M/S 5

A nurse is caring for school-age child who has seasonal allergies and has been taking diphenhydramine. The provider recommends fexofenadine for the child. The child's parent asks the nurse about the advantage of taking fexofenadine. Which of the following responses should the nurse make?

"Fexofenadine is less sedation."

During data collection on a patient who reports fatigue and vague joint pain, the nurse documents a reddened area over the bridge of the nose and hears a pericardial friction rub. What should the nurse ask the patient after reviewing the medical history?

"Has anyone in your family had systemic lupus erythematosus?

The nurse is assisting in the care of a patient who received hemodialysis for 3 years and recently underwent a kidney transplant. Which patient statement indicates further teaching is necessary?

"I'll need to take medicine to suppress my immune system for a few months

A patient who has been diagnosed with SLE is being discharged. The patient reports leaving on a 3-week tour of the Grand Canyon and going whitewater rafting in 1 week. Which of the following patient statements conveys the patient's understanding of the plan of care?

"I'll wear clothing on all exposed skin and use sunscreen."

In planning care for a patient who has allergic rhinitis, the nurse understands that without adherence to the treatment regimen, the patient is at risk for developing which of the following?

Sinusitis

In collecting data for a patient with angioedema, the nurse understands how angioedema differs from urticaria because angioedema is characterized by which of the following?

Angioedema has small, fluid-filled vesicles that crust

Which of the following is a disease process characterized by a chronic progressive inflammation of the sacroiliac and costovertebral joints and adjacent soft tissue?

Ankylosing spondylitis

A nurse is reinforcing teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following information should the nurse include in the teaching?

SLE affects the connective tissue of the body

A type III reaction in which antigen-antibody complexes form and lodge in small vessels, which leads to inflammation, tissue damage, and necrosis. Often occurs occasionally after administration of penicillin or sulfonamide

Serum Sickness

A patient reports malaise, muscle soreness, nausea and diarrhea, severe itching, and a skin lesion on the upper arm. In the history, the nurse notes that the patient received penicillin for a bacterial sinus infection a week and a half ago and on examination, notes a slight fever and splenomegaly. What possible complication does the nurse suspect the patient is experiencing?

Serum sickness

A 68-year-old patient had a tetunus, diphtheria, and pertussis booster at age 63. What should the nurse instruct the patient about this vaccination?

The next booster would be due in 5 years

A patient has a long-standing history of allergies to pollen. Which of the following actions indicates that further teaching is necessary?

The patient drives the car with the windows open

A nurse is reinforcing teaching with a client who is pregnant and has a prescription for Rho(D) immune globulin. Which of the following information should the nurse include?

This medication prevents the formation of RH antibodies by a woman who is Rh-negative

The nurse is providing information at a health clinic on infectious disease prevention. How should the nurse explain the process of obtaining artificially acquired active immunity?

Through vaccine-induced production of antibodies

An allergic response occurs when antibodies respond to foreign but harmless antigens.

True

Serum sickness can occur 7 to 10 Days After Penicillin or Sulfonamide is given.

True

A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?

Tuberculin skin test

A patient is being given penicillin via intravenous infusion and develops signs and symptoms of an anaphylactic reaction. Which of the following should be the nurse's first action?

Turn off the antibiotic

A patient is diagnosed with a hypersensitivity reaction mediated by immunoglobulin E (IgE) antibodies. For which type of hypersensitivity reaction should the nurse plan care for this patient?

Type I

The nurse understands that an anaphylactic reaction is considered which of the following types of hypersensitivity reactions?

Type I

A patient is diagnosed with Hashimoto thyroiditis and asks what cause it. The nurse would respond that the destruction of thyroid cells in this condition is due to which of the following?

Autoantibodies

A patient report on admission being "very sick" after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take first regarding the antibiotic?

Do not give the antibiotic

A patient is admitted with an autoimmune disease and asks the nurse what autoimmune means. Which of the following responses by the nurse would be appropriate?

"Immune cells are unable to distinguish between 'self' and 'not self.'

A patient asks the nurse how an allergy can develop to a medication that has been taken before without problems. Which of the following is the most appropriate for the nurse to respond?

"Viral illnesses and exposure to various chemicals and environmental substances can alter the immune system and its response to previously benign stimuli."

The nurse has taught the patient with atopic dermatitis ways to treat and prevent episodes of itching and dryness. What statement by the patient indicates that additional teaching is necessary?

