Immune Disorders

12. The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? *Select all that apply.* 1. Muscle flaccidity 2. Lethargy 3. Dysmetria 4. Fatigue 5. Dysphagia

*1. Muscle flaccidity is a hallmark symptom of MS.* 2. Lethargy is the state of prolonged sleepiness or serious drowsiness and is not associated with MS. *3. Dysmetria is the inability to control muscular action characterized by overestimating or underestimating range of movement.* *4. Fatigue is a symptom of MS.* *5. Dysphagia, or difficulty swallowing, is associated with MS.*

2. The client newly diagnosed with multiple sclerosis (MS) states, "I don't understand how I got multiple sclerosis. Is it genetic?" On which statement should the nurse base the response? 1. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. 2. There is no evidence suggesting there is any chromosomal involvement in developing MS. 3. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS. 4. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.

*1. The exact cause of MS is not known, but there is a theory stating a slow virus is partially responsible. A failure of a part of the immune system may also be at fault. A genetic predisposition involving chromosomes 2, 3, 7, 11, 17, 19, and X may be involved.* 2. There is some evidence supporting a genetic component involved in developing MS. 3. A specific gene has not been identified to know if the gene is recessive or dominant. 4. The X chromosome, not the Y chromosome, may be involved.

9. The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is *most appropriate* by the nurse? 1. Encourage the therapy if it is not contraindicated by the medical regimen. 2. Tell the client only the health-care provider should discuss this with him. 3. Ask how his significant other feels about this deviation from the medical regimen. 4. Suggest the client research an investigational therapy instead.

*1. The nurse should listen without being judgmental about any alterative therapy the client is considering. Alternative therapies, such as massage and relaxation, are frequently beneficial and enhance the medical regimen.* 2. The nurse can discuss alternative therapy with the client. 3. This is not addressing the client's concern of using alternative treatment. 4. Investigational therapies are treatments that may have efficacy if proved by scientific methods. It is the health-care provider's responsibility to discuss these therapies with the client.

11. The nurse writes the client problem of "altered sexual functioning" for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented? 1. Encourage the couple to explore alternative ways of maintaining intimacy. 2. Make an appointment with a psychotherapist to counsel the couple. 3. Explain daily exercise will help increase libido and sexual arousal. 4. Discuss the importance of keeping physically calm during sexual intercourse.

*1. This will assist the client and significant other to maintain a close relationship without putting undue pressure on the client.* 2. This is a real physical problem, not a psychological one. 3. The problem is impotence, not libido. 4. The problem is not psychosocial. It is a physical problem, and staying calm will not help.

Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching? 1. "I will not have any menstrual cycles because of this disease." 2. "I should avoid people who have respiratory infections." 3. "I should not take a hot bath or swim in cold water." 4. "I will drink at least 2,500 mL of water a day."

1. "I will not have any menstrual cycles because of this disease." 1. MG has no effect on the ovarian function and the uterus is an involuntary muscle, not a skeletal muscle, so the menstrual cycle is not affected. 2. Infections can result in an exacerbation and extreme weakness. 3. An extremely hot or cold environment may cause an exacerbation of MG. 4. This will help the client mobilize and expectorate sputum.

4. The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the *most therapeutic* response for the nurse to make? 1. "Why are you crying? The medication will help the disease." 2. "You seem upset. I will sit down and we can talk for awhile." 3. "Multiple sclerosis is a disease that has good times and bad times." 4. "I will have the chaplain come and stay with you for a while."

1. "Why" is requesting an explanation, and the client does not owe the nurse an explanation. *2. This is stating a fact and offering self. Both are therapeutic techniques for conversations.* 3. The client did not ask about the nature of MS. The client needs to be able to verbalize feelings. 4. This is "passing the buck." Therapeutic communication is an integral part of nursing.

The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)? 1. Administer the medication 30 minutes prior to meals. 2. Instruct the client to take with eight (8) ounces of water. 3. Explain the importance of sitting up for one (1) hour after taking medication. 4. Assess the client's blood pressure prior to administering medication.

1. Administer the medication 30 minutes prior to meals. 1. This medication will increase muscle strength to help enhance swallowing and chewing during meals. 2. There is no need for the client to take this medication with eight (8) ounces of water. 3. The client does not have to sit up after taking this medication. 4. These assessment data would not cause the nurse to question administering this medication.

The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply. 1. Assist the client to turn and cough every two (2) hours. 2. Place the client in a high or semi-Fowler's position. 3. Assess the client's pulse oximeter reading every shift. 4. Plan meals to promote medication effectiveness. 5. Monitor the client's serum anticholinesterase levels.

