AH3 Exam 3 -Immunity NCLEX

The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention? 1. Assess the client's body weight and ask what the client has been able to eat. 2. Place in contact isolation and don a mask and gown before entering the room. 3. Check the HCP's orders and determine what laboratory tests will be done. 4. Teach the client about total parenteral nutrition and monitor the subclavian IV site.

1. Assess the client's body weight and ask what the client has been able to eat. Rationale: The client has a malnutrition syndrome. The nurse assesses the body and what the client has been able to eat.

The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? 1. Flush the skin with water and try to get the area to bleed. 2. Notify the charge nurse and complete an incident report. 3. Report to the employee health nurse for prophylactic medication. 4. Follow up with the infection control nurse to have laboratory work done.

1. Flush the skin with water and try to get the area to bleed. Rationale: 1. The nurse should attempt to flush the skin and get the area to bleed. It is hoped this will remove contaminated blood from the body prior to infecting the nurse. 2. The nurse should notify the charge nurse after flushing the area and trying to get it to bleed. 3. This should be done within four (4) hours of the exposure, not before trying to rid the body of the potential infection. 4. This is done at three (3) months and six (6) months after initial exposure.

The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE? 1. Pericardial friction rub and crackles in the lungs. 2. Muscle spasticity and bradykinesia. 3. Hirsutism and clubbing of the fingers. 4. Somnolence and weight gain.

1. Pericardial friction rub and crackles in the lungs. Rationale: SLE can affect any organ. It can cause pericarditis and myocardial ischemia as well as pneumonia or pleural effusions.

The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? 1. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. 2. The HIV virus can be eradicated from the host body with the correct medical regimen. 3. It is difficult for the HIV virus to replicate in humans because it is a monkey virus. 4. The HIV virus uses the client's own red blood cells to reproduce the virus in the body.

1. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. Rationale: Retroviruses never die; the virus may become dormant, only to be reactivated at a later time.

The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with SLE who is complaining of chest pain. 2. The client diagnosed with MS who is complaining of pain at a "10." 3. The client diagnosed with myasthenia gravis who has dysphagia. 4. The client diagnosed with GB syndrome who can barely move his toes.

1. The client diagnosed with SLE who is complaining of chest pain. Rationale: Chest pain should be considered a priority regardless of the admitting diagnosis. Clients diagnosed with SLE can develop cardiac complications.

The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? 1. The client who has flushed, warm skin with tented turgor. 2. The client who states the staff ignores the call light. 3. The client whose vital signs are T 99.9°F, P 101, R 26, and BP 110/68. 4. The client who is unable to provide a sputum specimen.

1. The client who has flushed, warm skin with tented turgor. Rationale: 1. Flushed warm skin with tented turgor indicates dehydration. The HCP should be notified immediately for fluid orders or other orders to correct the reason for the dehydration.

The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply. 1. Use a sunscreen of SPF 30 or greater when in the sunlight. 2. Notify the HCP immediately when developing a low-grade fever. 3. Some dyspnea is expected and does not need immediate attention. 4. The hands and feet may change color if exposed to cold or heat. 5. Explain the client can be cured with continued therapy.

1. Use a sunscreen of SPF 30 or greater when in the sunlight. 2. Notify the HCP immediately when developing a low-grade fever. 4. The hands and feet may change color if exposed to cold or heat. Rationale: 1. Sunlight or UV light exposure has been shown to initiate an exacerbation of SLE, so the client should be taught to protect the skin when in the sun. 2. A fever may be the first indication of an exacerbation of SLE. 3. Dyspnea is not expected and could signal respiratory involvement. 4. Raynaud's phenomenon is a condition in which the digits of the hands and feet turn red, blue, or white in response to heat or cold and stress. It occurs with some immune inflammatory processes. 5. SLE is a chronic disease and there is no known cure.

The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit.Which HCP's order should the nurse implement first? 1. Draw a serum for CD4 and complete blood count STAT. 2. Administer oxygen to the client via nasal cannula. 3. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB. 4. Obtain a sputum specimen for culture and sensitivity.

2. Administer oxygen to the client via nasal cannula. Rationale: 1. Serum blood work, although ordered STAT, does not have priority over oxygenation of the client. 2. Oxygen is a priority, especially with a client diagnosed with a respiratory illness. 3. It is extremely important to initiate IV antibiotic therapy to a client diagnosed with an infection as quickly as possible, but this does not have priority over oxygen. 4. Culture specimens should be obtained prior to initiating antibiotic therapy, but oxygen administration is still the first action.

The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is suspected? 1. Complete metabolic panel and liver function tests. 2. Complete blood count and antinuclear antibody tests. 3. Cholesterol and lipid profile tests. 4. Blood urea nitrogen and glomerular filtration tests.

2. Complete blood count and antinuclear antibody tests. Rationale: No single laboratory test diagnoses SLE, but the client usually presents with moderate to severe anemia, thrombocytopenia, leukopenia, and a positive antinuclear antibody.

The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? 1. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush. 2. Notify the HCP for an order for an antifungal swish-and-swallow medication. 3. Have the client gargle with an antiseptic-based mouthwash several times a day. 4. Determine what types of food the client has been eating for the last 24 hours.

2. Notify the HCP for an order for an antifungal swish-and-swallow medication. Rationale: This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition.

The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation? 1. Assign a different nurse every shift to the client. 2. Ask the HCP to tell the client not to yell at the staff. 3. Call a team meeting and discuss options with the staff. 4. Tell one (1) staff member to care for the client a week at a time.

3. Call a team meeting and discuss options with the staff. Rationale: The health-care team should meet to discuss ways to best help the client deal with the anger being expressed, and the staff should be consistent in working with the client.

Which intervention is an important psychosocial consideration for the client diagnosed with AIDS? 1. Perform a thorough head-to-toe assessment. 2. Maintain the client's ideal body weight. 3. Complete an advance directive. 4. Increase the client's activity tolerance.

3. Complete an advance directive. Rationale: 3. Clients diagnosed with AIDS should be encouraged to discuss their end-of-life issue with the significant others and to put those wishes in writing. This is important for all clients, not just those diagnosed with AIDS.

The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing? 1. Tapering the medication prevents the client from having withdrawal symptoms. 2. So the thyroid gland starts working, because this medication stops it from working. 3. Tapering the dose allows the adrenal glands to begin to produce cortisol again. 4. This is the health-care provider's personal choice in prescribing the medication

3. Tapering the dose allows the adrenal glands to begin to produce cortisol again. Rationale: Tapering steroids is important because the adrenal gland stops producing cortisol, a glucocorticosteroid, when the exogenous administration of steroids exceeds what normally is produced. The functions of cortisol in the body are to regulate glucose metabolism and maintain blood pressure.

