Hypersensitivity and Lupus

Antiretroviral drugs are used to a.cure acute HIV infection. b.decrease viral RNA levels. c.treat opportunistic diseases. d.decrease pain and symptoms in terminal disease.

. b.decrease viral RNA levels

1. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes the information that SLE is a(n): A. Hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant. B. Autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body. C. Disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression. D. Disease that causes production of antibodies that bind with cellular estrogen receptors, causing an inflammatory response.

1. Answer: C Rationale: SLE has an unpredictable course, even with appropriate treatment. Women are more at risk for SLE, but it is not confined exclusively to women. Clinical symptoms may worsen during pregnancy but are not confined to pregnancy or the perinatal period. All nucleated cells are not destroyed by the antinuclear antibodies. The inflammation in SLE is not caused by antibody binding to cellular estrogen receptors.

10. 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

10. Answer: D Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE. Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many conditions but are not associated with SLE.

11. 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

11. Answer: D An African-American female

12. The nurse monitors a patient to have Systemic Lupus Erythematosus. Which of the following symptoms is characteristic of this diagnosis? A. Increased T-cell count B. Scaley, inflamed rash on shoulders, neck, and face C. Swelling of the extremities D. Decreased erythrocyte sedimentation rate (ESR)

12. Answer: B Scaley, inflamed rash on shoulders, neck, and face

13. In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes: A. Circulating immune complexes formed from IgG autoantibodies reacting with IgG B. An autoimmune T-cell reaction that results in destruction of the deep dermal skin layer C. Immunologic dysfunction leading to chronic inflammation in the cartilage and muscles D. The production of a variety of autoantibodies directed against components of the cell nucleus

13. Answer: D Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. Autoimmune reactions characteristically are directed against constituents of the cell nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune complexes containing antibody against DNA are deposited in the basement membranes of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and inflammation occurs. The overaggressive antibody response is also related to activation of B and T cells. The specific manifestations of SLE depend on which cell types or organs are involved. SLE is a type III hypersensitivity response.

14. A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections."

14. Answer: C "I'm hoping that surgery will be an option for me in the future." Rationale: SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.

15. The pathophysiology of systemic lupus erthematosus (SLE) is characterized by: A. Destruction of nucleic acids and other self-proteins by autoantibodies B. Overproduction of collagen that disrupts the functioning of internal organs C. Formation of abnormal IgG that attaches to cellular antigens, activating complement D. Increased activity of T-suppressor cells with B-cell hypoactivity, resulting in an immunodeficiency

15. Answer: A Destruction of nucleic acids and other self-proteins by autoantibodies

17. During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate: A. Increased RBCs B. Decreased ESR C. Decreased anti-DNA D. Increased complement

17. Answer: C Decreased anti-DNA

2. A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching? A. "I should limit my time to 10 minutes in the tanning bed." B. "I will apply powder to any skin rash." C."I should use a mild hair shampoo." D."I will inspect my skin once a month for rashes."

2. A. A client who has SLE should avoid the use of tanning beds, as well as prolonged sun exposure. B. A client who has SLE should apply steroid-based creams to skin rashes, not a powder. C. CORRECT: A client who has SLE should use a mild hair shampoo that does not irritate the scalp. D. A client who has SLE should inspect her skin daily for any open areas or rashes. NCLEX® Connection: Physiological Adaptation, Illness Management

2. A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care? A. Institute seizure precautions. B. Reorient to time and place PRN. C. Monitor intake and output. D. Place on cardiac monitor.

2. Answer: C Rationale: Lupus nephritis is a common complication of SLE, and when the patient is taking corticosteroids, it is especially important to monitor renal function. There is no indication that the patient is experiencing any nervous system or cardiac problems with the SLE.

3. A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply.) A. Diuretic use B. Obesity C. Deep sleep deprivation D. Depression E. Cardiovascular disease

3. A. CORRECT: The use of diuretics is a risk factor for gout. B. CORRECT: Obesity is a risk factor for gout. C. Deep sleep deprivation is a manifestation of fibromyalgia and is not a risk factor for gout. D. Depression is a manifestation of SLE and is not a risk factor for gout. E. CORRECT: Cardiovascular disease is a risk factor for gout. NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. A nurse is assessing a client who has SLE. Which of the following findings should the nurse expect? A. Weight loss B. Petechiae on thighs C. Systolic murmur D. Alopecia

4. A. Weight gain can occur in a client who has SLE due to being treated with corticosteroids. This is an adverse effect of this medication. B. A butterfly rash on the face is a finding in a client who has lupus. C. A cardiac friction rub is an expected finding of SLE. D. CORRECT: Alopecia (hair loss) is an expected finding in a client who has SLE. NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. A patient with polyarthralgia with joint swelling and pain is being evaluated for systemic lupus erythematosus (SLE). The nurse knows that the serum test result that is the most specific for SLE is the presence of: A. Rheumatoid factor. B. Anti-Smith antibody (Anti-Sm). C. Antinuclear antibody (ANA). D. Lupus erythematosus (LE) cell prep.

