Assessment questions

The nurse is providing education to a client with an IgE-mediated hypersensitivity reaction. What statement made by the patient indicates that further education is required?

"Complement system is involved in IgE-mediated hypersensitivity reactions."

Which statement by a patient would alert the nurse to a risk for decreased immune function?

"I had my spleen removed after a car accident."

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching?

"I will take oral antihistamines before going to work."

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient has understood the nurse's teaching about the condition?

"I will use sunscreen when I am outside."

Which information about intradermal skin testing should the nurse teach to a patient with possible allergies?

"Plan to wait in the clinic for 20 to 30 minutes after the testing."

A woman with advanced systemic lupus erythematosus (SLE) who suffers from profound kidney and lung dysfunction would like to become pregnant. Based on the nurse's knowledge of SLE, what can the nurse tell the patient?

"Women with profound effects from SLE should not become pregnant."

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first?

Place a tourniquet above the site.

Which diagnostic laboratory studies are utilized in the evaluation of systemic lupus erythematosus (SLE)? Select all that apply.

Urinalysis Serum complement Complete blood cell count (CBC)

An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient?

Consequences of aging on cell-mediated immunity

Which of the following factors affect proper immune system function?

Age, exercise sunlight, nutrients in diet diagnosis with co-morbidities

A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first?

Administer a dose of epinephrine.

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administer a skin test by the cutaneous scratch method.

The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question?

Administer varicella vaccine.

A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review?

Anti-Smith antibody (Anti-Sm)

A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action?

Assess the patient's airway.

Which example should the nurse use to explain an infant's "passive immunity" to a new mother?

Breastfeeding

The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct?

Document the patient's history and teach about clinical manifestations of a type I latex allergy.

After a patient is diagnosed with systemic lupus erythematosus (SLE), the nurse educates the patient on the effects of sunlight on the disease. What is the best way for the nurse to do this?

Educates the patient on the importance of planning outdoor activities

Which result for a patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider?

Elevated blood urea nitrogen (BUN)

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value?

IgE

A nurse is administering epinephrine to a patient who has developed an anaphylactic reaction after the injection of an antibiotic. What should the nurse tell the patient regarding epinephrine? Select all that apply.

It relaxes bronchial smooth muscles It causes vasoconstriction of peripheral blood vessels.

The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform?

Observe for swelling of the patient's lips and tongue.

A nurse is caring for a patient with systemic lupus erythematosus (SLE) who is taking nonsteroidal antiinflammatory drugs (NSAIDs) for joint pain. Which adverse effects of NSAID therapy should the nurse educate the patient about? Select all that apply.

Pallor Petechiae Tarry stools

The nurse is educating a patient newly diagnosed with systemic lupus erythematosus (SLE). What should the nurse include in the education about things to avoid? Select all that apply.

Physical and emotional stress exposure to individuals with infections Drying soaps, powders, and household chemicals

After assessing a patient with delayed hypersensitivity reaction, the nurse suspects that the patient has contact dermatitis. Which symptoms support the nurse's conclusion? Select all that apply.

Pruritic lesions Erythematous skin lesions Skin lesions covered with papules, vesicles, and bullae

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient?

Screening for malignancies Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

The gerontology clinical nurse specialist is teaching a group of new graduate nurses how the body fights infection. When discussing humoral immunity, the nurse should explain that this protection is mediated by which cell?

The B cell

Which of the following statements are accurate about the humoral immune response and the cellular immune response? (Select all that apply.)

The humoral immune response is directly related to B cell surface receptors. The cellular immune response is directly related to the T cell surface receptors.

A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Match the order of the steps to the activity)

The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last.

A patient reports to the primary care clinic after being diagnosed with systemic lupus erythematosus (SLE). The patient's blood pressure is 175/90 mmHg. What does the nurse expect the healthcare provider to recommend? Select all that apply.

low sodium diet complete metabolic panel Aggressive antihypertensive therapy with oral medications

A patient with systemic lupus erythematosus (SLE) arrives at the clinic with a one-month history of a cough. The patient also says, "Sometimes I feel like my heart is racing." What does the nurse suspect the patient may have?

lung disease

A 25-yr-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." The nurse will plan interventions with the patient to address the nursing diagnosis of:

social isolation

In teaching a patient with SLE about the disorder, the nurse knows the pathophysiology of SLE includes?

the production of variety of autoantibodies directed against components of the cell nucleus.