Medical-Surgical: Immune and Infectious
Active Pulmonary Tuberculosis
An infectious disease involving the lungs caused by the tubercle bacillus. It can spread to the lymph nodes and gain access to the blood stream, thereby causing TB in other organs. A person with active TB suffers from weight loss, loss of appetite, night sweats. Tx: includes long term antibiotic therapy.
A nurse is assisting with the care of a client who has systemic lupus erythematosus (SLE). The client asks the nurse, "What should i do to care for my dry skin?" Which of the following responses should the nurse make?
Apply lotion twice per day to dry skin Nurse should instruct pt to clean, dry, moisturize skin using warm (not hot) water, along with unscented lotion Topical corticosteroid creams, not antibiotic creams, are indicated for cutaneous manifestations of SLE. instruct the client to gently pat, not rub, the lesions to dry. The nurse should instruct the client to wear a hat and protective clothing when outside. However, covering SLE lesions with a sterile dressing when outdoors is unnecessary. Most often, the lesions are dry and scaly, not open and draining.
A nurse is reinforcing teaching with a client who has AIDS about the transmission of Pnuemocystis jiroveci pneumonia (PCP). Which of the following information should the nurse include in the teaching?
PCP results from an impaired immune system nurse should explain that the organism that causes PCP exists as part of the normal flora of the lungs and develops into a fungus. It becomes an aggressive pathogen when the immune system is compromised and the infection results from an impaired immune system.
A nurse is reinforcing teaching with a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching?
Pour running water over the lesions when urinating
Vitamin A
Promotes growth & development of bones & teeth Necessary for night vision
A nurse is reinforcing teaching with a client who has Raynaud's disease. Which of the following information should the nurse include in the teaching?
Protect against the cold by wearing layers of clothing
A nurse is collecting data from a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect with this condition?
Reddish-purple skin lesions
SLE (systemic lupus erythematosus)
A chronic inflammatory disease considered an autoimmune connective disease that effects multiple systems, such as the skin, joints, kidney, nervous and mucous membrane. Maintenance of skin integrity, focusing on reduction of rashes and skin lesions is a primary goal during acute exacerbation of SLE. Symptoms: *anemia, *skin rashes, *fever *glomerulonephritis. Tx: nonsteroidal anti-inflammatory drugs corticosteroids.
human immunodeficiency virus (HIV)
A positive reaction indicates the client has been infected with the human immunodeficiency virus but does not have AIDS. HIV is transmitted through direct contact with the blood or body secretions of an infected person. Sx: *fever, swollen glands, muscle pain. HIV tx: with antiviral medications can lead to AIDS.
A nurse is collecting data from a client who is concerned about the possibility of the contracting Lyme disease after being bitten by a tick. For which of the following early manifestations of Lyme disease should the nurse monitor the client?
A progressive, circular rash Early Lyme disease is characterized by fever, influenza-like manifestations, and erythema migrans, a distinct progressive circular or bulls-eye rash that often develops at the bite site, but can also develop at other sites, such as the thighs and knees.
AIDS
Acquired immunodeficiency syndrome is a disease characterized by infections from opportunistic organisms and malignancies, such as Kaposi's sarcoma and non-Hodgkins lymphoma; it results from significant impairment of the immune system by a previous infection with the human immunodeficiency virus (HIV).
Rifampin
Administration Consideration Give on an empty stomach unless with GI distress. Rifampin also causes the urine and body secretions of the client to take on an orange/red color. Adverse Reaction pancreatitis, thrombocytopenia and liver disease (rare). confusion and dizziness. Available Forms Capsules and injection. Class macrocytic antibiotic Contraindications Include drug allergy. Indications Usage includes the treatment of tuberculosis. IV_Facts Dilute and infuse slowly, over 30 minutes to 3 hours. Nursing Consideration Monitor liver enzymes and for adverse reactions. Monitor fluids and electrolytes. Therapeutic Actions Stops the growth of susceptible bacteria.
A nurse is assisting with the care of a client who is 2 days postoperative. Which of the following findings should alert the nurse that the client is developing an infection?
Erythema at the incision site
A nurse is reinforcing teaching with an assistive personnel about standard precautions when caring for a client who has vancomycin resistant Enterococcus of the urine. Which of the following of personal protection equipment should the nurse recommend the AP to use when caring for this client?
Gloves
A nurse is reinforcing teaching with an assistive personnel (AP) who is caring for a client who has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest x-ray. Which of the following instructions should the nurse include in the teaching?
Have the client wear surgical mask
A nurse is preparing to administer a Mantoux skin test to a client. The nurse should inform the client that the purpose of a Mantoux skin test using purified protein derivative (PPD) is to do which of the following actions?
Identify if a client has been infected with mycobacterium tuberculosis (or if client lacks immunity to TB)
A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory values can indicate arthritis?
Rheumatoid factor
A nurse is collecting data from a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect to see?