The client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? 1. The client is fortunate not to have contracted HIV from an infected needle. 2. The client must be repeatedly exposed to HIV before becoming infected. 3. The client may be in the primary infection phase of an HIV infection. 4. The antibody test is negative because the client has a different flu virus.

3. The client may be in the primary infection phase of an HIV infection. rationale: The primary phase of infection ranges from being asymptomatic to severe flu-like symptoms, but during this time, the test may be negative although the individual is infected with HIV.

The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client? 1. The client will maintain reproductive ability. 2. The client will verbalize feelings of body-image changes. 3. The client will have no deterioration of organ function. 4. The client's skin will remain intact and have no irritation.

3. The client will have no deterioration of organ function. Rationale: SLE can invade and destroy any body system or organ. Maintaining organ function is the primary goal of SLE treatment.

The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE? 1. The steroids will increase the body's ability to fight the infection. 2. The steroids will decrease the chance of the SLE spreading to other organs. 3. The steroids will suppress tissue inflammation, which reduces damage to organs. 4. The steroids will prevent scarring of skin tissues associated with SLE.

3. The steroids will suppress tissue inflammation, which reduces damage to organs. Rationale: The main function of steroid medications is to suppress the inflammatory response of the body.

The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? 1. Females taking birth control pills are protected from becoming infected with HIV. 2. Protected sex is no longer an issue because there is a vaccine for the HIV virus. 3. Adolescents with a normal immune system are not at risk for developing AIDS. 4. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.

4. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV. Rationale: Abstinence is the only guarantee the client will not contract a sexually transmitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relationship is the safest sexual relationship.

The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority? 1. Altered nutrition, less than body requirements. 2. Anticipatory grieving. 3. Knowledge deficit, procedures and prognosis. 4. Risk for injury.

4. Risk for injury. Rationale: 4. Safety is always an issue with a client with diminished mental capacity.

The client recently diagnosed with SLE asks the nurse, "What is SLE and how did I get it?" Which statement best explains the scientific rationale for the nurse's response? 1. SLE occurs because the kidneys do not filter antibodies from the blood. 2. SLE occurs after a viral illness as a result of damage to the endocrine system. 3. There is no known identifiable reason for a client to develop SLE. 4. This is an autoimmune disease that may have a genetic or hormonal component.

4. This is an autoimmune disease that may have a genetic or hormonal component. Rationale: There is evidence for familial and hormonal components to the development SLE. SLE is an autoimmune disease process in which there is an exaggerated production of autoantibodies.

The nurse is caring for a client who is newly diagnosed with HIV. The client asks the nurse if there are ways to protect the client's sexual partner. Which client statement indicates the need for further instruction? A) "I know to use an oil-based lubricant to prevent spread of the disease to my partner." B) "I know I can't donate blood anymore, as I have HIV." C) "I will not share my toothbrush or razor with my partner." D) "I know I have to practice safe sex with my partner by using a latex condom."

A) "I know to use an oil-based lubricant to prevent spread of the disease to my partner." Rationale: The nurse should educate the client regarding the prevention of the spread of HIV. The client will need further education when he states that he will use an oil-based lubricant. The client should be educated to use latex condoms for oral, vaginal, or anal intercourse and to avoid natural or animal skin condoms, which allow passage of HIV. The client should use only water-based lubricants-not oil-based, such as petroleum jelly, which can result in condom damage. The client is correct in stating that it is not an acceptable practice to share toothbrushes or razors. The client is also correct in stating that blood donation is prohibited.

The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which client statement indicates plan of care understanding? A) "I will take birth control pills while I am taking cytotoxic medications." B) "I do not need to contact the doctor if I develop a fever or rash." C) "I plan to go to the movies this weekend so that I get out of the house." D) "I can take ibuprofen as indicated for pain."

A) "I will take birth control pills while I am taking cytotoxic medications." Rationale: Treatment for SLE can include cytotoxic drugs. The client is taught to avoid pregnancy by using contraceptives, as these drugs can cause birth defects. The client is taught to avoid crowds, as they are potential sources of infection. Client with SLE should contact their primary care providers should signs of infection occur, as the immune system is compromised. Aspirin and ibuprofen can cause bleeding and should be taken with extreme care.

A client who has been diagnosed with untreated HIV comes in complaining of fatigue and weight loss. What are some important elements of the physical exam for evaluating the client's AIDS status? Select all that apply. A) Assess the general appearance. B) Assess skin color, temperature, and moisture. C) Assess hair loss. D) Inspect the skin for evidence of rashes or lesions. E) Inspect the mouth for lesions.

A) Assess the general appearance. B) Assess skin color, temperature, and moisture. D) Inspect the skin for evidence of rashes or lesions. E) Inspect the mouth for lesions. Rationale: Assess height, weight, and body type for apparent weight loss or wasting. Pallor may indicate bone marrow suppression with accompanying immunodeficiency. Skin lesions may be indicative of Kaposi sarcoma. Hair loss is not usually related to AIDS. Mouth lesions, which may have a "cottage cheese" appearance, may indicate candida.

A nurse caring for a client with SLE on immunosuppressive therapy understands that careful teaching is required to make sure both clients and family members understand appropriate precautions against the threat of infection. Teaching points should include: Select all that apply. A) Avoid large crowds and situations that increase exposure to infection. B) Report difficulty breathing or cough to the physician if taking cyclophosphamide. C) Use ibuprofen instead of acetaminophen if fever develops. D) Women may develop heavy menstrual bleeding during therapy.

A) Avoid large crowds and situations that increase exposure to infection. B) Report difficulty breathing or cough to the physician if taking cyclophosphamide. Rationale: The nurse should teach the client and family regarding avoiding large crowds and situations that increase exposure to infection and to report difficulty breathing or cough. The client should report a fever if it develops, and ibuprofen should not be used, as this may increase the risk for bleeding. Women may have an absence of menstruation, not heavy bleeding, during therapy.

A client with SLE is being treated with immunosuppressant drugs and corticosteroids. Which precautions should the nurse provide this client? Select all that apply. A) Avoid large crowds. B) Don't get a flu shot. C) Use contraception to prevent pregnancy D) Refrain from taking aspirin or ibuprofen. E) Report signs of infection to the physician.