4. Answer: B Rationale: The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

5. A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate? A. Swelling of joints of the fingers B. Pallor of toes with cold exposure C. Feet that become reddened with ambulation D. Client report of intense feeling of heat in the fingers

5. A. Swelling, pain, and joint tenderness are findings in a client who has SLE and is not specific to an episode of Raynaud's phenomenon. B. CORRECT: Pallor of the extremities occurs in Raynaud's phenomenon in a client who has SLE and has been exposed to cold or stress. C. The extremities becoming red, white, and blue when exposed to cold or stress is characteristic of an episode of Raynaud's phenomenon in a client who has SLE. D. A client report of intense pain in the hands and feet is characteristic of an episode of Raynaud's phenomenon in a client who has SLE. NCLEX® Connection: Physiological Adaptation, Pathophysiology

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. A. Use nonlatex gloves. B. Use medications from glass ampules. C. Place the client in a private room only. D. Keep a latex-safe supply cart available in the client's area. E. Avoid the use of medication vials that have rubber stoppers. F. Use a blood pressure cuff from an electronic device only to

A, B, D, E

The HIV-infected patient is taught health promotion activities including good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? A. Delaying disease progression B. Preventing disease transmission C. Helping to cure the HIV infection D. Enabling an increase in self-care activities

A. Delaying disease progression

The community health nurse is conducting a research study and 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. Hairdressers B. The homeless C. Children in day care centers D. Individuals living in a group home

A. Hairdressers Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; or those who have had multiple surgeries, have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

The nurse is caring for a client who requires a course of oral steroids more than once a year for the treatment of asthma related to allergens. Which alternative therapy should the nurse anticipate being prescribe for the client to avoid the frequent use of steroids? A. Immunotherapy B. Omalizumab C. Plasmapheresis D. Antihistamines

A. Immunotherapy

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 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. Protecting the client from infection The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

Which nonpharmacologic treatments should the nurse suggest for the client who is experiencing seasonal allergic rhinitis due to the pollen in the air? (select all that apply) A. Remain indoors during the day B. Maintain a clean, dust-free environment C. Use special filters on the air conditioners D. Shower before exiting the house E. Keep doors and windows closed

A. Remain indoors during the day B. Maintain a clean, dust-free environment C. Use special filters on the air conditioners E. Keep doors and windows closed

Which strategy can the nurse teach the patient to eliminate the risk of HIV transmission? a.Using sterile equipment to inject drugs b.Cleaning equipment used to inject drugs c.Taking zidovudine (AZT, ZDV, Retrovir) during pregnancy d.Using latex or polyurethane barriers to cover genitalia during sexual contact

A. Using sterile equipment to inject drugs

When planning care for a client admitted with a hypersensitivity reaction, the nurse addresses the potential problem of impaired tissue perfusion. Which intervention will assist in addressing this potential problem? A. Monitoring urine output B. Providing calm reassurance C. Assessing for pain D. Elevating the head of the bed

A. monitoring urine output

The nurse is providing discharge teaching for a teenager who has experienced anaphylaxis related to a food allergy. Which statement by the nurse addresses the most common risk factor for an allergic reaction in a teenager? A. "eat nutritional meals and drink plenty of fluids." B. "Monitor what you are eating outside the home." C. Seek emergency medical help if you feel you have experiencing anaphylaxis." D. "limit your exposure to the food that caused the reaction."

B. "Monitor what you are eating outside the home."

to determine the causes of hypersensitivity reaction, a prick test may be used. Which statement is the most accurate to describe this procedure and results? (select all that apply) A. The client must avoid contact with the allergen for 48 hours after the skin test. B. A positive response may include pruritus, erythema, and development of a wheal. C. The allergen is diluted only if a severe systemic reaction is anticipated. D. A positive response can be determined within 15-20 minutes. E. The diluted allergen extract is intradermally injected in the forearm area.