1. Assist the client to turn and cough every two (2) hours. 2. Place the client in a high or semi-Fowler's position. 4. Plan meals to promote medication effectiveness. 1. Position changes promote lung expansion, and coughing helps clear secretions from the tracheobronchial tree. 2. This position expands the lungs and alleviates pressure from the diaphragm. 3. The respiratory system and pulse oximeter reading should be assessed more frequently than every shift; it should be done every four (4) hours or more often. 4. The medications should be administered 30 minutes before the meal to provide optimal muscle strength for swallowing and chewing. 5. There is no serum level available for medications used to treat MG; the client's signs/symptoms are used to determine the effectiveness of this medication.

The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with SLE who is complaining of chest pain. 2. The client diagnosed with MS who is complaining of pain at a "10." 3. The client diagnosed with myasthenia gravis who has dysphagia. 4. The client diagnosed with GB syndrome who can barely move his toes.

1. Chest pain should be considered a priority regardless of the admitting diagnosis. Clients diagnosed with SLE can develop cardiac complications.

63. The client diagnosed with a bee sting allergy is being discharged from the emergency department. Which priority discharge instruction should be taught to the client? 1. Demonstrate how to use an EpiPen, an adrenergic agonist. 2. Teach the client to never go outdoors in the spring and summer. 3. Have the client buy diphenhydramine over the counter to use when stung. 4. Discuss wearing a Medic Alert bracelet when going outside.

1. Clients who are allergic to bee sting venom should be taught to keep an EpiPen with them at all times and how to use the device. This could save their lives.

The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others? 1. Discuss ways to help prevent choking episodes. 2. Explain how to care for a client on a ventilator. 3. Teach how to perform passive range-of-motion exercises. 4. Demonstrate how to care for the client's feeding tube.

1. Discuss ways to help prevent choking episodes. 1. The client is at risk for choking; knowing specific measures to help the client helps decrease the client's, as well as the significant other's, anxiety and promotes confidence in managing potential complications. 2. Clients diagnosed with MG may end up on a ventilator at the end stage of the disease, but these clients would not be cared for at home; this would be a very unusual situation. 3. The client should be encouraged to perform active range-of-motion exercises, but the most important intervention is treating choking episodes. 4. The client with MG doesn't necessarily have a feeding tube, and this information is not in the stem.

59. The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? 1. The client who has flushed, warm skin with tented turgor. 2. The client who states the staff ignores the call light. 3. The client whose vital signs are T 99.9˚F, P 101, R 26, and BP 110/68. 4. The client who is unable to provide a sputum specimen.

1. Flushed warm skin with tented turgor indicates dehydration. The HCP should be notified immediately for fluid orders or other orders to correct the reason for the dehydration.

79. The 20-year-old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications? 1. "Are you sexually active, and, if so, are you using birth control?" 2. "Have you discussed taking these drugs with your parents?" 3. "Which arm do you prefer to have an IV in for four (4) days?" 4. "Have you signed an informed consent for investigational drugs?"

1. Immunosuppressive medications are considered class C drugs and should not be taken while pregnant. These drugs are teratogenic and carcinogenic, and the client is only 20 years old.

3. The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is *most important* for the nurse to ask the client? 1. "Have you experienced any difficulty with your menstrual cycle?" 2. "Have you noticed a rash across the bridge of your nose?" 3. "Do you get tired easily and sometimes have problems swallowing?" 4. "Are you taking birth control pills to prevent conception?"

1. MS does not affect the menstrual cycle. 2. A rash across the bridge of the nose suggests systemic lupus erythematosus. *3. These are clinical manifestation of MS and can go undiagnosed for years because of the remitting-relapsing nature of the disease. Fatigue and difficulty swallowing are other symptoms of MS.* 4. Taking birth control medications should not produce these symptoms or the pattern of occurrence.

84. The nurse is preparing to administer morning medications. Which medication should the nurse administer first? 1. The pain medication to a client diagnosed with RA. 2. The diuretic medication to a client diagnosed with SLE. 3. The steroid to a client diagnosed with polymyositis. 4. The appetite stimulant to a client diagnosed with OA.

1. Pain medication is important and should be given before the client's pain becomes worse.

53. The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? 1. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. 2. The HIV virus can be eradicated from the host body with the correct medical regimen. 3. It is difficult for the HIV virus to replicate in humans because it is a monkey virus. 4. The HIV virus uses the client's own red blood cells to reproduce the virus in the body.