A) Avoid large crowds. C) Use contraception to prevent pregnancy D) Refrain from taking aspirin or ibuprofen. E) Report signs of infection to the physician. Rationale: Crowds may increase exposure to infection. Annual influenza vaccination is recommended but clients with significant immunosuppression should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects. Aspirin or ibuprofen may increase the risk of bleeding. Chills, fever, sore throat, fatigue, or malaise should be reported.

The nurse is caring for a client with AIDS who is taking an antiretroviral medication. The client complains of nausea, fever, severe diarrhea, and anorexia. Which of the following medications would the nurse determine to be most effective to relieve the anorexia, as well as to stimulate the client's appetite? Select all that apply. A) Dronabinol (Marinol) B) Zidovudine (Retrovir, AZT) C) Abacavir (Ziagen) D) Ciprofloxacin (Cipro) E) Megestrol (Megace)

A) Dronabinol (Marinol) E) Megestrol (Megace) Rationale: Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase the client's appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.

The nurse is caring for a client who is hospitalized due to an exacerbation of systemic lupus erythematosus (SLE). The nurse is reviewing the client's lab work and finds the white blood cell count (WBC) is shifted to the left. Based on this information, which is a priority nursing diagnosis for this client? A) Ineffective Protection B) Ineffective Health Maintenance C) Ineffective Individual Coping D) Risk for Impaired Skin Integrity

A) Ineffective Protection Rationale: All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in the WBC count indicates an increased risk for infection. A shift to the left in a WBC differential is indicative of a large number of immature cells, suggesting infection, and is therefore the priority for the client with the diagnosis Ineffective Protection.

The client enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts." The triage nurse assesses the client and finds a butterfly rash over the bridge of nose and on the cheeks. Which diagnosis does the nurse expect? A) Systemic lupus erythematosus B) Fibromyalgia C) Lyme disease D) Gout

A) Systemic lupus erythematosus rationale: The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE), although not every client diagnosed with this disorder will have this rash. While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks.

During the initial​ interview, the nurse assesses the psychosocial history of a client diagnosed with HIV. Which information is the nurse​ seeking? (Select all that​ apply.) A. Access to support systems B. Contacts who will require notification of potential exposure C. Presence of​ viral-like symptoms that will aid in staging infection D. Access to resources for future care E. Client understanding information relating to the condition

A. Access to support systems D. Access to resources for future care E. Client understanding information relating to the condition ​Rationale: An initial psychosocial assessment is important to determine the​ client's developmental age and ability to understand the​ diagnosis, coping​ mechanisms, and support​ systems, as well as access to and availability of resources in order to provide competent care. The psychosocial assessment does not include assessment of​ symptoms, or determination of exposed individuals.

A nurse is caring for a client with systemic lupus erythematosus (SLE). The client begins to cry and tells the nurse that she is afraid that her skin will be disfigured with lesions. Which intervention does the nurse plan to teach this client to minimize skin infections associated with SLE? Select all that apply. A) Use sunscreen with an SPF of 15 or greater. B) Remain indoors on sunny days. C) Avoid swimming in a pool or the ocean. D) Avoid sun exposure between 10:00 a.m. and 3:00 p.m. E) Decrease sun exposure between 3:00 p.m. and 5:00 p.m.

A) Use sunscreen with an SPF of 15 or greater. D) Avoid sun exposure between 10:00 a.m. and 3:00 p.m. Rationale: The nurse teaches the client to live a normal life with a few extra precautions. There is a relationship between sun exposure and infection, so the client is taught to use sunscreen with an SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The client may swim but should reapply sunscreen after swimming. The client does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m.

The nurse is discharging an HIV-positive pediatric client who has recently developed AIDS. The nurse is teaching the client's mother about health promotion activities for the child. It is important for the nurse to tell the mother that the client should not receive which immunizations due to HIV/AIDS status? A) Varicella vaccine B) Haemophilus influenzae type B (HIB conjugate vaccine) C) Hepatitis B vaccine (hep B) D) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

A) Varicella vaccine Rationale: A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.

A client with HIV is being treated with a nucleoside reverse transcriptase inhibitor medication. The client asks the​ nurse, "How will I know if this drug is​ working?" Which response by the nurse is​ correct? A. "If your CD4 count rises and your viral load​ decreases." B. ​"If your Western blot test converts to​ negative." C. "It is impossible to​ know, so your doctor will frequently change your​ therapy." D. "If you​ don't develop viral symptoms for a​ 3-month period."

A. "If your CD4 count rises and your viral load​ decreases." ​Rationale: Although treatment may decrease viral​ symptoms, therapy is not evaluated by a lack of symptoms in a specific time period. Periodic blood tests will be performed to measure the effectiveness of therapy. A favorable response would show an increase in CD4 counts and a decrease in viral load. A Western blot test is used at the time of initial diagnosis and is not used to determine response to therapy. Therapies may be changed periodically because the virus might mutate and therapy may not be as​ effective, but therapy is not changed randomly.

A client with a new diagnosis of HIV infection asks the nurse how to control the disease. Which statement is most accurate regarding HIV management to prevent disease​ progression? A. "You should take antiretroviral medications as​ prescribed." B. ​"You should eat healthy meals and​ exercise." C. "You should refrain from having unprotected​ sex." D. ​"You should obtain routine​ vaccinations."

A. "You should take antiretroviral medications as​ prescribed." ​Rationale: Once an individual is diagnosed with​ HIV, the healthcare provider will prescribe antiretroviral therapy to attempt to eradicate or control the disease.​ Therefore, the nurse would instruct the client to take antiretroviral therapy as prescribed. Obtaining routine​ vaccinations, eating​ healthy, and exercising help maintain health but are not the most effective in preventing disease progression. The nurse would instruct the client to refrain from having unprotected sex to prevent disease transmission to others.

The nurse is teaching a client newly diagnosed with systemic lupus erythematosus​ (SLE). Which information should the nurse include in the​ client's teaching? A. Avoiding large crowds B. Using​ high-dose birth control pills C. Increasing daily sun exposure D. Using only acetaminophen for pain relief

A. Avoiding large crowds Rationale: The client should be advised to avoid large crowds to decrease exposure to infection. Instruct the client to limit sun exposure and to use sunscreen with an SPF rating of 15 or higher when outdoors. The client should take aspirin or ibuprofen for​ pain, but should monitor for side effects of bleeding. The client should be encouraged to use contraception to prevent​ pregnancy, because the prescribed drugs for treatment may increase the risk for birth defects.