B. A positive response may include pruritus, erythema, and development of a wheal. D. A positive response can be determined within 15-20 minutes

The nurse is teaching a group of clients with allergies to foods and a history of asthma about the risk factors for the development of anaphylaxis. The nurse identifies which age group as having the highest risk for the development and severity of anaphylaxis? A. Adolescent B. Older adult C. Adult D. Child

B. Older adult

Which is the nurse's PRIORITY action when managing a client experiencing a type I hypersensitivity? A. Management of arthralgia B. Airway management C. Stopping the blood transfusion D. Decreasing a fever

B. airway management

5. You are providing discharge teaching to a patient being discharged home after hospitalization with pericarditis. The physician has ordered the patient to take Colchicine. Which of the following statements indicates the patient did NOT understand the education you provided?* A. "I can take this medication with or without food." B. "I will notify the doctor immediately if I start experiencing nausea, vomiting, or stomach pain while taking this medication." C. "I like to take all my medications in the morning with grapefruit juice." D. "This medication is also used to treat patients with gout."

C. "I like to take all my medications in the morning with grapefruit juice." The answer is C. Patients should not take Colchicine with grapefruit juice because it increases the amount of Colchicine the body absorbs (causing an increased chance of Colchicine toxicity). This medication can be taken WITH or WITHOUT food.

2. A patient is hospitalized with chronic pericarditis. On assessment, you note the patient has pitting edema in lower extremities, crackles in lungs, and dyspnea on excretion. The patient's echocardiogram shows thickening of the pericardium. This is known as what type of pericarditis?* A. Pericardial effusion B. Acute pericarditis C. Constrictive pericarditis D. Effusion-Constrictive pericarditis

C. Constrictive pericarditis The answer is C. This describes constrictive pericarditis. The key words in this question are: the patient's signs and symptoms which indicate heart failure (a common finding with patients who have constrictive pericarditis) and that the echo showed "thickening" of the pericardium.

A client presents to the clinic with erythema and vesicles on the trunk and bilateral upper and lower extremities. Which type of skin testing should the nurse anticipate being prescribed for the client to determine the cause of hypersensitivity reaction? A. Food allergy test B. Intradermal test C. Epicutaneous test D. Patch test

C. Epicutaneous Test

A client is starting treatment for a hypersensitivity reaction. Which pharmacologic therapy should the nurse anticipate will be initiated to develop IgG antibodies to the allergen? A. Nonsteroidal anti-inflammatory medications B. Corticosteroids C. Immunotherapy D. Antihistamines

C. Immunotherapy

The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment? A. It will gather platelets for use later when needed. B. It will cause anemia because it removes whole blood and RBCs are damaged. C. It will remove the IgG autoantibodies and antigen complexes from the plasma. D. It will remove the peripheral stem cells in order to cure the autoimmune disease

C. It will remove the IgG autoantibodies and antigen complexes from the plasma

A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse explains that plasmapheresis is used in her treatment to a.remove T lymphocytes in her blood that are producing antinuclear antibodies. b.remove normal particles in her blood that are being damaged by autoantibodies. c.exchange her plasma that contains antinuclear antibodies with a substitute fluid. d.replace viral-damaged cellular components of her blood with replacement whole blood.

C. exchange her plasma that contains antinuclear antibodies with a substitute fluid.

The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that a.Hodgkin's lymphoma occurs only in young adults. b.Hodgkin's lymphoma is considered potentially curable. c.non-Hodgkin's lymphoma can manifest in multiple organs. d.non-Hodgkin's lymphoma is treated only with radiation therapy.

C. non-Hodgkin's lymphoma can manifest in multiple organs.

Opportunistic diseases in HIV infection a.are usually benign. b.are generally slow to develop and progress. c.occur in the presence of immunosuppression. d.are curable with appropriate drug interventions.

C. occur in the presence of immunosuppression.

Multiple drugs are often used in combinations to treat leukemia and lymphoma because a.there are fewer toxic and side effects. b.the chance that one drug will be effective is increased. c.the drugs are more effective without causing side effects. d.the drugs work by different mechanisms to maximize killing of malignant cells.

D. .the drugs work by different mechanisms to maximize killing of malignant cells.

How are the systemic type I IgE-mediated responses initiated? A. With contact of the allergen and IgE in the conjunctival tissues. B. by contact of the allergen with IgE in the bronchial tree C. the allergen makes contact with the IgE in the circulatory system D. Allergens are absorbed in the GI mucosa

D. Allergens are absorbed in the GI mucosa

A female patient presents to the primary care clinic with a reddened, raised rash over her nose and cheeks. The patient also complains about painful joints in her left hand. Which laboratory tests would the nurse anticipate being ordered by the provider to confirm a diagnosis of systemic lupus erythematosus (SLE)? A. Anti-DNA antibody test B. Complete blood count (CBC) C. Antiphospholipid antibody test D. Antinuclear antibody (ANA) test E. Determination of the erythrocyte sedimentation rate (ESR)

D. Antinuclear antibody (ANA) test Anti-DNA antibody, Antiphospholipid antibody, and ANA tests are *most effective and specific* in diagnosing SLE. CBC and ESR may also be completed, but may indicate other disorders, so they are not very reliable in diagnosing SLE.

