Chapter 84: Allergic, Immune, and Autoimmune Disorders and Chapter 24: The Immune System
A 16-year old boy is brought to the ER by his parents with symptoms of dyspnea, tightness in the chest, cyanosis, and increased pulse rate and respirations. Which of the following allergic disorders would the nurse suspect? A) Bronchial asthma B) Allergic rhinitis C) Food allergy D) Serum reaction
A
A client calls the health care clinic and tells the nurse that he was bitten by a tick. The client is concerned and asks the nurse about the first signs of Lyme disease. The nurse informs the client that stage 1 of Lyme disease is characterized by: a. Skin rash b. Painful joints c. Tremors and weakness d. Headaches and blurred vision
A
A client is experiencing respiratory complications related to asthma. What classification of medications is commonly prescribed for this condition? A) Leukotriene antagonists B) Sedating drugs C) Nonsedating drugs D) Adrenergic decongestants
A
A nurse is assessing a client who is experiencing an allergic reaction to peanuts. Which of the following signs and symptoms should the nurse look for in this client? A) Swelling of the lips and throat B) Paroxysms of dyspnea C) Bluish skin coloration D) Profuse perspiration
A
A nurse is caring for a client with latex allergy. For which sign of this condition should the nurse monitor? A) Urticaria B) Petechiae C) Pertussis D) Vomiting
A
A nurse is caring for an asthmatic client on antihistamine therapy. For which of the following side effects of antihistamines should the nurse assess in this client? A) Difficulty swallowing B) Pupillary dilation C) Excessive salivation D) Frequent urination
A
The client is diagnosed with stage I of Lyme disease. The nurse assesses the client for which characteristic of this stage? a. Arthralgias b. Flu-like symptoms c. Enlarged and inflamed joints d. Signs of neurological disorders
B
The nurse is caring for a client who has systemic lupus erythematosus. Which of the following is one of the recommended treatments for this and other autoimmune disorders? Select all answers that apply. A) Antihypertensives B) Corticosteroids C) Iron supplements D) Mild analgesics E) Sedatives F) Radiation
B, D, F
A nurse is preparing a client for an intradermal skin test. Which of the following precautionary measures should the nurse take when conducting the test? A) Keep ready epinephrine 1:10,000. B) Caution the client to wear a face mask. C) Have an ice pack readily available. D) Caution that the test will be painful.
C
The nurse caring for clients with allergies knows people can have an allergic reaction to any medication. Which of the following medication routes elicits a faster and more dramatic allergic reaction? A) Parenteral B) Intramuscular C) Subcutaneous D) Intradermal
A
A nurse is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? a. Children in day care centers b. Individuals with spina bifida c. Individuals with cardiac disease d. Individuals living in a group home
B
The nurse is treating a client who presents in the ER with airway obstruction owing to laryngeal edema and vasodilation resulting in hypotension and hypoperfusion of the organs. Which of the following conditions is this client most likely experiencing? A) Serum reaction B) Anaphylaxis C) Graves' disease D) Systemic lupus erythematosus
B
The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate in the plan during the bathing of this client? a. Wearing gloves b. Wearing a gown and gloves c. Wearing a gown, gloves, and a mask d. Wearing a gown and gloves to change the bed linens and gloves only for the bath
B
A client is diagnosed with urticaria. The nurse explains to the client that this condition is caused by an allergic reaction. Which of the following types of allergic reaction is this client experiencing? A) Respiratory response B) Multisystem response C) Skin response D) Gastrointestinal response
C
A nurse reads the chart of a client who has been diagnosed with stage 3 Lyme disease. Which clinical manifestation supports this diagnosis? a. A generalized skin rash b. A cardiac dysrhythmia c. Complaints of joint pain d. Paralysis of a facial muscle
C
The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is: a. A local rash that occurs as a result of allergy b. A disease caused by overexposure to sunlight c. An inflammatory disease of collagen contained in connective tissue d. A disease caused by the continuous release of histamine in the body
C
A client is positively diagnosed with stage 1 Lyme disease. The client asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which of the following will be part of the treatment plan? a. Ultraviolet light therapy b. No treatment unless symptoms develop c. Treatment with intravenous (IV) penicillin G d. A 3- to 4-week course of oral antibiotic therapy
D
A client who is human immunodeficiency virus (HIV) positive has had a Mantoux skin test. The results show a 7-mm area of induration. The nurse evaluates that this result is: a. Negative b. Borderline c. Uncertain d. Positive
D
A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which of the following nursing actions is appropriate? a. Refer the client for a blood test immediately. b. Inform the client that there is not a test available for Lyme disease. c. Tell the client that testing is not necessary unless arthralgia develops. d. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.
