Saunders Adult Immune

A client diagnosed with Lyme disease tells the nurse, "I heard this disease can affect the heart. Is this true?" The nurse would make which response to the client?

"It can, but you will be monitored closely for cardiac complications."

The nurse reinforces home care instructions to a client diagnosed with systemic lupus erythematosus and instructs the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching?

"I should take hot baths because they are relaxing."

The nurse is assessing the 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?

"Did you have chicken pox as a child?"

A client with cancer has received a course of chemotherapy with fluorouracil. The nurse would plan to reinforce which instructions?

"Do not get any immunizations without primary health care provider approval."

The nurse determines that the client diagnosed with neutropenia needs further teaching if which statement is made by the client?

"I will include plenty of fresh fruits in my diet."

Indinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV). The nurse has reinforced instructions to the client regarding ways to maximize absorption of the medication. Which statement by the client indicates an adequate understanding of the use of this medication?

"I need to take the medication with water but on an empty stomach."

The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching?

"I should not use insect repellent because it will attract the ticks."4

The nurse is teaching a nursing student about measures to decrease the risk of antibiotic-resistant infection. Which of the following statements made by the nursing student indicates a need for further teaching?

"Skipping a few doses of an antibiotic does not increase the risk of antibiotic-resistant infection."

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 question would the nurse ask next?

"When were you bitten by the tick?"

The primary health care provider aspirates synovial fluid from a knee joint of a client diagnosed with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to best indicate which finding?

Cloudy synovial fluid

A client diagnosed with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine therapy. The clinic nurse would reinforce which instruction to this client?

Come to the health care clinic to be seen by the primary health care provider.

A client diagnosed with stage I Lyme disease asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which treatment would be included in the care plan?

A 3- to 4-week course of oral antibiotic therapy

Which findings would cause the nurse to postpone administration of an immunization and do further data collection? Select all that apply.

- Immune deficiency disease - Familial history of severe allergic response to the immunization

A client recently diagnosed with toxoplasmosis asks the nurse, "What is toxoplasmosis? How did I get it, and what do I have to do to get rid of it"? Which information would the nurse include in the response? Select all that apply.

- Toxoplasmosis is treated with sulfadiazine. - Pregnant people should not empty litter boxes. - Toxoplasmosis is an organism found in rare pork. - Toxoplasmosis may cause a severe inflammatory response.

Which interventions would be implemented in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

- Use nonlatex gloves. - Use medications from glass ampules. - Do not puncture rubber stoppers with needles. - Keep a latex-safe supply cart available in the client's area.

The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE) that is affecting the hematopoietic system. Which data regarding signs and symptoms would the nurse anticipate collecting? Select all that apply.

- anemia - splenomegaly - lymphadenopathy

A client reports to the health care clinic to obtain testing regarding human immunodeficiency virus (HIV) status after being exposed to an individual who is HIV positive. The test results are reported as negative and the client tells the nurse that he feels so much better knowing that he has not contracted HIV. The nurse would explain the test results to the client, including which information?

A negative HIV test is not considered accurate during the first 6 months after exposure.

The nurse is assisting with the administration of immunizations at a health care clinic. The nurse would understand that immunization provides which protection?

Acquired immunity from disease

The nurse is assisting in developing a plan of care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. Which nursing intervention would be included in the plan of care to manage this symptom?

Administer an antipyretic at bedtime.

A client diagnosed with pemphigus is being seen in the clinic regularly. The nurse would plan care based on which description of this condition?

An autoimmune disease that causes blistering in the epidermis

Which individual is least at risk for the development of Kaposi's sarcoma?

An individual working in an environment where exposure to asbestos exists

The client diagnosed with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been prescribed pentamidine isethionate. The nurse assisting in caring for the client should monitor the client most closely for which adverse effect?

Anemia rationale: Pentamidine isethionate is an anti-infective medication. Adverse effects of this medication include leukopenia, thrombocytopenia, and anemia.

The client calls the emergency department and tells the nurse that he received a bee sting to the arm. The client states that he has received bee stings in the past and is not allergic to bees, but the site is painful. The client asks the nurse how to alleviate the pain. Which primary action would the nurse instruct the client to take?

Apply ice and elevate the site.

A client arrives at the health care clinic requesting to be tested for Lyme disease. The client tells the nurse that he removed the tick and flushed it down the toilet. The nurse would respond with which most appropriate action?

Arrange for the client to return in 4 to 6 weeks to be tested.

The nurse reads the chart of the client who has been diagnosed with stage III Lyme disease. The nurse would determine that which sign/symptom best supports this diagnosis?

Complaints of joint pain

The nurse is assisting in the care of a client diagnosed with systemic lupus erythematosus (SLE). The nurse would most appropriately administer which prescribed medication to manage the condition?