The nurse advises a friend who asks him to administer his allergy shots that a.it is illegal for nurses to administer injections outside of a medical setting. b.he is qualified to do it if the friend has epinephrine in an injectable syringe provided with his extract. c.avoiding the allergens is a more effective way of controlling allergies, and allergy shots are not usually effective. d.immunotherapy should only be administered in a setting where emergency equipment and drugs are available.

D. immunotherapy should only be administered in a setting where emergency equipment and drugs are available.

8. On physical assessment of a patient with pericarditis, you may hear what type of heart sound?* A. S3 or S4 B. mitral murmur C. pleural friction rub D. pericardial friction rub

D. pericardial friction rub The answer is D. A common sign of pericarditis is being able to auscultate a pericardial friction rub.

Which hypersensitivity reaction releases enzymes that increase tissue damage? A. Type III B. Type IV C. Type I D. Type II

Type III

Which statements accurately describe HIV infection (select all that apply)? a.Untreated HIV infection has a predictable pattern of progression. b.Late chronic HIV infection is called acquired immunodeficiency syndrome (AIDS). c.Untreated HIV infection can remain in the early chronic stage for a decade or more. d.Untreated HIV infection usually remains in the early chronic stage for 1 year or less. e.Opportunistic diseases occur more often when the CD4+ T cell count is high and the viral load is low.

a.Untreated HIV infection has a predictable pattern of progression. b.Late chronic HIV infection is called acquired immunodeficiency syndrome (AIDS). c.Untreated HIV infection can remain in the early chronic stage for a decade or more.

In a severely anemic patient, the nurse would expect to find a.dyspnea and tachycardia. b.cyanosis and pulmonary edema. c.cardiomegaly and pulmonary fibrosis. d.ventricular dysrhythmias and wheezing.

a.dyspnea and tachycardia.

The most common type of leukemia in older adults is a.acute myelocytic leukemia. b.acute lymphocytic leukemia. c.chronic myelocytic leukemia. d.chronic lymphocytic leukemia.

d.chronic lymphocytic leukemia.

An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).

D ~ Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the clients TB test could be a false negative.

4. You are providing care to a patient with pericarditis. Which of the following is NOT a proper nursing intervention for this patient?* A. Monitor the patient for complications of cardiac tamponade. B. Administer Ibuprofen as scheduled. C. Place the patient in supine position to relieve pain. D. Monitor the patient for pulsus paradoxus and muffled heart sounds.

C. Place the patient in supine position to relieve pain. The answer is C. Placing the patient in supine position is not a proper nursing intervention for a patient experiencing pericarditis because this increases pain. The high Fowler's position or leaning forward is the best position for a patient with pericarditis.

The patient with diabetes mellitus has been ill for some time with a severe lung infection needing corticosteroids and antibiotics. The patient does not feel like eating. The nurse understands that this patient is likely to develop A. major histoincompatibility. B. primary immunodeficiency. C. secondary immunodeficiency. D. acute hypersensitivity reaction

C. secondary immunodeficiency.

During HIV infection a.the virus replicates mainly in B-cells before spreading to CD4+ T cells. b.infection of monocytes may occur, but antibodies quickly destroy these cells. c.the immune system is impaired predominantly by the eventual widespread destruction of CD4+ T cells. d.a long period of dormancy develops during which HIV cannot be found in the blood and there is little viral replication.

C. the immune system is impaired predominantly by the eventual widespread destruction of CD4+ T cells.

7. You are providing care to a patient experiencing chest pain when coughing or breathing in. The patient has pericarditis. The physician has ordered the patient to take Ibuprofen for treatment. How will you administer this medication?* A. strictly without food B. with a full glass of juice C. with a full glass of water D. with or without food

C. with a full glass of water The answer is C. Ibuprofen should be taken with a full glass of water to prevent GI problems, such as ulcers or bleeding.

Screening for HIV infection generally involves a.laboratory analysis of blood to detect HIV antigen. b.electrophoretic analysis for HIV antigen in plasma. c.laboratory analysis of blood to detect HIV antibodies. d.analysis of lymph tissues for the presence of HIV RNA.

C.laboratory analysis of blood to detect HIV antibodies.