D
A nurse is performing skin testing on a client suspected to have an allergic disorder. Which of the following measures should the nurse employ when performing the injection? A) Face the needle bevel downward during insertion. B) Insert the needle to the level under the dermis. C) Insert the needle approximately one-fourth of an inch. D) Hold the needle nearly flat against the client's skin.
D
A nurse is required to educate nursing students about the mechanisms that antibodies use to destroy antigens. Which ways do antibodies destroy antigens? 1. Destroy toxins 2. Facilitate phagocytosis 3. Imprison invader cells 4. Complementing fixation A) 1, 2, 3 B) 1, 2, 4 C) 1, 3, 4 D) 2, 3, 4
D
A nurse researches the incidence of autoimmune diseases to determine clients who are at risk for the disorders. Which of the following statements regarding the etiology or incidence of these diseases is accurate? A) There is no familial tendency in these disorders. B) Men are more likely to develop these disorders than women. C) Children are more likely to get the diseases than adults. D) Multiple autoimmune disorders are known to occur in the same client.
D
Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma? a. A kidney transplant client b. A male with a history of same-sex partners c. A client receiving antineoplastic medications d. An individual working in an environment where exposure to asbestos exists
D
A health care provider aspirates synovial fluid from a knee joint of a client with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to indicate which finding? a. Cloudy synovial fluid b. Presence of organisms c. Bloody synovial fluid d. Presence of urate crystals
A
A nurse determines that the neutropenic client needs further discharge teaching if which of the following statements is made by the client? a. "I will include plenty of fresh fruits in my diet." b. "If I develop a fever over 100° F, I will call my doctor." c. "Petting my dog is fine as long as I wash my hands after doing so." d. "My husband will just have to take over cleaning the cat's litter box."
A
A nurse is addressing a group of nursing students about gamma globulins. What is the best response to the nursing students about the function of IgM? A) Stimulates complement activity B) Functions as an antigen receptor C) Protects the fetus before birth against antitoxins, viruses, and bacteria D) Helpful in defense against invasion of microbes via nose, eyes, lungs, and intestines
A
A nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse understands that which problem is a priority for the client? a. Infection b. Inability to cope c. Lack of information about the disease d. Feeling uncomfortable about body changes
A
A nurse is caring for a client who has just had organ transplant surgery. Which nursing intervention should the nurse perform in case a rejection response is seen in the client? A) Administer prescribed specific anti-rejection medication. B) Ensure that the client does not entertain visitors. C) Ensure that the client consumes only a liquid diet after surgery. D) Administer prescribed cytokines through injection.
A
A nurse is caring for a client with bronchial asthma who is also an avid soccer player. What should the nurse include in the client education? A) Use inhalers, as prescribed, before rigorous sports activities. B) Wear a face mask during sports activities. C) Interactions with foods are not a concern with bronchial asthma. D) Avoid participating in any sports.
