation detected on palpation, and laboratory findings. The history and physical examination focuses on manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tend to be significantly elevated in the acute phases of RA and are therefore useful in monitoring active disease and disease progression. The red blood cell count and C4 complement component are decreased. Antinuclear antibody (ANA) test results may also be positive. pg.1066

Which of the following clinical manifestations would the nurse expect to find in a client who has had rheumatoid arthritis for several years? a) Small joint involvement b) Asymmetric joint involvement c) Bouchard's nodes d) Obesity

a) Small joint involvement Explanation: Clinical manifestations of rheumatoid arthritis are usually bilateral and symmetrical and include small joint involvement and joint stiffness in the morning. Other systemic manifestations occur. pg.1065

The nurse is gathering objective data for a client at the clinic complaining of arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as? a) Boutonnière deformity b) Swan neck deformity c) Ulnar deviation d) Rheumatoid nodules

b) Swan neck deformity

A client with rheumatoid arthritis has experienced increasing pain and progressing inflammation of the hands and feet. What would be the expected goal of the likely prescribed treatment regimen? a) Eradicating pain b) Promoting sleep c) Eliminating deformities d) Minimizing damage

d) Minimizing damage Explanation: Although RA cannot be cured, much can be done to minimize damage. Treatment goals include decreasing joint inflammation before bony ankylosis occurs, relieving discomfort, preventing or correcting deformities, and maintaining or restoring function of affected structures. Early treatment leads to the best results. pg.1066

A client is administered methotrexate for the treatment of severe rheumatoid arthritis. Administration of this drug should be performed with particular care because of the associated high risk of: intracapsular bleeding. thrombophlebitis. hepatotoxicity. myocardial infarction or CVA.

hepatotoxicity. Explanation: Even in the low doses used in rheumatoid arthritis and psoriasis, methotrexate may cause hepatotoxicity. Consequently, many clinicians recommend serial liver biopsies for clients on long-term, low-dose methotrexate. This drug is not closely associated with bleeding disorders, MI, or stroke.

A client has a known allergy to peanuts, meaning that the client's immune system has identified peanuts as a foreign invader and has produced specific cells to attack if the client should come in contact with peanuts again. The formation of these specific cells is known as: humoral response. cell-mediated response. inflammatory response. memory response.

humoral response. Explanation: The B-cell lymphocytes mature in the bone marrow and migrate to the spleen and other lymphoid tissues such as the lymph nodes. When stimulated by T cells, the B cells become either plasma or memory cells. Plasma cells produce antibodies. Formation of antibodies is called a humoral response.

The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?

lymphoid tissue

A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wartlike lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding? testing the client for the presence of HIV instructing the client to wear cotton underwear having the client abstain from sexual activity for 6 weeks while the medication is working using a medicated douche in order to keep the vaginal pH normal

testing the client for the presence of HIV Explanation: Abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may correlate with HIV infection. Wearing cotton underwear can help with the prevention of candidiasis but does not address the recurrent vaginal infection that may not be caused by a fungus. Abstaining from sexual intercourse does not address the recurrent vaginal infection. A medicated douche can alter the normal flora of the vaginal wall.

When describing cell-mediated immunity, a nurse would explain that this type of immunity depends on which response or action? the action of T lymphocytes the action of B lymphocytes antigen-antibody response globulin production

the action of T lymphocytes Explanation: Cell-mediated immunity depends on the actions of T lymphocytes. Antibody-mediated immunity involves the B lymphocytes and is referred to as humoral immunity. When exposed to an antigen, the B cells produce antibodies as a defense against the offending antigen. Antigen--antibody response is antibodies formed in response to exposure to a specific antigen. Globulins are proteins present in blood serum or plasma that contain antibodies. Immune globulins are solutions obtained from human or animal blood containing antibodies that have been formed by the body to specific antigens. Globulin production occurs when antigens are present. During a cell-mediated response, T-cell lymphocytes survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. For example, a cell-mediated response occurs when an organ is transplanted. Immunoglobulins hinder the antigens physically by neutralizing their toxins through agglutination or by causing them to precipitate.