1. A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply.) A. Positive ANA titer B. Increased hemoglobin C. 2+ urine protein D. Increased serum C3 and C4 E. Elevated BUN

1. A. CORRECT: A positive antinuclear antibody (ANA) titer is an expected finding in a client who has SLE. The ANA test identifies the presence of antibodies produced against the client's own DNA. B. Pancytopenia, rather than an elevated hemoglobin, is an expected finding in a client who has SLE. C. CORRECT: Increased urine protein is an expected finding due to kidney injury as a result of SLE. D. The client who has SLE is expected to have a decreased level of serum C3 and C4. E. CORRECT: Elevated BUN is an expected finding due to kidney injury in a client who has SLE. NCLEX® Connection: Reduction of Risk Potential, Laboratory Values

The nurse is caring for an adolescent patient with systemic lupus erythematosus (SLE) who is receiving antihypertensive therapy and has been eating a low-salt diet. Which assessment finding should prompt the nurse to alert the health care provider immediately? A. Blood pressure of 98/60 B. Bilateral edema of both wrists C. Mild confusion during conversation D. Bright red rash on the shoulders following sun exposure

C. Mild confusion during conversation Mild confusion during conversation Confusion is a symptom of hyponatremia, which can result from a low-salt diet. Hyponatremia can be life-threatening if it progresses. This finding should prompt the nurse to notify the health care provider immediately.

8) 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.

Answer: D Explanation: A) 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. Page Ref: 515 Cognitive Level: Analyzing Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 7. Evaluate expected outcomes for an individual with systemic lupus erythematosus.

Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? A. "You will need to get rid of your pets." B. "You should sleep in an air-conditioned room." C. "You would do best to stay indoors during the winter months." D. "You will need to dust your house with a dry feather duster twice a week."

B . You should sleep in an air-conditioned room.

The patient was seen in the clinic for hypertension and received a prescription for a new antihypertensive medication. The patient arrived in the emergency department a few hours after taking the medication with severe angioedema. What medication prescribed maybe responsible for the reaction ? A. Beta blocker B. Angiotensin- converting enzyme (ACE) C. Angiotensin receptor blocker D. Vasodialator

B. Angiotensin- converting enzyme (ACE)

16. A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. The best response by the nurse is: A. You can plan to have a near-normal life since SLE rarely causes death B. It is difficult to tell because to disease is so variable in its severity and progression C. Life span is shortened somewhat in people with SLE, but the disease can be controlled with long-term use of corticosteroids D. Most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage

16. Answer: B It is difficult to tell because to disease is so variable in its severity and progression

3. A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I hate the way I look! I never go anyplace except here to the health clinic." An appropriate nursing diagnosis for the patient is: A. Activity intolerance related to fatigue and inactivity. B. Impaired skin integrity related to itching and skin sloughing. C. Social isolation related to embarrassment about the effects of SLE. D. Impaired social interaction related to lack of social skills.

3. Answer: C Rationale: The patient's statement about not going anyplace because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

The nurse is caring for a client newly diagnosed with seasonal allergic rhinitis. The client is experiencing rhinorrhea, water eyes, and itchy throat. Which prescribed initial treatment does the nurse anticipate? A. Inhaled corticosteroids B. Antihistamine C. Antibiotic D. Oral steroids

B. Antihistamine

18. Teaching that the nurse will plan for the patient with SLE includes: A. Ways to avoid exposure to sunlight B. Increasing dietary protein and carbohydrate intake C. The necessity of genetic counseling before planning a family D. The use of no pharmacologic pain interventions instead of analgesics

18. Answer: A Ways to avoid exposure to sunlight

5. Following instruction for a patient with newly diagnosed systemic lupus erythematosus (SLE), the nurse determines that teaching about the disease has been effective when the patient says: A. "I should expect to have a low fever all the time with this disease." B. "I need to restrict my exposure to sunlight to prevent an acute onset of symptoms." C. "I should try to ignore my symptoms as much as possible and have a positive outlook." D. "I can expect a temporary improvement in my symptoms if I become pregnant."

5. Answer: B Rationale: Sun exposure is associated with SLE exacerbation, and patients should use sunscreen with an SPF of at least 15 and stay out of the sun between 11:00 AM and 3:00 PM. Low-grade fever may occur with an exacerbation but should not be expected all the time. A positive attitude may decrease the incidence of SLE exacerbations, but patients are taught to self-monitor for symptoms that might indicate changes in the disease process. Symptoms may worsen during pregnancy and especially during the postpartum period.

