Nclex Immune

A client presents at the primary health care provider's office with complaints of a ring-like rash on his upper leg. Which question should the nurse ask first? 1."Do you have any cats in your home?" 2."Have you been camping in the last month?" 3."Have you or close contacts had any flu-like symptoms within the last few weeks?" 4."Have you been in physical contact with anyone who has the same type of rash?"

2 Rationale:The nurse should ask questions to assist in identifying a cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ring-like rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? 1.Provide large, nutritious meals. 2.Serve foods while they are hot. 3.Add spices to food for added flavor. 4.Remove dairy products and red meat from the meal.

4 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The client with AIDS who has nausea and vomiting should avoid fatty products such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. The client should avoid spices and odorous foods because they aggravate nausea. Foods are best tolerated cold or at room temperature.

The nursing student enrolled in an anatomy and physiology course is studying the immune system. The nursing instructor determines that the student understands the chemical barriers against a nonspecific immune response if which statement is made? 1."The skin is considered a chemical barrier." 2."The mucous membranes act as chemical barriers." 3."The cilia lining the respiratory tract are chemical barriers." 4."Acids and enzymes found in body fluids function as chemical barriers."

4 Rationale:Chemical barriers include various acids and enzymes found in body fluids. The skin, the mucous membranes, and the action of cilia lining the respiratory tract are physical barriers.

A CD4+ lymphocyte count is performed in a client with human immunodeficiency virus (HIV) infection. When providing education about the testing, what should the nurse tell the client? 1."It establishes the stage of HIV infection." 2."It confirms the presence of HIV infection." 3."It identifies the cell-associated proviral DNA." 4."It determines the presence of HIV antibodies in the bloodstream."

1 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A CD4+ lymphocyte count is performed to establish the stage of HIV infection, to help with decisions regarding the timing of initiation of antiretroviral therapy and prophylaxis for opportunistic infections, and to monitor treatment effectiveness. The remaining options are unrelated to the CD4+ lymphocyte count.

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1.Maintain bed rest as much as possible. 2.Administer capsaicin cream as prescribed for pain. 3.Advise the client to remain supine for 1 to 2 hours after meals. 4.Keep the room temperature warm during the day and cool at night.

2 Rationale:Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation; however, they may cause renal failure and have little effect on scleroderma. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present.

The nursing instructor asks a nursing student to identify the components of natural resistance as it relates to the immune system. Which statement by the nursing student indicates a need for further research? 1."It also is called inherited immunity." 2."It is the immunity with which a person is born." 3."It does not require previous exposure to the antigen." 4."It includes all antigen-specific immunities a person develops during a lifetime."

4 Rationale:Natural resistance, also called innate inherited or innate-native immunity, is the immunity with which a person is born. It does not require previous exposure to the antigen. Acquired immunity includes all antigen-specific immunities that a person develops during a lifetime.

A client with human immunodeficiency virus infection has signs and symptoms of cryptosporidiosis. The nurse should prepare the client for which test that will assist in confirming the diagnosis? 1.Stool culture 2.Bronchoscopy 3.Sputum culture 4.Chest x-ray study

1 A client with human immunodeficiency virus infection has signs and symptoms of cryptosporidiosis. The nurse should prepare the client for which test that will assist in confirming the diagnosis?

A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas exchange. Which finding indicates that the expected outcome of care has yet to be achieved? 1.The client limits fluid intake. 2.The client has clear breath sounds. 3.The client expectorates secretions easily. 4.The client is free of complaints of shortness of breath.

1 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The status of the client with a problem concerning gas exchange would be evaluated against the standard outcome criteria for a P. jiroveci infection. These would include options 2, 3, and 4 where breath sounds are clear, the nurse notes that secretions are being coughed up effectively, and the client states that breathing is easier. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

A client is suspected of having discoid lupus erythematosus (DLE). Which diagnostic test will primarily confirm the diagnosis? 1.Skin biopsy 2.Anti-Smith test 3.Extractable nuclear antigens 4.Anti-deoxyribonucleic acid (DNA)

1 Rationale:Discoid lupus erythematosus (DLE) is one classification of lupus. DLE is not a systemic condition and affects only the skin; therefore, the only significant test is a skin biopsy. A microscopic evaluation of skin cell scrapings from the rash will reveal the characteristic lupus cell and a number of inflammatory cells. Other specific immunological tests, such as anti-SS-a (RO), anti-SS-b (La), anti-Smith, anti-DNA, and extractable nuclear antigens, may be performed. High titers of some of these antibodies are associated with lupus, but some can also be found in persons without the disease.