Unilateral, localized, nodular skin lesions Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces unilateral, localized, nodular skin lesions. Confluent (gathered together), honey-colored, crusted lesions are typically associated with impetigo. Large tender nodule located on hair follicle describes furuncle or bacterial infection on a hair follicle.
A nurse is reinforcing teaching with a client who is HIV positive about the early manifestations of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include in the teaching?
You can expect a persistent fever and swollen glands Clients who have AIDS can have persistent fever, swollen glands, diarrhea, weight loss, and fatigue. These manifestations indicate the onset of AIDS. Clients who have AIDS are more likely to have a decreased WBC count as a result of the HIV virus destroying CD4-T-cells. This decrease in the client's WBC and CD4-T-cell count is the primary reason that clients who have AIDS are at increased risk for infection.
A nurse is reinforcing teaching with a client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent transmission of his sexually transmitted infection (STI)?
I will bring my sexual partner in for treatment
A nurse is reinforcing teaching with a client who has tested positive for an allergy to dust about how to reduce her exposure to the allergen. The nurse should determine that the client understands how to reduce her exposure to the allergen when she states which of the following?
I will install an electrostatic filter in my furnace
Lyme disease
An infectious disease transmitted from a tick bite. Sx: flu-like symptoms that progress to weakness of the extremities and Bell's palsy. Complications of Lyme disease are meningitis and encephalitis. Tx: abx therapy
A nurse is reinforcing teaching with a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching when she identifies which of the following as a factor that can exacerbate SLE?
Exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and the manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with her provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active. Pregnancy can exacerbate SLE *Monitor for renal & cardio effects Infections: strep or viral, stress body & trigger exacerbation of SLE Pts with SLE usually take steroids, ^ their risk for infection Exposure to sunlight and artificial ultraviolet light is the leading cause of SLE exacerbations, especially the characteristic skin lesions and butterfly rash. Clients should use a sunscreen with a high solar protection factor (SPF), and cover their skin with appropriate clothing and hats when they must be exposed to sunlight.
A nurse is reinforcing teaching with a client who has human immunodeficiency virus about how the virus is transmitted. Which of the following statements should the nurse include in the teaching?
HIV can be transmitted to anyone who has had contact with infected blood The concentration of the virus is highest in blood but also has been isolated in other body fluids, including sputum, saliva, cerebrospinal fluid, urine, and semen. Clients who have HIV are cautioned to practice safe sex, avoid donating blood, and abstain from sharing needles with others. HIV can be transmitted before a person develops manifestations. The virus is commonly transmitted during the time at which a person is asymptomatic and unaware of having the virus. HIV has not been found to be transmitted through the respiratory route. Although the virus has been isolated in sputum, it is not a disease of airborne or droplet transmission. Evidence has indicated that HIV is transmitted only through intimate sexual contact, parenteral exposure to infected blood or blood products, sharing of contaminated needles, and perinatal transmission from mother to neoborn. HIV has not been found to be transmitted through the respiratory route. Although the virus has been isolated in sputum, it is not a disease of airborne or droplet transmission. Evidence has indicated that HIV is transmitted only through intimate sexual contact, parenteral exposure to infected blood or blood products, sharing of contaminated needles, and perinatal transmission from mother to neoborn.
A nurse is collecting data from a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments?
Heat paraffin therapy applied to the client's hands The nurse should anticipate the use of heat paraffin to be prescribed as a nonpharmacologic intervention. The elevated ESR indicates an acute inflammatory process due to client's rheumatoid arthritis. The use of the warm paraffin relives the stiffness of the client's joints and provides comfort.
A nurse is reinforcing teaching with a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?
I can expect this medication to turn my skin orange
A nurse in a provider's office is reinforcing teaching with a client who has a new diagnosis of rheumatoid arthritis and a new prescription for naproxen tablets. Which of the following statements by the client requires further teaching?
I can take this medication with Aspirin
A nurse is reinforcing teaching with a client who has a recent diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching?
I should not smoke Raynaud's disease is a disorder of the blood vessels that supply blood to the skin and cause the distal extremities to feel numb and cool in response to cold temperatures or stress. During a Raynaud's attack, these arteries narrow, limiting blood circulation to affected areas. Strong emotion or exposure to the cold causes these areas to become white, due to a lack of blood flow in the area. They then turn blue, as tiny blood vessels dilate to allow more blood to remain in the tissues. When the flow of blood returns, the area becomes red and then later returns to normal color. This can cause tingling, swelling and painful throbbing. The attacks can last from minutes to hours. If the condition progresses, blood flow to the area could become permanently decreased, causing the fingers to become thin and tapered, with smooth, shiny skin and slow-growing nails. If an artery becomes blocked completely, gangrene or ulceration of the skin can occur. Smoking cessation, not just reduction, is an action the client should take to prevent the onset of the manifestations of Raynaud's disease. Foods high in purine, such as organ meats, are contraindicated for clients who have gout, but not Raynaud's disease.