A
A nurse is collecting data on a client with rheumatoid arthritis. The nurse looks at the client's hands and notes these characteristic deformities. The nurse identifies this deformity as: Refer to figure. a. Ulnar drift b. Rheumatoid nodules c. Swan neck deformity d. Boutonniere deformity
A
A nurse is doing discharge teaching with a client who has sickle cell disease. The nurse instructs the client to avoid which factor that could precipitate a sickle cell crisis? a. Infection b. Mild exercise c. Fluid overload d. Warm weather
A
A nurse is providing dietary instructions to a client with systemic lupus erythematosus. Which of the following dietary items would the nurse instruct the client to avoid? a. Steak b. Turkey c. Broccoli d. Cantaloupe
A
The camp nurse prepares to instruct a group of children about Lyme disease. Which of the following information would the nurse include in the instructions? a. Lyme disease is caused by a tick carried by deer. b. Lyme disease is caused by contamination from cat feces. c. Lyme disease can be contagious by skin contact with an infected individual. d. Lyme disease can be caused by the inhalation of spores from bird droppings.
A
The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. Which client population is at most risk for developing this type of allergy? a. Hairdressers b. The homeless c. Children in day care centers d. Individuals living in a group home
A
The nurse assists and educates clients about the structure and function of the immune system. Both B cells and T cells derive from stem cells in the bone marrow. Based on this information, what is the best information for the nurse to provide the client on the function of T lymphocytes? 1. Help protect against viral infections 2. Can detect and destroy some cancer cells 3. Develop into cells that produce antibodies 4. Provide humoral immunity A) 1, 2 B) 1, 3 C) 2, 4 D) 3, 4
A
The nurse assists and educates clients on the difference between nonspecific and specific immunity. The body possesses several defense systems. Which nonspecific defense mechanism provides a physical barrier and secretes enzymes that kill or reduce the virulence of bacteria? A) Skin B) Mechanical reactions C) Chemical barriers D) Tears
A
The nurse is assessing a client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection? a. "Did you have chicken pox as a child?" b. "How many sexual partners have you had?" c. "Did you use an electric blanket on your side?" d. "Why don't you try docosanol cream (Abreva) on your lesions?"
A
The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care? a. Protecting the client from infection b. Providing emotional support to decrease fear c. Encouraging discussion about lifestyle changes d. Identifying factors that decreased the immune function
A
The nurse is describing the process of antibody-mediated immunity. What is the best explanation of antibody-mediated immunity to the client by the nurse? A) Changes an antigen, rendering it harmless to the body B) Destruction of antigens by T cells C) Exposure to disease-causing organisms over one's lifetime D) Antigens bind to the antibody, forming an antigen-antibody complex
A
The nurse is providing discharge teaching for a client who had a kidney transplant. Which of the following accurately describes a teaching point appropriate for this patient? A) "You will probably be on immunosuppressive drugs for the rest of your life." B) "Because tissue typing was successful, there is no need to worry about organ rejection." C) "Signs of rejection of the organ are different from D) "If you take immunosuppressive drugs, the organ will not be rejected."
A
The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? a. "I should take hot baths because they are relaxing." b. "I should sit whenever possible to conserve my energy." c. "I should avoid long periods of rest because it causes joint stiffness." d. "I should do some exercises, such as walking, when I am not fatigued."
A
The student nurse studying the immune system is aware that normal immunity is based on the body's ability to recognize foreign proteins and to marshal its defenses to destroy foreign matter. Which of the following statements accurately describes a function of the immune system? A) When an antigen enters the body, the body responds by producing antibodies. B) The antigen-antibody reaction releases chemical mediators known as allergies. C) An allergic reaction may occur at the first exposure to an antigen. D) Normally, the body is not able to distinguish "self" from "not self."