Which laboratory test is used in the diagnosis of systemic lupus erythematosus​ (SLE)? (Select all that​ apply.) A. Erythrocyte sedimentation rate​ (ESR) B. Triglyceride levels C. Complete blood count​ (CBC) D. Anti-DNA antibody testing E. Urinalysis

A. Erythrocyte sedimentation rate​ (ESR) C. Complete blood count​ (CBC) D. Anti-DNA antibody testing E. Urinalysis ​Rationale: The laboratory tests that are used in the diagnosis of SLE are​ anti-DNA antibody testing to detect antibodies that occur in​ SLE, erythrocyte sedimentation rate​ (ESR) to detect elevation related to​ SLE, serum complement levels to detect depletion by​ antigen-antibody complexes of​ SLE, complete blood count​ (CBC) to detect anemia and overall​ pancytopenia, and urinalysis for abnormal traces of blood and protein indicating kidney dysfunction related to SLE. Triglycerides are measured in the diagnosis of cardiovascular diseases like atherosclerosis.

The nurse is caring for a client with AIDS and has identified the problem of imbalanced nutrition. The client is currently underweight. Which intervention is appropriate for this​ client? (Select all that​ apply.) A. Identifying the cause of altered nutrition B. Assisting with oral hygiene C. Providing supplementary vitamins D. Serving large portions E. Providing foods that are high in protein and calories

A. Identifying the cause of altered nutrition B. Assisting with oral hygiene C. Providing supplementary vitamins E. Providing foods that are high in protein and calories Rationale: Appropriate interventions for a client experiencing imbalanced nutrition related to AIDS include providing foods that are high in protein and​ calories, assisting with oral​ hygiene, providing supplementary​ vitamins, and identifying the cause of the altered nutrition. Serving larger portions is not an appropriate intervention for this client.

The nurse is providing discharge instructions for a client with AIDS. Which instruction should the nurse​ emphasize? (Select all that​ apply.) A. Importance of regular​ follow-up examinations and monitoring of immune status B. Infection prevention and transmission C. Necessity of spiritual counseling D. Signs and symptoms of opportunistic infections and cancers E. Medications and side effects

A. Importance of regular​ follow-up examinations and monitoring of immune status B. Infection prevention and transmission D. Signs and symptoms of opportunistic infections and cancers E. Medications and side effects ​Rationale: Discharge instructions for a client with AIDS should focus on infection prevention and​ transmission, the importance of​ follow-up appointments and monitoring the immune​ status, signs and symptoms of opportunistic infections and​ cancer, and medication teaching to include side effects. If the client asks about spiritual​ counseling, information should be provided.​ However, this is not a necessity for discharge teaching.

A client with newly diagnosed HIV​ states, "I​ don't know if I want to take the mediation.​ What's the​ point?" Which information should the nurse include when explaining the goals of pharmacologic management to the​ client? (Select all that​ apply.) A. It will prolong life for the affected individual. B. It will cure the infection. C. It will decrease the symptoms. D. It will treat opportunistic infections and cancers. E. It will stimulate hematopoietic response.

A. It will prolong life for the affected individual. C. It will decrease the symptoms. D. It will treat opportunistic infections and cancers. E. It will stimulate hematopoietic response. Rationale: HIV infection cannot be​ cured, but the viral load can be controlled using​ antiretrovirals, opportunistic infections can be​ treated, hematopoiesis can be​ stimulated, and individuals can greatly prolong their lives with effective therapy.

The nurse is assessing a client with systemic lupus erythematosus​ (SLE). Which manifestation should the nurse recognize as a result of​ inflammation? (Select all that​ apply.) A. Malaise B. Maculopapular rash C. Joint pain D. Cough E. Fever

A. Malaise B. Maculopapular rash C. Joint pain E. Fever ​Rationale: In​ SLE, the immunocomplexes that are deposited in the connective tissue trigger an inflammatory response. Joint​ pain, fever,​ malaise, and maculopapular rash are all signs of the inflammation that result from local tissue damage. A cough is a sign of​ infection, not of inflammation resulting from tissue damage.

A client reports to the nurse that they have not been feeling well and is concerned about being exposed to HIV. Which assessment finding supports a diagnosis of clinical stage 1​ (acute) HIV​ infection? (Select all that​ apply.) A. Malaise and​ flu-like symptoms B. Presence of arthralgia and myalgia C. Oral hairy leukoplakia D. Ataxia E. CD4+ T-lymphocyte count higher than ​500/mm3

A. Malaise and​ flu-like symptoms B. Presence of arthralgia and myalgia E. CD4+ T-lymphocyte count higher than ​500/mm3 Rationale: Malaise,​ flu-like symptoms, a normal lymphocyte​ count, and presence of arthralgia and myalgia are all findings that support the diagnosis of a clinical stage 1​ (acute) HIV infection. Ataxia and oral hairy leukopenia are associated with later stages of infection.

Which personal protective equipment should be utilized when using a bulb syringe to suction the nose of an infant infected with​ HIV? (Select all that​ apply.) A. Masks B. N-95 respirator C. Goggles D. Gloves E. Covered footwear

A. Masks C. Goggles D. Gloves Rationale: When using a bulb syringe to suction the nares of an​ HIV-positive infant, the personal protective equipment should include​ masks, gloves, and goggles.​ N-95 respirators are used to care for​ HIV-positive/AIDS clients with tuberculosis. Covered footwear is not necessary when suctioning the nasal passages.

The nurse is caring for a client with systemic lupus erythematosus​ (SLE) who presents with pain and discomfort. Which treatment option should the nurse​ anticipate? (Select all that​ apply.) A. Moderate exercise B. Proper nutrition C. NSAIDs D. Increasing sun exposure E. Corticosteroids

A. Moderate exercise C. NSAIDs E. Corticosteroids Rationale: NSAIDs are used to treat inflammation and pain in clients with SLE. A prescribed exercise plan can alleviate pain but must be balanced with adequate rest.​ Low-dose corticosteroids are used to reduce pain and inflammation in SLE. Improving nutrition promotes a​ well-balanced diet, improving overall health in​ clients, but does not specifically impact pain. Some medications that are used to treat SLE cause sun​ sensitivity; therefore, clients are advised to decrease the amount of time in the sun and to use sunscreen and other forms of sun protection when outdoors.