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? 1.Hairdressers 2.The homeless 3.Children in day care centers 4.Individuals living in a group home

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

A home care nurse is assigned to visit a client who has 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 instruction regarding crutch walking. On admission assessment, the nurse discovered that the client has an allergy to latex. Before providing instructions regarding crutch walking, what action should the nurse take? 1.Cover the crutch pads with cloth. 2.Contact the primary health care provider (PHCP). 3.Call the local medical supply store and ask that a cane be delivered. 4.Tell the client that the crutches must be removed from the house immediately

1 Rationale:Latex allergy is a type I hypersensitivity reaction in which a specific allergen is a processed natural latex rubber protein. The rubber pads used on crutches may contain latex. If the client requires crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. No reason exists to contact the PHCP at this time. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may not be appropriate, considering this client's injury. Telling the client that the crutches must be removed from the house is inappropriate and may alarm the client.

The nurse works with high-risk clients in an urban outpatient setting. Which groups should be tested for human immunodeficiency virus (HIV)? Select all that apply. 1.Injection drug abusers 2.Prostitutes and their clients 3.People with sexually transmitted infections (STIs) 4.People who have had frequent episodes of pneumonia 5.People who recently received a blood transfusion for a surgical procedure

123 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Injection drug abusers, those engaged in prostitution, and people with STIs are high-risk groups that should be tested for HIV per the Centers for Disease Control and Prevention's recommendations. Those who have had frequent episodes of pneumonia and those who recently received a blood transfusion for a surgical procedure are not at risk for HIV unless another compounding factor places them at risk. However, if a blood transfusion was received between 1978 and 1985, the client should be tested.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. 1.Keep liquids at the bedside. 2.Place a towel over the pillowcase. 3.Make sure the pillow has a plastic cover. 4.Keep a change of bed linens nearby in case they are needed. 5.Administer an antipyretic after the client has a spike in temperature.

1234 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is profuse. The client should have liquids at the bedside to drink.

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1.Use nonlatex gloves. 2.Use medications from glass ampules. 3.Place the client in a private room only. 4.Keep a latex-safe supply cart available in the client's area. 5.Avoid the use of medication vials that have rubber stoppers. 6.Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1245 Rationale:If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse should recognize that which are early clinical manifestations of this disorder? Select all that apply. 1.Fatigue 2.Anorexia 3.High fever 4.Weight loss 5.Generalized weakness

125 Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early manifestations of RA include fatigue, anorexia, generalized weakness, low-grade fever, and paresthesias. Weight loss is one of the late manifestations.

The nurse asks a nursing student to identify the locations of macrophages in the body. The student responds correctly if the student indicates which organs and tissues contain a large number of these cells? Select all that apply. 1.Liver 2.Tonsils 3.Spleen 4.Bone marrow 5.Intestinal tract

135 Rationale:Macrophage functions include phagocytosis, repair, antigen presenting/processing, and secretion of cytokines for immune system control. The liver, spleen, and intestinal tract contain large numbers of macrophages. Bone marrow and tonsils contain no macrophages.

The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select all that apply. 1.Oliguria 2.Hypotension 3.Fluid retention 4.Temperature of 99.6º F (37.6º C) 5.Serum creatinine of 3.2 mg/dL (282 mcmol/L)

135 Rationale:Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection is the most common type that occurs with kidney transplants and occurs 1 week to any time postoperatively. It occurs over days to weeks. Findings consistent with acute rejection include oliguria or anuria; temperature higher than 100º F (37.8º C); increased blood pressure; enlarged, tender kidney; lethargy; elevated serum creatinine, blood urea nitrogen, and potassium levels; and fluid retention.

