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LP2 MAJOR EXAM 4 Files Merged 2 Files Merged
LP2 MAJOR EXAM 4 Files Merged 2 Files Merged
The dose is
available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has
a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the
IVPB to infuse? Record your answer using a whole number.
25
A client is diagnosed with emphysema (COPD). For what long-term problem should the
nurse monitor this client?
A nurse assesses that several clients have low oxygen saturation levels. Which client
would benefit the most from receiving oxygen via a nasal cannula?
Which of the following diets would be most appropriate for a client with chronic
obstructive pulmonary disease (COPD)?
The nurse cares for a client with chronic obstructive pulmonary disease (COPD). The
physician orders oxygen via nasal cannula for this client. Which action should the nurse
take?
prolonged inspiration
Which of the following indicates that the client with chronic obstructive pulmonary
disease (COPD) who has been discharged to home understands the care plan?
The nurse instructs a client diagnosed with chronic obstructive pulmonary disease
(COPD) about positions to use during times of dyspnea. The nurse recognizes further
teaching is necessary when the client states:
When developing a discharge plan to manage the care of a client with chronic
obstructive pulmonary disease (COPD), the nurse should advise the client to expect to
The nurse is providing teaching to the client with COPD about the purpose of pursed-lip
breathing. Which explanation is most appropriate?
What nursing action will most help a client obtain maximum benefits after postural
drainage?
cyanosis
flushed skin
irritability
anxiety
The nurse reviews arterial blood gas results for his client with chronic obstructive
pulmonary disease (COPD). The pH is 7.3, PaCO2 is 56 mm Hg, and HCO3 is 24
mEq/L. Which acid–base imbalance is this client experiencing?
respiratory acidosis
metabolic acidosis
respiratory alkalosis
metabolic alkalosis
The nurse reviews an arterial blood gas report for a client with chronic obstructive
pulmonary disease (COPD). The results are: pH 7.35; PCO2 62 (8.25 kPa); PO2 70
(9.31 kPa) (34 mmol/L); HCO3 34. The nurse should first:
1.
0.8 / 1 point
These are all considered as immunologic criteria of systemic lupus
erythematosus. Select all that applies:
Your Answer:
Malar Rash
Discoid Rash
Serositis
Photosensitivity
3.
1 / 1 point
A 26-year-old woman has been diagnosed with early systemic lupus
erythematosus (SLE) involving her joints. In teaching the patient about the
disease, the nurse includes the information that SLE is a(n):
Hereditary disorder of women but usually does not show clinical symptoms unless a
woman becomes pregnant.
Autoimmune disease of women in which antibodies are formed that destroy all
nucleated cells in the body.
Disorder of immune function, but it is extremely variable in its course, and there is no
way to predict its progression.
Disease that causes production of antibodies that bind with cellular estrogen receptors,
causing an inflammatory response.
4.
1 / 1 point
Lupus is an infection
True
False
5.
1 / 1 point
A patient with an acute exacerbation of systemic lupus erythematosus (SLE) was
hospitalized with incapacitating fatigue, acute hand and wrist pain, and
proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg
twice daily. Which nursing action should include in the plan of care?
True
False
7.
1 / 1 point
Nurse Dakota is making morning rounds, and as she assists the patient to dress,
she recognizes that the patient's fingers are white in color and cold to touch. The
nurse is correct when she thinks that the condition is
Arthritis
Arthralgia
Raynaud's Phenomenon
Seizures
8.
1 / 1 point
Nurse Paco is asking for the health history and family health history of the
patient. Which among the options does not apply to ask?
Have your neighbors been diagnosed with any other medical conditions?
Immunosuppressive agent
Antimalarial drug
Topical corticosteroid
10.
1 / 1 point
When a symptom becomes significantly worse than it was previously is called
_______.
Urticaria
Butterfly-shaped rash
Purpura
Photosensitivity
12.
1 / 1 point
When symptoms are inactive and under control is called _______.
Remission of symptoms
Flare of symptoms
14.
1 / 1 point
Although the exact cause of lupus isn't yet known, which of these are believed to
be factors?
Inherited gene
Estrogen
Testosterone
A, B, C
Glaucoma
Lung Cancer
Dislocated shoulders
16.
1 / 1 point
Who are the people who are most likely to develop lupus?
Pap test
Ear examination
Eye examination
Colorectal examination
19.
0.67 / 2 points
A 20-year-old African-American woman visits the clinic because she had generalized
joint discomfort in her hips and knees for the previous five months. During this period,
she has also noticed a rash on her nose and cheeks. Her medical history is
unremarkable, and she does not suffer from any allergies. Her current temperature is
100.5°F. A physical exam is notable for warmth and swelling in both of the patient’s
knees. Lab studies are performed and shown below:
What is the symptom disclosed by the patient that diagnoses the relevance of
SLE?
Your Answer:
Joint pain
Malar rash
ESR: 43 mm/h
Your Answer:
Hydroxychloroquine
Prednisone.
Azathioprine
Belimumab
21.
1 / 1 point
You're giving a Systemic Lupus Erythematosus support group information on
how to avoid flares. Which statement by a participant requires re-education about
this topic?
"I always wear large-brimmed hats and long sleeves when I'm outside."
"Exercise should be avoided due to the physical stress it causes on the body."
Isoniazid
Procainamide
Plaquenil
Hydralazine.
23.
1 / 1 point
On a client with systemic lupus erythematosus, a complete blood cell count is
performed. The nurse would suspect that which of the following findings will be
reported from this blood test?
Increased neutrophils
24.
1 / 1 point
How many unique criteria (least) must a patient meet simultaneously or in
sequential evaluation to get diagnosed with systemic lupus erythematosus
(SLE)?
Your Answer: Correct
Six
Five
Three
Four
25.
1 / 1 point
A patient voices concerns about taking procainamide. States that a friend was
recently hospitalized for drug-induced lupus erythematosus. What is your best
response?
"If this hasn't occurred yet, there is no continued risk of drug-induced SLE."
"Drug-induced SLE generally occurs months to a year after continuous use of this drug."
Autoantibody
Antigens
Antibody
Neutrophils
27.
1 / 1 point
A patient is diagnosed with systemic lupus erythematosus (SLE). What
neurologic manifestations should the nurse closely monitor? Select all that apply.
Stroke
Seizures
Alopecia
Synovitis
Psychosis
28.
1 / 1 point
A client diagnosed with lupus is experiencing pulmonary interstitial fibrosis.
Which classification of lupus should the nurse suspect?
Systemic
Drug-induced
Discoid
Cutaneous
29.
0 / 1 point
Your immune system is made up of white blood cells that recognize the antigens
from the invaders. And your white blood cells create antibodies to mark those
invaders as targets for your immune system to destroy them.
Logout
10/20
A condition of multisystem, inflammatory, autoimmune disorder characterized by
formation of autoantibodies directed against self-antigens and immune-complex
formation resulting in damage to essentially any organ.
(Title Case)
Answer: Systemic Lupus Erythematosus
Give an example of medication that can cause a lupus-like disease when prescribed.
(Sentence case)
Corticosteroids
Surgery
Gastrointestinal upset
Fever
Pregnancy
Divorce
Hypotension
A type of inflammatory response where a reaction to sun or light causes a skin rash to
appear or get worse.
Serositis
Malar rash
Discoid Rash
Photosensitivity
Prednisone was prescribed for a patient with SLE. What nursing action should be
included?
I&O monitoring.
Older men
Asians
If patient is asking on how does SLE affects her life, nurse's reply should be:
"You should enjoy your life now with your families, you will be expired soon."
"It is hard to tell because the severity and progression of the disease varies.
"Using a long-term corticosteroid can manage SLE, but your life span is lessened."
"SLE causes death once in a while, you can still plan to have a normal life."
Weight gain
Abdominal pain
Fatigue
Rash
Fever
Alopecia
Joint pain
They are all to be considered as immunologic criteria of systemic lupus erythematous,
select all that applies:
Physical exam
History taking
Skin biopsy
Patient Lyn is INCORRECT about preventing flares in SLE if she states that:
"When I plan to go outside, I should wear sun hats and long clothes for my protection."
True
False
A nurse is educating patient Jen about what she can do to manage fatigue during
exacerbation, the patient needs a further teaching if she states that:
Corticosteroid
Oral contraceptive
Immunosuppressants
Antineoplastic
Broccoli
Garlic
Turkey
Bacon
Potatoes
\Give one goal of treatment for SLE.
Prevent progressive loss \of organ function.
A medication for SLE aimed to decrease the inflammation rapidly and it is for short-term
usage only. This is also susceptible to osteoporosis, DM, and infection.
Azathioprine
Plaquenil
Prednisone
Paracetamol
To diagnose SLE, 4 or more should be met from 14 classification criteria given by ACR.
True
False
LP: CARE of CLIENTS with AUTO
IMMUNE DISORDER
Total points18/20
1. Which of the following is recommended for patients with mild or remittent SLE with
prominent arthralgias?
1/1
A. Nonsteroidal anti-inflammatory drugs
B. Iron supplementation
C. Corticosteroids
D. Heparin
2. Which of the following is the best screening test to evaluate a patient for possible
SLE?
1/1
A. Anti-Ro antibody test
B. Antiphospholipid antibody test
C. Serum complement levels
D. Fluorescent test for ANA
B. bluishness
C. paleness
D. purpleness
B. alar rash
C. manard rash
D. apoptotic rash
7. Very active lupus (sometimes called severe lupus) is treated immediately with which
of the following?
0/1
A. Heparin or warfarin
B. Antimalarial drugs such as hydroxychloroquine
Correct answer
D. A corticosteroid such as prednisone
Feedback
A corticosteroid such as prednisone (taken by mouth) or methylprednisolone (given by vein) is the
immediate treatment for very severe lupus.
9. A patient with systemic lupus erythematosus (SLE) who has a facial rash and
alopecia tells the nurse, "I hate the way I look! I never go anyplace except here to the
health clinic." An appropriate nursing diagnosis for the patient is:
1/1
A. Activity intolerance related to fatigue and inactivity.
B. Impaired skin integrity related to itching and skin sloughing.
C. Social isolation related to embarrassment about the effects of SLE.
10. A client is suspected of having systemic lupus erythematous. The nurse monitors
the client, knowing that which of the following is one of the initial characteristic sign of
systemic lupus erythematous?