A client with a history of systemic lupus erythematosus​ (SLE) anxiously​ states, "My chest hurts when I lie down. I think it is from coughing so much. Please sit me​ up." Which condition should the nurse first​ suspect? A. Pericarditis B. Myocardial infarction C. Thrombocytopenia D. Anemia

A. Pericarditis ​Rationale: A client diagnosed with SLE is at risk for pericarditis. Clinical manifestations of pericarditis include chest pain radiating to the​ back, relieved by sitting forward and worsening when lying​ down, and a dry cough. Electrocardiogram​ (ECG) findings in pericarditis are an ST elevation and PR depression. Although clients with SLE are prone to thrombocytopenia and​ anemia, the clinical presentation is not consistent with these conditions. While a myocardial infarction should be​ considered, the symptoms combined with the​ client's history should first lead the nurse to suspect pericarditis.

The nurse is assessing a client with systemic lupus erythematosus​ (SLE). Which clinical manifestation should the nurse expect to​ observe? (Select all that​ apply.) A. Red butterfly rash on the face B. Psoriatic lesions C. Leg and eye edema D. Alopecia E. Painful or swollen joints

A. Red butterfly rash on the face C. Leg and eye edema D. Alopecia E. Painful or swollen joints ​Rationale: Painful swollen​ joints, alopecia, red butterfly rash on the​ face, and leg and eye edema are all characteristics of SLE. Psoriatic lesions are caused by​ psoriasis, which is an autoimmune disease characterized by patches of abnormal skin.

In a community​ setting, the nurse is providing care to a client who was recently diagnosed with systemic lupus erythematosus​ (SLE). Which is the goal of care for this​ client? (Select all that​ apply.) A. Reducing pain B. Preventing infections C. Reducing inflammation D. Limiting fluid intake E. Maintaining skin integrity

A. Reducing pain B. Preventing infections C. Reducing inflammation E. Maintaining skin integrity ​Rationale: The treatment goals for clients with SLE are to reduce​ pain, reduce​ inflammation, prevent​ infections, maintain skin​ integrity, prevent​ exacerbations, and improve coping skills. Fluid and nutrition should be balanced while taking kidney function into consideration.

The nurse is admitting a client with systemic lupus erythematosus​ (SLE) for an upper respiratory infection. Which nursing goal is the priority​? A. The client demonstrates proper hand hygiene. B. The client can verbalize the importance of oral care. C. The client can verbalize the impact of the diagnosis to the healthcare provider. D. The client can verbalize skin care needs to reduce the risk of altered skin integrity.

A. The client demonstrates proper hand hygiene. Rationale: The client demonstrating proper hand hygiene will reduce the risk of infection. Alterations in skin​ integrity, including those in the oral​ cavity, can increase the risk of acute exacerbation of SLE. It is important for the client diagnosed with SLE to be able to verbalize the impact of the disease to the healthcare provider in order to address the​ client's psychosocial​ well-being.

The nurse is preparing a presentation on systemic lupus erythematosus​ (SLE). Which statement should the nurse​ include? (Select all that​ apply.) A. The immune complex deposits trigger an inflammatory response. B. Manifestations can be mild to​ fatal, with remissions and exacerbations. C. SLE is a result of deposition of antigen-antibody complexes in connective tissues. D. The etiology is known to be linked to environmental factors. E. The inflammatory response leads to anaphylactic shock.

A. The immune complex deposits trigger an inflammatory response. B. Manifestations can be mild to​ fatal, with remissions and exacerbations. C. SLE is a result of deposition of antigen-antibody complexes in connective tissues. ​Rationale: The pathophysiology of systemic lupus erythematosus is a result of the formation of antigen-antibody immunocomplexes that are deposited in the connective tissue and trigger an inflammatory response. The manifestations of the disease can be mild to​ fatal, and remissions are followed by exacerbations. The inflammatory response leads to tissue damage but not anaphylactic shock​ (allergic reaction). Although the exact etiology of SLE is​ unknown, genetic,​ ethnic, environmental, and hormonal factors play a role in its development.

The nurse is caring for a​ 59-year-old woman who is recently divorced. The nurse understands that this client falls into the population of individuals who are called the​ "invisible population" due to which​ factor? (Select all that​ apply.) A. Their HIV symptoms may be overlooked. B. They are not comfortable talking about condom use. C. They may not understand the importance of HIV testing. D. They will frequently engage in​ same-sex relationships. E. They commonly experiment with drugs.

A. Their HIV symptoms may be overlooked. B. They are not comfortable talking about condom use. C. They may not understand the importance of HIV testing. ​Rationale: Older clients who have been in monogamous relationships earlier in their lives often find themselves newly single as a result of divorce or death of a​ partner; when these clients resume sexual​ relations, they may not understand the risks for HIV due to lack of knowledge about its transmission. They may not take preventive​ measures, such as using​ condoms, or may not feel comfortable discussing​ HIV/AIDS risk or condom use with their new partners. Individuals in this age group also may not be aware of the importance of getting tested for HIV or discussing it with their healthcare provider. In​ addition, manifestations of HIV may be overlooked by healthcare​ professionals, being attributed to normal​ age-related physiologic changes. There is not evidence that this group frequently engages in​ same-sex relationships or commonly experiments with drugs.

A home health nurse has just received the list of clients who need to be seen during the shift. Which client should the nurse plan to see first? A) A client with AIDS who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count B) A client with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath C) A client with wasting syndrome who has end-stage AIDS who needs modifications and education regarding dietary changes D) A client with a long history of AIDS who is receiving IV antibiotics daily for toxoplasmosis

B) A client with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath Rationale: The home health nurse should see the client with PCP because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain vital signs and perform a respiratory assessment.

The nurse is caring for a client who has been diagnosed with discoid lupus erythematosus. The nurse is collaborating with the client to set goals for the nursing plan of care. What is an appropriate goal for this client? A) Work through the stages of death and dying. B) Comply 100% of the time with a sun protection plan. C) Gain weight to within 10 pounds of normal for height. D) Report pain no higher than four on a scale of 1-10.

B) Comply 100% of the time with a sun protection plan. Rationale: Discoid lupus erythematosus is an autoimmune disorder of the skin, so the client must protect against the sun to avoid skin cancers and other complications. It is not fatal, is not related to weight, and is rarely painful unless complications arise.

Which clinical manifestation should the nurse expect to find in a client with a diagnosis of Pneumocystis jiroveci​ pneumonia? (Select all that​ apply.) A. Diarrhea B. Cough C. Dyspnea D. Fever E. Oral lesions

B. Cough C. Dyspnea D. Fever Rationale: Pneumocystis jiroveci pneumonia is an opportunistic infection that can affect clients with HIV. The clinical manifestations include​ fever, cough,​ dyspnea, tachypnea, and tachycardia. Diarrhea causes wasting syndrome. Oral lesions are seen with candidiasis.