A
The nurse is caring for a 12-year-old boy who is brought to the ER by a camp counselor with signs of anaphylaxis following a bee sting. Which of the following signs might the nurse observe with this condition? Select all answers that apply. A) Rash B) Edema at the site of the sting C) Hypertension D) Strong rapid pulse E) Pupillary dilation F) Severe dyspnea
A, B, E, F
Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply. a. Use non-latex gloves. b. Use medications from glass ampules. c. Place the client in a private room only. d. Do not puncture rubber stoppers with needles. e. Keep a latex-safe supply cart available in the client's area. f. Use a blood pressure cuff from an electronic device only to measure the blood pressure.
A, B, E, F
The nurse is performing a physical assessment for a client manifesting symptoms of an immune disorder. Which of the following are typical symptoms of this type of disorder? Select all answers that apply. A) Fatigue B) Hyperactivity C) Dyspnea D) Frequent infections E) Vomiting F) Joint pain
A, C, D, F
A client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which of the following questions should the nurse ask next? a. "Was the tick small or large?" b. "When were you bitten by the tick?" c. "Did you save the tick for inspection?" d. "Did the tick bite anyone else in the family?"
B
A client calls the office of his primary care health care provider and tells the nurse that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction, because the client's neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to: a. Advise the client to soak the site in hydrogen peroxide. b. Ask the client if he ever sustained a bee sting in the past. c. Tell the client to call an ambulance for transport to the emergency room. d. Tell the client not to worry about the sting unless difficulty with breathing occurs.
B
A client has been prescribed immunotherapy. Which of the following measures should the nurse employ to desensitize the client for the allergy? A) Give minute doses of allergens intradermally. B) Give minute doses of allergens subcutaneously. C) Give moderate doses of allergens intradermally. D) Give moderate doses of allergens subcutaneously.
B
A client who is prescribed zidovudine (Retrovir) has been diagnosed with severe neutropenia. The nurse anticipates which intervention will be implemented? a. The medication dose will be reduced. b. The medication will be temporarily discontinued. c. Prednisone will be added to the medication regimen. d. Epoetin alfa (Epogen) will be added to the medication regimen.
B
A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which of the following descriptions of this condition? a. The presence of tiny red vesicles b. An autoimmune disease that causes blistering in the epidermis c. The presence of skin vesicles found along the nerve caused by a virus d. The presence of red, raised papules and large plaques covered by silvery scales
B
A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse would suspect that which of the following findings will be reported from this blood test? a. Increased red blood cell count b. Decrease of all cell types c. Increased white blood cell count d. Increased neutrophils
B
A nurse caring for elderly clients in an assisted living facility is required to educate the clients on the effects of aging on the immune system. What are effects of aging on the immune system? A) More B cells and fewer T cells B) Immune system acts with slower, muted inflammatory process C) Baseline temperature above 98.6°F D) Slowly progress to septic shock when bacteremia is present
B
A nurse is assigned to care for a client who returned home from the emergency department following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should: a. Contact the health care provider (HCP). b. Cover the crutch pads with cloth. c. Call the local medical supply store, and ask for a cane to be delivered. d. Tell the client that the crutches must be removed immediately from the house.
B
A nurse is caring for a client with contact dermatitis. Which of the following measures should the nurse employ in this client? A) Apply warm compresses over the affected area. B) Encourage the client to pat the area lightly. C) Teach clients to use hourly topical corticosteroids. D) Bandage and keep the area covered.