1/1
A. Weight gain
B. Subnormal temperature
C. Elevated red blood cell count
D. Rash on the face across the bridge of the nose
11. The nurse is assigned to care for a client with systemic lupus erythematosus
(SLE). The nurse plans care knowing that this disorder is:
1/1
A. A local rash that occurs as a result of allergy
B. A disease caused by overexposure to sunlight
C. An inflammatory disease of collagen contained in connective tissue
D. Opioid analgesic
13. The nurse monitors a patient to have Systemic Lupus Erythematosus. Which of
the following symptoms is characteristic of this diagnosis?
1/1
A. Increased T-cell count
B. Scaley, inflamed rash on shoulders, neck, and face
14. In teaching a patient with SLE about the disorder, the nurse knows that the
pathophysiology of SLE includes:
1/1
A. Circulating immune complexes formed from IgG autoantibodies reacting with IgG
B. An autoimmune T-cell reaction that results in destruction of the deep dermal skin layer
C. Immunologic dysfunction leading to chronic inflammation in the cartilage and muscles
D. The production of a variety of autoantibodies directed against components of the cell nucleus
15. A female patient's complex symptomatology over the past year has culminated in
a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following
statements demonstrates the need for further teaching about the disease?
1/1
A. "I'll try my best to stay out of the sun this summer."
B. "I know that I probably have a high chance of getting arthritis."
C. "I'm hoping that surgery will be an option for me in the future."
17. A patient with newly diagnosed SLE asks the nurse how the disease will affect her
life. The best response by the nurse is:
1/1
A. You can plan to have a near-normal life since SLE rarely causes death
B. It is difficult to tell because to disease is so variable in its severity and progression
C. Life span is shortened somewhat in people with SLE, but the disease can be controlled with
long-term use of corticosteroids
D. Most people with SLE have alternating periods of remissions and exacerbations with rapid
progression to permanent organ damage
18. During an acute exacerbation, a patient with SLE is treated with corticosteroids.
The nurse would expect the steroids to begin to be tapered when serum laboratory
results indicate:
1/1
A. Increased RBCs
B. Decreased ESR
C. Decreased anti-DNA
D. Increased complement
19. Teaching that the nurse will plan for the patient with SLE includes:
1/1
A. Ways to avoid exposure to sunlight
Correct answer
B.Systemic lupus erythematosus
CHRONIC
OBSTRUCTIVE
PULMONARY
DISEASE
BY: ANGELICA CRISTALES
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
A pulmonary disease that causes a chronic obstruction of
airflow from the lungs
It is irreversible. Airflow limitation is usually progressive
Abnormal inflammatory response of the lung to noxious
particles or gases = narrowing of airways,
hypersecretion of mucus and changes in the pulmonary
vasculature
CHRONIC
EMPHYSEMA
BRONCHITIS impaired gas exchange (oxygen, carbon dioxide)
presence of cough and sputum production for results from destruction of the walls of
at least 3 months in each of 2 consecutive years overdistended alveoli
PATIENT HISTORY -
PULMONARY FUNCTION
STUDIES
SPIROMETRY
ARTERIAL BLOOD GAS
CHEST X-RAY
SCREENING FOR ALPHA1-
ANTIRYPSIN DEFICIENCY
PULMONARY FUNCTION TEST
Medical Management
Smoking cessation
Bronchodilators - relieve
bronchospasm and reduce airway
obstruction
Corticosteroids - improves the
symptoms
Oxygen administration
Surgery: Bullectomy - help reduce
dyspnea and improve lung function
Nursing Management
Patient Education Monitor and manage potential complications
include normal anatomy and physiology of the Monitor cognitive changes. The nurse should monitor for
lung, pathophysiology and changes with COPD, cognitive changes such as personality and behavior
medications and home oxygen therapy, nutrition, changes and memory impairment.
respiratory therapy treatments Monitor pulse oximetry values. Pulse oximetry values are
used to assess the patient’s need for oxygen and
Breathing Exercise administer supplemental oxygen as prescribed.
Pursed lip breathing helps to slow expiration,
Prevent infection. The nurse should encourage the
prevents collapse of small airways, and helps the
patient to be immunized against influenza and S.
patient to control the rate and depth of
pneumonia because the patient is prone to respiratory
respiration.
infection.
Activity Pacing
Manage daily activities. Daily activities must be
paced throughout the day and support devices
can be also used to decrease energy
expenditure.
Systemic Lupus
Erythematosus
affects multiple organs
Systemic Lupus
Erythematosus
affects multiple organs
Systemic Lupus
Erythematosus
reddening of skin
affects multiple organs
Systemic Lupus
Erythematosus
reddening of skin
diseases affecting skin
affects multiple organs
Systemic Lupus
Erythematosus
reddening of skin
Systemic Lupus
Erythematosus
a disease that is systemic, and affects a wide variety of organs,
but notably often causes red lesions on the skin.
TYPES OF
LUPUS
SYSTEMIC LUPUS ERYTHEMATOSUS
NEONATAL LUPUS
What Causes
SLE?
SLE is an autoimmune
disorder that develops when
the body’s immune system
begins to attack its own
tissues.
SLE is an autoimmune
disorder that develops when
the body’s immune system
begins to attack its own
tissues.
UNKNOWN
but likely a combination of the following factors:
GENETIC
ENVIRONMENTAL
HORMONAL
MEDICATION
PATHOPHYSIOLOGY
SLE IS A RESULT OF DISTURBED
IMMUNE REGULATION THAT
CAUSES AN EXAGGERATED
PRODUCTION OF
AUTOANTIBODIES.
In SLE, the increase in autoantibody production is
thought to result from abnormal suppressor T-cell
function, leading to immune complex deposition
and tissue damage. Inflammation stimulates
antigens, which in turn stimulate additional
antibodies, and the cycle repeats.
CLINICAL
MANIFESTATIONS
GENERAL SYMPTOMS
GASTROINTESTINAL
Abdominal pain
Nausea & vomiting
DERMATOLOGICAL
Alopecia
Mucous membrane lesion
Photosensitivity
Purpura
Raynaud's phenomenon
DIAGNOSIS
Diagnosis is based on clinical
symptoms & lab findings
-immunological…
-hypersensitivity reactions
Exaggerated or inappropriate state of normal immune response
-autoimmune disorder
Dermatitis medicamentosa
Type 2 cytotoxic
Reaction may be general other organs may take 3-10 hours after exposure to antigen
immunodefficiency disorders
-infectious disease is compromised or entirely upset
type1-primary
-congenital
type 2-secondary
-acquired
skin test
Epidermis
wheal 15 degree angle
30 minutes
Autoimmune disorder
Attacks body by mistake
Type 1 diabetes
Ibd
Psoriasis
Multiple sclerosis
-Can affect brain and spine, problems vision movement sensation and balance, serious disability
-Rheumatois arthritis
Sle
ks its own tissues, causing widespread inflammation and tissue damage in the affected organs. It can
affect the joints, skin, brain, lungs, kidneys, and blood vessels.
Severe fatigue, joint pains with swelling, butterfly rash, pathognomonic sign, hair loss
Genetics, environmental factors (uv rays, meds, viruses, physical/emotional distress and trauma),
sex(affects women more, estrogen MIGHT play a role) and hormones
Diagnosed by: phys exam, signa and symtoms, mucous mebranes, arthritis
Fatigue
Absence of complications
1. What is the most common coping problem for individuals diagnosed with lupus?
1 point
A) Pain
B) Fear
C) Guilt
D) Depression
Clear selection
A) antimalarials.
B) corticosteroids.
C) cytotoxic drugs.
D) nonsteroidal anti-inflammatory drugs.
Clear selection
3. Which test is the most specific and sensitive test for SLE?
1 point
A) Anti-DNA antibody test
B) Complete blood count (CBC)
C) Antinuclear antibody (ANA) test
D) Erythrocyte sedimentation rate (ESR)
Clear selection
4. Which of the following is a comorbidity that is recognized to increase the risk for
morbidity and mortality in patients with SLE?
1 point
Clear selection
5. Which of the following are among the most common symptoms in new cases or
recurrent active SLE flares?
1 point
Clear selection
A. Alopecia
B. Raynaud phenomenon
C. Malar rash
D. Livedo reticularis
Clear selection
Clear selection
8. A 30-year-old woman has been diagnosed with early systemic lupus erythematosus
(SLE) involving her joints. In teaching the patient about the disease, the nurse
includes the information that SLE is a(n):
1 point
A. Hereditary disorder of women but usually does not show clinical symptoms unless a woman
becomes pregnant.
B. Autoimmune disease of women in which antibodies are formed that destroy all nucleated cells
in the body.
C. Disorder of immune function, but it is extremely variable in its course, and there is no way to
predict its progression.
D. Disease that causes production of antibodies that bind with cellular estrogen receptors,
causing an inflammatory response.
Clear selection
Clear selection
10. Following instruction for a patient with newly diagnosed systemic lupus
erythematosus (SLE), the nurse determines that teaching about the disease has been
effective when the patient says:
1 point
A. "I should expect to have a low fever all the time with this disease."
B. "I need to restrict my exposure to sunlight to prevent an acute onset of symptoms."
C. "I should try to ignore my symptoms as much as possible and have a positive outlook."
D. "I can expect a temporary improvement in my symptoms if I become pregnant."
Clear selection
11. A client is suspected of having systemic lupus erythematous. The nurse monitors
the client, knowing that which of the following is one of the initial characteristic sign of
systemic lupus erythematosus.
1 point
A. Weight gain
B. Subnormal temperature
C. Elevated red blood cell count
D. Rash on the face across the bridge of the nose
Clear selection
12. The nurse is assigned to care for a client with systemic lupus erythematosus
(SLE). The nurse plans care knowing that this disorder is:
1 point
Clear selection
13. 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 of the following medications would the nurse expect to be
prescribed?
1 point
A. Antibiotic
B. Antidiarrheal
C. Corticosteroid
D. Opioid analgesic
Clear selection
Clear selection
15. Teaching that the nurse will plan for the patient with SLE includes:
1 point
1/1
A Myasthenia gravis.
C Pernicious anemia.