Corticosteroid

The home care nurse is selecting dressing supplies for a client who has an allergy to latex. The nurse would ask the medical supply personnel to deliver which items?

Cotton pads and silk tape

The clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse would assess for an early manifestation of Pneumocystis jiroveci infection by monitoring for which sign/symptom at each client visit?

Cough

The home care nurse is assigned to care for a client who returned home following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads, and the nurse needs to reinforce 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 would do which action?

Cover the crutch pads with cloth.

A complete blood cell count is performed on a client with a diagnosis of systemic lupus erythematosus (SLE). The nurse would suspect that which finding will most likely be reported from this blood test?

Decrease of all cell types3

The nurse is assisting in developing a plan of care for the pregnant client diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse would determine that which is the priority concern for this client?

Development of an infection

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking zidovudine 200 mg orally 3 times daily. The client reports to the health care clinic for follow-up blood studies, and the results indicate severe neutropenia. Which would the nurse next anticipate to be prescribed for the client?

Discontinuation of the medication

The client is diagnosed with stage I of Lyme disease. The nurse would check the client for which characteristic of this stage?

Flu-like symptoms

A client is diagnosed with stage I Lyme disease. In addition to the rash, the nurse would check the client for which manifestation?

Flulike symptoms

The nurse is assisting in preparing a plan of care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure would the nurse most likely include in the plan?

Foods that are at room temperature

A nursing student is asked to discuss human immunodeficiency virus (HIV) during a clinical conference. The nursing student would include which correct item in the discussion?

HIV virus attacks the immune system by destroying T lymphocytes. Rationale: The virus attacks the immune system by destroying T lymphocytes. Children born to HIV-positive women test positive for HIV antibody, not HIV virus. This is actually a measure of maternal antibody and not indicative of true infection. T4 cells are depleted in number and cannot signal B cells to form protective antibodies to fight off the invading virus.

The nurse is assigned to care for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the primary health care provider's prescriptions. Which medication would the nurse expect to be prescribed to aid in long-term control?

Hydroxychloroquine Rationale: Hydroxychloroquine, an antimalarial drug, aids in long-term control of SLE. Aspirin is not used in the treatment of SLE. Dehydroepiandrosterone (DHEA), a mild male hormone, is given to treat hair loss, joint pain, fatigue, and memory issues. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to reduce inflammation and control pain.

The nurse is assisting with identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?

Individuals with spina bifida

The nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse would determine that which problem is a priority for the client?

Infection

The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate?

Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable. Submit

The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse would plan care considering which factor regarding this diagnosis?

It is an inflammatory disease of collagen contained in connective tissue.

The camp nurse prepares to instruct a group of children about Lyme disease. Which information would the nurse include in the instructions?

Lyme disease is caused by a tick carried by deer.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure would the nurse implement to assist the client in performing activities of daily living?

Provide supportive care with hygiene needs.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client verbalizes the intent to increase intake of which food(s)?

Puddings

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse would determine that this has been confirmed by which finding?

Punch biopsy of the cutaneous lesions4

The client is suspected of having systemic lupus erythematous (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of SLE?

Rash on the face across the nose and on the cheeks

Tacrolimus is prescribed for a client. Which disorder in the client's record would the nurse note that indicates the medication needs to be administered with caution?

Renal insufficiency

The nurse has a prescription to give a first dose of hydrochlorothiazide to an assigned client. The nurse would question the prescription if the client had a history of allergy to which item?

Sulfa drugs

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking didanosine. The nurse reinforces instructions to the client to watch for which signs/symptoms that the medication may have caused the adverse effect of pancreatitis?

Vomiting and abdominal pain

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate in the plan during the bathing of this client?

Wearing a gown and gloves rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy.

The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. The nurse would determine that which client population is at risk for developing this type of allergy?

hairdressers

A client who is diagnosed positive for human immunodeficiency virus (HIV) has had a tuberculin skin test. The results show a 7-mm area of induration. The nurse would interpret the test results as which response?

it is positive

A client prescribed infliximab via intravenous (IV) injection is complaining of difficulty swallowing. Which would be the initial nursing action?

notify the RN

The client with a diagnosis of acquired immunodeficiency syndrome has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that which procedure will be done to confirm whether these lesions are due to Kaposi's sarcoma?

skin biopsy

The client calls the health care clinic and tells the nurse that he was bitten by a tick. The client asks the nurse about the first signs of Lyme disease. The nurse would respond with which characteristic of stage 1 of Lyme disease?

skin rash

The nurse is collecting data on a client with a diagnosis of rheumatoid arthritis. The nurse looks at the client's hands and notes characteristic deformities. The nurse would identify this as which deformity? Refer to figure.

ulnar drift

The nurse is providing instructions to a client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. The nurse would advise the client to do which action to best increase comfort while minimizing symptoms?

