Immune

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

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

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 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

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

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 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 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

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 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 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

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

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 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 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

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

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

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 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 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 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 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 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 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

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 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 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 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 collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food item? a. Eggs b. Milk c. Yogurt d. Bananas

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 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

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