A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding? 1.The histoplasmosis is resolving. 2.The client has disseminated histoplasmosis infection. 3.This is a side effect of the medications given to treat AIDS. 4.The client probably has another infection that is developing.

2 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respiratory infection in the client with AIDS and then becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver. The client experiences dyspnea, fever, cough, and weight loss. The remaining options are incorrect.

The nursing student conducted a clinical conference on the role of B lymphocytes in the immune system. Which statement by a fellow nursing student indicates successful teaching? 1."They activate T cells." 2."They produce antibodies." 3."They initiate phagocytosis." 4."They attack and kill the target cell directly."

2 Rationale:B lymphocytes have the job of making antibodies and mediating humoral immunity. They do not activate T cells. T cells attack and kill target cells directly. The primary function of macrophages is phagocytosis.

A client asks the nurse about obtaining a home test kit to test for human immunodeficiency virus (HIV) status. What should the nurse tell the client? 1.Home test kits are not available for testing at this time. 2.Home test kits may not be as reliable as laboratory blood tests. 3.Home test kits are most reliable immediately after a risk event occurs. 4.Home test kits should not be used; rather, it is important to contact the primary health care provider (PHCP) with concerns about the HIV status.

2 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Should a client wish to know his or her HIV status, testing is available from a PHCP or a local public health clinic, or a home test kit can be used. Some test kits may not be as reliable as a laboratory blood test. It is also recommended that a home test be performed at least 3 months after a risk event occurs. If a positive result on a home test occurs, then the individual requires additional testing.

The nurse is assigned to care for a client with human immunodeficiency virus (HIV) infection. The nurse reviews the client's health care record and notes documentation of toxoplasmosis encephalitis. On the basis of this information, the nurse would assess for which manifestation? 1.Lesions on the skin 2.Mental status changes 3.Changes in bowel pattern 4.Lesions on the oral mucosa

2 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Toxoplasmosis encephalitis, caused by Toxoplasma gondii, is acquired through contact with contaminated cat feces or by ingesting infected, undercooked meat. It manifests with signs and symptoms such as an altered mental status, neurological deficits, headaches, and fever. Additional manifestations include difficulties with speech, gait, and vision; and seizures. The other options are not associated with toxoplasmosis.

A client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse should take? 1.Place the client on 100% oxygen and prepare for intubation. 2.Assess for anaphylaxis and prepare for emergency treatment. 3.Teach the client about the relationship between asthma and allergies. 4.Obtain an arterial blood gas and immunoglobulin E (IgE) blood level.

2 Rationale:Hypersensitivity or allergy is excessive inflammation occurring in response to the presence of an antigen to which the person usually has been previously exposed. If a client is experiencing an allergic or hypersensitivity response, the nurse's initial action is to assess for anaphylaxis. Promptly notifying the health care provider and preparing emergency equipment, including medication such as epinephrine and possible corticosteroids, is essential in preventing progression of anaphylaxis. Laboratory work is not a priority in this situation. The nurse would expect the IgE level to be elevated; the client may be hypoxic. The nurse would give the client supplemental oxygen; however, 100% is not given unless prescribed, and based on the information in the question, intubation is not the first thing the nurse would prepare this client for. Teaching the client is important; however, this is not the right time. When the client is stabilized, the nurse should teach or reinforce that allergies, including some medications, are common triggers for asthma attacks and that people with asthma are predisposed to more allergies than people without asthma.

A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan? 1.Ultraviolet light therapy 2.A 14- to 21-day course of doxycycline 3.No treatment unless symptoms develop 4.Treatment with intravenous (IV) penicillin G

2 Rationale:Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. A 3- to 4-week course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with IV antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA? 1.Anemia 2.Anorexia 3.Amenorrhea 4.Night sweats

2 Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early clinical manifestations of RA include complaints of fatigue, generalized weakness, anorexia, and weight loss. Anemia, amenorrhea, and night sweats are not early manifestations of RA.

A client presents at the primary health care provider's office with complaints of a bulls-eye rash on his upper leg. Which question should the nurse ask first? 1."Do you have any cats in your home?" 2."Have you been camping in the last month?" 3."Have you or close contacts had any flu-like symptoms within the last few weeks?" 4."Have you been in physical contact with anyone who has the same type of rash?"