1. Retroviruses never die; the virus may become dormant, only to be reactivated at a later time.

72. The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply. 1. Prepare to administer Solu-Medrol, a glucocorticoid, IV. 2. Request and obtain a STAT chest x-ray. 3. Initiate the Rapid Response Team. 4. Administer epinephrine, an adrenergic blocker, SQ then IV continuous. 5. Assess for the client's pulse and respirations.

1. Steroid medications decrease inflammation and therefore are one of the treatments for anaphylaxis. 2. A STAT chest x-ray is not indicated at this time. 3. The Rapid Response Team should be called because this client will be in respiratory and cardiac arrest very shortly. 4. Because of its ability to activate a combination of alpha and beta receptors, epinephrine is the treatment of choice for anaphylactic shock. 5. The first step in initiating cardiopulmonary resuscitation is to assess for a pulse and respirations.

10. The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented? 1. Discuss discontinuing the proton pump inhibitor with the HCP. 2. Hold the medication until after all cultures have been obtained. 3. Monitor the client's serum blood glucose levels frequently. 4. Provide supplemental dietary sodium with the client's meals.

1. Steroid medications increase gastric acid; therefore, a proton pump inhibitor is an appropriate medication for the client. 2. Cultures are ordered prior to administering antibiotics, not steroids. *3. Steroids interfere with glucose metabolism by blocking the action of insulin; therefore, the blood glucose levels should be monitored.* 4. Steroid medications cause the client to retain sodium; therefore, a low-sodium diet should be encouraged.

38. The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply. 1. Use a sunscreen of SPF 30 or greater when in the sunlight. 2. Notify the HCP immediately when developing a low-grade fever. 3. Some dyspnea is expected and does not need immediate attention. 4. The hands and feet may change color if exposed to cold or heat. 5. Explain the client can be cured with continued therapy.

1. Sunlight or UV light exposure has been shown to initiate an exacerba tion of SLE, so the client should be taught to protect the skin when in the sun. 2. A fever may be the first indication of an exacerbation of SLE. 4. Raynaud's phenomenon is a condition in which the digits of the hands and feet turn red, blue, or white in response to heat or cold and stress. It occurs with some immune inflammatory processes.

50. The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention? 1. Assess the client's body weight and ask what the client has been able to eat. 2. Place in contact isolation and don a mask and gown before entering the room. 3. Check the HCP's orders and determine what laboratory tests will be done. 4. Teach the client about total parenteral nutrition and monitor the subclavian IV site.

1. The client has a malnutrition syndrome. The nurse assesses the body and what the client has been able to eat.

The client with myasthenia gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is effective? 1. The client is able to feed self independently. 2. The client is able to blink the eyes without tearing. 3. The client denies any nausea or vomiting when eating. 4. The client denies any pain when performing ROM exercises.

1. The client is able to feed self independently. 1. This medication promotes muscle contraction, which improves muscle strength, which, in turn, allows the client to perform ADLs without assistance. 2. This medication does not affect secretions of the eye. 3. This medication does not help with the digestion of food. 4. This medication does not help with pain; clients with MG do not have muscle pain.

The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention? 1. The client's BP is 94/60 and AP is 112. 2. Negative Chvostek's and Trousseau's signs. 3. The serum potassium level is 3.5 mEq/L. 4. Ecchymosis at the vascular site access.

1. The client's BP is 94/60 and AP is 112. 1. Hypovolemia is a complication of plasmapheresis, especially during the procedure, when up to 15% of the blood volume is in the cell separator. 2. Positive Chvostek's and Trousseau's signs (not negative signs) warrant intervention and indicate hypocalcemia, which is a complication of plasmapheresis. 3. This is a normal serum potassium level (3.5 to 5.5 mEq/L), which does not warrant intervention, but the level should be monitored because plasmapheresis could cause hypokalemia. 4. Ecchymosis (bruising) does not warrant immediate intervention. Signs of infiltration or infection warrant immediate intervention.

8. The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which nursing task should *not* be assigned to the LPN? 1. Administer a skeletal muscle relaxant to a client diagnosed with low back pain. 2. Discuss bowel regimen medications with the HCP for the client on strict bedrest. 3. Draw morning blood work on the client diagnosed with bacterial meningitis. 4. Teach self-catheterization to the client diagnosed with multiple sclerosis.