"When the itching is bad, I soak the area in warm water."

A nurse is evaluating and discussing plans and options with a patient who is scheduled for elective hip replacement surgery in 4 weeks. Which topic is important to discuss with the patient?

. The option of autologous (self) blood donation

Which of these is one of the classes of human antibodies? Select all that apply.

1) Immunoglobulin (I g)G 2) I g D 3) I g E

A patient is suspected as experiencing anaphylaxis. Which actions should the nurse anticipate being needed for this patient? Select all that apply.

1. Administer oxygen. 2. Establish a patent IV access 3. Position the patient in a semi- to high-Fowler's position.

patient with Hashimoto's thyroiditis is prescribed levothyroxine. What should the nurse instruct the patient when taking this medication? Select all that apply.

1. Avoid foods high in iodine 2. Do not take within 4 hours of ingesting a calcium supplement.

The nurse is caring for a patient who asks what ankylosing spondylitis is. Which of the following responses from the nurse is appropriate?

1. Chronic progressive inflammatory disease of large limb joints

The nurse is collecting data on a patient with suspected pernicious anemia. Which of these signs or symptoms would the nurse expect to find for this patient?

1. Glossitis

The nurse would recognize the need for further teaching about H I V if the patient stated which of the following about H I V? Select all that apply.

1."H I V is an acute infection." 2."H I V is curable." 3."A R T Increases H I V replication."

The nurse is assisting with education at a health fair. Which of these would the nurse include as modes of transmission for H I V? Select all that apply.

1.Men who have sex with men 2.Heterosexual contact 3.Injection drug use

Which of these is nursing care for Type I hypersensitivity reactions? Select all that apply.

1.Monitor Respiratory Status 2.Monitor Level of Consciousness 3.Provide Information

Which of the following would the nurse include when teaching about P r E P? Select all that apply.

1.Prevention for those at high risk 2.Antiretroviral drug 3. Daily pill

The nurse experiences a needle stick. Which of these actions should the nurse take? Select all that apply.

1.Wash exposure site with soap/water. 2.Seek urgent medical care. 3. Begin ordered therapy within hours after exposure.

If a mother is HIV positive, how long will they mother and infant both take AZT after delivery?

6 weeks

in planning an educational session for a patient with HIV, the nurse would include that contact with which of the following body fluids can transmit HIV? Select all that apply.

A) Breast milk B) Semen C) Blood

Which of the following is used to determine the presence of inflammation? Select all that apply

A) C-reactive protein B) Erythrocyte sedimentation rate

Then nurse is caring for a patient with HIV. Which of the following foods would the nurse teach the patient are safe to eat to reduce the risk of infection? Select all that apply

A) Cooked vegetables B) Self-peeled fruits

Which of these are the three categories of immune disorders? Select all that apply.

A) Hypersensitivity Reactions B) Autoimmune Disorders C) Immune Deficiencies

Which of these would the nurse reinforce to a patient who received vaccine education? Select all that apply.

A) Provides artificially acquired immunity B) Stimulates production of small amounts of antibodies C) Stimulates production of memory cells

A patient who was talking in the woods disturbed a beehive, was stung two times, and was taken to the emergency department immediately due to allergies to bee stings. Which of the following symptoms would the nurse expect to see upon admission of this patient? Select all that apply.

A) Respiratory stridor B) Tachycardia C) Dyspnea

The nurse is assisting with data collection on a patient. Which of the following past surgeries found in the patients history would alert the nurse to possible immune system dysfunction when planning care?

A) Splenectomy B) Thymectomy

Which of these can be signs of anaphylaxis? Select all that apply.

A) Stridor B) Wheezing C) Respiratory Arrest

Which of the following best defines AIDS?

AIDS is the final phase of a chronic progressice immune disorder caused by HIV

A nurse is caring for a client who received an injection of penicillin G procaine and begins to experience an anaphylactic reaction. Which of the following actions should the nurse take first?

Administer epinephrine subcutaneously

A nurse is assisting in preparing a presentation at a community center about systemic lupus erythematosus (SLE). The nurse should identify which of the following groups as having the highest risk for developing this disorder?

African American women

The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse's best response?

After pretest counseling, you decide whether HIV testing should be done

The nurse would evaluate that the patient understands what triggers allergic rhinitis by which of the following patient responses?