2 Rationale:The nurse should ask questions to assist in identifying the cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ring-like rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

A 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 actions are most appropriate? Select all that apply. 1.Tell the client that testing is not necessary unless arthralgia develops. 2.Tell the client to avoid any woody, grassy areas that may contain ticks. 3.Instruct the client to immediately start to take the antibiotics that are prescribed. 4.Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5.Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic.

234 Rationale:A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic. Options 1 and 5 are incorrect.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has begun to experience multiple opportunistic infections. Which laboratory test would be most helpful in assessing the client's need for reassessment of treatment? 1.Western blot 2.B lymphocyte count 3.CD4+ cell or T lymphocyte count 4.Enzyme-linked immunosorbent assay (ELISA)

3 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The T lymphocyte or CD4+ cell count indicates whether the client is responding to the medication treatment. The count should increase if the client is responding and should decrease if the client's response is poor. The Western blot and ELISA are tests to assist in diagnosing human immunodeficiency virus infection. The B lymphocyte count is not a priority marker to monitor with AIDS clients.

A client is admitted to the hospital with a diagnosis of parasitic worms. By reviewing the client's complete blood cell (CBC) count results, which cells indicate attack by these foreign bodies? 1.Basophils 2.Neutrophils 3.Eosinophils 4.Dendritic cells

3 Rationale:Eosinophils attack and destroy foreign particles that have been coated with antibodies of the immunoglobulin E (IgE) class. Their usual target is helminths (parasitic worms). Basophils mediate immediate hypersensitivity reactions. Neutrophils phagocytize foreign particles such as bacteria. Dendritic cells perform the same antigen-presenting task as macrophages.

A client is tested for human immunodeficiency virus (HIV) infection with an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. What should the nurse tell the client? 1.HIV infection has been confirmed. 2.The client probably has a gastrointestinal infection. 3.The test will need to be confirmed with a Western blot. 4.A positive test result is normal and does not mean that the client has acquired HIV

3 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A negative result on an ELISA indicates that infection is absent or that not enough time has passed since exposure for seroconversion. A positive ELISA result must be confirmed with a Western blot. The other options are incorrect.

The nurse is caring for a client with human immunodeficiency virus (HIV) infection and notes a diagnosis of cryptococcosis in the client's medical record. The nurse understands that this opportunistic infection most likely was diagnosed by which test? 1.Skin biopsy 2.Viral culture 3.Sputum culture 4.Bone marrow biopsy

3 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Cryptococcosis is a fungal infection caused by Cryptococcus neoformans. It usually affects the lungs and central nervous system (brain and spinal cord), but it can also affect other parts of the body. Symptoms of lung involvement include cough, shortness of breath, chest pain, and fever. When it spreads to the brain, manifestations include headache, fever, neck pain, nausea and vomiting, sensitivity to light, confusion, or changes in behavior. Diagnostic tests to confirm its presence in the lungs include chest x-ray studies and a sputum culture.

A client is diagnosed with Goodpasture's syndrome. The nurse determines that this client's renal disease is caused by a type II hypersensitivity response. Which laboratory result would be most important for the nurse to evaluate? 1.Urinalysis 2.Electrolytes 3.Glomerular filtration rate (GFR) 4.Partial thromboplastin time (PTT)

3 Rationale:In the autoimmune disease known as Goodpasture's syndrome, autoantibodies attack the glomerulular basement membrane and neutrophils. As a result, the affected person will begin to experience decreased GFR with development of signs of chronic kidney disease. There will be an increased blood urea nitrogen (BUN) and creatinine but decreased GFR due to declining kidney function. Therefore, the remaining options are incorrect.

The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an altered immune system, and the role of interferons is discussed. Which statement by the nursing student indicates a need for further teaching? 1."They are produced by several types of cells." 2."They are effective against a wide variety of viruses." 3."They are effective against a wide variety of bacteria." 4."They have been effective to some degree in the treatment of melanoma."

