Inflammation & Autoimmune Disorders NCLEX
A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.
B, C, D, E ~ Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.
The nurse is teaching a client with rheumatoid arthritis (RA) about joint protection principles. What information does the nurse include? (Select all that apply.) a. Use smaller joints to rest the larger ones. b. Hold objects with two hands, not one. c. Sit most often in a reclining chair. d. Use assistive-adaptive devices. e. Bend at your knees to lift objects.
B, D, E ~ Clients with RA should use large joints to protect smaller ones, should hold objects with two hands instead of one, should sit in chairs with straight backs, should not bend at the waist but rather bend the knees while keeping the back straight, and should use assistive-adaptive devices wherever possible.
While assessing a patient, the nurse concludes that the patient has a severe form of scleroderma. Which symptoms in the patient support the nurse's conclusion? A. Althralgia B. Digit necrosis C. Joint contractures D. Periungual lesions E. Sausage-like fingers
B, D, E ~ Severe scleroderma is characterized by digit necrosis, the death of cells in the fingers. Periungual lesions (vasculitis lesions around the nail beds) is another symptom of severe scleroderma. Sausage-like fingers are the symptoms that may occur in severe scleroderma due to edema formation in the upper and lower extremities and face. Althralgia and joint contractures are common symptoms of scleroderma.
A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. Blood urea nitrogen (BUN) of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr
C ~ A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.
A client returns to the medical-surgical unit after a total hip replacement with a large wedge-shaped pillow between his legs. The clients daughter asks the nurse why the pillow is in place. What is the nurses best response? a. It will help prevent bedsores from developing. b. It will help prevent nerve damage and foot drop. c. It will keep the new hip from becoming dislocated. d. It will prevent climbing out of bed if he becomes confused.
C ~ Adduction of the operative leg beyond the midline could dislocate the new hip. The wedge pillow will help prevent this from happening. The wedge will not prevent bedsores from developing because it does not prevent pressure. The pillow will not prevent foot drop, because it is placed between the legs. The pillow is not a restraining device, and it will not prevent the client from climbing out of bed.
The nurse has taught a client with lupus about skin protection in the clinic. Later, the nurse sees the client at an outdoor music festival. Which observation by the nurse indicates that the client requires further instruction? a. Client is wearing a thin, long-sleeved shirt. b. Client is wearing a hat with a full brim. c. Client is discussing her new perm. d. Client is seen applying sunscreen twice.
C ~ Alopecia is common; the client should use gentle shampoo and avoid any harsh chemical treatments, such as a permanent wave. The other observations show good skin protection practices by the client.
The nurse is caring for a pregnant client who is taking Humira (adalimumab) to control symptoms of rheumatoid arthritis. The client mentions the pain and inconvenience of the subcutaneous injections and asks, While Im pregnant, can I take this drug by mouth instead? What is the nurses best response? a. I will ask the physician to write a prescription for you today. b. Humira takes much longer to work when it is given orally. c. Humira can be given only by subcutaneous injection. d. You can switch from Humira to oral leflunomide (Arava).
C ~ Humira is given by subcutaneous injection only. Arava causes birth defects; clients taking it must be on strict birth control and must inform their health care providers if pregnancy occurs.
The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive
C ~ Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. Inflammatory is not a type of immunity.
A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.
C ~ Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.
The nurse is caring for a client who has a history of severe rheumatoid arthritis. The client becomes combative and abusive to the staff when she is unable to perform personal care independently. What is the best statement the nurse can make to the client at this time? a. I will have to restrain your hands if you cannot keep them to yourself. b. I will ask your doctor for a psychiatrist to talk to you about anger management. c. You seem frustrated. Would you like to try to dress again in a few minutes? d. Would you like me to get an order for medication to help you settle down?
C ~ The client is acting out her frustration over her chronic illness and loss of use of her hands. The nurse should acknowledge this frustration. Allowing the client to make decisions regarding care will help the client regain some sense of control and will help improve self-esteem. Requesting sedation, suggesting psychiatric therapy, or threatening use of restraints is not appropriate, because the client is expressing frustration over the situation.
The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance
C ~ The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.
A nurse is caring for a client who has had rheumatoid arthritis (RA) for 5 years. Which laboratory value requires the most immediate intervention by the nurse? a. White blood cell count (WBC), 3800/mm3 b. Hemoglobin (Hg), 10.6 g/dL c. Blood urea nitrogen (BUN), 16 mg/dL d. Creatinine, 3.2 mg/dL
D ~ Clients with RA usually have pancytopenia, or a decrease in all cell types. WBC and hemoglobin are low, consistent with this condition. BUN is normal. Creatinine is very high; this indicates renal disease. This client may have renal consequences of his or her RA, which should be investigated.
An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).
D ~ Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the clients TB test could be a false negative.