1/1
A. Type 1 diabetes
B. Rheumatoid arthritis
C. Psoriasis
D. AIDS
E. A, B, and C
3. If you have an autoimmune disease, what happens with the immune system?
1/1
A. Your immune cells die
B. Antibodies from your immune system mistakenly attack tissues in the body
1/1
1/1
A. Skin
B. Joints
C. Thyroid
1/1
1/1
C. Symptoms may come and go, making it hard to pinpoint the problem
1/1
A. Lupus
B. Multiple sclerosis
C. Scleroderma
9. The transfusion of mismatched blood groups leads to transfusion reaction. This hypersensitivity
reaction is of following type:
1/1
A. Type-III hypersensitivity
B. Type-IV hypersensitivity
C. Type-II hypersensitivity
D. Type-I hypersensitivity
1/1
B. Atopic dermatitis
C. Allergic Rhinitis
D. Food allergy
1/1
A. SLE
B. Anaphylaxis
D. Multiple Sclerosis
12. The inappropriate response of immune system towards a relatively harmless antigen causing harm
to the host is referred as
1/1
A. hypersensitivity
B. auto-immune diseases
C. immunodeficiency
D. tolerance
1/1
A. Graves disease
B. Herpes Zoster
C. Rheumatoid arthritis
D. Addison’s disease
14. The most rapid effects of exposure to an allergen may be due to which of the following?
1/1
A. leukotrienes.
B. granulocytic infiltration.
D. histamine.
15. Which of the following are among the most common symptoms in new cases or recurrent active SLE
flares?
1/1
B Cranial neuropathy
C.Pleuritis
-serum sickness (a type III reaction that results from the injection of heterologous or
foreign protein or serum-- ie horse)
arthus reaction (localized swelling and inflammation following tetanus vaccine- The end
result is a localized area of redness and induration that typically lasts a day or so.)
example of type IV reaction
T cell mediated (no Ab) Delayed Type
T binds antigen-->activates macrophage
* do not appear until 24 hours after antigen contact
IMPORTANT: the Ab specificity is related to the disease presentation unlike Type III. Ie
in goodpasture or Graves or myasthenia gravis. The diseases only happen in specific
organs/vs specific receptors. IC not deposited just anywhere. It determines how the
disease presents.
What is type III hypersensitivity reaction?
* this is usually a complication of an underlying primary autoimmune disease
(if there is no free antigen-- only chemicals that must be bound to presenting cells and
no B cells are activated, no Ab will be produced)
what is the pathogenesis of Granuloma formation?
macrophage phagocytoses some foreign invader (ie bacteria, virus, fungus). but the
organism doesn't die inside the phagocyte. It is resistant to the macrophages. More are
recruited along with Cytotoxic T cells and TH1 cells. Fuse to form multinucleate giant
cells. Over time fibroblasts and calcification wall off the granuloma =.
Tx goals of SLE
Decrease inflammation
Decrease immune system response
Decrease complications
Reduce pain
Prevent flares
Tx of SLE
Meds:
NSAIDS
Steroids
Plaquenil
-Prevent
-Educate
Scleroderma S&S
Calcinosis
Raynauds
Esophageal hypomotility
Sclerodactyly
Telangiectasia
Scleroderma Tx
D-penicillamine
Symptomatic
PT/OT
Stretching
No smoking: will make Raynaud's worse.
DO NOT DO FINGER STICKS. Protect the fingers.
Thoroughly cleaning (or removing) cloth drapes, carpet, and upholstery will reduce
airborne pollen, dust mites, and mold. This may help prevent further allergic response.
Washing fruits and vegetables pertains to food allergies. Patients do not develop
immunity to known allergens by direct exposure; common interventions include
avoidance therapy, desensitization therapy, and symptomatic therapy. Honey is only
said to help some people with allergies to pollen; it does not have an impact on airborne
allergens.
A patient is experiencing reduced chest movement and impaired airflow, hypotension,
and a rapid, weak, irregular pulse. What should be the nurse's first priority?
1
Assessing gas exchange
2
Elevating the bed about 10 degrees
3
Starting an IV and running normal saline
4
Ensuring that intubation equipment is ready
1
Assessing gas exchange
Assessing gas exchange should be the nurse's first priority since emergency respiratory
management is critical during an anaphylactic reaction. Starting an IV and running
normal saline, elevating the bed above 10 degrees if hypotension is present, and
ensuring that intubation equipment is ready are all important components of emergency
care of the patient with anaphylaxis, but these can take place once the airway has been
assessed.
The nurse plans to assess a patient with type I hypersensitivity for which clinical
manifestation?
1
Poison ivy
2
Allergic asthma
3
Rheumatoid arthritis
4
Autoimmune hemolytic anemia
2
Allergic asthma
Serum sickness is a group of symptoms that occurs after receiving serum or certain
drugs. Serum sickness is often caused by penicillin or other antibiotics. Antipyretic
drugs may be useful in treating the fever that accompanies serum sickness.
Antihistamines and corticosteroids are also useful to treat symptoms.
A patient receiving antibiotic therapy for 2 months reports high fever, arthralgia, and
rashes. Diagnostic reports of the patient indicate polyarthritis and enlarged lymph
nodes. What is the best explanation for these clinical manifestations?
1
Secretion of vasoactive amines
2
Accumulation of macrophages in the joints
3
Deposition of immune complexes in blood vessel walls
4
Production of immunoglobulin G (IgG) antibodies against self blood cells
3
Deposition of immune complexes in blood vessel walls
The prolonged use of antibiotics may cause the deposition of immune complexes (drug-
antibody complex) in the blood vessel walls. This deposition results in fever, arthralgia,
polyarthritis, etc. Secretion of vasoactive amines does not cause some of the patient's
symptoms. Macrophages do not accumulate in joints. Production of IgG antibodies to
destroy self cells does not cause these symptoms.
The nurse is caring for a patient experiencing an anaphylactic reaction to an
intravenous (IV) drug. Which nursing intervention is priority for this patient?
1
Apply oxygen using a high-flow non-rebreather mask.
2
Prepare to administer epinephrine 1:10,000 concentration.
3
Keep the head of the bed flat if the patient experiences hypotension.
4
Discontinue the IV immediately and start a new IV with normal saline.
1
Apply oxygen using a high-flow non-rebreather mask.
The nurse should apply oxygen using a high flow, non-rebreather mask at 90% to 100%
before arterial blood gas results are obtained following the guideline of Airway,
Breathing and Circulation (ABC) management for an emergency event. The IV drug
should be promptly discontinued and normal saline administered through the same IV
after the tubing is changed. The nurse should prepare to administer epinephrine 1
mg/mL, which is a 1:1000 concentration, not a 1:10,000 concentration, 0.3 to 0.5 mL
intramuscularly; epinephrine constricts blood vessels, improves cardiac contraction, and
dilates bronchioles. The head of the bed is kept at 10 degrees if the patient experiences
hypotension. Test-Taking Tip: Become familiar with reading questions on a computer
screen. Familiarity reduces anxiety and decreases errors.
A patient has developed a type II hypersensitivity reaction. Which condition is
associated with this type of hypersensitivity?
1
Hay fever
2
Sarcoidosis
3
Serum sickness
4
Autoimmune hemolytic anemia
4
Autoimmune hemolytic anemia
Hemolytic anemia is a type II hypersensitivity. In this reaction, the body makes special
autoantibodies to kill the self cells (or blood cells), causing anemia due to loss of blood
cells. Hay fever, serum sickness, and sarcoidosis are type I, type III, and type IV
hypersensitivities respectively.
Which diseases can be categorized as autoimmune diseases? Select all that apply.
1
Pyelonephritis
2
Cholecystitis
3
Scleroderma
4
Rheumatic fever
5
Goodpasture's syndrome
3
Scleroderma
4
Rheumatic fever
5
Goodpasture's syndrome
In type II reactions, an autoantibody is produced against the self cell that contains an
antigen or foreign protein on its surface. The self cells are then destroyed by
phagocytosis or lysis. Activation of T-cells takes place in delayed hypersensitivity.
Stimulation of thyroid cells and secretion of histamines are the mechanisms of type V
and type I hypersensitivities, respectively.
A patient presents with fever, arthralgia, rash, malaise, lymphadenopathy, nephritis, and
polyarthritis. The patient has been admitted to the hospital several times in the past
month and was last discharged one week ago. What does the nurse suspect this patient
is experiencing?
1
Serum sickness
2
Rheumatoid arthritis
3
Systemic lupus erythematosus
4
Hemolytic transfusion reaction
1
Serum sickness
In a patient exposed to an allergen, elevated levels of IgE antibodies are produced. The
elevated level of antibodies causes inflammation, erythema, or edema in the affected
region. IgG antibodies play a crucial role in type II allergies. IgM antibodies act at the
first stage of an infection caused by viruses, microorganisms, or toxins. The role of IgD
antibodies is not clearly known, but they activate B-cells during infection.
A patient has been ordered by the health care provider to carry a "bee sting kit" at all
times. What does the nurse teach the patient about the care and use of the device?
1
Carry a drug-filled device at all times.
2
Inject the drug into the forearm when required.
3
Obtain a replacement device if the drug is discolored.
4
Go to the nearest hospital for a 2-hour observation after using the device.
3
Obtain a replacement device if the drug is discolored.
The patient should obtain a replacement device if the drug is discolored; the drug must
be clear, with sufficient time left before the expiration date. The patient must keep at
least two drug-filled devices on hand in case more than one dose is needed. The drug is
injected into the thigh muscle, not the forearm. The patient must go to the nearest
hospital for observation for at least 4 to 6 hours after the device is used.
A patient is undergoing a skin test for allergies. Which symptoms are associated with an
anaphylactic reaction? Select all that apply.
1
Red blotches
2
Itching and urticaria
3
High blood pressure
4
Diarrhea and vomiting
5
Erythema and angioedema
1
Red blotches
2
Itching and urticaria
5
Erythema and angioedema
Red blotches, itching, urticaria, erythema, and angioedema are the common symptoms
associated with anaphylactic reactions. During this reaction, vasodilation occurs and
blood is lost from the vascular system; therefore, the patient becomes hypotensive, not
hypertensive. Diarrhea and vomiting are not directly related to this reaction.
