Immune NCLEX-PN 6th Edition

The nurse is assessing a client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection?

"Did you have chicken pox as a child?"

Indinavir (Crixivan) is prescribed for a client 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."

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

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

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

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

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

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

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 should the nurse ask next?

"When were you bitten by the tick?"

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

An individual working in an environment where exposure to asbestos exists

Which are risk factors for systemic lupus erythematous (SLE)? Select all that apply.

Female gender African-American origin Being in the childbearing years

Which findings should 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 immunization

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

Lyme disease is caused by a tick carried by deer

Which symptoms should the nurse expect and monitor for in clients with Stage 4 human immunodeficiency virus (HIV) infection? Select all that apply.

Lymphoma Kaposi sarcoma Candidiasis of the esophagus

A 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 in planning care for a client with a diagnosis of immune deficiency. The nurse should incorporate which as a priority in the plan of care?

Protecting the client from infection

A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which is one of the initial characteristic signs/symptoms of systemic lupus erythematous?

Rash on the face across the nose and on the cheeks

A client is positively diagnosed with stage 1 Lyme disease. The client asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which treatment will be included in the care plan?

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

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 explains the test results to the client, providing which information?

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

The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that immunization provides which?

Acquired immunity from disease

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

Administer an antipyretic at bedtime

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

An autoimmune disease that causes blistering in the epidermis

The nurse is caring for a client with systemic lupus erythematosus (SLE) that is affecting the hematopoietic system. Based on this, which signs and symptoms should the nurse anticipate and collect data on? Select all that apply.

Anemia Splenomegaly Lymphadenopathy

A client calls the emergency department and tells the nurse that he received a bee sting to the arm while weeding a garden. The client states that he has received bee stings in the past and is not allergic to bees. The client states that the site is painful and asks the nurse for advice to alleviate the pain. Which action should the nurse tell 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. Which nursing action is appropriate?

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

A client calls the office of his primary care health care provider and tells the nurse that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because his neighbor experienced such a reaction just 1 week ago. Which is the appropriate nursing action?

Ask the client if he ever sustained a bee sting in the past

The nurse is providing information to a client with systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which foods? Select all that apply.

Beef Cheese

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 related to this diagnosis?

Butterfly rash on cheeks and bridge of the nose

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

Butterfly rash on the cheeks and bridge of the nose

The health care provider prescribes fluconazole (Diflucan) for a client. When administering this medication the nurse should explain to the client that it is used to treat which opportunistic infection?

Candidiasis

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

Cloudy synovial fluid

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

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

A client with acquired immunodeficiency syndrome (AIDS) is taking didanosine. The client calls the nurse at the health care provider's office and reports nausea, vomiting, and abdominal pain. Which instruction should the nurse provide to the client?

Come to the office to be seen by the health care provider

The nurse reads the chart of a client who has been diagnosed with stage 3 Lyme disease. Which sign/symptom supports this diagnosis?

Complaints of joint pain

The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which medication does the nurse expect to be prescribed?

Corticosteroid

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

Corticosteroid

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

Cotton pads and silk tape

A clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse assesses 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 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 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 should do which?

Cover the crutch pads with cloth

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

Decrease of all cell types

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

Development of an infection

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

Discontinuation of the medication

The client is diagnosed with stage I of Lyme disease. The nurse should 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 should check the client for which manifestation?

Flulike symptoms

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

Foods that are at room temperature

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

Hairdressers

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

Hives Stridor Dyspnea Urticaria Wheezing

The nurse is assisting in 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 understands that which problem is a priority for the client?

Infection

A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which 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

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

It is an inflammatory disease of collagen contained in connective tissue

A client who is human immunodeficiency virus (HIV) positive has had a tuberculin skin test. The results show a 7-mm area of induration. How should the nurse interpret the test?

It is positive

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

Keep liquids on the nightstand at home

The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food items? Select all that apply.

Kiwi Bananas

The nurse interprets that the client who is prescribed zalcitabine (Hivid) is experiencing an adverse effect of this medication when which event is reported by the client?

Numbness in the legs

Which medications should the nurse administer to reduce nasal edema and rhinorrhea (thin watery discharge from the nose)? Select all that apply.

Oxymetazoline (Dristan) Pseudoephedrine (Sudafed)

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

Provide supportive care with hygiene needs

A client 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

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?

Punch biopsy of the cutaneous lesions

The client with 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

A client calls the health care clinic and tells the nurse that he was bitten by a tick. The client is concerned and asks the nurse about the first signs of Lyme disease. Which is a characteristic of stage 1 of Lyme disease?

Skin rash

A client is diagnosed with stage 1 Lyme disease. The nurse checks the client for which hallmark characteristic of this stage?

Skin rash

The nurse is reinforcing dietary instructions to a client with systemic lupus erythematosus. Which dietary items should the nurse instruct the client to avoid?

Steak

The nurse is explaining about antigens and antibodies when the client asks where antibodies come from. Which is an appropriate response? Select all that apply.

Tears Spleen Saliva Blood serum Lymph nodes

A client 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 who is prescribed zidovudine (Retrovir) has been diagnosed with severe neutropenia. The nurse anticipates which intervention should be implemented?

The medication will be temporarily discontinued

A client just 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 should the nurse include in the reply? Select all that apply.

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

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

Ulnar Drift

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

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

Use of natural skin condoms

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

Wearing a gown and gloves