1. The licensed practical nurse (LPN) can administer a muscle relaxant. 2. The licensed practical nurse can talk with a health-care provider about medication the LPN can give. 3. The LPN can draw blood. *4. The nurse should not assign assessing, teaching, or evaluation to the LPN. Evaluating the client's ability to perform self-catheterization should not be assigned to the LPN.*

74. The client with RA has nontender, movable nodules in the subcutaneous tissue over the elbows and shoulders. Which statement is the scientific rationale for the nodules? 1. The nodules indicate a rapidly progressive destruction of the affected tissue. 2. The nodules are small amounts of synovial fluid that have become crystallized. 3. The nodules are lymph nodes which have proliferated to try to fight the disease. 4. The nodules present a favorable prognosis and mean the client is better.

1. The nodules may appear over bony prominences and resolve simultaneously. They appear in clients with the rheumatoid factor and are associated with rapidly progressive and destructive disease.

55. The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? 1. Flush the skin with water and try to get the area to bleed. 2. Notify the charge nurse and complete an incident report. 3. Report to the employee health nurse for prophylactic medication. 4. Follow up with the infection control nurse to have lab work done.

1. The nurse should attempt to flush the skin and get the area to bleed. It is hoped this will remove contaminated blood from the body prior to infecting the nurse.

6. The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss." Which intervention should be implemented *first*? 1. Consult the physical therapist for assistive devices for mobility. 2. Determine if the client has a legal power of attorney. 3. Ask if the client would like to talk to the hospital chaplain. 4. Discuss the client's wishes regarding end-of-life care.

1. The problem is grieving R/T loss of functioning. Assistive devices will not prevent loss of functioning and do not address grieving. 2. A legal power of attorney is for personal property and control of financial issues, which is not the focus of the nurse's care. A legal power of attorney for health care may be appropriate. 3. The nurse should and must discuss end-of-life issues with the client and does not need to contact the hospital chaplain. *4. The client should make personal choices about end-of-life issues while it is possible to do so. This client is progressing toward immobility and all the complications related to it.*

1. The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation *warrants immediate* intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia.

1. These are clinical manifestations of multiple sclerosis and are expected. 2. These are expected clinical manifestations of multiple sclerosis. 3. These are expected clinical manifestations of multiple sclerosis. *4. Dysphagia is a common problem of clients diagnosed with multiple sclerosis, and this places the client at risk for aspiration pneumonia. Some clients diagnosed with multiple sclerosis eventually become immobile and are at risk for pneumonia.*

69. The nurse is developing a care plan for a client diagnosed with allergic rhinitis. Which independent problem has priority? 1. Ineffective breathing pattern. 2. Knowledge deficit. 3. Anaphylaxis. 4. Ineffective coping.

1. This can be an independent or collabo rative nursing problem. It is an airway problem and has priority.

5. The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which information should the nurse teach the client about the test? 1. The client will have wires attached to the scalp and lights will flash off and on. 2. The machine will be loud and the client must not move the head during the test. 3. The client will drink a contrast medium 30 minutes to one (1) hour before the test. 4. The test will be repeated at intervals during a five (5)- to six (6)-hour period.

1. This describes an evoked potential electroencephalogram (EEG). *2. MRI scans require the client to lie still and not move the body; the client should be warned about the loud noise.* 3. The client does not drink any contrast medium. If contrast is used, it will be given IVP for a CT scan. 4. The test is performed at one time.

7. The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of *most importance*? 1. The client refuses to have a gastrostomy feeding. 2. The client wants to discuss if she should tell her fiancé. 3. The client tells the nurse life is not worth living anymore. 4. The client needs the flu and pneumonia vaccines.

1. This issue is not a priority concern of a newly diagnosed client with MS. 2. This is not priority over a potential suicide statement. *3. A potential suicide statement is priority for the nurse when caring for the client with MS.* 4. Flu and pneumonia vaccines are not priority.

37. The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is suspected? 1. Complete metabolic panel and liver function tests. 2. Complete blood count and antinuclear antibody tests. 3. Cholesterol and lipid profile tests. 4. Blood urea nitrogen and glomerular filtration tests.

2. No single laboratory test diagnoses SLE, but the client usually presents with moderate to severe anemia, thrombocytopenia, leukopenia, and a positive antinuclear antibody.

57. The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP's order should the nurse implement first? 1. Draw a serum for CD4 and complete blood count STAT. 2. Administer oxygen to the client via nasal cannula. 3. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB. 4. Obtain a sputum specimen for culture and sensitivity.