A 21-year-old student had taken amoxicillin once as a child for an ear infection. She is given an injection of Penicillin V and develops a systemic anaphylactic reaction. What manifestations would be seen first? A. Dyspnea B. Dilated pupils C. Itching and edema D. Wheal-and-flare reaction

C. Itching and edema

For which allergy will the nurse teach the parents that a child with spinal bifida is at increased risk? A. Drug allergy B. Contact dermatitis C. Latex allergy D. Food allergy

C. Latex allergy

6. A 19-year-old patient who is taking azathioprine (Imuran) for systemic lupus erythematosus has a check-up before leaving home for college. The health care provider writes all of these orders. Which one should the nurse question? A. Naproxen (Aleve) 200 mg BID B. Give measles-mumps-rubella (MMR) immunization C. Draw anti-DNA titer D. Famotidine (Pepcid) 20 mg daily

6. Answer: B Rationale: Live virus vaccines, such as rubella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

When planning care for a client admitted with a hypersensitivity reaction, the nurse addresses the potential problem of airway clearance. Which intervention will assistantships in addressing this potential problem? (Select all that apply) A. Assessing level of consciousness B. Administering oxygen C. Auscultating lung sounds D. Placing the client in a supine position e. Administering epinephrine

A. Assessing level of consciousness B. administering oxygen C. Auscultating lung sounds E. Administering epinephrine

7. A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous? A. Weight gain B. Subnormal temperature C. Elevated red blood cell count D. Rash on the face across the bridge of the nose

7. Answer: D Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response increases with age? A. Autoimmune response B. Cell-mediated immunity C. Hypersensitivity response D. Humoral immune response

A. Autoimmune response

A diagnosis of AIDS is made when an HIV-infected patient has a.a CD4+ T cell count below 200/µL. b.a high level of HIV in the blood and saliva. c.lipodystrophy with metabolic abnormalities. d.oral hairy leukoplakia, an infection caused by Epstein-Barr virus.

A. CD4+ T cell count below 200/µL.

8. 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

8. Answer: C An inflammatory disease of collagen contained in connective tissue Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because SLE is a systemic disorder, not a local one. Next eliminate option 2 because of its similarity to option 1. From the remaining options, select option 3 because of its systemic characteristic. If you are unfamiliar with this disorder, review its characteristics.

A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, what is the nurse's priority action? A. Monitor the patient's fluid balance. B. Assess the patient's need for analgesia. C. Monitor for signs and symptoms of an adverse reaction. D. Assess the patient for changes in level of consciousness.

C. Monitor for signs and symptoms of an adverse reaction.

9. 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

9. Answer: C Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. The incorrect options are not standard components of medication therapy for this disorder.

The nurse reminds the staff that standard precautions should be used when providing care for which type of patient? A. All patients regardless of diagnosis B. Pediatric and gerontologic patients C. Patients who are immunocompromised D. Patients with a history of infectious diseases

A

The nurse is conducting allergy skin testing on a client. Which post procedure interventions are most appropriate? Select all that apply. A. Record site, date, and time of the test. B. Give the client a list of potential allergens if identified. C. Estimate the size of the wheal and document the finding. D. Tell the client to return to have the site inspected only if there is a reaction. E. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

A, B Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected. A list of potential allergens is identified and reviewed and given to the client. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients only need to be monitored for about 30 minutes to assess for any adverse effects.

A patient is undergoing diagnostic testing for suspected systemic lupus erythematosus (SLE). Which assessment findings may help confirm the diagnosis? Select all that apply. A. Malar rash B. Photosensitivity C. Painful sores in the oral cavity D. Decreased white blood cell count E. Multiple swollen and painful joints

A, B, E - Malar rash (butterfly rash, photosensitivity, and swollen/painful joints are common S/S of SLE. Other common manifestations include *painless* sores in the mouth and *increased* WBC count (leukocytosis).

When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply)? A. Grapes B. Oranges C. Bananas D. Potatoes E. Tomatoes F. Pineapple

A,Grapes C,Bananas D, Potatoes F. Pineapple

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 instruction? 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. "I should take hot baths because they are relaxing." To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

When teaching a patient infected with HIV regarding transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? A. "I will need to isolate any tissues I use so as not to infect my family." B. "I will notify all of my sexual partners so they can get tested for HIV." C. "Unprotected sexual contact is the most common mode of transmission." D. "I do not need to worry about spreading this virus to others by sweating at the gym."

A. "I will need to isolate any tissues I use so as not to infect my family."

The nurse is alerted to possible anaphylactic shock immediately after a patient has received intramuscular penicillin by the development of a.edema and itching at the injection site. b.sneezing and itching of the nose and eyes. c.a wheal-and-flare reaction at the injection site. d.chest tightness and production of thick sputum.