3 Rationale:Interferon is produced by several types of cells and is effective against a wide variety of viruses (not bacteria). It works on the host cells to induce protection and differs from an antibody, which inactivates viruses found outside the cells. Interferons have been effective to some degree in the treatment of melanoma, hairy cell leukemia, renal cell carcinoma, ovarian cancer, and cutaneous T-cell lymphoma.

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1.Swelling in the genital area 2.Swelling in the lower extremities 3.Positive punch biopsy of the cutaneous lesions 4.Appearance of reddish-blue lesions noted on the skin

3 Rationale:Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity? 1. Sunlight 2. Going to parties 3. The use of latex condoms 4. Outdoor activities as much as possible

3 Rationale:Latex allergy is a type I hypersensitivity reaction in which a specific allergen is a processed natural latex rubber protein. Mucosal exposure to latex can occur on contact with latex condoms. The nurse most appropriately would provide instructions to the client about the need to avoid the use of condoms unless they are latex-free. No reason exists for the client to avoid outdoor activities or sunlight or to avoid parties; however, the client should be informed that certain forms of balloons are made of latex.

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. The client reports that he removed the tick and flushed it down the toilet. The nurse should take which nursing action? 1.Refer the client for a blood test immediately. 2.Ask the client about the size and color of the tick. 3.Tell the client to return to the clinic in 4 to 6 weeks. 4.Inform the client that the tick is needed to perform a test.

3 Rationale:Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. A blood test is available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks after the tick bite. Antibody formation takes place in the following manner: Immunoglobulin M (IgM) is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, then gradually disappears; IgG is detected 2 to 3 months after infection and may remain elevated for years. The actions in the remaining options are inaccurate.

The clinic nurse reads the chart of a client just seen by the primary health care provider (PHCP) and notes that the PHCP has documented that the client has stage III Lyme disease. Which clinical manifestation should the nurse expect to note in this client? 1.Generalized skin rash 2.Cardiac dysrhythmia 3.Complaints of joint pain 4.Paralysis of the affected extremity

3 Rationale:Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Stage III develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgias and enlargement or inflammation of joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage II. A rash occurs in stage I. Paralysis of the extremity on which the bite occurred is not a characteristic of Lyme disease.

The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 1."My skin will have tiny red vesicles." 2."The presence of the skin vesicles is caused by a virus." 3."I have an autoimmune disease that causes blistering in the epidermis." 4."The presence of red, raised papules and large plaques covered by silvery scales will be present on my skin."

3 Rationale:Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis.

The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 1."My skin will have tiny red vesicles." 2."The presence of the skin vesicles is caused by a virus." 3."I have an autoimmune disease that causes blistering in the skin." 4."Red, raised papules and large plaques covered by silvery scales will be present on my skin."

3 Rationale:Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis.

The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? 1.Ascites 2.Emboli 3.Facial rash 4.Two hemoglobin S genes

3 Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A butterfly rash on the cheeks and bridge of the nose is an essential sign of SLE. Ascites and emboli are found in many conditions but are not associated with SLE. Two hemoglobin S genes are found in sickle cell anemia.

A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE? 1.Fever 2.Fatigue 3.Skin lesions 4.Elevated red blood cell count

3 Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. The major skin manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE.

The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? Select all that apply. 1."I need to sit whenever possible." 2."I need to be sure to eat a balanced diet." 3."I need to take a hot bath every evening." 4."I need to rest for long periods of time every day." 5."I should engage in moderate low-impact exercise when I am not tired."

34 Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Hot baths may exacerbate the fatigue. To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, avoid hot baths, engage in moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness.

The nursing instructor asks a nursing student to identify the location of Peyer's patches. The nursing instructor determines that the student has an understanding of the location if which organ is identified? 1.The liver 2.The spleen 3.The tonsils 4.The small intestine

4 Rationale:Peyer's patches are lymphoid nodules located in the small intestine, where T cells congregate. Peyer's patches are most important in the secondary immune response, although they play a role in the primary immune response as well. These organs may enlarge as they become highly active in the immune response. The organs noted in the remaining options are incorrect.