2. Oxygen is a priority, especially with a client diagnosed with a respiratory illness.

Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis? 1. Weakness and fatigue. 2. Ptosis and diplopia. 3. Breathlessness and dyspnea. 4. Weight loss and dehydration.

2. Ptosis and diplopia. 1. These are musculoskeletal manifestations of myasthenia gravis. 2. These are ocular signs/symptoms of MG. Ptosis is drooping of the eyelid, and diplopia is unilateral or bilateral blurred vision. 3. These are respiratory manifestations of myasthenia gravis. 4. These are nutritional manifestations of myasthenia gravis.

45. The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse? 1. The UAP washes her hands before and after performing vital signs on a client. 2. The UAP dons sterile gloves prior to removing an indwelling catheter from a client. 3. The UAP raises the head of the bed to a high Fowler's position for a client about to eat. 4. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.

2. The UAP can remove an indwelling catheter with nonsterile gloves. This is a waste of expensive equipment. The nurse is responsible for teaching UAPs appropriate use of equipment and supplies and cost containment.

76. The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach? 1. Explain the medication loses its efficacy after a few months. 2. Continue to have checkups and lab work while taking the medication. 3. Have yearly magnetic resonance imaging to follow the progress. 4. Discuss the drug is taken for three (3) weeks and then stopped for a week.

2. The drug requires close monitoring to prevent organ damage.

77. The client diagnosed with RA has developed swan-neck fingers. Which referral is most appropriate for the client? 1. Physical therapy. 2. Occupational therapy. 3. Psychiatric counselor. 4. Home health nurse.

2. The occupational therapist assists the client in the use of the upper half of the body, fine motor skills, and activi ties of daily living. This is needed for the client with abnormal fingers.

65. The client in the HCP's office is complaining of allergic rhinitis. Which assessment question is important for the nurse to ask the client? 1. "What time of year do the symptoms occur?" 2. "Which over-the-counter medications have you tried?" 3. "Do other members of your family have allergies to animals?" 4. "Why do you think you have allergies?"

2. There are many over-the-counter remedies available. Therefore, the nurse should assess which medications the client has tried and what medica tions the client is currently taking.

70. The nurse on a medical unit has received the morning shift report. Which client should the nurse assess first? 1. The client who has a 0730 sliding-scale insulin order. 2. The client who received an initial dose of IV antibiotic at 0645. 3. The client who is having back pain at a "4" on a 1-to-10 scale. 4. The client who has dysphagia and needs to be fed.

2. This client has received an initial dose of antibiotic IV and should be assessed for tolerance to the medication within 30 minutes.

51. The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? 1. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush. 2. Notify the HCP for an order for an antifungal swish-and-swallow medication. 3. Have the client gargle with an antiseptic-based mouthwash several times a day. 4. Determine what types of food the client has been eating for the last 24 hours.

2. This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition.

Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process? 1. There is no surgical option. 2. A transsphenoidal hypophysectomy. 3. A thymectomy. 4. An adrenalectomy.

3. A thymectomy. 1. There is a surgical option available. 2. This surgery is performed in clients with pituitary tumors and is accomplished by going through the client's upper lip though the nasal passage. 3. In about 75% of clients with MG, the thymus gland (which is usually inactive after puberty) continues to produce antibodies, triggering an autoimmune response in MG. After a thymectomy, the production of autoantibodies is reduced or eliminated, and this may resolve the signs/symptoms of MG. 4. An adrenalectomy is the surgery for a client diagnosed with Cushing's disease, a disease in which there is an increased secretion of glucocorticoids and mineralocorticoids.

81. The nurse is caring for clients on a medical floor. Which client should the nurse assess first? 1. The client diagnosed with RA complaining of pain at a "3" on a 1-to-10 scale. 2. The client diagnosed with SLE who has a rash across the bridge of the nose. 3. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV. 4. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.

3. Antineoplastic drugs can be caustic to tissues; therefore, the client's IV site should be assessed. The client should be assessed for any untoward reactions to the medications first.

61. The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse? 1. The nurse explains the IVP diuretic will make the client urinate. 2. The nurse dons nonsterile gloves to remove the client's dressing. 3. The nurse administers a medication without checking for allergies. 4. The nurse asks the UAP for help moving a client up in bed.

3. Checking for allergies is one (1) of the five (5) rights of medication. Is it the right drug? Even if the drug is the one the HCP ordered, it is not the right drug if the client is allergic to it. The nurse should always assess a client's allergies prior to administering any medication.