A. .edema and itching at the injection site

In performing a physical assessment on a client who is experiencing a hypersensitivity reaction, which findings should the nurse anticipate? (select all that apply) A. altered respiratory rate B. eyes with tearing and redness C. cold, moist skin D. Skin lesions or rashes E. Adventitious breath sounds

A. Altered respiratory rate B. eyes with tearing and redness D. Skin lesions or rashes E. Adventitious breath sounds

Which nursing interventions address the immediate priority of care for a client experiencing a severe hypersensitivity reaction? (select all that apply) A. Assess respiratory status continuously B. Administer subcutaneous epinephrine as prescribed C. Monitor urine output D. Teach the client when and how to use an anaphylactic kit E. Administer oxygen via nasal cannula at the prescribed rate

A. Assess respiratory status continuously B. Administer subcutaneous epinephrine as prescribed E. Administer oxygen via nasal cannula at the prescribed rate

A patient presents with malaise, a fever, and joint pain. If a systemic lupus erythematosus (SLE) diagnosis is being considered, which additional assessments should the nurse perform? Select all that apply.] A. Take patient blood pressure B. Assess for enlarged thyroid gland C. Ensure that urine is collected for a urinalysis D. Palpate the abdomen and listen to bowel sounds E. Ask the patient simple questions and note patient response

A. Take patient blood pressure C. Ensure that urine is collected for a urinalysis E. Ask the patient simple questions and note patient response Cardiovascular manifestations, such as hypertension, is common in children with SLE, so BP should be assessed. Urinary manifestations, such as proteinuria, hematuria, and nephritis, are often seen in children with SLE. Collecting a urine sample for a urinalysis is an assessment the nurse can perform to help identify SLE. Asking the patient questions and noting the response is indicated because neurological alterations are often seen in children with SLE. Endocrine disorders are not frequently seen in SLE, so thyroid assessment is an unnecessary. GI manifestations are not common in SLE, so palpating the abdomen and listening to bowel sounds would not help the nurse identify SLE.

The nurse is caring for a client with a history of anaphylaxis related to a known latex allergy. Which is a priority goal when planning a nursing intervention for the client? A. the client will avoid the known allergen B. The client will teach family members about the life-threatening condition C. The client will verbalize an understanding of the goal D. The client will avoid the foods linked to the latex allergy.

A. the client will avoid the known allergen

The most common cause of secondary immunodeficiencies is a.drugs. b.stress. c.malnutrition. d.human immunodeficiency virus.

A.drugs

4) 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

Answer: A Explanation: A) 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. Page Ref: 516 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with systemic lupus erythematosus.

1) 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

Answer: A Explanation: A) 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. Page Ref: 510 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of systemic lupus erythematosus.

9) 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."

Answer: A Explanation: A) 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. Page Ref: 514 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 7. Evaluate expected outcomes for an individual with systemic lupus erythematosus.

11) 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.

Answer: A, B Explanation: A) 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. Page Ref: 514 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with systemic lupus erythematosus.

5) 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.

Answer: A, C, D, E Explanation: A) 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. Page Ref: 516 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with systemic lupus erythematosus.

6) 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.

Answer: A, D Explanation: A) 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. Page Ref: 513 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 6. Plan evidence-based care for an individual with systemic lupus erythematosus and his or her family in collaboration with other members of the healthcare team.

7) 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.

Answer: B Explanation: A) 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. Page Ref: 515 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 7. Evaluate expected outcomes for an individual with systemic lupus erythematosus.

10) A nurse is caring for a client with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). The nurse understands that the primary concern with this drug is: A) Pulmonary fibrosis. B) Cushingoid effects. C) Retinal toxicity. D) Renal toxicity.

Answer: C Explanation: A) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity and possible irreversible blindness. Cushingoid effects are a concern with corticosteroid therapy. Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil. Renal toxicity is not the primary concern with Plaquenil. Page Ref: 514 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with systemic lupus erythematosus.

2) 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."

Answer: C Explanation: A) 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. Page Ref: 510 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 2. Identify risk factors and prevention methods associated with systemic lupus erythematosus.

3) 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.

Answer: D Explanation: A) 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. Page Ref: 510 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with systemic lupus erythematosus.

A 25-year-old male patient has been diagnosed with HIV. The patient does not want to take more than one antiretroviral drug. What reasons can the nurse tell the patient about for taking more than one drug? A. Together they will cure HIV. B. Viral replication will be inhibited. C. They will decrease CD4+ T cell counts. D. It will prevent interaction with other drugs.

B

A hospital has seen a recent increase in the incidence of hospital care-associated infections (HAIs). Which measure should be prioritized in the response to this trend? A. Use of gloves during patient contact B. Frequent and thorough hand washing C. Prophylactic, broad-spectrum antibiotics D. Fitting and appropriate use of N95 masks

B

The patient has vancomycin-resistant enterococci (VRE) infection in a surgical wound. What infection precautions should the nurse use to best prevent transmission of the infection to the nurse, other patients, staff, and those outside the hospital? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions

B

A client calls the nurse in the emergency department and states 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. Which action should the nurse take? 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 department. D. Tell the client not to worry about the sting unless difficulty with breathing occurs.

