RN learning system medical surgical: immune and infectious practice

A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse give?

-"It sounds like you are unsure what to say to your partner." **This response uses the therapeutic communication tools of clarifying and restatement. It identifies that the client is unsure about if or how to approach the issue of being HIV positive with his partner, a common concern of clients due to fear of rejection. This response shows that the nurse is open to further communication with the client and encourages his expression of feelings.

A nurse is caring for a client who had radioallergosorbent (RAST) testing completed due to seasonal allergies. The nurse should anticipate an elevation in which of the following laboratory tests?

-IgE (immunoglobulin E) **RAST testing involves measuring the quantity of IgE present in serum after exposure to specific antigens selected on a basis of the client's symptom history. An elevated IgE indicates a positive response and is common among clients who have a history of allergic manifestations, anaphylaxis, and asthma.

A nurse is teaching a client who has Raynaud's disease. Which of the following information should the nurse include in the teaching?

-Protect against the cold by wearing layers of clothing. **Clients who have Raynaud's disease are prone to attacks during cold weather. Extreme cold can lead to tissue damage. Therefore, the client needs to be protected with layers of clothing to promote warmth and increase circulation to the extremities.

A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory tests can indicate arthritis?

-Rheumatoid factor **An increase in the client's rheumatoid factor can indicate rheumatoid arthritis or other connective tissue diseases.

A nurse in a provider's office is providing teaching to a client who has a recent diagnosis of rheumatoid arthritis and has a new prescription for naproxen tablets. Which of the following statements by the client requires further teaching?

-"I can take this medication with aspirin." **The nurse should instruct the client to avoid taking this medication with any other NSAIDs, such as aspirin, because this can increase the risk for bleeding and gastrointestinal ulceration.

A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about the skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of the following responses should the nurse give?

-"Apply moisturizer after bathing the lesions with warm water. **The nurse should instruct the client to clean, dry, and moisturize the skin using warm (not hot) water, along with an unscented lotion.

A nurse is teaching a client who has human immunodeficiency virus about how the virus is transmitted. Which of the following statements should the nurse include the teaching?

-"HIV can be transmitted to anyone who has had contact with the infected blood." **The concentration of the virus is highest in blood but also has been isolated in other body fluids, including sputum, saliva, cerebrospinal fluid, urine, and semen. Clients who have HIV are cautioned to practice safe sex, avoid donating blood, and abstain from sharing needles with others.

A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

-"I can expect this medication to turn my skin orange." **The nurse should instruct the client to expect his skin and urine to turn a reddish-orange tinge while taking rifampin.

A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching?

-"I should not smoke." **Raynaud's disease is a disorder of the blood vessels that supply blood to the skin and cause the distal extremities to feel numb and cool in response to cold temperatures or stress. During a Raynaud's attack, these arteries narrow, limiting blood circulation to affected areas. Strong emotion or exposure to the cold causes these areas to become white, due to a lack of blood flow in the area. They then turn blue, as tiny blood vessels dilate to allow more blood to remain in the tissues. When the flow of blood returns, the area becomes red and then later returns to normal color. This can cause tingling, swelling and painful throbbing. The attacks can last from minutes to hours. If the condition progresses, blood flow to the area could become permanently decreased, causing the fingers to become thin and tapered, with smooth, shiny skin and slow-growing nails. If an artery becomes blocked completely, gangrene or ulceration of the skin can occur. Smoking cessation, not just reduction, is an action the client should take to prevent the onset of the manifestations of Raynaud's disease.

A nurse is providing teaching to a client who has a diagnosis of Hepatitis A. Which of the following statements by the client indicates an understanding of the teaching?

-"I should stop eating raw clams." **Hepatitis A is transmitted via the fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, or uncooked shellfish. Individuals who eat raw or steamed shellfish are at increased risk for acquiring hepatitis A.

A nurse is teaching a client who has tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen when she states which of the following?

-"I will apply a mattress cover to my bed." **The nurse should instruct the client to apply a hypoallergenic mattress cover that can be zipped over her bed to control the amount of dust. The client should remove the mattress cover periodically and machine wash to clean.

A nurse is providing discharge instructions to a client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent transmission of the sexually transmitted infection (STI)?

-"I will bring my sexual partner in for treatment." **The client should bring his partner in to be screened for genital warts and treated.

A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome. Which of the following statements by the client's partner indicates the need for further teaching?

-"I'll clean up blood spills immediately with hot water." **The client's partner should clean blood or potentially contaminated body substances with a bleach solution and wear gloves when coming into contact with blood products.