A nurse is reinforcing teaching with a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching?
I should stop eating raw clams Hepatitis A is transmitted via the fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, or uncooked shellfish. Individuals who eat raw or steamed shellfish are at increased risk for acquiring hepatitis A. Hepatitis B can be transmitted by shared needles or unclean tattoo equipment. Hepatitis A is transmitted through fecal contamination or contaminated food and water. Passive immunity to hepatitis A can be conferred for 6 to 7 weeks by the administration of immune serum globulin during the incubation period if the treatment is instituted within 2 weeks of exposure. A booster shot every year is not required. "I am unable to donate blood." There is no danger of contracting any form of hepatitis or any other bloodborne pathogen from the sterile, single-donor blood collection process used at blood banks.
A nurse is reinforcing discharge teaching with the partner of a client who has acquired immune deficiency syndrome (AIDS). Which of the following statements by the client's partner indicates the need for further teaching?
I'll clean up blood spills immediately with hot water. client's partner should clean blood or potentially contaminated body substances with a bleach solution and wear gloves when coming into contact with blood products. client's partner should use a separate plastic bag to dispose soiled tissues. Any items that cannot be disposed of in the toilet should be kept in a closed plastic bag until trash disposal. client's partner should implement measures such as hand washing to prevent the spread of infection. The client's partner should wash soiled clothes in hot water along with 1 cup of bleach to clean clothing.
A nurse is collecting data from a client who had radioallergosorbent (RAST) testing completed due to seasonal allergies. The nurse should anticipate an elevation in which of the following laboratory values?
IgE (immunoglobulin E) RAST testing involves measuring the quantity of IgE present in serum after exposure to specific antigens selected on a basis of the client's symptom history. An elevated IgE indicates a positive response and is common among clients who have a history of allergic manifestations, anaphylaxis, and asthma. An elevated IgG indicates the production of antibodies to all types of infections, especially blood borne and tissue infections. elevated IgA is associated with autoimmune diseases and chronic infections. An elevated IgM is associated with a bacterial or viral infection. IgM produces antibodies to protect the body against infections.
A nurse is reinforcing teaching with a client about the manifestations of an allergic reaction. The nurse should explain that histamine release causes which of the following reactions?
Increased mucus secretion The nurse should instruct client that increased mucus secretion is a manifestation of histamine release. Histamine is neurotransmitter body produces during an allergic reaction. Symptoms with histamine release: * Increased mucus secretion * Bronchospasms and bronchial constriction * Rapid, weak pulse
Mantoux skin test
Injection of a small amount of purified protein derivative (PPD) tuberculin antigen just under the skin to determine if an individual has been exposed to tubercle bacillus.
A nurse is caring for a client who test positive for the human immunodeficiency virus. The client asks the nurse, "Should i tell my partner that i HIV positive?" Which of the following is an appropriate nursing response?
It sounds like you are unsure what to say to your partner
A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse plan to include in the teaching?
Monitor your body temperature and report any elevations promptly
A nurse is collecting data from a client who has systemic scleroderma. Which of the following findings should the nurse expect?
Skin tightening Finger contractions Definition Is a thickening of the skin associated with systemic sclerosis. Symptoms include tight, firm, swollen skin, that may itch and become hyper-pigmented. Decreased salivation with increased risk of dental caries & gum disease, ankle & pedal edema due to construction of blood vessels as result of renal failure. Tx for scleroderma: corticosteroids and vasodilators. Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are two types of scleroderma: localized scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs. The manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With scleroderma, the body produces and deposits too much collagen, causing thickening and hardening. In addition to the client's skin and subcutaneous tissues becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma unless clients follow a regimen of range-of-motion and muscle-strengthening exercises.
A nurse is assisting with the care of a client who has human immunodeficiency virus. Which of the following types of isolate should the nurse implement to prevent transmission of HIV
Standard precautions Standard precautions should be implemented with every client, to prevent the spread of infection transmitted by direct or indirect contact with infectious blood or body fluids. Because HIV is spread through blood and bodily fluids, standard precautions are appropriate.N Protective isolation keeps a client who is immunocompromised from acquiring communicable infections prevalent in the hospital setting
Nurse teaching a client who has genital herpes about self management. Which instruction should nurse include in teaching
Use mild soap to clean lesions Pat dry with towel Avoid sexual activity when lesions are present 3-4 sits baths daily to relieve discomfort Apply warm compress to lesions to relieve discomfort
A nurse is reinforcing teaching with a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching?
Wash genitalia using an antimicrobial soap bathe daily using an antimicrobial soap to prevent the spread of infection. If bathing is not possible, washing the genitalia using an antimicrobial soap is recommended. client's toothbrush should be cleaned once per week by running it through the dishwasher or rinsing it with bleach. client should avoid raw fruits and vegetables due to the bacteria they carry.