B. Ask the client if he ever sustained a bee sting in the past. In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

The nurse was accidently stuck with a needle used on an HIV-positive patient. After reporting this, what care should this nurse first receive? A. Personal protective equipment B. Combination antiretroviral therapy C. Counseling to report blood exposures D. A negative evaluation by the manager

B. Combination antiretroviral therapy

3. Select-all-that-apply: Which of the following are NOT typical signs and symptoms of pericarditis?* A. Fever B. Increased pain when leaning forward C. ST segment depression D. Pericardial friction rub E. Radiating substernal pain felt in the left shoulder F. Breathing in relieves the pain

B. Increased pain when leaning forward C. ST segment depression F. Breathing in relieves the pain The answers are B, C, and F. These are findings NOT found in pericarditis. B is wrong because leaning forward actually helps relieve pain felt in pericarditis (supine position makes it worst). C is wrong because ST segment ELEVATION is seen not depression. F is wrong because inspiration (breathing in) increases the pain felt with pericarditis.

A pregnant woman who was tested and diagnosed with HIV infection is very upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? A. "The baby will probably be infected with HIV." B. "Only an abortion will keep your baby from having HIV." C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." D. "The duration and frequency of contact with the organism will determine if the baby gets HIV infection."

C

The nurse has taught a client with lupus about skin protection in the clinic. Later, the nurse sees the client at an outdoor music festival. Which observation by the nurse indicates that the client requires further instruction? a. Client is wearing a thin, long-sleeved shirt. b. Client is wearing a hat with a full brim. c. Client is discussing her new perm. d. Client is seen applying sunscreen twice.

C ~ Alopecia is common; the client should use gentle shampoo and avoid any harsh chemical treatments, such as a permanent wave. The other observations show good skin protection practices by the client.

The nurse is providing care for a patient who has been living with HIV for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? A. A new onset of polycythemia B. Presence of mononucleosis-like symptoms C. A sharp decrease in the patient's CD4+ count D. A sudden increase in the patient's WBC count

C. A sharp decrease in the patient's CD4+ count

The nurse is instructing a client about management of discoid lupus erythematosus (DLE). Which statement indicates that the client requires additional teaching? a. I will be sure to apply sunscreen whenever I am outside. b. I will apply small amounts of the steroid cream to my face twice a day. c. I will take Plaquenil (hydroxychloroquine sulfate) with breakfast each morning. d. Steroids weaken the immune system, so I will wash my hands frequently.

D ~ Steroid creams used for the treatment of discoid lupus will not weaken the immune system because they should be applied in small amounts to affected areas. The client will be more sensitive to sun exposure while using the steroid cream, so sunscreen should be used whenever the client goes outside. The client should use only small amounts of the cream on her face. Plaquenil should be taken with meals or a glass of milk.

What is the most appropriate nursing intervention to help an HIV-infected patient adhere to a treatment regimen? a."Set up" a drug pillbox for the patient every week. b.Give the patient a video and a brochure to view and read at home. c.Tell the patient that the side effects of the drugs are bad but that they go away after a while. d.Assess the patient's routines and find adherence cues that fit into the patient's life circumstances.

D. Assess the patient's routines and find adherence cues that fit into the patient's life circumstances.

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1 A. Eggs B. Milk C. Yogurt D. Bananas

D. Bananas Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for 2201 developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen. Options 1, 2, and 3 are unrelated to latex allergy.

The nurse is providing teaching for a client on dietary intake and anaphylaxis. Which food should the nurse identify that trigger anaphylaxis in a sensitized individual (Select all that apply) A. Fish B. Coconut oil C. Milk D. Chocolate E. Grains

D. Chocolate E. Grains

6. A patient with severe pericarditis has developed a large pericardial effusion. The patient is symptomatic. The physician orders what type of procedure to help treat this condition?* A. Pericardiectomy B. Heart catheterization C. Thoracotomy D. Pericardiocentesis

D. Pericardiocentesis The answer is D. The physician will probably order a pericardiocentesis. This is a procedure to remove excessive fluid from the pericardial sac.

The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action? A. Administer IV diphenhydramine (Benadryl). B. Administer nitroprusside as soon as possible. C. Anticipate tracheostomy with laryngeal edema. D. Place the patient recumbent and elevate the legs

D. Place the patient recumbent and elevate the legs