A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse plan to include?

-"Monitor your body temperature and report any elevations promptly." **SLE is a chronic autoimmune disorder that can affect any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack tissues and organs, including the skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation and remissions. The nurse should teach the client to monitor body temperature and report any elevations promptly, as fever can suggest either an exacerbation or a potentially life-threatening infection.

A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following information should the nurse include in the teaching?

-"PCP results from an impaired immune system." **The nurse should explain that the organism that causes PCP exists as part of the normal flora of the lungs and develops into a fungus. It becomes an aggressive pathogen when the immune system is compromised and the infection results from an impaired immune system.

A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching?

-"Wash your genitalia using an antimicrobial soap." **The nurse should instruct the client to bathe daily using an antimicrobial soap to prevent the spread of infection. If bathing is not possible, washing the genitalia using an antimicrobial soap is recommended.

A nurse is teaching a client who has human immunodeficiency virus about the early manifestations of acquired immune deficiency syndrome. Which of the following statements should the nurse include in the teaching?

-"You can expect a persistent fever and swollen glands." **Clients who have AIDS can have persistent fever, swollen glands, diarrhea, weight loss, and fatigue. These manifestations indicate the onset of AIDS.

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE?

-Exercise **SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and the manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with her provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active.

A nurse is caring for a client who is 2 days postoperative. Which of the following findings should alert the nurse that the client is developing an infection?

-Erythema at the incision site **Redness, or erythema, at the incision site is an initial sign of a wound infection and requires intervention by the nurse.

A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect?

-Finger contractures **Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are two types of scleroderma: localized scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs. The manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With scleroderma, the body produces and deposits too much collagen, causing thickening and hardening. In addition to the client's skin and subcutaneous tissues becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma unless clients follow a regimen of range-of-motion and muscle-strengthening exercises.

A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest x-ray. The nurse should instruct the newly licensed nurse to take which of the following actions?

-Have the client wear a surgical mask. **The nurse should instruct the client to wear a surgical mask. The mask will protect anyone who comes into contact with the client, including the nurse.

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments?

-Heat paraffin therapy applied to the client's joints **The nurse should anticipate the use of heat paraffin to be prescribed as a nonpharmacologic intervention. The elevated ESR indicates an acute inflammatory process due to client's rheumatoid arthritis. The use of the warm paraffin relives the stiffness of the client's joints and provides comfort.

A nurse is preparing to administer a Mantoux skin test to a client. The nurse should inform the client that the purpose of a Mantoux skin test using purified protein derivative (PPD) is to do which of the following actions?

-Identify if a client has been infected with mycobacterium tuberculosis. **The nurse should inform the client that the Mantoux test is used to identify individuals who have been infected with mycobacterium tuberculosis.

A nurse is teaching a client about manifestations of an allergic reaction. The nurse should explain that histamine release causes which of the following reactions?

-Increased mucus secretion **The nurse should instruct that the client that increased mucus secretion is a manifestation of histamine release. Histamine is the neurotransmitter the body produces during an allergic reaction.

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect?

-Reddish-purple skin lesions **Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following biopsy, the lesions are treated with radiation and/or chemotherapy.

A nurse is caring for client who has human immunodeficiency virus. Which of the following types of isolation should the nurse implement to prevent transmission of HIV?

-Standard precautions **Standard precautions should be implemented with every client, to prevent the spread of infection transmitted by direct or indirect contact with infectious blood or body fluids. Because HIV is spread through blood and bodily fluids, standard precautions are appropriate.

A nurse is teaching an assistive personnel about standard precautions when caring for a client who has vancomycin resistant Enterococcus of the urine. Which of the following images of personal protection equipment should the nurse recommend the AP to use when caring for this client?

-The nurse should don clean gloves when caring for a client who has vancomycin-resistant enterococcus of the urine. This protects the nurse from coming in contact with bodily fluids contaminated with the bacteria of the client.

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect?

-Unilateral, localized, nodular skin lesions **Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces unilateral, localized, nodular skin lesions.

A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching?

Apply a warm compress to the lesions. **The nurse should instruct the client to apply a warm compress to the lesions to relieve discomfort.

A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client?

_A progressive, circular rash **Early Lyme disease is characterized by fever, influenza-like manifestations, and erythema migrans, a distinct progressive circular or bulls-eye rash that often develops at the bite site, but can also develop at other sites, such as the thighs and knees.