A client is suspected to have rheumatoid arthritis. Which manifestations does the nurse assess this client carefully for? a. Crepitus when the client moves the shoulders b. Numbness and tingling in the clients fingers c. Client has cool feet, with weak pedal pulses d. Low-grade fever, fatigue, anorexia with weight loss
D ~ Low-grade fever is common with rheumatoid arthritis because of the inflammatory response. Fatigue, anorexia, and weight loss are also common symptoms. Impaired neurologic status, popping sounds with range of motion (ROM), and poor circulation are not common symptoms of rheumatoid arthritis.
The nurse is instructing a client about management of discoid lupus erythematosus (DLE). Which statement indicates that the client requires additional teaching? a. I will be sure to apply sunscreen whenever I am outside. b. I will apply small amounts of the steroid cream to my face twice a day. c. I will take Plaquenil (hydroxychloroquine sulfate) with breakfast each morning. d. Steroids weaken the immune system, so I will wash my hands frequently.
D ~ Steroid creams used for the treatment of discoid lupus will not weaken the immune system because they should be applied in small amounts to affected areas. The client will be more sensitive to sun exposure while using the steroid cream, so sunscreen should be used whenever the client goes outside. The client should use only small amounts of the cream on her face. Plaquenil should be taken with meals or a glass of milk.
The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells
D ~ Suppressor T cells help prevent hypersensitivity to ones own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.
The nurse is teaching a client who has osteoarthritis ways to slow progression of the disease. Which statement indicates that the client understands the nurses instruction? a. I will eat more vegetables and less meat. b. I will avoid exercising to minimize wear on my joints. c. I will take calcium with vitamin D every day. d. I will start swimming twice a week.
D ~ Swimming is an excellent form of exercise for clients with arthritis because it involves minimal weight bearing and stress on the joints from gravity. Eating more vegetables will not decrease the progression of osteoarthritis. Taking calcium with vitamin D will decrease the risk of osteoporosis, not osteoarthritis. Gentle exercise is important to help slow progression of the disease.
What is the NORMAL HEMOGLOBIN lab value?
Men: 13.5 to 17.5 Women: 12.0 to 15.5
What is the NORMAL CREATININE lab value?
0.6 to 1.2 mg/dL males 0.5 to 1.1 mg/dL females
What is the NORMAL WBC lab value?
4,500 to 11,000
A clients white blood cell count is 7500/mm3. Calculate the expected range for this clients neutrophils. (Record your answer using whole numbers separated with a hyphen; do not use commas.) ______/mm3
4125-5625/mm3 The normal range for neutrophils is 55% to 75% of the white blood cell count. 7500*0.55 = 4125 7500*0.75 = 5625 So the range would be expected to be 4125/mm3 to 5625/mm3.
What is the NORMAL BUN lab value?
7 to 20 mg/dL
A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.
A ~ Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.
A client with rheumatoid arthritis had abdominal surgery and has returned to the postoperative nursing unit. The client is unable to use the incentive spirometer correctly, demonstrating limited lung volume and fatiguing easily. What action by the nurse takes priority? a. Notify the physician immediately. b. Have respiratory therapy re-instruct the client. c. Assess for pain and medicate if necessary. d. Let the client rest for a few hours.
A ~ Clients with rheumatoid arthritis can have cervical spine involvement resulting in subluxation. This may lead to decreased respiratory function and can be life threatening. This client was recently intubated for an operation and so is at higher risk for this problem. The nurse should notify the physician immediately and continue assessing the client.
An older adult client is scheduled for knee replacement surgery. Which statement by the client indicates a need for further preoperative instruction? a. I need to keep my leg positioned away from my body. b. I may have a continuous passive motion machine for a few days. c. I may need more pain medicine than I did with my hip replacement. d. I probably can get back to work within 2 to 3 weeks.
A ~ Dislocation is not a problem with knee replacement surgery, so the client does not need to keep his or her leg abducted. The other statements indicate accurate understanding of the instructions.
A client with a history of rheumatoid arthritis will be starting drug therapy with etanercept (Enbrel). What is most important for the nurse to teach the client? a. The correct technique for subcutaneous injections b. How to self-monitor blood glucose levels c. How to set up and prime the IV tubing d. How to calculate the dosage based on symptoms
A ~ Enbrel is a parenteral medication that is given by subcutaneous injection. The client and/or the family will need to be taught how to give a subcutaneous injection correctly. Blood glucose levels should not be affected by this medication. The medication is not administered IV. Drug dosages are not changed and recalculated by the client.
A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis
A ~ Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.
A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. It increases the elimination of T lymphocytes from circulation. b. It inhibits cytokine production in most lymphocytes. c. It prevents DNA synthesis, stopping cell division in activated lymphocytes. d. It prevents the activation of the lymphocytes responsible for rejection.
A ~ Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.
The nurse is teaching a community health class about health promotion techniques. Which statement by a student indicates a strategy to help prevent the development of osteoarthritis? a. I will keep my BMI under 24. b. I will switch to low-tar cigarettes. c. I will start jogging twice a week. d. I will have a family tree done.
A ~ Obesity increases the stress on weight-bearing joints and contributes to the development of degenerative joint disease. Smoking does not decrease risk for osteoarthritis. Jogging increases the risk because of increased wear and tear on the joints. There is a genetic link to osteoarthritis; creating a family tree might help the client discover if there is any familial link but will not help prevent the disorder.