A woman who is breastfeeding is diagnosed with rheumatoid arthritis. She does not
want to stop breastfeeding. Which medication is safest for her to take?
1
Anakinra (Kineret)
2
Abatacept (Orencia)
3
Adalibumab (Humira)
4
Tocilizumab (Actemra)
3
Adalibumab (Humira)
In order to identify the causative allergen, the nurse asks if the patient has any allergy to
some foods, drugs, or other chemical compounds. The exposure to such compounds
can result in mild to severe type I reactions. This type of hypersensitivity can be a
hereditary problem; therefore, asking about family history of the disease will be useful.
In order to understand the severity of the disease, information about onset and duration
can be beneficial. Rather than asking about favorite foods or beverages, the nurse
should inquire about any allergies to food items or beverages. Transplantation-related
problems are associated with autoimmunity, not with type I hypersensitivity.
A patient recently admitted to the hospital is to receive an antibiotic intravenously for the
first time for a urinary tract infection. Before checking the five rights prior to
administration, what is the nurse's first action?
1
Check the patient's identification band for any allergies.
2
Check with the pharmacy for any known allergies for this patient.
3
Review the clinical records and ask the patient about any known allergies.
4
Ask the nurse who previously cared for the patient about any known allergies.
3
Review the clinical records and ask the patient about any known allergies.
The clinical record should have all known hypersensitivities listed for the patient. The
patient should also be asked directly about any known allergies. The pharmacy is not
responsible for obtaining information on all of the patient's known allergies. Checking
the patient's identification band for allergies is part of the "five rights" process at the
bedside before the medication is given. Asking the previous nurse is not an appropriate
safety measure before medication administration.
located...
brain
lungs
liver
kidneys
What bacteria causes toxic shock syndrome?
Staphylococcus aureus
Seasonal allergic rhinitis is most commonly caused by pollens from trees, weeds, and
grasses. Airborne allergies can be controlled by sleeping in an air-conditioned room,
daily damp dusting, covering the mattress and pillows with hypoallergenic covers, and
wearing a mask outdoors.
When caring for a patient with a known latex allergy, the nurse would monitor the
patient closely for a cross-sensitivity to which foods (select all that apply)?
A. Grapes
B. Oranges
C. Bananas
D. Potatoes
E. Tomatoes
A, C, D, E
Because some proteins in rubber are similar to food proteins, some foods may cause an
allergic reaction in people who are allergic to latex. The most common of these foods
are bananas, avocados, chestnuts, kiwi fruit, tomatoes, water chestnuts, guava,
hazelnuts, potatoes, peaches, grapes, and apricots.
Ten days after receiving a bone marrow transplant, a patient develops a skin rash on
his palms and soles, jaundice, and diarrhea. What is the most likely etiology of these
clinical manifestations?
A. Type I
B. Type II
C. Type III
D. Type IV
B. Type II
A. Autoimmune response
B. Cell-mediated immunity
C. Hypersensitivity response
D. Humoral immune response
A. Autoimmune response
With aging, autoantibodies increase, which lead to autoimmune diseases (e.g., systemic
lupus erythematosus, acute glomerulonephritis, rheumatoid arthritis, hypothyroidism).
Cell-mediated immunity decreases with decreased thymic output of T cells and
decreased activation of both T and B cells. There is a decreased or absent delayed
hypersensitivity reaction. Immunoglobulin levels decrease and lead to a suppressed
humoral immune response in older adults.
A 21-year-old student had taken amoxicillin once as a child for an ear infection. She is
given an injection of Penicillin V and develops a systemic anaphylactic reaction. What
manifestations would be seen first?
A. Dyspnea
B. Dilated pupils
C. Itching and edema
D. Wheal-and-flare reaction
C. Itching and edema
A systemic anaphylactic reaction starts with edema and itching at the site of exposure to
the antigen. Shock can rapidly develop with rapid, weak pulse; hypotension; dilated
pupils; dyspnea, and possible cyanosis. The wheal-and-flare reaction occurs with a
localized anaphylactic reaction such as a mosquito bite.
The patient with an autoimmune disease will be treated with plasmapheresis. What
should the nurse teach the patient about this treatment?
Plasmapheresis removes plasma that contains autoantibodies (usually IgG class) and
antigen-antibody complexes to remove the pathologic substances in the plasma without
causing anemia. Plateletpheresis removes platelets from normal individuals for use by
patients with low platelet counts. Apheresis is used to collect stem cells from peripheral
blood that does not cure autoimmune disease.
The patient with diabetes mellitus has been ill for some time with a severe lung infection
needing corticosteroids and antibiotics. The patient does not feel like eating. The nurse
understands that this patient is likely to develop
A. major histoincompatibility.
B. primary immunodeficiency.
C. secondary immunodeficiency.
D. acute hypersensitivity reaction.
C. secondary immunodeficiency.
A. "My drug dosages will be lower because the medications enhance each other."
B. "Taking more than one medication will put me at risk for developing allergies."
C. "I will be more prone to malignancies because I will be taking more than one drug."
D. "The lower doses of my medications can prevent rejection and minimize the side
effects."
D. "The lower doses of my medications can prevent rejection and minimize the side
effects."
Decongestants
Cause systemic vasoconstriction, so increases BP
Hypersensitivity/Allergy
Increased or excessive response to the presence of an antigen to which the client has
been exposed. Overproduction of IgE. Degree of reaction ranges from uncomfortable to
life threatening.
Type 1: Rapid Hypersensitivity Reactions
Most common type. AKA atopic allergy. Can be local; just in the areas exposed to the
antigen. OR systemic; affecting the whole body.
Examples of Type 1 Reactions
latex allergy
Allergic asthma
Anaphylaxis
Ways that we contact allergens
*Inhaled (plant pollens, fungal spores, animal
dander, house dust, grass, ragweed)
*Ingested (foods, food additives, drugs)
*Injected (bee venom, drugs, biologic substances)
*contacted (pollens, foods, environmental
proteins)
Collaborative Management of Allergies
History / close relative with allergies,
Physical/Assesments / s/s
Lab Assessments:
Increased eosinophils
Possibly increased WBCs
Increased IgE
RAST (radioallergosorbant test)
RAST (radioallergosorbant test)
a type of blood test used to test for allergies. These tests, which use radioactivity, have
largely been abandoned by doctors in favor of newer, more accurate forms of allergy
testing.
Allergy Testing
*Skin testing/scratch and intradermal
*Oral food challenge
*Avoidance therapy
*Symptomatic therapy/premedicate
*Drug therapy/Zyrtec, Allegra, Singulair..
Drug therapy
Decongestants/ not for pt. with glaucoma, high
BP or urinary retention
Antihistamines dries secretions. not for
breastfeeding mothers
Corticosteroids (discontinue 5 days before
allergy testing) MONITOR BLOOD SUGAR
Mast cell stabilizers
Leukotriene antagonists
Complementary and alternative therapy/Essential
Oils, honey
Desensitization therapy/allergy shot 2-3 times per week for 5 years. Stay 20 minutes
after injection.
Anaphylaxis
The widespread reaction that occurs in response to contact with a substance to which
the person has a severe allergy (antigen); characterized by blood vessel and
bronchiolar smooth muscle involvement causing widespread bold vessel dilation,
decreased cardiac output, and bronchoconstriction; results in cell damage and the
release of large amounts of histamine, severe hypovolemia, vascular collapse,
decreased cardiac contraction, and dysrhythmias and causes extreme whole-body
hypoxia.
Anaphylaxis facts
Not common, episodes vary in severity, and it can be fatal. The major factor in fatal
outcomes is a delay in the administration of epinephrine.
*Drugs and dyes are common causes in acute care setting
*Food and insect stings are common causes in community settings.
Initial manifestations of anaphylaxis
feelings of uneasiness, apprehension, weakness, impending doom, anxious, frightened.
These feelings are followed quickly by generalized itching, urticaria.
Manifestations of anaphylaxis
Initial manifestations are followed by erythema and sometimes angioedema of the eyes,
lips, or tongue. Intensely itchy skin wheals or hives may appear and sometimes merge
to form large, red blotches.
Respiratory manifestations of anaphylaxis
Histamine and other mediators cause inflammation, bronchoconstriction, mucosal
edema, and excess mucus production. Symptoms include. Symptoms include
congestion, rhinorrhea, dyspnea, and increasing respiratory distress with audible
wheezing. Crackles, wheezing, and reduced breath sounds are heard. Pt may have
laryngeal edema as a lump in the throat, hoarseness, and stridor. Distress increases as
the tongue and larynx swell and more mucus is produced. Stridor increases as the
airway begins to close. Increasing bronchoconstriction can lead to reduced chest
movement and impaired airflow. Respiratory failure may follow from laryngeal edema,
suffocation, or lower airway constriction causing hypoxemia.
Cardiac manifestations of anaphylaxis
Patient is usually hypotensive and has a rapid, weak, irregular pulse from extensive
capillary leak and vasodilation. Patient is faint and diaphoretic with increasing anxiety
and confusion.
A patient with a family history of allergies has suffered an allergic response based on a
genetic predisposition. This atopic response is usually mediated by what
immunoglobulin?
A)
Immunoglobulin A
B)
Immunoglobulin M
C)
Immunoglobulin G
D)
Immunoglobulin E
D)
Immunoglobulin E
An office worker takes a cupcake that contains peanut butter. He begins wheezing, with
an inspiratory stridor and air hunger and the occupational health nurse is called to the
office. The nurse should recognize that the worker is likely suffering from which type of
hypersensitivity?
A)
Anaphylactic (type 1)
B)
C)
D)
Anaphylactic (type 1)
A patient is learning about his new diagnosis of asthma with the asthma nurse. What
medication has the ability to prevent the onset of acute asthma exacerbations?
A)
Diphenhydramine (Benadryl)
B)
Montelukast (Singulair)
C)
Albuterol sulfate (Ventolin)
D)
Epinephrine
B)
Montelukast (Singulair)
A nurse is preparing a patient for allergy skin testing. Which of the following
precautionary steps is most important for the nurse to follow?
A)
B)
C)
D)
A)
The patient should only be tested for grass, mold, and dust initially.
C)
The nurse should have an emergency cart available in case of anaphylaxis during the
test.
D)
A)
B)
C)
Maintain room temperature at 75F to 80F whenever possible.