B
The nurse assists and educates clients on the difference between nonspecific and specific immunity. Specific defense mechanisms are considered the final line of defense against disease. Based on this information, what is the best response to the client's question by the nurse about when artificially acquired active immunity occurs? A) Occurs between a mother and her infant B) Occurs through injection of a causative agent into the person's system C) Occurs when a child is exposed to, or develops, a disease D) Occurs with the injection of ready-made antibodies into the person's system
B
The nurse assists and educates clients on the difference between nonspecific and specific immunity. Which would be the best description by the nurse to the clients about cell-mediated immunity? A) Destruction of antigens by antibodies B) Destruction of antigens by T cells C) Exposure to disease-causing organisms over one's lifetime D) Protects the body against circulating disease-producing antigens and bacteria
B
The nurse assists and educates clients on the difference between nonspecific and specific immunity. Which would be the best description by the nurse to the clients about humoral immunity? 1. Destruction of antigens by antibodies 2. Destruction of antigens by T cells 3. Exposure to disease-causing organisms over one's lifetime 4. Protects the body against circulating disease producing antigens and bacteria A) 1, 2 B) 1, 4 C) 2, 3 D) 3, 4
B
The nurse dropped the index cards with the correct order for the process of complement fixation for antigen destruction. The cards are currently in random order and need to be placed in the correct order. Which is the correct order for the steps that occur during the process of complement fixation for antigen destruction? 1. Complements help in the formation of highly specialized antigen-antibody complexes. 2. Complements become active. 3. Specific cells are targeted. 4. Complexes cause holes to develop in the cell membrane. 5. Sodium and water flow into the cell, causing it to burst open A) 1, 2, 3, 4, 5 B) 2, 1, 3, 4, 5 C) 3, 4, 1, 5, 2 D) 4, 3, 2, 5, 1
B
The nurse is administering fexofenadine (Allegra) to a client with severe allergies. Which type of drug is this antihistamine? A) Sedating drugs B) Nonsedating drugs C) Leukotriene antagonists D) Adrenergic decongestant
B
The nurse is assisting with a skin test for a client suspected of having allergies to animals. Which of the following is a sign of a positive reaction? A) Bruising B) Red wheal C) Flat macule D) Bleeding
B
The nurse is following the emergency protocol when dealing with a client in anaphylactic shock. Which of the following is a step in this protocol? A) Administer antibiotics. B) Place an endotracheal tube, if needed. C) Place the client in a prone position. D) Do not administer CPR.
B
A client is diagnosed with an immune deficiency. The nurse focuses on which of the following as the highest priority when providing care to this client? a. Encouraging discussion about emotional impact of the disorder b. Identifying historical factors that placed the client at risk c. Providing emotional support to decrease fear d. Protecting the client from infection
D
A client who has been diagnosed with a compromised immune system is eager to know about the condition. Which explanation should the nurse provide regarding the potential consequences of a compromised immune system? A) Depletes the thymic humoral factor B) Results in cell-mediated immunity C) Results in allergies and autoimmune disorders D) Results in immunodeficiency diseases
D
A client with human immunodeficiency virus (HIV) who has contracted tuberculosis (TB) asks the nurse how long the medication therapy lasts. The nurse responds that the duration of therapy would likely be for at least: a. 6 total months and at least 1 month after cultures convert to negative b. 6 total months and at least 3 months after cultures convert to negative c. 9 total months and at least 3 months after cultures convert to negative d. 9 total months and at least 6 months after cultures convert to negative
D
A nurse caring for elderly clients in an assisted living facility is required to educate the nursing students on the effects of aging on the immune system. What should the nurse tell the students about in what body system infections frequently manifest themselves in older adults? A) Cardiovascular B) Pulmonary C) Urinary D) Mental
D
A nurse is addressing LPN students who want to know more about naturally acquired passive immunity. Which explanation should the nurse give on how naturally acquired passive immunity occurs? A) Immunity occurs when ready-made antibodies are injected into a person's system. B) Immunity occurs when the causative agent is injected into a person's system. C) Immunity occurs when a person is deliberately exposed to a causative agent. D) Immunity is transferred from the mother to the fetus during pregnancy.