Airborne pollens and molds

The most common form of allergy. Pathophysiology - The result of an antigen-antibody reaction. Ciliary action decreases and mucous secretions increase. Vasodilation and local tissue edema occur.

Allergic Rhinitis

A nurse in a provider's office is collecting data from a client who reports a red rash on her face, fever, weight loss and joint pain. The nurse should plan to prepare the client for which of the following laboratory tests?

Antinuclear antibody (ANA) titer

The nurse is collecting data from a patient with contact dermatitis. What data are essential for the nurse to obtain?

Appearance of skin lesions

The nurse teaches a patient about vaccines. The nurse would evaluate the patient as understanding the presented information if the patient states that a vaccine provides which of these types of immunity?

Artificially acquired active immunity

The nurse is reviewing the humoral immune response mechanism with a patient. What should the nurse explain when reviewing this mechanism?

B cells are stimulated by T helper cells or macrophages and turn into plasma cells, which produce antibodies or memory cells.

A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions?

Bacterial infection

A mother brings her children into the clinic, and the children are diagnosed with chickenpox. The mother had chickenpox as a child. Which of the following statements should the nurse include in the patient teaching?

Because you have an active natural immunity to chickenpox, you can take care of the children at home

What is the opportunistic infection Cytomegalovirus?

CMV, Causes retinitis -->Blindness

A nurse is collecting data from a client who has AIDS. When checking the clients mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions?

Candidiasis

The nurse is caring for a patient who is to have a Schilling test. What action would the nurse take for this test?

Collect 24-hour urine specimen.

In response to questions about medical history, diet, and lifestyle, the patient reports taking prednisone for rheumatoid arthritis and several herbal preparations, including echinacea and licorice. For which potential complication should the nurse be aware when planning care for this patient?

Decreased immune response

The nurse is caring for a patient undergoing a biopsy. Which action is appropriate for the nurse to take?

Ensure that informed consent is obtained before the procedure

Which of the following is the medication of choice for anaphylaxis that the nurse should anticipate would be ordered?

Epinephrine

The nurse contributes to the teaching plan of a patient who is allergic to peanuts by including that it is MOST important for the patient to carry which of the following?

Epinephrine autoinjector

A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

Facial Rash.

Antibodies recognized as foreign by the immune system are destroyed.

False

Which of the following is a common nursing diagnosis that the nurse will include in the plan of care for a patient with systemic lupus erythematosus?

Fatigue

A nurse is preparing an in-service about HIV for a group of newly hired assistive personnel. Which of the following statements should the nurse include about HIV transmission?

HIV is transmitted through contact with infected body fluids

The activation of B cells in humoral immunity is assisted by which of the following?

Helper T cells

A type II reaction in which incompatiible surface antigens on RBCs are transfused is?

Hemolytic Transfusion Reaction

The nurse is caring for a patient with HIV who has diarrhea. Which of the following would be most therapeutic to teach the patient to avoid in the diet to reduce diarrhea?

High fiber diet

The reaction is localized and evolves over several hours, with symptoms ranging from a red, edematous skin lesion to hemorrhage and necrosis

Hypersensitivity Reaction - Type III

A type I reaction, an anaphylactic reaction, is an immediate reaction that occurs on exposure to a specific antigen is?

Hypersensitivity Reactions - Type I

Anaphylactic reactions to latex can be fatal * Exposure to latex for health care workers has increased dramatically since the implementation of universal precautions and the use of latex gloves began in 1987

Hypersensitivity Reactions - Type IV

A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching?

I will need to take this medication for the rest of my life

A nurse is reinforcing home instructions for a client who has an immunodeficiency. Which of the following client statements indicates a need for further teaching?

I will take my temperature once a week

A patient is scheduled for erythrocytapheresis. For which health problem should the nurse expect to plan care for this patient?

Idiopathic autoimmune hemolytic anemia

Which of the following immunoglobulins is first produced during an acute infection?

IgM

Autoimmunity is defined as a phenomenon involving which of the following

Inability to differentiate self from nonself

While attending a family picnic, a child with a known allergy to bee stings is stung and develops flushing and shortness of breath. A dose of epinephrine is provided through the use of the child's EpiPen, and the child's breathing becomes more relaxed. Which of the following actions should the nurse take?