The nurse is reviewing the laboratory values of a client who has been newly diagnosed with AIDS. Which laboratory values would the nurse report to the physician? Select all that apply. A) CD4 cell count 1,100/mm3 B) T4 cell count 150 C) CD4 lymphocytes 12% D) Viral load 11,500 copies/mL E) WBC 6,500

B) T4 cell count 150 C) CD4 lymphocytes 12% D) Viral load 11,500 copies/mL Rationale: The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range (4,500-10,000).

The nurse is planning care for a pediatric client with HIV. The nurse selects Risk for Infection as a priority nursing diagnosis for this client. Which interventions are appropriate for a child with this diagnosis? Select all that apply. A) Give frequent baths to the family dog. B) Teach proper food-handling techniques to the family. C) Provide ample fresh fruits and vegetables to bolster the immune system. D) Assess the health status of all visitors. E) Teach hand-washing techniques to the family.

B) Teach proper food-handling techniques to the family. D) Assess the health status of all visitors. E) Teach hand-washing techniques to the family. Rationale: A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. If there are pets, they should be kept outside, as they are a source of infection to the child. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.

The laboratory results of a client with systemic lupus erythematosus​ (SLE) indicates anemia. Which collaborative therapy should the nurse​ anticipate? A. Administering corticosteroids B. Administering erythropoietin C. Treating the underlying cause D. Performing a splenectomy

B. Administering erythropoietin ​Rationale: For the client with​ anemia, medications such as erythropoietin may be given to stimulate red blood cell production. A splenectomy and the administration of corticosteroids are clinical therapies to treat thrombocytopenia. The underlying cause of the anemia is SLE. The disease cannot be​ cured, but the symptoms can be managed.

The nurse is caring for a client with systemic lupus erythematosus​ (SLE). Which system should the nurse consider as being most affected by the formation of immune complexes and tissue​ damage? A. Cardiac B. Renal C. Integumentary D. Respiratory

B. Renal ​Rationale: When the SLE autoantibodies react with their corresponding​ antigen, they form immune​ complexes, which are then deposited in the connective tissue of blood​ vessels, lymphatic​ vessels, and other tissues. These deposits trigger an inflammatory response that leads to local tissue damage. The kidneys are a frequent site of complex deposition and damage. The other systems include​ cardiac, respiratory, and integumentary.

An older adult client is experiencing an acute episode of systemic lupus erythematosus​ (SLE). Which primary concern should the nurse consider when administering newly prescribed​ medications? A. Cardiovascular function B. Renal function C. Respiratory function D. Neurological function

B. Renal function ​Rationale: Treatment for the older adult client is the same regardless of the age at onset of the disease. In addition to taking into consideration that older adults may be taking multiple​ medications, these individuals may have decreased renal function. Pharmacokinetics and​ drug-to-drug interactions need to be considered prior to the initiation of medications commonly used to treat SLE.​ Respiratory, neurological, and cardiovascular function are​ important, but the renal system remains a primary concern.

The nurse working in a clinic discusses HIV prevention with an adolescent. Which behavior should the nurse instruct the adolescent to avoid to minimize the risk of contracting​ HIV? (Select all that​ apply.) A. Smoking crack cocaine B. Sharing needles C. Getting tattoos D. Having unprotected sex E. Using public restrooms

B. Sharing needles C. Getting tattoos D. Having unprotected sex ​Rationale: HIV is spread through contact with blood and body fluids.​ Therefore, the nurse should instruct the adolescent to refrain from getting​ tattoos, sharing​ needles, and having unprotected sex. Using public restrooms does not increase an​ individual's likelihood of contracting HIV. Smoking crack cocaine does not lead to the spread of​ HIV, because there is no contact with blood or body fluids.

The nurse is teaching a new colleague the effects of drugs used for clients with systemic lupus erythematosus​ (SLE). Which statement by the colleague indicates the need for further​ teaching? A. "Thrombosis prevention is a positive side effect with aspirin​ therapy." B. ​"When the client is on aspirin​ therapy, I should monitor for renal​ toxicity." C. "If a cytotoxic agent is​ prescribed, infection may​ occur." D. ​"Corticosteroid therapy can cause cushingoid​ effects."

B. ​"When the client is on aspirin​ therapy, I should monitor for renal​ toxicity." ​Rationale: Aspirin therapy may cause liver toxicity and​ hepatitis, not renal toxicity. Corticosteroid therapy can cause cushingoid effects. Aspirin is particularly beneficial for clients with SLE because its antiplatelet effects help to prevent thrombosis. Cytotoxic drugs can cause​ immunosuppression, placing the client at risk for​ infection, malignancy, and bone marrow depression.

A female client asks the nurse if there are any conditions that can exacerbate systemic lupus erythematosus (SLE). Which is the best nurse response? A) "Conditions that cause hypotension can often exacerbate SLE." B) "GI upset is often associated with SLE exacerbation." C) "Pregnancy is often associated with an SLE exacerbation." D) "Fever is a known trigger for an SLE exacerbation."

C) "Pregnancy is often associated with an SLE exacerbation." Rationale: Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels. Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.

A nurse is developing a plan of care for a client who was recently diagnosed with HIV. The client admits to being sexually active and states that he will remain sexually active. Which would be a priority nursing diagnosis for this client based on this information? A) Risk for Infection related to immunodeficiency B) Death Anxiety C) Deficient Knowledge related to preventing transmission of HIV D) Social Isolation related to fear of AIDS

C) Deficient Knowledge related to preventing transmission of HIV Rationale: All options are potential nursing diagnoses for this client. Deficient knowledge related to preventing transmission of HIV would be the priority diagnosis for this client due to his statement of wanting to remain sexually active. The client will need to be educated on safer sex practices to decrease the risk of transmission to potential sexual partners.

A nurse in the Intensive Care Unit (ICU) is assigned a client diagnosed with AIDS. The type of precautions the nurse will adhere to in caring for this client is: A) Droplet. B) Reverse. C) Standard. D) Contact.

C) Standard. Rationale: Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the healthcare professionals treat all clients alike, eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.