D
A nurse is addressing a group of nursing students about gamma globulins. What is the best response to the nursing students about the function of IgA? A) Stimulates complement activity B) Functions as an antigen receptor C) Protects the fetus before birth against antitoxins, viruses, and bacteria D) Helpful in defense against invasion of microbes via nose, eyes, lungs, and intestines
D
A nurse is assisting a healthcare provider perform a skin test on a client suspected to have an allergic disorder. Which of the following units of measurement will the nurse use to measure the degree of edema? A) Centimeters B) Inches C) Micrometers D) Millimeters
D
A nurse is caring for a client who has undergone organ transplant surgery. The client asks the nurse what antibodies are. What is the best response by the nurse to the client about antibodies? A) Body's ability to recognize and destroy specific pathogens B) Body's ability to prevent infectious diseases C) Any foreign substance or molecule entering the body that stimulates an immune response D) A protein substance that the body produces in response to an antigen
D
A nurse is caring for a client who is receiving antiserum for treatment of rabies. For what should the nurse assess in this client? A) Cold clammy extremities B) Migraine headaches C) Cyanosis and pallor D) Enlarged lymph nodes
D
A nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse further checks for which of the following that is also indicative of the presence of SLE? a. Emboli b. Ascites c. Two hemoglobin S genes d. Butterfly rash on cheeks and bridge of nose
D
The home care nurse is ordering dressing supplies for a client who has an allergy to latex. The nurse asks the medical supply personnel to deliver which of the following? a. Elastic bandages b. Adhesive bandages c. Brown Ace bandages d. Cotton pads and silk tape
D
The nurse assists and educates clients about the structure and function of the immune system. Both B cells and T cells derive from stem cells in the bone marrow. Based on this information, what is the best information for the nurse to provide the client on the function of B lymphocytes? 1. Help protect against viral infections 2. Can detect and destroy some cancer cells 3. Develop into cells that produce antibodies 4. Provide humoral immunity A) 1, 2 B) 1, 3 C) 2, 4 D) 3, 4
D
The nurse assists and educates clients about the structure and function of the immune system. Cells in the bone marrow are capable of developing into different types of blood cells. White blood cells defend the body against disease organisms, toxins, and irritants. Which white blood cells should the nurse tell the nursing students are agranular? 1. Neutrophils 2. Basophils 3. Eosinophils 4. Monocytes 5. Lymphocytes A) 1, 2 B) 2, 3 C) 3, 4 D) 4, 5
D
The nurse assists and educates clients on the difference between nonspecific and specific immunity. Specific defense mechanisms are considered the final line of defense against disease. Based on this information, what is the best response to the client's question by the nurse about when artificially acquired passive immunity occurs? A) Occurs between a mother and her infant B) Occurs through injection of a causative agent into the person's system C) Occurs when a child is exposed to, or develops, a disease D) Occurs with the injection of ready-made antibodies into the person's system
D
The nurse interprets that the client who is prescribed zalcitabine (Hivid) is experiencing an adverse effect of this medication when which event is reported by the client? a. Diarrhea b. Tinnitus c. Burning with urination d. Numbness in the legs
D
The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that immunization provides which of the following? a. Protection from all diseases b. Innate immunity from disease c. Natural immunity from disease d. Acquired immunity from disease
D
The nurse is caring for a client in the ER who presents with a severe rash caused by direct contact with an allergen. Which of the following might be the cause of this client's rash? A) Pollen B) Medications C) Insect sting D) Poison ivy
D
The nurse is caring for a client with anaphylactic shock related to antibiotic administration. Which of the following is the immediate nursing intervention for anaphylactic shock? A) Perform an allergy test. B) Administer epinephrine. C) Place a warm compress at the site. D) Administer antihistamines.
D
The nurse is performing a physical assessment for a client who states that she is allergic to latex. To what food would this client most likely be hypersensitive? A) Peanuts B) Milk C) Beef D) Bananas
D
Which client is at the highest risk for systemic lupus erythematous (SLE)? a. An Asian male b. A white female c. An African-American male d. An African-American female
D
A Cub Scout leader who is a nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions? a. "I need to bring a hat to wear during the trip." b. "I should wear long-sleeved tops and long pants." c. "I should not use insect repellent because it will attract the ticks." d. "I need to wear closed shoes and socks that can be pulled up over my pants."