Keep liquids on the nightstand at home.

A client is diagnosed with stage II Lyme disease. The nurse would check the client for which characteristic of this stage?

Nervous system disorders Rationale: If untreated, stage II of Lyme disease begins 2 to 12 weeks after the first stage with carditis and nervous system disorders such as meningitis, peripheral neuritis, or a facial paralysis similar to Bell palsy. Flulike symptoms, "bull's-eye" rash, and stiffness in the joints are symptoms seen in stage I of the disease.

The nurse should interpret that the client prescribed zalcitabine is experiencing an adverse effect of this medication when which event is reported by the client?

Numbness in the legs

A client diagnosed as human immunodeficiency virus (HIV) seropositive is prescribed stavudine. Which measure would the nurse assess most closely while the client is taking this medication?

Presence of paresthesias

The client is diagnosed with an immune deficiency. The nurse focuses on which nursing responsibility as the highest priority when providing care to this client?

Protecting the client from infection

The nurse is assisting with planning the care of a client with a diagnosis of immunodeficiency. The nurse would incorporate which intervention as a priority in the plan of care?

Protecting the client from infection

Dapsone is prescribed for the client diagnosed with acquired immunodeficiency syndrome for the treatment of toxoplasmosis. The nurse should reinforce medication instructions and determine that the client understands the instructions if the client makes which statement?

Report a sore throat to the primary health care provider.

The nurse is instructing a client with a diagnosis of systemic lupus erythematosus (SLE) about dietary alterations. The nurse would remind the client to avoid which primary foods? Select all that apply.

- beef - cheese

Which signs/symptoms would indicate to the nurse that the client is experiencing an anaphylactic reaction? Select all that apply.

- hives - stridor - dyspnea - urticaria - wheezing

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 would question the client about an allergy to which food items? Select all that apply.

- kiwi - bananas

Which symptoms would the nurse anticipate and monitor for in clients diagnosed with stage 4 human immunodeficiency virus (HIV) infection? Select all that apply.

- lymphoma - Kaposi's sarcoma - candidiasis of the esophagus

The nurse is explaining about antigens and antibodies when the client asks where antibodies come from. The nurse would include which areas as the most appropriate response? Select all that apply.

- tears - spleen - saliva - blood serum - lymph nodes

The nurse would determine that which are risk factors for systemic lupus erythematous (SLE)? Select all that apply.

-Female gender -African American origin - Being in the childbearing years

The nurse is preparing a client scheduled for an intravenous pyelogram (IVP). The nurse would take which important action before the test?

Ask about allergies to iodine or shellfish.

The nurse is reinforcing dietary instructions to a client diagnosed with systemic lupus erythematosus. Which dietary item would the nurse most instruct the client to avoid?

Steak rationale: The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake.

A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) has a low T4 count. The nurse initiates prophylactic treatment as prescribed with aerosolized pentamidine isethionate and would monitor for which expected outcome?

The client has a respiratory rate and depth within normal limits for the activity level. Rationale: Aerosolized pentamidine is given prophylactically to clients with a T4 count below 200 to prevent Pneumocystis jiroveci pneumonia, which is the most common opportunistic infection that occurs in clients with AIDS. A respiratory rate and depth within normal limits for activity level would indicate that the client was not experiencing the respiratory difficulty that is associated with pneumonia

A client diagnosed with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a client problem of impaired gas exchange written in the plan of care. Which indicates that the expected outcome of care has not yet been achieved?

The client limits fluid intake.

A client prescribed zidovudine has been diagnosed with severe neutropenia. The nurse anticipates which intervention would be implemented?

The medication will be temporarily discontinued.

The nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse would inform the students that which behavior is most unsafe?

Use of natural skin condoms

The nurse is reviewing the medical record of a client who is suspected of having systematic lupus erythematosus (SLE). Which sign would the nurse expect to be documented in the record that is most related to this diagnosis?

Butterfly rash on cheeks and bridge of the nose

The nurse is collecting data on a client complaining of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse would further check for which manifestation that is also indicative of the presence of SLE?

Butterfly rash on the cheeks and bridge of the nose

The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which would be the appropriate nursing action?

Ask the client if they ever sustained a bee sting in the past.

The licensed practical nurse (LPN) is caring for a client with a wound culture positive for methicillin-resistant Staphylococcus aureus (MRSA). Which client data would be the priority to immediately report to the registered nurse (RN)?

Blood cultures are positive for gram-positive cocci in clusters

The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). The nurse assesses a rash on the client's face. What is the name of the major skin manifestation of discoid lupus erythematosus (DLE) and SLE?

Butterfly rash

The primary health care provider prescribes fluconazole for the client. When administering this medication the nurse would explain to the client that it is prescribed to treat which opportunistic infection?

Candidiasis Rationale: Fluconazole is a broad-spectrum antifungal medication.