Unit 3 - Immunity - NCO
A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). Which recommendations are essential for the nurse to include? Select all that apply. 1 "Wear a large-brimmed hat." 2 "Take your temperature daily." 3 "Balance periods of rest and activity." 4 "Use a strong soap when washing the skin." 5 "Expose the skin to the sun as often as possible."
1 "Wear a large-brimmed hat." 2 "Take your temperature daily." 3 "Balance periods of rest and activity." A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. SLE can cause alopecia, and hair care recommendations include the use of mild protein shampoos and avoidance of harsh treatments, like permanents or highlights, and use of large-brimmed hat for skin protection. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not recommended. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.
A client is experiencing an exacerbation of systemic lupus erythematosus. To reduce the frequency of exacerbations, what would be important for the nurse to include in the client's teaching plan? 1 Basic principles of hygiene 2 Techniques to reduce stress 3 Measures to improve nutrition 4 Signs of an impending exacerbation
2 Techniques to reduce stress \Systemic lupus erythematosus is an autoimmune disorder, and physical and emotional stresses have been identified as contributing factors to the occurrence of exacerbations. Although basic principles of hygiene should be performed, inadequate hygiene is not known to produce exacerbations. Although measures to improve nutrition should be done, nutritional status is not significantly correlated to exacerbations. Knowledge of the symptoms will not decrease the occurrence of exacerbations.
An adolescent has been admitted with symptoms of fatigue, intermittent fever, weight loss, and arthralgia, and the diagnosis is systemic lupus erythematosus. What is the best intervention at this time? 1 Implementation of corticosteroids 2 Education about diet, rest, and exercise 3 Sun avoidance and calcium supplements 4 Avoidance of destructive coping mechanisms
2 Education about diet, rest, and exercise Client education about the integrative interventions of diet, rest, and exercise will be of the most help to the adolescent client with newly diagnosed lupus. These are interventions that the client has some control over, and this is important to the adolescent. Corticosteroids may not be used until other therapies are unsuccessful. Although sun avoidance and calcium supplements may be helpful, they are not most important. Avoidance of negative coping strategies may be helpful if they are noted, but control over diet, rest, and exercise is a positive coping strategy.
A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? 1 Albumin 2 Globulin 3 Thrombin 4 Hemoglobin
2 Globulin The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen.
A client is admitted with systemic lupus erythematosus (SLE). The laboratory report shows the presence of neutrophils and monocytes as mediators of injury. Which type of hypersensitivity reaction most likely occurred in the client? 1 Type I 2 Type II 3 Type III 4 Type IV 00:00:44 Question Answer Confidence Buttons
3 Type III Type III hypersensitivity reaction involves immunoglobulin IgG- and IgM-mediated release of neutrophils and monocytes as mediators of injury. It is an immune complex-mediated hypersensitivity reaction that occurs in SLE or rheumatoid arthritis. Allergic rhinitis and asthma may occur when mediators such as histamine and prostaglandins are involved, resulting in a type I hypersensitivity reaction. Type II hypersensitivity reaction is cytotoxic mediated, which occurs in transfusion reaction and Goodpasture syndrome. Type IV hypersensitivity reaction is a delayed hypersensitivity reaction that may occur in contact dermatitis involving T cytotoxic cells.
A client reports hair loss, joint pain, and a facial rash. The nurse documents the presence of a butterfly rash on the face in the client's medical record. Which disorder does the nurse suspect? 1 Scleroderma 2 Angioedema 3 Rheumatoid arthritis 4 Systemic lupus erythematosus
4 Systemic lupus erythematosus Systemic lupus erythematosus is an autoimmune connective tissue disorder characterized by joint pain, alopecia, and rashes on the face. A characteristic butterfly rash is a major skin manifestation of systemic lupus erythematosus. Scleroderma is a chronic, inflammatory, autoimmune connective tissue disease characterized by hardening of the skin. Angioedema is the diffuse swelling of the eyes and lips. Rheumatoid arthritis is an inflammatory autoimmune disease process that affects primarily the synovial joints. The primary symptom of rheumatoid arthritis is painful swollen joints.
A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply. 1 Butterfly facial rash 2 Firm skin fixed to tissue 3 Inflammation of the joints 4 Muscle mass degeneration 5 Inflammation of small arteries
1 Butterfly facial rash 3 Inflammation of the joints The connective tissue degeneration of SLE leads to involvement of the basal cell layer, producing a butterfly rash over the bridge of the nose and in the cheek region. Polyarthritis occurs in most clients, with joint changes similar to those seen in rheumatoid arthritis. Firm skin fixed to tissue occurs in scleroderma; in an advanced stage the client has the appearance of a living mummy. Muscle mass degeneration occurs in muscular dystrophy; it is characterized by muscle wasting and weakness. Inflammation of small arteries occurs in polyarteritis nodosa, a collagen disease affecting the arteries and nervous system.
What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? Select all that apply. 1 Joint pain 2 Facial rash 3 Pericarditis 4 Weight gain 5 Hypotension
1 Joint pain 2 Facial rash 3 Pericarditis SLE is a chronic, autoimmune disease that affects connective tissue; joint pain is common. A butterfly rash on the face is characteristic of SLE. Pericarditis is the most common cardiac indicator of SLE. Weight loss, not gain, is a classic sign of SLE because of gastrointestinal effects. Renal impairment with SLE may cause hypertension, not hypotension.
Which manifestations may indicate a client has systemic lupus erythematosus (SLE)? Select all that apply. 1 Pericarditis 2 Esophagitis 3 Fibrotic skin 4 Discoid lesions 5 Pleural effusions
1 Pericarditis 4 Discoid lesions 5 Pleural effusions SLE is a chronic, progressive inflammatory connective tissue disorder that can cause major organs and systems to fail. Pericarditis is a cardiovascular manifestation of SLE. Discoid lesion is a skin manifestation that is a key indicator of the presence of SLE. Pleural effusion, a pulmonary manifestation, is a key indicator of the presence of SLE. Esophagitis is one of the gastrointestinal manifestations of systemic sclerosis. Fibrotic skin is one of the skin manifestations of systemic sclerosis.
What type of hypersensitivity reaction is the cause of systemic lupus erythematosus? 1 Type I 2 Type II 3 Type III 4 Type IV
3 Type III Systemic lupus erythematosus is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I or immediate hypersensitive reaction. Cytotoxic or type II hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions that are caused by delayed or type IV hypersensitivity reactions.