D)
Keep her hands well-moisturized at all times.
D)
Keep her hands well-moisturized at all times.
A patient with severe environmental allergies is scheduled for an immunotherapy
injection. What should be included in teaching the patient about this treatment?
A)
The patient will be given a low dose of epinephrine before the treatment.
B)
The patient will remain in the clinic to be monitored for 30 minutes following the
injection.
C)
Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3
months.
D)
The patient will remain in the clinic to be monitored for 30 minutes following the
injection.
The nurse in an allergy clinic is educating a new patient about the pathology of the
patients health problem. What response should the nurse describe as a possible
consequence of histamine release?
A)
B)
C)
D)
A)
B)
C)
Myasthenia gravis
D)
Rheumatoid arthritis
A)
A)
Forearm
B)
Thigh
C)
Deltoid muscle
D)
Abdomen
B)
Thigh
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a
patients plan of care. The presence of what chronic health problem would most likely
prompt this diagnosis?
A)
Herpes simplex
B)
HIV
C)
Spina bifida
D)
Hypogammaglobulinemia
C)
Spina bifida
A patient has a documented history of allergies presents to the clinic. She states that
she is frustrated by her chronic nasal congestion, anosmia (inability to smell) and
inability to concentrate. The nurse should identify which of the following nursing
diagnoses?
A)
Deficient Knowledge of Self-Care Practices Related to Allergies
B)
Ineffective Individual Coping with Chronicity of Condition and Need for Environmental
Modification
C)
D)
Ineffective Individual Coping with Chronicity of Condition and Need for Environmental
Modification
A patients decline in respiratory and renal function has been attributed to Goodpasture
syndrome, which is a type II hypersensitivity reaction. What pathologic process
underlies the patients health problem?
A)
B)
The patients body has mistakenly identified a normal constituent of the body as foreign.
C)
D)
Mast cells have released histamines that directly cause cell lysis.
B)
The patients body has mistakenly identified a normal constituent of the body as foreign.
A child is undergoing testing for food allergies after experiencing unexplained signs and
symptoms of hypersensitivity. What food items would the nurse inform the parents are
common allergens?
A)
B)
C)
D)
A)
Increased eosinophils
B)
Increased neutrophils
C)
Increased serum albumin
D)
Increased eosinophils
A nurse is aware of the need to assess patients risks for anaphylaxis. What health care
procedure constitutes the highest risk for anaphylaxis?
A)
B)
C)
D)
A)
C)
D)
A)
Food allergies are a life-long condition, but most families adjust quite well to the
necessary lifestyle changes.
B)
Consistent use of over-the-counter antihistamines can often help a child overcome food
allergies.
C)
Make sure that you carry a steroid inhaler with you at all times, especially when you eat
in restaurants.
D)
Many children outgrow their food allergies in a few years if they avoid the offending
foods.
D)
Many children outgrow their food allergies in a few years if they avoid the offending
foods.
A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic
reaction. What is a priority for health education?
A)
B)
C)
D)
The need for the child to avoid all foods that have a high potential for allergies
B)
A)
Bronchitis
B)
C)
Rheumatoid arthritis
D)
Asthma
D)
Asthma
The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis,
which commonly affects both of her hands and forearms. What risk nursing diagnosis
should the nurse include in the patients care plan?
A)
B)
C)
D)
A)
Foods
B)
Medications
C)
Insect stings
D)
Autoimmunity
E)
Environmental pollutants
A)
Foods
B)
Medications
C)
Insect stings
A school nurse is caring for a child who appears to be having an allergic response.
What should be the initial action of the school nurse?
A)
B)
Assess for erythema and urticaria.
C)
D)
Administer epinephrine.
A)
A)
Anaphylactic (type 1)
B)
C)
D)
B)
C)
D)
A)
The faster the onset of symptoms, the more severe the reaction.
B)
The reaction will be about one-third more severe than the patients last reaction to the
same antigen.
C)
There is no way to gauge the severity of a patients anaphylaxis, even if it has occurred
repeatedly in the past.
D)
The reaction will generally be slightly less severe than the last reaction to the same
antigen.
A)
The faster the onset of symptoms, the more severe the reaction.
A nurse knows of several patients who have achieved adequate control of their allergy
symptoms using over-the-counter antihistamines. Antihistamines would be
contraindicated in the care of which patient?
A)
B)
C)
D)
A)
B)
Most people find that they develop a tolerance to sedation after a few months.
C)
The newer antihistamines are different than in years past, and cause less sedation.
D)
The newer antihistamines are different than in years past, and cause less sedation.
A child has been transported to the emergency department (ED) after a severe allergic
reaction. The ED nurse is evaluating the patients respiratory status. How should the
nurse evaluate the patients respiratory status? Select all that apply.
A)
B)
C)
D)
E)
D)
E)
A)
I can only imagine how you feel. Would you like to talk about it?
B)
Lets find a quiet spot and Ill teach you a few coping strategies.
C)
Thats the same way that most patients who have a chronic illness feel.
D)
Do you think that maybe you could be managing things more efficiently?
A)
I can only imagine how you feel. Would you like to talk about it?
A nurse at an allergy clinic is providing education for a patient starting immunotherapy
for the treatment of allergies. What education should the nurse prioritize?
A)
The importance of scheduling appointments for the same time each month
B)
C)
D)
A)
B)
C)
D)
A)
Encourage the woman to continue with the medication while monitoring her skin
condition closely.
B)
Refer the woman to her primary care provider to have the medication changed.
C)
D)
Encourage the woman to take an OTC antihistamine with each dose of the antibiotic.
B)
Refer the woman to her primary care provider to have the medication changed.
A patient has sought care, stating that she developed hives overnight. The nurses
inspection confirms the presence of urticaria. What type of allergic hypersensitivity
reaction has the patient developed?
A)
Type I
B)
Type II
C)
Type III
D)
Type IV
A)
Type I
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema.
When planning this patients care, what nursing diagnosis should be prioritized?
A)
B)
C)
D)
A)
Cytotoxic reaction due to contact with the powder in the gloves
B)
C)
D)
A)
B)
C)
Teach the patient to seek medical attention at the first sign of an allergic reaction.
D)
A)
B)
C)
D)
A)
B)
C)
D)
Avoid live attenuated vaccinations.
A)
A)
B)
C)
D)
Which factor indicates to the nurse the only similarity between discoid lupus
erythematosus (DLE) and systemic lupus erythematosus (SLE)?
a. Feeling tired and having a temperature that runs about 100° F (37.8° C) during the
day
b. Disfiguring and embarrassing rash
c. Peripheral neuropathies and cranial nerve palsies
d. High risk for renal inflammation
b. Disfiguring and embarrassing rash
Skin lesions associated with disfiguring and embarrassing rash are common to SLE and
DLE.
Fatigue and fever are common only to SLE. Neurologic manifestations and inflammation
of the kidneys are common in SLE.
The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates
that the client will also have which common condition?
a. Dry eyes
b. Abdominal bloating after eating
c. Excessive production of saliva in the mouth
d. Intermittent episodes of diarrhea
a. Dry eyes
Clients with Sjögren's syndrome experience dry eyes
Before administering low-molecular-weight heparin (LMWH) to an older adult client after
total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3 (50
x 109/L). What action is most important for the nurse to take?
a. Notify the health care provider of the platelet count.
b. Administer the prescribed LMWH on schedule.
c. Assess the activated partial thromboplastin time (aPTT).
d. Assess the international normalized ratio (INR).
a. Notify the health care provider of the platelet count.
Normal platelet count is between 150,000 mm³ (150 x 109/L) and 400,000 mm³ (400 x
109/L), so 50,000 mm³ (50 x 109/L) is quite low. If the platelet count falls below
20,000/mm3 (20 x 109/L) spontaneous bleeding could occur. Notifying the health care
provider before the LMWH is given is essential.
Before administering prednisone IV push to a middle-aged adult with rheumatoid
arthritis (RA), the nurse notes that the client's random blood glucose level is 139 mg/dl
(7.7 mmol/L). Which action is most important for the nurse to take?
a. Instruct the client to drink diet soda to prevent elevation of blood sugar.
b. Administer the prescribed prednisone on schedule.
c. Notify the health care provider of the random blood glucose result.
d. Review the client's antinuclear antibody (ANA) level.
b. Administer the prescribed prednisone on schedule.
OA is unilateral and usually affects a single joint, whereas RA is bilateral and affects
multiple joints.
A client has symptoms of rheumatoid arthritis (RA). Which laboratory finding indicates to
the nurse that the client may have RA?