Instruct the family to seek immediate medical attention

Anaphylaxis

Is a severe systemic type I hypersensitivity reaction

A school-age child is diagnosed with an allergy to peanuts. How should the nurse instruct the mother to ensure this child's safety?

Keep an epinephrine autoinjector in the home

A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Limit the number of health care workers entering the room

During a health history, a patient asks the nurse about a rash that is over the body and worsens when sitting out in the sun. Which health problem should the nurse suspect the patient is experiencing?

Lupus erythematosus

A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

Make sure the needle retracts into the barrel of the syringe

The nurse is reviewing the immune system with a patient newly diagnosed with allergies. What should the nurse explain as the role of the thymus gland?

Maturates T cells

Immunity to a disease after recovery is possible because the first exposure to the pathogen has stimulated the formation of which of the following?

Memory cells

A baby is born temporarily immune to the diseases to which the mother is immune. The nurse would explain this to the mother as being which of the following types of immunity?

Naturally acquired passive immunity

A nurse is a clinic is reviewing the prescriptions for a client who had a delayed hypersensitivity reaction to an unknown trigger. The nurse should expect the provider to prescribe which of the following tests?

Patch test

Antibodies that destroy gastric parietal cells lead to decreased production of intrinsic factor

Pernicious Anemia

A portions of a patient's stomach was removed, so the patient is to take vitamin B12. Which of the following statements should be included in the patient's teaching?

Pernicious anemia is a complication of this surgery, so you need lifelong vitamin B12

Which of the following is the function of macrophages and neutrophils?

Phagocytosis

A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needlestick injuries. Which of the following actions should the nurse recommend?

Place uncapped needles in a puncture-proof container after use

A nurse is caring for a client who was diagnosed with HIV 6 months ago. The client came to the clinic for testing to determine disease progression. Which of the following laboratory tests should the nurse expect the provider to prescribe?

Quantitative RNA assay

A patient is admitted with a 2-month history of fatigue, shortness of breath, pallor, and dizziness. The patient is diagnosed with idiopathic autoimmune hemolytic anemia. On reviewing the laboratory results, the nurse notes the presence of which of the following which confirms this diagnosis?

Red blood cell fragments

A nurse is reviewing the medical record of a client who just returned to the unit following surgery and notes the client has a history of anaphylaxis in response to penicillin. The client's postoperative prescriptions include a dose of cephalexin. Which of the following actions should the nurse take?

Request that the surgeon prescribe a different antibiotic

A young, healthy woman who is Rh-negative recently gave birth to an Rh-positive infant. She reports that she plans to have more children within a year or so. What would be an appropriate intervention for this patient?

Review the patient's orders to see if an RhoGAM injection has been ordered

The nurse is reviewing the function of the immune system. In what part of the lymphatic system should the nurse recognize that B cells and T cells carry out immune functions?

Spleen

A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, "My heart is racing." The nurse notes that the client's face become flushed. Which of the following actions should the nurse take first?

Stop the transfusion

A patient's immune response to an allergen has diminished. Which type of cell should the nurse consider as being the immune system's shutoff mechanism that is functioning in this patient?

Suppressor T cells

A patient's laboratory report indicates the presence of antinuclear antibodies, increased rheumatic factor and C-reactive protein, decreased CD8⁺ count, and deficiencies of specific complement proteins. While awaiting the physician's diagnosis, the nurse should recognize that these laboratory values are found in which of the following diseases?

Systemic lupus erythematosus

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

Take temperature once a day

A nurse in a clinic is reviewing the facility's testing process and procedures for human immune deficiency virus (HIV) with a new employee. Which of the following information should the nurse include in the review?

The Western blot assay is used to confirm the diagnosis of HIV.

A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza?

The composition of the influenza vaccine changes yearly

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

Wash the puncture site with soap and water

A nurse is reinforcing discharge with a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include in the teaching?

Wash your hair with a mild shampoo

When caring for a patient with AIDS, which of the following actions should the nurse take for infection control?

Wear gloves for blood/body fluid contact

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain to the client that, after the laboratory has the enzyme immunoassay (EIA) results, it will use which of the following tests to confirm the diagnosis?

Western blot assay

As the nurse collects data on a patient, which of the following is a symptom that the patient with anaphylaxis may be experiencing?

Wheezing

As the nurse collects data on a patient, which of the following is a symptom the nurse would find for the patient with anaphylaxis?

Wheezing