A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes
A ~ Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.
A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. Avoid large crowds and people who are ill. b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed. d. You have a higher risk of developing cancer.
A ~ Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).
A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils
A ~ The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.
The nurse is caring for a postoperative client on the medical-surgical unit following a total left hip replacement the previous day. During the assessment, the nurse notes that the clients left leg is cool, with weak pedal pulses. What is the nurses first action? a. Assess circulatory status of the right leg. b. Notify the surgeon immediately. c. Measure leg circumference at the calf. d. Check for bilateral Homans signs.
A ~ The symptoms may represent impaired circulation or may be normal for this client. Before the surgeon is notified, the status of the nonoperative leg should be assessed and assessment findings on both legs compared with the clients baseline. Homans sign (pain in the calf on dorsiflexion of the foot) is not always indicative of a deep vein thrombosis and should not be evaluated until other assessments are made. Measuring calf circumference would provide additional data related to deep vein thrombosis.
For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells
A, B, C ~ The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.
Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization
A, B, D, E ~ The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.
The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.
A, C, D, E ~ Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.
The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth
A, D, E ~ The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.
The nurse is caring for an older adult client who will be discharged home to live with an adult daughter. The client will be given prescriptions for four new medications for rheumatoid arthritis. How does the nurse ensure that the client will be able to take the medications correctly at home? a. Monitor the client self-administering medications while in the hospital. b. Include the clients daughter when teaching the client about the medications. c. Provide the client with pamphlets and information about all the medications. d. Make a chart showing which medications the client should take at different times.
B ~ Because the client will be living with the daughter, she should be included in the teaching plan about the medications. Providing pamphlets or charts about the medications does not ensure that the client knows how to take them correctly at home. Self-administering medications may or may not be permitted by hospital policy and might be helpful, but including the daughter would be the best option.
A client is admitted for a total hip replacement. Past medical history includes diabetes mellitus type 2, a heart attack 5 years ago, and allergies to sulfa drugs. The client currently takes insulin on a sliding scale and celecoxib (Celebrex). Before administering the clients medications, which action by the nurse is most appropriate? a. Take the clients blood pressure in both arms. b. Call the physician to clarify the orders. c. Schedule a preoperative electrocardiogram. d. Review the clients laboratory values.
B ~ Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs are thought to cause serious adverse reactions such as myocardial infarction and renal problems. This client already has coronary artery disease and a past myocardial infarction, so the nurse should discuss the order with the physician before giving the medication. Reviewing laboratory results could indicate renal impairment, but taking the clients blood pressure and scheduling an electrocardiogram (ECG) would not take priority over discussion with the physician.
A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site
B ~ During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.
The nurse is working with a client who will be taking 20 mg of prednisone daily for rheumatoid arthritis. Which precautions does the nurse give the client about taking this medication? a. Take this medication at bedtime because it will make you sleepy. b. Take calcium and vitamin D supplements daily. c. Eat a high-fiber diet with lots of lean meats. d. Wash your face twice a day with an antibacterial soap.
B ~ Long-term steroid use is associated with many complications, including diabetes, infection, and osteoporosis, among others. The client should be instructed to take calcium and vitamin D supplements to help prevent osteoporosis. Prednisone does not cause constipation, so increased fiber would not be helpful. Prednisone should be taken in the morning because it may interfere with sleep if taken at bedtime. Washing the face with antibacterial soap may cause skin dryness and breakdown.
A female client with rheumatoid arthritis has taken Rheumatrex (methotrexate) for the past year to control her symptoms. The client comes to the clinic and tells the nurse that a home pregnancy test was positive. What is the nurses best response? a. You need to schedule a prenatal appointment with your obstetrician right away. b. Stop taking Rheumatrex immediately. Ill tell the physician you are pregnant. c. Continue taking the Rheumatrex, and increase the dose if you have a flare. d. See a genetic counselor to determine whether your baby will have rheumatoid arthritis.
B ~ Rheumatrex is highly teratogenic and should not be taken during pregnancy. A prenatal appointment should be made right away, but the first priority is to stop taking methotrexate. Genetic counseling is not appropriate because the counselor will not be able to determine whether the baby will develop rheumatoid arthritis.
The nurse is working with a client who has severe rheumatoid arthritis in her hands. The client states that she is frustrated at mealtime because it is difficult for her to manage cups and silverware. What is the nurses best response? a. Ill have the nursing assistants set up your meal trays while you are in the hospital. b. Lets see if the occupational therapist can provide you with some utensils that are easier for you to use. c. Ill arrange for a home nursing assistant to help you with your meals after you are discharged from the hospital. d. Lets see if the physical therapist can suggest some muscle strengthening exercises for you.
B ~ The client wishes to be more independent at mealtimes; adaptive eating utensils from the occupational therapist will help her meet this goal. Muscle-strengthening exercises will not be as effective for the clients mealtime needs. The client wishes to remain as independent as possible, so a home nursing assistant should not be suggested.
The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling
B ~ The recipients immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.