a. Total serum complement, 75 units/mL
b. Positive total antinuclear antibody (ANA)
c. Erythrocyte sedimentation rate (ESR), 20 mm/hr
d. Beta-globulin level, 1.0 g/dL (10 g/L)
b. Positive total antinuclear antibody (ANA)
autoimmune disease
is an immune response against the self
-the immune system will fail to differentiate between self and non-self, therefore attack
its own cells
causes of autoimmunity
-unknown
-age
-gender (more common in women)
-genetics
-environmental triggers such as viral infections and certain drugs
autoimmune classification
can be:
-organ specific
-systemic
organ specific
includes the blood, CNS, muscle, heart, endocrine, GI, kidney, liver, eye
systemic
includes: scleroderma, rheumatoid arthritis, systemic lupus
hemolytic anemia
-hematological autoimmune disorders
-autoimmune destruction of RBCs at a rate exceeding that which the body can replace
-results in severe anemia usually requiring blood transfusions, corticosteroids, and a
splenectomy
immune thrombocytopenic purpura
-hematological autoimmune disorder
-is the autoimmune tagging and sequestration of platelets in the spleen
-resulting in the shortened lifespan of platelets
-increased risk of bleeding
-may be acute or chronic
multiple sclerosis
-central nervous system autoimmune disease
-defined as the chronic-progressive, degenerative demyelinating disease of the CNS
-attacks the brain and spinal cord resulting in impaired transmission of nerve impulses
between brain and body
guillain barre
-central nervous system autoimmune disease
-occurs after viral/bacterial infection
-defined as the attack/demyelination of the peripheral nervous system (affecting
transmission of nerves)
-can cause pain, numbness/tingling, lack of reflexes, weakness of extremities
-respiratory muscles can be affected and may require mechanic ventilation
myanthesia gravis
-neuromuscular autoimmune disease
-defined as the attack of voluntary muscles
-characterized by fluctuating weakness of skeletal muscles
-muscles used to move eye/eyelids, chew, swallow, speak, breathe (eyes go first)
-muscles are strongest in the morning and fatigue with activity (so rest will restore
strength)
rheumatic fever
-cardiac autoimmune disease
-defined as the acute inflammatory disease of the heart
-complication of inadequately treated strep infection
-can cause permanent damage to the heart, including damaged heart valves and heart
failure
celiac disease
-GI autoimmune disease
-defined as the ingestion of gluten which leads to damage in the small intestine
-can cause foul smelling stool, diarrhea, flatus, abdominal distention, dermatitis,
herpetiformis
inflammatory bowel disease
-GI autoimmune disease
-defined as the chronic inflammation of the digestive tract such as ulcerative colitis, and
chron's disease
pernicious anemia
-GI autoimmune disease
-defined as when the body cannot absorb enough vitamin B2 (which is required to
produce healthy RBCs)
glomerulonephritis
-renal autoimmune disease
-defined as the inflammation of the glomeruli
-glomeruli normally function to remove excess fluid, electrolytes, and waste from the
bloodstream and pass them into the urine
-causes fluid retention and a decreased glomerular filtratio
-edema, htn, oliguria, hematuria, proteinuria
rhuematoid arthritis
-systemic autoimmune diseases
-characterized by the inflammation of connective tissue in synovial joints
-marked by periods of exacerbation and remission
-joints will become painful and stiff with limited mobility
-most common in the small joints of the hands and feet
-the inflammation will eventually lead to bone deformity
scleroderma
-systemic autoimmune disease
-defined as the disease of the connective tissue resulting in hardening of the skin
-CREST
CREST
c= calcinosis
Deposits of Ca2+ in skin (painful)
R= Raynaud's phenomenon
Vasospasm of fingertips in response to cold
E= Esophageal dysfunction
Difficulty swallowing d/t internal scarring
S= Sclerodactyly
Tightening of skin on fingers and toes
T= Telangiectasia
Red spots from capillary dilation
lupus
-systemic autoimmune disease
-defined as an autoimmune disease where the immune system of the body mistakenly
attacks healthy tissue
-is a chronic disease that affects multiple organs such as the skin, muscles, heart,
lungs, nervous tissue, kidneys
SLE cuases
-genetic
-hormones: often correlates with meses, pregnancy, oral contraceptives
-environmental: UV light exposures, stress, viruses, medications
SLE prevalence
-affects women 10 more times than men
-african americans, asians, latinas, native americans
-most often diagnosed in childbearing years (20-40)
SLE clinical manifestations
-tachypnea, cough, pleural inflammation/effusion
-weight loss, fatigue, fever, infection, arthritis, emotional liability
-hematological disorders ,neurological disorders, raynaud's phenomenon, pericarditis,
vascular inflammation
SLE lab tests
-increased ESR and CRP
-CBC
-BMP/CMP
SLE pharmacological interventions
-NSAIDs
-antimalarial drugs
-corticosteroids
-immunosuppressive drugs
-anticoagulants
SLE management
-plasmapheresis to remove blood plasma from the body in order to remove antibodies in
treating autoimmunity
-avoid sunlight
SLE patient teaching
-disease process
-drug actions, dosing, side effects
-pain management
-stress avoidance
-minimize exposure to Infection
-use of sunscreen
-lab follow ups
-pregnancy counseling
-support groups
treatment of autoimmunity
-aphresis
-platelet pheresis
-leukocytopheresis
-plamsapheresis
aphresis
procedure that separates and removes one or more blood components
platelets pheresis
removal of platelets
leukocytapheresis
remove white blood cells
pasmapheresis
removes plasma
What is RA?
Inflammation of connective tissue within synovial joints
What are Rheumatoid Factors (RF)?
auto-antibodies we see that the body is attacking itself - abnormal antibodies
What are clinical manifestations of RA?
fatigue, anorexia, weight loss, generalized stiffness, low grade fevers
Defuse - everything happens all at once - worse than limited, reynauds happening at the
same time
What is Sclerodactyly?
tight taunt skin
What is fibromyalgia?
Widespread burning pain and tenderness
Clinical manifestations of fibromyalgia?
Chronic syndrome with widespread musculoskeletal pain & fatigue
Peripheral numbness and tingling due to all of the tenderness points happening
What do you need to have to be diagnosed with Fibromyalgia?
Pain in 11 of 18 tender points on palpation
Give Atropine!!
Where should the HOB be for a patient with MG?
Keep HOB elevated - risk for aspiration
Widespread inflammation
Autoimmune disorders are all similar due to their shared characteristic of... throughout
the body
Connective tissue
Synovial joints
(joints that allow for movement)
Rheumatoid Arthritis is the inflammation of... within the...
1. Chronic
2. Systemic
Rheumatoid Arthritis is a... (2) autoimmune disease
1. Exacerbation
2. Remission
Patients with autoimmune diseases will have periods of... (2)
Age
The incidence of Rheumatoid Arthritis increases with...
Symmetrical
Extra-articular
(inflammation outside the joints)
Rheumatoid Arthritis presents with inflammation of the joints that are ALWAYS...
Synovial joint
Massive inflammation
(VERY painful)
In Rheumatoid Arthritis, when triggered, abnormal immunoglobulins begin to attack
the...
1. Smoking
2. Stress
3. Infections
Rheumatoid Arthritis is a... disease that can also be caused by... (3)
Deformed
With Rheumatoid Arthritis, overtime, the joints and bones will become...
Morning
Flu-like
1. Joint pain
2. Inflammation
Rheumatoid Arthritis is a... (2) disease that usually starts initially with... symptoms and
eventually... (2)
Rheumatoid Arthritis
Ulnar drift, Hallux valgus, Boutonniere and swan neck deformity are all seen in...
1. ADL performance
2. Nutrition (too much pain to feed)
3. Pain
4. Safety
Concerns as a nurse for a patient with Rheumatoid Arthritis include... (4)
Dry
(ex. eyes, skin, mouth)
Sjogren's syndrome is an autoimmune disorder where everything is...
Cold (ice)
Warm
During an Rheumatoid Arthritis exacerbation, use... therapy
Up
Ankylosing Spondylitis is a chronic, inflammatory disease that starts in the... and works
its way...
Spinal bones
1. "bamboo spines"
2. "RA of the spine"
In Ankylosing Spondylitis,... start to fuse together
Mild activity
When is Ankylosing Spondylitis pain worse?
Bowel/bladder incontinence
Cauda Equina syndrome is considered a... that consists of bilateral... and...
Compression
Nerve root
Paralysis
Cauda Equina syndrome is caused due to major... over the... over the base of the spine
1. Respiratory
2. Mobility
Interventions for Ankylosing Spondylitis involve correcting... and maintaining... (2)
function
Supine with a pillow under their knees
Viral infections
(ex. Herpes)
Bell's Palsy is... of the... caused by...
7 (CN)
ONE SIDE
Bell's Palsy involves inflammation, ischemia and demyelination of facial nerve... that
affects... of the face
Stroke
Trigger (virus)
Patients with Bell's Palsy may appear as though they are having a...
1. Moist heat
2. Gentle massage
How is Bell's Palsy go away?
1. Fatigue
2. Memory/thinking issues
3. Gait difficulty
LATE clinical manifestations of Lyme disease include... presentations such as... (3)
2 step testing
1. Serum
2. Tissue
Lupus is an overaggressive... response where immune complexes form in the... (2)
Women
1. Miscarriage
2. Birth deformities
Pregnancy in a patient with Lupus can lead to severe...
1. Tissue fibrosis
2. Blood vessel occlusion
Scleroderma is an overproduction of... resulting in... (2)
1. Genetic
2. Environmental
What is the cause of Scleroderma? (2)
1. Hardening/thickening of skin
2. "CREST" syndrome
Clinical manifestations of Scleroderma include... (2)
1. Localized
2. Systemic
What are the 2 types of Scleroderma?
Systemic
Calcinosis
Raynaud's
Esophageal dysfunction
Sclerodactyly
Telangiectasia
"CREST" syndrome involves... symptoms
18
3 months
For diagnosis of Fibromyalgia, the patient must be tender inattentive least... out of...
points
Stress factors
Fibromyalgia involves many... and...
Degenerative
CNS
1. Brain
2. Spinal cord
Multiple Sclerosis is a chronic, progressive and... disorder of the... characterized by
disseminated demyelination of the nerve fibers of the... (2)
Terminal (no known cure)
Unknown
Autoimmune
Multiple Sclerosis is a... disease
Exacerbations
In Multiple Sclerosis, a patients symptoms will... with pregnancy
Symptom relief
What is the cure for Multiple Sclerosis?
ACh receptors
Muscle weakness
Myasthenia Gravis affects the NM junction causing weakness of...
Muscle weakness
ACh makes... move
Rest
Myasthenia Gravis weakness gets worse with... and stronger with...
Diaphragm
Myasthenia Gravis involves fluctuating weakness of skeletal muscles from the... and up
UNDER medicated
LOW
DRY
A patient experiencing a myasthenia crisis is...
HIGH
WET
(SLUGBAM)
A patient experiencing a cholinergic crisis is...
Aspiration
A myasthenia crisis causes muscular weakness affecting normal... (2)
UNDER medicated
If the patient gets BETTER with tensilon, they were experiencing a... which means they
were...
Cholinergic crisis
OVER medicated
GIVE ATROPINE
If the patient gets WORSE (weaker) with tensilon, they were experiencing a... which
means they were...
(nonspecific)
What are examples of 2 inflammatory markers?
Methotrexate
It can treat cancer of the blood, bone, lung, breast, head, and neck. It can also treat
rheumatoid arthritis and psoriasis.
Trade Name(s)
Metoject [Canada]
Otrexup
Rasuvo
Rheumatrex
Trexall
CAN CAUSE HEPATIC FIBROSIS AND CIRRHOSIS, BONE MARROW
SUPRESSION, ULCERATIVE STOMATITIS AND RENAL DAMAGE
Plaquenil/hydroxychloroquine
It can treat and prevent malaria. It can also treat lupus and arthritis.