The nurse is assigned to care for four clients today in the clinic. Which client has the highest risk for contracting HIV​ infection? A. A​ 30-year-old female in a heterosexual monogamous relationship B. A​ 50-year-old female with cervical dysplasia C. A​ 60-year-old male who has unprotected sex D. A​ 40-year-old male who smokes marijuana

C. A​ 60-year-old male who has unprotected sex Rationale: HIV is becoming more prevalent in older adults due to inadequate knowledge of HIV transmission. They may not take preventive​ measures, such as using​ condoms, or may not feel comfortable discussing​ HIV/AIDS risk or condom use with their new partners.​ Therefore, the​ 60-year-old male who has unprotected sex is at highest risk. Intravenous drug​ use, not inhaled and oral drug​ abuse, is a risk factor. Cervical dysplasia can occur from HIV​ infection, but it is not a risk factor. A​ 30-year-old female in a heterosexual monogamous relationship is at low risk for contracting HIV

The nurse is planning care for an adolescent client with systemic lupus erythematosus​ (SLE). Which nursing diagnosis is a special consideration for this​ client? A. Fluid​ Volume: Imbalanced, Risk for B. Infection, Risk for C. Body​ Image, Disturbed D. Memory, Impaired

C. Body​ Image, Disturbed ​Rationale: The adolescent client with SLE needs special consideration for body image​ disturbance, such as hair loss and moon​ face, resulting from the effects of medication for treatment of SLE. A risk for infection and increased risk of fluid volume imbalance apply to all clients with SLE. Impaired memory is not a typical clinical manifestation of SLE.​ (NANDA-I ©2014)

The nurse is teaching a client who has HIV about preventing secondary infections. Which action is most important for the nurse to include for helping the client prevent a secondary​ infection? A. Adhering to prophylactic antibiotics B. Avoiding cleaning up pet excrement C. Frequently washing hands D. Wearing a mask in public places

C. Frequently washing hands ​Rationale: Individuals who become immunosuppressed due to HIV are at risk for contracting secondary infections. The most important strategy to prevent infection is frequent handwashing using correct technique. Prophylactic antibiotics are not indicated at this point in the HIV spectrum. Wearing masks and avoiding pet excrement may or may not be​ indicated, but are not more important than handwashing.

The nurse preceptor is reviewing a plan of care created by a new graduate for a client with AIDS with a nursing diagnosis of ​Nutrition, Imbalanced: Less than Body Requirements. Which nursing intervention requires​ follow-up by the​ preceptor? A. Administer prescribed preprandial antiemetic prior to meals. B. Administer prescribed megestrol​ (Megace) prior to meals. C. Keep the client NPO if diarrhea occurs. D. Provide oral care before and after meals.

C. Keep the client NPO if diarrhea occurs. Rationale: Diarrhea is a common occurrence for a client with AIDS. The client should not be​ NPO, but rather antidiarrheal medications should be administered after stools and the client should receive an antiemetic prior to meals. Reducing diarrhea improves nutrient absorption. Preprandial medication with an antiemetic reduces nausea and improves food intake. Administering appetite stimulants such as megestrol​ (Megace) may increase appetite and promote weight gain. Oral care before and after meals will help maintain intact mucosa.​ (NANDA-I ©2014)

Which medical record should indicate to the nurse that the client has converted from being HIV positive to having fully contracted​ AIDS? A. Herpes zoster infection B. CD4 count of ​400/mm3 C. Pneumocystis jiroveci pneumonia D. Weight loss of​ 5% of total body weight

C. Pneumocystis jiroveci pneumonia Rationale: A client has a diagnosis of AIDS when the client develops Pneumocystis jiroveci​ pneumonia, tuberculosis, Kaposi​ sarcoma, or sustains weight loss of greater than​ 10% total body​ weight, or the CD4 count drops below ​200/mm3. Herpes zoster is seen in​ HIV-positive individuals in stage 2.

A new graduate nurse is performing an admission assessment on a client with symptoms that indicate the client may have HIV. Which question does the nurse ask to identify a major risk factor for contracting HIV? A) "Has your partner been experiencing these symptoms?" B) "Do you always practice safe sex?" C) "Have you had any fever, diarrhea, or chills over the last 48 hours?" D) "Have you ever experimented with intravenous drugs?"

D) "Have you ever experimented with intravenous drugs?" Rationale: Use of recreational drugs, such as intravenous drugs, is a risk factor for contracting HIV. Asking about safe sexual practices is important, but intravenous drug use would put the client at greater risk for contracting HIV. The nurse cannot ask about the partner without the partner's consent; however, if the partner were present and positive, it would be a risk factor. Recent symptoms are not a risk factor.

The nurse is planning care for an adolescent client who has systemic lupus erythematosus (SLE). The nurse knows that the treatment plan implemented by the healthcare team is appropriate for the situation when the client: A) Refuses to attend school. B) Does not want to attend any social functions. C) Discusses skin changes with the healthcare personnel. D) Discusses skin changes with a good friend.

D) Discusses skin changes with a good friend. Rationale: Peer interaction is important to teens. Being able to discuss the physical changes related to SLE with a friend indicates acceptance of the change in body image. Refusing to go to school or attend social functions indicates nonacceptance of the changes to body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to the body image changes.

The nurse is providing health education to a diverse group at a neighborhood community center. Why does the nurse plan to include signs and symptoms of systemic lupus erythematosus (SLE)? A) The neighborhood is composed of many young female children. B) The audience has asked the nurse to include the information. C) The audience is mainly composed of Caucasian women. D) The audience is mainly females of Asian-American descent.

D) The audience is mainly females of Asian-American descent. Rationale: Among women who are of child-bearing age, SLE is seen in more African-Americans, Hispanics, and Asian-Americans than Caucasians. There is no evidence that the audience asked for the information.

Which statement made by a​ 34-week pregnant client who is HIV positive indicates a need for further​ teaching? A. "My newborn baby will begin treatment with zidovudine after​ birth." B. "I will enter the hospital in a month for a planned cesarean​ section." C. "If I follow the treatment​ regimen, my baby may not develop HIV​ infection." D. "I plan to breastfeed my baby to save money on infant​ formula."

D. "I plan to breastfeed my baby to save money on infant​ formula." Rationale: When the pregnant client who is HIV positive states that they wish to​ breastfeed, it requires​ correction, because breastfeeding can increase the risk of disease transmission to the infant. Women who are HIV positive will undergo a cesarean section to decrease the risk of transmission. The newborn will begin zidovudine after birth to decrease the risk of seroconversion.

The nurse is providing teaching for a client diagnosed with systemic lupus erythematosus​ (SLE) experiencing alterations in skin integrity. Which client statement indicates effective​ teaching? A. "I will cover the lesions on my head with a​ wig." B. ​"I will apply sunscreen immediately prior to going​ outdoors." C. "I will use fluorescent​ lighting." D. "I will limit the use of​ cosmetics."