A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine. The nurse assesses the complete blood cell (CBC) count, knowing that which is an adverse effect of this medication? 1.Polycythemia 2.Leukocytosis 3.Thrombocytosis 4.Agranulocytopenia

4 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Zidovudine is a neucloside-nucleotide reverse transcriptase inhibitor used to the virus. An adverse effect of this medication is agranulocytopenia with anemia. The nurse carefully monitors CBC count results for changes that could indicate this occurrence. With early infection in the client who is asymptomatic, the CBC count is monitored monthly for 3 months and then every 3 months thereafter. In clients with advanced disease, the CBC count is monitored every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. The remaining options are not side or adverse effects of the medication.

The nursing student conducting a clinical conference on immunity places an emphasis on active immunity. Which statement by fellow nursing students indicates successful teaching? 1."Passive immunity can last for years." 2."Active immunity only lasts from days to months." 3."Active immunity provides protection immediately and forever." 4."Active immunity lasts for years and can be easily reactivated by a booster dose of antigen."

4 Rationale:Active immunity lasts for years and is natural by infection or artificial by stimulation of the body's immune defenses for example by vaccination. It can be easily reactivated by a booster dose of antigen. Protection from active immunity takes 5 to 14 days to develop after the first exposure to the antigen and 1 to 3 days after subsequent exposures. Active immunity lasts much longer and is more effective at preventing subsequent infections than passive immunity; however, it does not last forever. Passively received human antibodies have a half-life of about 30 days. Passive immunity provides protection immediately.

The nurse instructs a client with candidiasis (thrush) of the oral cavity on how to care for the disorder. Which client statement indicates the need for further instruction? 1."I need to eat foods that are liquid or pureed." 2."I need to eliminate spicy foods from my diet." 3."I need to eliminate citrus juices and hot liquids from my diet." 4."I need to rinse my mouth 4 times daily with a commercial mouthwash."

4 Rationale:Candidiasis is caused by Candida albicans, which is a part of the intestinal tract's natural flora. Fungal infection occurs by overgrowth of normal body flora. Candida stomatitis or esophagitis occurs often in immunocompromised clients. On examination of the mouth and throat, the nurse would note cottage cheese-like, yellowish white plaques and inflammation. Clients with candidiasis cannot tolerate commercial mouthwashes because the high alcohol concentration in these products can cause pain and discomfort to the lesions. A solution of warm water or mouthwash formulas without alcohol are better tolerated and may promote healing. A change in diet to liquid or pureed food often eases the discomfort of eating. The client should avoid spicy foods, citrus juice, and hot liquids.

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.Eggs 2.Milk 3.Yogurt 4.Bananas

4 Rationale:Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for 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 provides education to the client about the primary purpose of neutrophils. Which statement by the client indicates successful teaching? 1."They open up blood vessels." 2."They close up blood vessels." 3."They increase fluids at the injury site." 4."They engulf any potential foreign materials."

4 Rationale:Neutrophil function provides protection after invaders, especially bacteria, enter the body. In the inflammatory response, neutrophils appear in the area of injury in 30 to 60 minutes. Their primary purpose is to phagocytize (ingest and destroy) any potentially harmful agents, such as microorganisms. The remaining options are incorrect.

A fluorescent antinuclear antibody titer (FANA) is performed in a client suspected of having rheumatoid arthritis (RA). Which laboratory value is most consistent with RA? 1.0:5 2.0:8 3.1:5 4.1:20

4 Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The antinuclear antibody test measures the titer of antibodies that destroy the nuclei cells and cause tissue death. When the fluorescent method is used, the test sometimes is referred to as FANA. If this test is positive, a value greater than 1:8 will be present. Therefore, the options below this value are incorrect.

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this disease? 1.Neutropenia 2.Hyperglycemia 3.Antigens of immunoglobulin A (IgA) 4.Unusual antibodies of the IgG and IgM type

4 Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type, which develop in a number of connective tissue diseases. The other options are incorrect.

A complete blood cell (CBC) count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE? 1.Decreased platelets only 2.Increased red blood cell count 3.Increased white blood cell count 4.Decreased number of all cell types

4 Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. In the client with SLE, a CBC count commonly shows pancytopenia, a decrease in the number of all cell types. This finding is most likely caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.