Colchicine
It can treat and prevent gout attacks. It can also treat familial Mediterranean fever
(FMF).
Trade Name(s)
Colcrys
Mitigare
Allopurinol
It can treat gout and kidney stones.
Trade Name(s)
Aloprim
Lopurin
Zyloprim
Uloric (Febuxostat)
It can treat high uric acid in the blood of patients with gout.
Antihistamines
Antihistamines are drugs which treat allergic rhinitis and other allergies. Antihistamines
can give relief when a person has nasal congestion, sneezing, or hives because of
pollen, dust mites, or animal allergy.
Decongestants
A decongestant, or nasal decongestant, is a type of pharmaceutical drug that is used to
relieve nasal congestion in the upper respiratory tract. The active ingredient in most
decongestants is either pseudoephedrine or phenylephrine.
Epinephrine
Blood pressure support and vasoconstrictor
It can treat severe asthma attacks and allergic reactions (including anaphylaxis) in an
emergency situation.
Isoproterenol
Blood pressure support
It can treat certain types of heart problems. It can also improve breathing while a patient
is under anesthesia.
Ephedrine
Involuntary nervous system stimulant
It can treat low blood pressure caused by other medications. It can also improve
breathing.
Corticosteriods
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex
of vertebrates, as well as the synthetic analogues of these hormones.
Vasopressors
are a powerful class of drugs that induce vasoconstriction and thereby elevate mean
arterial pressure (MAP).
Things that contain latex
ACE bandages, Elastic/adhesive bandages, Ambu bag, Balloons, BP cuff tubing,
catheters, gloves, feminine hygiene pads, IV catheters, tubing, rubber injection ports
and syringes.
Anaphylaxis
Whole body: fainting, lightheadedness, low blood pressure, dizziness, or flushing
Respiratory: difficulty breathing, rapid breathing, shortness of breath, or wheezing
Skin: hives, swelling under the skin, blue skin from poor circulation, or rashes
Gastrointestinal: nausea or vomiting
Also common: fast heart rate, feeling of impending doom, itching, tongue swelling,
difficulty swallowing, facial swelling, mental confusion, nasal congestion, or impaired
voice
Stages of lyme disease
1, 2, 3
Stage 1 lyme disease
Several days to months following the bite, small red pimples develops that may spread
into ring shaped rash. Flu like symptoms occur, stiff neck, muscle aches and fatigue
Stage 2 lyme disease
This stage occurs several weeks following bite, joint pain occurs, neurological
complications occur and cardiac complications occur
Stage 3 lyme disease
Large joints become involves arthritis progresses
Arthroscopy
visualization of internal structures of a joint , infection and lack of joint mobility are
contraindications
Nuclear scans
evaluates entire skeletal system, radioactive isotope injected 2-3 hours prior, less
common due to MRI's
Gallium and thallium scan
A gallium scan is a test to look for swelling (inflammation), infection, or cancer in the
body. It uses a radioactive material called gallium and is a type of nuclear medicine
exam.
A thallium stress test is a nuclear imaging test that shows how well blood flows into your
heart while you're exercising or at rest. This test is also called a cardiac or nuclear
stress test. ... The radioisotope will flow through your bloodstream and end up in your
heart.
Nuclear scan preprocedure considerations
Informed consent, assess for allergy, pregnancy or kidney disease
DXA scan
is a special type of X-ray that measures bone mineral density (BMD). DEXA stands for
"dual energy X-ray absorptiometry". This type of scan may also be called: a DXA scan.
a bone density scan. Remove metallic objects prior..
EMG
measures the electrical activity of muscles when they're at rest and when they're being
used. Nerve conduction studies measure how well and how fast the nerves can send
electrical signals. Nerves control the muscles in the body with electrical signals called
impulses.
EMG post procedure
client can apply ice to prevent hematomas at needle insertion site and reduce swelling
use a warm compress for discomfort.
Osteoarthritis disease process
Cartilage destruction with bone spur growth at joint ends (degenerative)
Osteoarthritis findings
Pain with activity that improves w/ rest
Osteoarthritis effusions
localized inflammatory response
Osteoarthritis body size
usually overweight
Osteoarthritis system involvment
none, localized
Osteoarthritis nodes
heberdens and bouchards nodes
Osteoarthritis symetrical
No
Osteoarthritis diagnostic tests
Xray
RA disease process
Synovial membrane inflammation in cartilage destruction and bone erosion
inflammatory
RA findings
selling, redness, warmth, pain at rest after immobility
RA effusions
All joints
RA nodes
Swan neck and boutonniere of hands
RA body size
usually underweight
RA systemic
Yes, lungs, heart, skin and extra-articular
RA Symmetrical?
Yes
RA diagnostic tests
Xrays positive and Rheumatoid factor
Osteoarthritis health promotion
Encourage weight loss if needed, avoid repetitive strain like jogging or contact sports,
recommend wearing well fitting shoes.
Osteoarthritis risk factors
Aging
genetic
joint injury
obesity
metabolic disorders (DM, Sickle cell disease)
Osteoarthritis expected findings
Joint pain/stiffness
Pain on joint palpation or ROM
Crepitus
Enlarged joint
Bouchards nodes
joint effusion
vertebral radiating pain
limping gait
back pain
OA diagnostic procedures
Xrays, MRI, CT, NBS, CT myelogram, EMG, Arthrogram
Arthrogram
xray study of a joint
Patient assessment for OA
Pain monitoring, musculoskeletal assessment/muscle tone, Neuro/sensory ans
psychosocial assessment
Maximum administration of acetominophen
4,000mg/24 hr
NSAID side effects
black tarry stool, indigestion and SOB
Muscle relaxants can cause what in older adults?
Confusion
Tramadol use in OA?
Considered a weak opioid that can be use for short term management of OA and long-
term use in lower back pain
Glucosamine supplements
is a compound that is naturally made in humans. It is involved in the creation of
molecules that form cartilage.
Interprofessional care for OA
PT, nutritionist and occupational therapy
Total joint arthroscopy
is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve
pain and disability. It is most commonly performed for osteoarthritis,[1] and also for
other knee diseases such as rheumatoid arthritis and psoriatic arthritis. In patients with
severe deformity from advanced rheumatoid arthritis, trauma, or long-standing
osteoarthritis, the surgery may be more complicated and carry higher risk. Osteoporosis
does not typically cause knee pain, deformity, or inflammation and is not a reason to
perform knee replacement.
Open diskectomy
removal of herniated disk
Laminectomy
Removal of part of the laminae and facet of joints
HIV infection stages
Stage 1-4
Stage 1
CD4: 500 cells/mm3 or more
%: 29
Stage 2
CD4: 200-499 cells/mm3
%: 14-28
Stage 3 AIDS
CD4: 200 or less
%:14
or one or more opportune infection
HIV manifestation can occur as early as
2-4 weeks after infection(flu like symptoms)
AIDS death usually occurs within....
5 years
HIV encourage
hygiene, frequent immunizations and drug regimen be followed
HIV expected findings
Chills, rash, anorexia, weight loss, nausea, weakness and fatigue, headache and sore
throat and night sweats
Diagnostic tests for HIV
Viral load test, HIV genotype or HIV tropism, Liver profile, biopsies and testing of stool
for parasites and brain or lung MRI or CT scan.
Neoplasms
Kaposi's sarcoma purplish-red lesions of internal organs and skin, B cell and non-
hodgkins lymphoma cervical cancer
Fusion inhibitors
enfuvirtide blocks fusion of HIV host in cell
Entry inhibitors
Maraviroc
Nucleoside reverse transcriptase inhibitors
Zidovudine interferes with the virus' ability to convert RNA into DNA
Non-nucleoside reverse transcriptase inhibitors
Delavirdine and efavirenz inhitbit viral replication in cells
Protease inhibitors
Atazanavir, nelfinavir, saquinavir and indinavir inhibit enzym needed for virus to
replicate
Integrase inhibitors
Raltegravir
Antineoplastic medication
Interleukin is an immunostimulant that enhances the immune response and reduces the
production of cancer cells used commonly with Kaposis sarcoma.
HIV interprofessional care
Infectious disease, resp. services, nutritional services, rehab services, support groups,
home health, longterm care and hospice.
Opportunistic bacterial diseases
TB, bacterial pneumonia, septicemia
Opportunistic malignancies
Kaposis sarcoma, lymphoma, abd squamous cell carcinoma
Opportunistic viral diseases
cytomeglovirus, herpes simplex and herpes zoster
Opportunistic fungal diseases
PCP(pnemonia) candidasis, cryptospoidosis, and penicilliosis
Opportunistic protazoal diseases
OCO, toxoplasmosis, microsporidosis, cryptosporidosis isoporiasis and leishmaniasis
Wasting syndrome
A general state of ill health involving marked weight loss and muscle loss.