D. "I will limit the use of​ cosmetics." Rationale: Cosmetics can irritate the skin and increase the risk of integumentary symptoms. It is important for the​ client's safety to use adequate lighting to prevent​ injury, and to specifically avoid fluorescent lighting. Fluorescent lighting has been linked to exacerbation of SLE. If the client experiences​ alopecia, it is important that a wig is avoided when skin integrity is impaired. The client should apply sunscreen 30 minutes prior to going out in the sun.

The nurse is caring for a client with exacerbation of systemic lupus erythematosus​ (SLE). Which statement by the nurse is​ accurate? A. ​"The client is at risk for a macronutrient​ deficiency." B. "The client is at risk for a micronutrient​ deficiency." C. ​"The client is at risk for weight​ loss." D. "The client is at risk for weight​ gain."

D. "The client is at risk for weight​ gain." Rationale: The client is at risk for weight gain associated with the treatment involving steroids and a decreased activity level during exacerbation of the disease. The client is not at risk for weight​ loss, micronutrient​ deficiency, or macronutrient deficiency unless the GI tract is compromised. OK

The nurse is caring for a pregnant client with systemic lupus erythematosus​ (SLE). Which neonatal complication related to maternal lupus should the nurse anticipate the fetus to be tested for during the second trimester of​ pregnancy? A. Liver involvement B. Renal anomalies C. Anemia D. Congenital heart block​ (CHB)

D. Congenital heart block​ (CHB) Rationale: Congenital heart block​ (CHB) may occur in the fetus of a mother diagnosed with SLE. Fetal echocardiography may be used to assess for CHB in the second trimester of pregnancy. The prognosis for CHB​ varies, depending on when the congenital heart defect is detected. With​ treatment, early CHB may be reversible.​ However, late CHB could require the insertion of a pacemaker at the time of delivery. Fetal​ anemia, renal​ anomalies, and liver involvement are not tested for in the second trimester of pregnancy

A client diagnosed with systemic lupus erythematosus​ (SLE) presents with​ fatigue, joint​ pain, oral​ ulcers, and a red rash over the face and upper trunk. Which collaborative therapy should the nurse expect to​ implement? A. Surgical drainage of affected joints B. Antibiotic therapy C. Physical therapy to improve mobility D. Corticosteroid therapy

D. Corticosteroid therapy Rationale: The nurse would expect corticosteroid therapy to be ordered. SLE is an autoimmune​ disorder, and corticosteroids and rest are the​ first-line treatment. It is a disorder of the​ muscles, so the nurse would not expect surgical drainage of the joints. It is​ autoimmune, not​ infective, in​ origin, so the nurse would not expect antibiotic therapy as a​ first-line treatment unless the client also has signs of infection.​ Also, a priority treatment is​ rest, so the nurse would not expect physical therapy to be ordered to improve mobility.

The nurse is teaching a client who is HIV positive about needed immunizations. Which vaccination should the client obtain on an annual​ basis? A. Zostavax B. Hepatitis B C. Pneumovax D. Influenza

D. Influenza ​Rationale: The client who is HIV positive should receive an annual influenza vaccine to decrease the risk of obtaining the flu. Zostavax is a​ one-time vaccination to prevent shingles. Hepatitis B vaccine is administered over a​ 6-month time frame and three injections. Pneumovax is given 5 years apart over two injections.

The nurse is caring for a client that presents with oral candidiasis related to HIV and AIDS immunosuppression. Which medication should the nurse expect the healthcare provider to​ prescribe? A. Trimethoprim-sulfamethoxazole B. Amphotericin B C. Ganciclovir D. Nystatin

D. Nystatin Rationale: ​Rationale: The client with oral candidiasis would be prescribed nystatin swish and spit. Ganciclovir is used to treat cytomegalovirus. Amphotericin B is an antifungal medication that is used to treat esophagitis.​ Trimethoprim-sulfamethoxazole is used to treat bacterial infections such as Pneumocystis jiroveci pneumonia.

The nurse is reviewing medications ordered for a newly admitted female client with systemic lupus erythematosus​ (SLE). Which medication order should the nurse​ question? A. Corticosteroid B. Antineoplastic C. Immunosuppressive D. Oral contraceptive

D. Oral contraceptive Rationale: High-dose​ corticosteroids, immunosuppressants, and antineoplastic drugs are all used for the treatment of acute SLE. Caution needs to be taken with the use of oral contraceptives because estrogen triggers the symptoms of SLE.

A client diagnosed with systemic lupus erythematosus​ (SLE) is experiencing pulmonary interstitial fibrosis. Which classification of lupus should the nurse​ suspect? A. Cutaneous B. Discoid C. Drug-induced D. Systemic

D. Systemic ​Rationale: The classification of lupus the client is experiencing is systemic. There are three major classifications of​ SLE: discoid or​ cutaneous, systemic, and​ drug-induced. Systemic lupus involves one or more of these​ systems: cardiovascular, central​ nervous, hematologic,​ kidneys, lungs, and musculoskeletal. Cutaneous or discoid lupus is limited to the skin. Many drugs can cause a syndrome that mimics lupus​ (drug-induced lupus).

The nurse is reviewing the medical record of a client with a diagnosis of​ AIDS-related dementia. Which clinical manifestation should the nurse expect to find during the physical​ assessment? (Select all that​ apply.) A. Myalgia B. Urinary incontinence C. Lethargy D. Rash E. Ataxia

​B. Urinary incontinence C. Lethargy E. Ataxia Rationale: AIDS-related dementia is the most common reason for mental status changes in the client with AIDS. The clinical manifestations include memory​ loss, confusion, and lethargy. As the disorder​ progresses, the client will develop ataxia​ (an abnormal​ gait) and incontinence. A rash and myalgia are early clinical manifestations of HIV infection.

The healthcare team is discussing the care of a client with wasting syndrome secondary to AIDS. Which intervention would be appropriate for the nurse to include in the plan of care to address the​ client's nutritional​ needs? (Select all that​ apply.) A. Turning the client every 2 hours B. Administering intravenous fluids C. Obtaining daily weights D. Infusing total parenteral nutrition E. Reviewing total protein and albumin levels

​C. Obtaining daily weights D. Infusing total parenteral nutrition E. Reviewing total protein and albumin levels Rationale: The client has wasting syndrome related to AIDS. The​ collaborative-care interventions would be to weigh the client every day to assess response to total parenteral nutrition. The nurse would collaborate with the pharmacist and the healthcare provider for this intervention. The healthcare provider would prescribe laboratory diagnostic testing such as total protein and albumin​ levels, which the nurse would review.