C
A client calls the emergency department and tells the nurse that he received a bee sting to the arm while weeding a garden. The client states that he has received bee stings in the past and is not allergic to bees. The client states that the site is painful and asks the nurse for advice to alleviate the pain. The nurse tells the client to first: a. Take two acetaminophen (Tylenol). b. Place a heating pad to the site. c. Apply ice and elevate the site. d. Lie down and elevate the arm.
C
A client diagnosed with Lyme disease says to the nurse, "I heard this disease can affect the heart. Is this true?" The nurse should make which response to the client? a. "Where did you get your information?" b. "Yes, that's true but it rarely ever occurs." c. "It can, but you will be monitored closely for cardiac complications." d. "It primarily affects the joints with the occasional facial paralysis."
C
A nurse is addressing a group of nursing students about gamma globulins. What is the best response to the nursing students about the function of IgG? A) Stimulates complement activity B) Functions as an antigen receptor C) Protects the fetus before birth against antitoxins, viruses, and bacteria D) Helpful in defense against invasion of microbes via nose, eyes, lungs, and intestines
C
A nurse is caring for a client with an immune disorder. Which of the following cardiovascular symptoms should the nurse assess in this client? A) Stridor B) Dyspnea C) Syncope D)Hypertension
C
A nurse is caring for an elderly client with a respiratory disorder. The nurse assesses which in the client as a result of aging? A) Hypothermia as a response to illness B) Intermittent fevers C) A lower baseline body temperature D) Presence of febrile response
C
Disorders of the immune system can cause many systemic symptoms and problems. Which of the following conditions is directly related to allergies? A) Pressure ulcers B) Renal failure C) Asthma D) Arrhythmias
C
Indinavir (Crixivan) is prescribed for a client with human immunodeficiency virus (HIV). The nurse has provided instructions to the client regarding ways to maximize absorption of the medication. Which of the following, if stated by the client, indicates an adequate understanding of the use of this medication? a. "I need to take the medication with my large meal of the day." b. "I need to store the medication in the refrigerator." c. "I need to take the medication with water but on an empty stomach." d. "I need to take the medication with a high-fat snack."
C
Latex allergies may be caused by an IgE-mediated reaction. For what signs and symptoms should the nurse assess a client who is suspected of a latex allergy? 1. Urticaria 2. Dermatitis 3. Asthma 4. Tachycardia 5. Severe anaphylaxis A) 1, 2, 3, 4 B) 1, 3, 4, 5 C) 1, 2, 3, 5 D) 2, 3, 4, 5
C
The nurse assists and educates clients about the structure and function of the immune system. Cells in the bone marrow are capable of developing into different types of blood cells. Based on this information, what cells should the nurse tell a group of nursing students are considered the "cornerstone" of the immune system and alone have the ability to recognize foreign substances in the body? A) Erythrocytes B) Leukocytes C) Lymphocytes D) Thrombocytes
C
The nurse assists and educates clients on the difference between nonspecific and specific immunity. Specific defense mechanisms are considered the final line of defense against disease. Based on this information, what is the best response to the client's question by the nurse about when naturally acquired active immunity occurs? A) Occurs between a mother and her infant B) Occurs through injection of a causative agent into the person's system C) Occurs when a child is exposed to, or develops, a disease D) Occurs with the injection of ready-made antibodies into the person's system
C
The nurse is administering an antihistamine to a client with a severe allergic reaction to pollen. What class of drugs is being used? A) H2-receptor antagonists B) Leukotrienes C) H1-receptor antagonists D) Epinephrine
C
The nurse is assessing a client who has leukemia. Which of the following immune disorders is most likely involved in this condition? A) Infectious disease B) Immunosuppression C) Overproduction of gamma globulins D) Severe immune response to an invading antigen
C
The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed? a. Antibiotic b. Antidiarrheal c. Corticosteroid d. Opioid analgesic
C