58. Which intervention is an important psychosocial consideration for the client diagnosed with AIDS? 1. Perform a thorough head-to-toe assessment. 2. Maintain the client's ideal body weight. 3. Complete an advance directive. 4. Increase the client's activity tolerance.

3. Clients diagnosed with AIDS should be encouraged to discuss their end-of-life issue with the significant others and to put those wishes in writing. This is important for all clients, not just those diagnosed with AIDS.

68. The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach? 1. Tell the client never to scratch the rash. 2. Instruct the client in administering IM Benadryl. 3. Explain how to take a steroid dose pack. 4. Have the client wear shirts with long sleeves and high necks.

3. Clients with poison ivy are frequently prescribed a steroid dose pack. The dose pack has the steroid provided in descending doses to help prevent adrenal insufficiency.

71. The nurse in the holding area of the operating room is assessing the client prior to surgery. Which information warrants immediate intervention by the nurse? 1. The client is able to mark the correct site for the surgery. 2. The client can only tell the nurse about the surgery in lay terms. 3. The client is allergic to iodine and does not have an allergy bracelet. 4. The client has signed a consent form for surgery and anesthesia.

3. Iodine is the basic ingredient in Betadine (povidone-iodine), which is a common skin prep used for surgeries. Therefore, the nurse should notify the surgeon if the client has an allergy to iodine.

48. The nurse is discussing autoimmune diseases with a class of nursing students. Which signs and symptoms are shared by rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE)? 1. Nodules in the subcutaneous layer and bone deformity. 2. Renal involvement and pleural effusions. 3. Joint stiffness and pain. 4. Raynaud's phenomenon and skin rash.

3. Joint stiffness and pain are symptoms occuring in both diseases.

73. The client diagnosed with RA is being seen in the outpatient clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits? 1. Perform joint x-rays to determine progression of the disease. 2. Send blood to the lab for an erythrocyte sedimentation rate. 3. Recommend the flu and pneumonia vaccines. 4. Assess the client for increasing joint involvement.

3. RA is a disease with many immunologi cal abnormalities. The clients have increased susceptibility to infectious disease, such as the flu or pneumonia, and therefore vaccines, which are preventive, should be recommended.

The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client? 1. The client will maintain reproductive ability. 2. The client will verbalize feelings of body-image changes. 3. The client will have no deterioration of organ function. 4. The client's skin will remain intact and have no irritation.

3. SLE can invade and destroy any body system or organ. Maintaining organ function is the primary goal of SLE treatment.

47. The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing? 1. Tapering the medication prevents the client from having withdrawal symptoms. 2. So thyroid gland starts working, because this medication stops it from working. 3. Tapering the dose allows the adrenal glands to begin to produce cortisol again. 4. This is the health-care provider's personal choice in prescribing the medication.

3. Tapering steroids is important because the adrenal gland stops producing cor tisol, a glucocorticosteroid, when the exogenous administration of steroids exceeds what normally is produced. The functions of cortisol in the body are to regulate glucose metabolism and maintain blood pressure.

80. Which client problem is priority for a client diagnosed with RA? 1. Activity intolerance. 2. Fluid and electrolyte imbalance. 3. Alteration in comfort. 4. Excessive nutritional intake.

3. The client diagnosed with RA has chronic pain; therefore, alteration in comfort is a priority problem.

64. The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first? 1. Initiate an IV with normal saline. 2. Prepare to intubate the client. 3. Administer oxygen at 100%. 4. Ask the client about an iodine allergy.

3. The client is cyanotic with dyspnea and wheezing. The nurse should adminis ter oxygen first.

60. The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation? 1. Assign a different nurse every shift to the client. 2. Ask the HCP to tell the client not to yell at the staff. 3. Call a team meeting and discuss options with the staff. 4. Tell one (1) staff member to care for the client a week at a time.

3. The health-care team should meet to discuss ways to best help the client deal with the anger being expressed, and the staff should be consistent in working with the client.

82. The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse? 1. Administer methotrexate, an antineoplastic medication, IV. 2. Assess the lung sounds of a client with RA who is coughing. 3. Demonstrate how to use clothing equipped with Velcro fasteners. 4. Discuss methods of birth control compatible with treatment medications.

3. The licensed practical nurse (LPN) can demonstrate how to use adaptive clothing.

41. The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE? 1. The steroids will increase the body's ability to fight the infection. 2. The steroids will decrease the chance of the SLE spreading to other organs. 3. The steroids will suppress tissue inflammation, which reduces damage to organs. 4. The steroids will prevent scarring of skin tissues associated with SLE.

3. The main function of steroid medica tions is to suppress the inflammatory response of the body.

62. The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves? 1. Use only sterile, nonlatex gloves for any procedure requiring gloves. 2. Do not use gloves when starting an IV or performing a procedure. 3. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform. 4. Wear white cotton gloves at all times to protect the hands.

3. The nurse should be prepared to care for a client at all times and should not place himself or herself at risk because the facility does not keep nonlatex gloves available in the rooms. The nurse should carry the needed equip ment (nonlatex gloves) with him or her.

54. The client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? 1. The client is fortunate not to have contracted HIV from an infected needle. 2. The client must be repeatedly exposed to HIV before becoming infected. 3. The client may be in the primary infection phase of an HIV infection. 4. The antibody test is negative because the client has a different flu virus.

3. The primary phase of infection ranges from being asymptomatic to severe flu-like symptoms, but during this time, the test may be negative although the individual is infected with HIV.

The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented? 1. Use astringent lotion on the face and skin. 2. Inspect the skin weekly for open areas or rashes. 3. Dry the skin thoroughly by patting. 4. Apply anti-itch medication between the toes.

3. The skin should be washed with mild soap, rinsed, and patted dry. Rubbing can cause abrasions and skin breakdown.

49. The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? 1. Females taking birth control pills are protected from becoming infected with HIV. 2. Protected sex is no longer an issue because there is a vaccine for the HIV virus. 3. Adolescents with a normal immune system are not at risk for developing AIDS. 4. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.

4. Abstinence is the only guarantee the client will not contract a sexually trans mitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relation ship is the safest sexual relationship.

66. The client asks the nurse, "Which time of the year is allergic rhinitis least likely to occur?" Which statement is the nurse's best response? 1. "It is least likely to occur during the springtime." 2. "Allergic rhinitis is not likely to occur during the summer." 3. "It is least likely to occur in the early fall." 4. "Allergic rhinitis is least likely to occur in early winter."

4. Early winter is the beginning of deciduous plants becoming dormant. Therefore, allergic rhinitis is least prevalent during this time of year.

83. The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instruction should the nurse teach regarding the use of nonsteroidal anti inflammatory drugs (NSAIDs)? 1. Take with an over-the-counter medication for the stomach. 2. Drink a full glass of water with each pill. 3. If a dose is missed, double the medication at the next dosing time. 4. Avoid taking the NSAID on an empty stomach.

4. NSAID medications decrease prostaglandin production in the stomach, resulting in less mucus production, which creates a risk for the development of ulcers. The client should take the NSAID with food.

56. The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority? 1. Altered nutrition, less than body requirements. 2. Anticipatory grieving. 3. Knowledge deficit, procedures and prognosis. 4. Risk for injury.

4. Safety is always an issue with a client with diminished mental capacity.

The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse? 1. Discuss the Myasthenia Foundation with the client's wife. 2. Refer the client to a local myasthenia gravis support group. 3. Ask the client's wife if she would like to talk to a counselor. 4. Sit down and allow the wife to ventilate her feelings to the nurse.

4. Sit down and allow the wife to ventilate her feelings to the nurse. 1. This is an appropriate action by the nurse, but it is not the best action. 2. Support groups are helpful to the client's significant others, but in this situation, it is not the best action for the nurse. 3. A counselor is an appropriate intervention, but it is not the best action. 4. Directly addressing the wife's feelings is the best action for the nurse in this situation. All the other options can be done, but the best action is to address the wife's feelings.

78. The nurse is planning the care for a client diagnosed with RA. Which intervention should be implemented? 1. Plan a strenuous exercise program. 2. Order a mechanical soft diet. 3. Maintain a keep-open IV. 4. Obtain an order for a sedative.

4. Sleep deprivation resulting from pain is common in clients diagnosed with RA. A mild sedative can increase the client's ability to sleep, promote rest, and increase the client's tolerance of pain.

Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis? 1. Occupational therapist. 2. Recreational therapist. 3. Vocational therapist. 4. Speech therapist.

4. Speech therapist. 1. The occupational therapist assists the client with ADLs, but with MG the client has no problems with performing them if the client takes the medication correctly (30 minutes prior to performing ADLs). 2. A recreational therapist is usually in a psychiatric unit or rehabilitation unit. 3. A vocational therapist or counselor helps with the client finding a job which accommodates the disease process; clients with MG are usually not able to work in the late stages. 4. Speech therapists address swallowing problems, and clients with MG are dysphagic and at risk for aspiration. The speech therapist can help match food consistency to the client's ability to swallow, which enhances client safety.

52. Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections? 1. Contact Precautions. 2. Airborne Precautions 3. Droplet Precautions. 4. Standard Precautions.

4. Standard Precautions are used for all contact with blood and body secretions.

The client diagnosed with myasthenia gravis is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a cholinergic crisis? 1. The serum assay of circulating acetylcholine receptor antibodies is increased. 2. The client's symptoms improve when administering a cholinesterase inhibitor. 3. The client's blood pressure, pulse, and respirations improve after IV fluid. 4. The Tensilon test does not show improvement in the client's muscle strength.

4. The Tensilon test does not show improvement in the client's muscle strength. 1. This is a diagnostic test done to diagnose MG. 2. These assessment data indicate the client is experiencing a myasthenic crisis, which is the result of undermedication, missed doses of medication, or the development of an infection. 3. The vital signs do not indicate if the client is experiencing a cholinergic crisis. 4. The injection of edrophonium chloride (Tensilon test) not only diagnoses MG but helps to determine which type of crisis the client is experiencing. In a myasthenic crisis, the test is positive (the client's muscle strength improves), but in cholinergic crisis, the test is negative (there is no improvement in muscle strength), or the client will actually get worse and emergency equipment must be available.

75. The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention? 1. The client complains of joint stiffness and the knees feel warm to the touch. 2. The client has experienced one (1)-kg weight loss and is very tired. 3. The client requires a heating pad applied to the hips and back to sleep. 4. The client is crying, has a flat facial affect, and refuses to speak to the nurse.

4. The client has the signs and symptoms of depression. The nurse should attempt to intervene with therapeutic conversation and discuss these findings with the HCP.

The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis? 1. The client has no apparent change in the assessment data. 2. There is increased amplitude of electrical stimulation in the muscle. 3. The circulating acetylcholine receptor antibodies are decreased. 4. The client shows a marked improvement of muscle strength.

4. The client shows a marked improvement of muscle strength. 1. No change in the client's muscles strength indicates it is not MG. 2. There is reduced amplitude in an electromyogram (EMG) in a client with MG. 3. The serum assay of circulating acetylcholine receptor antibodies is increased, not decreased, in MG, and this test is only 80% to 90% accurate in diagnosing MG. 4. Clients with MG show a significant improvement of muscle strength lasting approximately five (5) minutes when Tensilon (edrophonium chloride) is injected.

42. The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response? 1. "I know you are upset, but stress makes the SLE worse." 2. "Please explain to me why you are crying." 3. "I recommend going to an SLE support group." 4. "I see you are crying. We can talk if you would like."

4. The nurse stated a fact, "You are crying," and then offered self by saying "Would you like to talk?" This addresses the nonverbal cue, crying, and is a therapeutic response.

46. The client recently diagnosed with SLE asks the nurse, "What is SLE and how did I get it?" Which statement best explains the scientific rationale for the nurse's response? 1. SLE occurs because the kidneys do not filter antibodies from the blood. 2. SLE occurs after a viral illness as a result of damage to the endocrine system. 3. There is no known identifiable reason for a client to develop SLE. 4. This is an autoimmune disease that may have a genetic or hormonal component.

4. There is evidence for familial and hor monal components to the development SLE. SLE is an autoimmune disease process in which there is an exagger ated production of autoantibodies.

40. The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE? 1. Pericardial friction rub and crackles in the lungs. 2. Muscle spasticity and bradykinesia. 3. Hirsutism and clubbing of the fingers. 4. Somnolence and weight gain.

40. 1. SLE can affect any organ. It can cause pericarditis and myocardial ischemia as well as pneumonia or pleural effusions.

67. The client is highly allergic to insect venom and is prescribed venom immunotherapy. Which statement is the scientific rationale for this treatment? 1. Immunotherapy is effective in preventing anaphylaxis following a future sting. 2. Immunotherapy will prevent all future insect stings from harming the client. 3. This therapy will cure the client from having any allergic reactions in the future. 4. This therapy is experimental and should not be undertaken by the client.

67. 1. Immunotherapy does not cure the problem. However, if immunotherapy is done following a reaction, it provides passive immunity to the insect venom (similar to the way RhoGAM prevents a mother who is Rh negative from building antibodies to the blood of a baby who is Rh positive). This is the purpose for immunotherapy in clients who are allergic.