HIV F and E
encourage 2,000ml-3,000ml of fluid intake
HIV encephalopathy
Seizure precautions
Arthrodesis/spinal fusion
fusion of two or more vertebras
DLE(Discoid lupus erythmatosus)
only effects the skin
Systemic lupus (SLE)
affects connective tissue of multiple organ systems and can lead to major organ failure
Medication induced (LE)
can be caused by procainamide, hydralizine, isoniazid. Resolved after medication is d/c
Lupus risk factors
women b/w 20-40
African american, asian and native americans
incidence declines in women who are post menopausal but remains steady in men
Can be harder to notice in adults b/c symptoms mimic normal aging process
Lupus expected findings
Fatigue
Alopecia
Blurred vision
pleuritic pain
anorexia/weight loss
Lupus physical assessment findings
Fever
Anemia
Lymphendopathy
Pericarditis
Raynauds phenomenon
Organ involvement
Raised dry scaly rash over nose and cheeks
Alopecia
Lupus lab tests
ANA antibody, serum complement c3 and c4 decrease, ESR elevated due to
inflammation, BUN and creatinine increase, Urinalysis + for protein and RBC's, CBC
pancytopenia (eduction in the number of red and white blood cells, as well as platelets)
Nursing care lupus
Assess and monitor pain, mobility and fatigue
HTN and edema
Urine output
Diminished breath sounds
Tachycardia
Rubor, pallor or cyanosis of hands and feet
Joint and connective tissue problems
Change in MS
BUN/ Creatinine and urinary output for renal involvement
Nutritional status
Encourage limit of salt intake for fluid retention secondary to steroid therapy
Lupus medication therapy
NSAID, Corticosteroids, immunosuppressant agents, antimalarial(hydroxychloroquine
used for suppression of synovitis, fever and fatigue)
Complications of lupus
lupus nephritis, pericardiatis and myocarditis
Gout
The most common inflammatory arthritis. Caused by disruption of purine metabolism in
which uric crystals are deposited in joints and body tissues can be primary or secondary
Primary gout
Most common uric acid production is greater than excretion of it by kidneys, genetic
component middle and older adults males ages 40 to 50 as well as post menopausal
Secondary gout
Caused by another disease or condition chronic kidney, failure, excessive diuretic use
of uric acid in blood. Treatment is based on treating the underlying condition can affect
people of any age
Assessment
Obesity
Cardiovasular disease
Trauma
Alchol ingestion
Starvation diet
Diuretic use
Some chemo agents
Chronic kidney failure
Gout expected findings
Severe joint pain in great toes (metatarsophalangeal) redness, swelling, and warmth of
affected joint(painful if touched) or chronic gout
Gout lab test
ESR: elevated
Serum uric acid: 6.5mg above
Urinary uric acid: elevated
BUN and creatinine: elevated
Acute gout medication
Antigout, NSAIDS and corticosteroids
Antigout agent
*Colchicine* (PO or parenteral) is used to decrease pain and inflammation. Use
cautiously on kidney patients
NSAIDS
Indomethacin or ibuprofen is used to decrease pain and inflammation
Corticosteroids
Prednisone used for inflammation, monitor for fluid retention, HTN and impaired kidney
function and do not take on empty stomach
Chronic gout medication
Xanthine oxidase inhibitor and uricosuric
Xanthine oxidase inhibitor
Allopurinal is used as maintenance medication to promote uric acid excretion and
decreased its production
increase fluid intake
Take after meals on a full stomach with a glass of water
Uricosuric
Probenecid is used as a maintenance medication to promote uric acid excretion.
Monitor uric acid levels. Do not use aspirin b/c it will decrease the effectiveness of
meds.
Fibromyalgia
Is often accompanied by fatigue and altered sleep, memory, and mood.
Widespread muscle pain and tenderness are the most common symptoms.
Medications, talk therapy, and stress reduction may help control symptoms.
Fibromyalgia risk factors
Females between 30-50
History of rhematologic conditions chronic fatigue syndrome or lyme disease
deep sleep deprivation
Fibromyalgia medications
Serotonin-norepinephrine re uptake inhibitors (SNRIs) and anticonvulsants
NSAIDS
Try cyclic antidepressants
Fibromyalgia interprofessional care
PT, support groups and alternative therapy (acupuncture and stress management)
Rheumatoid Arthritis
A chronic inflammatory disorder affecting many joints, including those in the hands and
feet.
Rheumatoid Arthritis Risk Factors
Females gender 3:1
Age 20-50
Genetic predisposition
Epstein-Barr virus
Stress
Environmental factors
Older age
Rheumatoid Arthritis Expected Findings
Pain at rest and with movement
Morning stiffness
Pleuritic pain upon inspiration
Dry mouth
Anorexia/wgt. loss
Fatigue
Paresthesias
Recent illness/stressor
Joint swelling
Subq nodules
Fever(low grade)
Muscle weakness/atrophy
Reddened sclera or abnormal pupils
Lymph node enlargement
RA lab tests
Anti-CCP antibodies
RA factor antibody
ESR
C-reactive positive
ANA titer
Elevated WBC
RA diagnostic procedures
Arthrocentesis
XRAY
RA nursing care
Apply heat and cold to the affected areas indicated based on client response
Assist w/ physical activity to maintain joint mobility
Monitor for indications of fatigue
Teach client measures to maximize functional activity
Provide a safe environment
Use progressive muscle relaxation
Administer meds and proper positioning
Monitor for medication effectiveness
Teach client signs/symptoms that need to be reported immediately
RA nutritional suggestions
Encourage foods high in vitamins, protein and iron also encourage small frequent meals
RA medications
NSAIDs, Cox 2 enzyme blockers (corticosteroids), disease modifying anti-rheumatic
drugs
DMARDS
Slow the progression of RA and suppress immune system
DMARD medication
Antimalarial agent: Hydroxychloroquine
Antibiotic: Minocycline
Sulfonamide: Sulfasalzine
Biologic response modifiers: Etanercept, infliximab, adalimumab, and cheltor
penicillamine
Cytotoxic medications: Methotrexate, leflunomide, cyclophosphamide and azathioprine
can cause severe adverse effects
Plasmapheresis
Removes circulating antibodies from plasma decreasing attacks on client tissues. May
be done for severe life threatening exacerbation. The process is similar to kidney
dialysis
RA complications
Sjogrens syndrome, secondary osteoporosis, vasculitis(organ ischemia)
Sjogrens syndrome
An immune system disorder characterized by dry eyes, vagina and dry mouth.
Secondary osteoporosis
is caused by certain medical conditions or treatments that interfere with the attainment
of peak bone mass and may cause bone loss.
Vasculitis
An inflammation of the blood vessels that causes changes in the blood vessel walls.
Monitor for skin lesions, decrease in vision and symptoms of cognitive dysfunction
A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral
antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed
diagnostic workup that reveals a phagocytic disorder. This patient faces an increased
risk of what complication?
A) Thrombocytopenia
B) HIV/AIDS
C) Neutropenia
D) Hemophilia
C
(Feedback:
Patients with phagocytic cell disorders may develop severe neutropenia. None of the
other listed health problems is a common complication of phagocytic disorders.)
A patient is admitted for the treatment of a primary immunodeficiency and intravenous
immunoglobulin (IVIG) is ordered. What should the nurse monitor for as a potential
adverse effect of IVIG administration?
A)
Anaphylaxis
B)
Hypertension
C)
Hypothermia
D)
Joint pain
A
(Feedback:
Potential adverse effects of an IVIG infusion include hypotension, flank pain, chills, and
tightness in chest, terminating with a slightly elevated body temperature and
anaphylactic reaction. Hypertension, hypothermia, and joint pain are not usual adverse
effects of IVIG.)
A nurse is admitting a patient with an immunodeficiency to the medical unit. In planning
the care of this patient, the nurse should assess for what common sign of
immunodeficiency?
A) Chronic diarrhea
B) Hyperglycemia
C) Rhinorrhea
D) Contact dermatitis
A
(Feedback:
The cardinal symptoms of immunodeficiency include chronic or recurrent severe
infections, infections caused by unusual organisms or organisms that are normal body
flora, poor response to treatment of infections, and chronic diarrhea. Hyperglycemia,
rhinorrhea, and contact dermatitis are not symptoms the patient is likely to exhibit.)
A young couple visits the nurse practitioner stating that they want to start a family. The
husband states that his brother died of a severe infection at age 6 months. He says he
never knew what was wrong but his mother had him undergo "blood testing" as a child.
Based on these statements, what health problem should the nurse practitioner suspect?
A) Severe neutropenia
B) X-linked agammaglobulinemia
C) Drug-induced thrombocytopenia
D) Aplastic anemia
B
(Feedback:
There is no evidence of drug-induced thrombocytopenia or aplastic anemia. The child
would have only suffered from severe neutropenia if there was evidence of bacterial or
fungal infections. The fact the mother of this individual had him tested for gamma-
globulin as a child would indicate that his sibling had X-linked agammaglobulinemia.
More than 10% of patients with X-linked agammaglobulinemia are hospitalized for
infection at less than 6 months of age. Since the condition is X-linked it is important for
the couple to undergo genetic testing.)
The parents of a 1-month-old infant bring their child to the pediatrician with symptoms of
congestive heart failure. The infant is ultimately diagnosed with DiGeorge syndrome.
What will prolong this infant's survival?
(Feedback:
Transplantation of fetal thymus, postnatal thymus, or human leukocyte antigen (HLA)-
matched bone marrow has been used for permanent reconstitution of T-cell immunity in
infants with DiGeorge syndrome. Antibiotics and chemotherapy do not address the
etiology of the infant's disease. Stem cell transplantation is not a common treatment
modality.)
A patient who has received a heart transplant is taking cyclosporine, an
immunosuppressant. What should the nurse emphasize during health education about
infection prevention?
(Feedback:
Hand hygiene is imperative in infection control. A well-balanced diet is important, but for
most patients this is secondary to hygiene as an infection-control measure. Prophylactic
antibiotics are not normally used. Limiting physical activity will not protect the patient
from infection.)
The nurse is caring for a patient who has a diagnosis of paroxysmal nocturnal
hemoglobinuria. When planning this patient's care, the nurse should recognize the
patient's heightened risk of what complication?
A) Venous thromboembolism
B) Acute respiratory distress syndrome (ARDS)
C) Myocardial infarction
D) Hypertensive urgency
A
(Feedback:
Patients with paroxysmal nocturnal hemoglobinuriahave a high incidence of life-
threatening venous thrombosis, which occurs most commonly in the abdominal and
cerebral veins. This health problem is not linked to ARDS, MI, or hypertensive urgency.)
A patient diagnosed with common variable immune deficiency (CVID) has been
admitted to the acute medicine unit. When reviewing this patient's laboratory findings,
the nurse should prioritize what values?
(Feedback:
A patient diagnosed with CVID often develops pernicious anemia; the patient's
hemoglobin and vitamin B12 levels would be used to assess for this common
complication of CVID. None of the other listed blood values directly relates to the signs
and complications of CVID.)
Patient teaching regarding infection prevention for the patient with an immunodeficiency
includes which of the following guidelines?
(Feedback:
All foods must be cooked to avoid food-borne illness. The patient should avoid contact
with individuals who have recently been ill or vaccinated. The nurse should apply
creams and emollients to any dry, chaffed, or cracked skin. Vitamin supplements may or
may not be indicated.)
A nurse has admitted a patient diagnosed with severe combined immunodeficiency
disease (SCID) to the unit. The patient's orders include IVIG. How will the patient's dose
of IVIG be determined?
(Feedback:
The optimal dosage of IVIG is determined by the patient's response. In most instances,
an IV dose of 200 to 800 mg/kg of body weight is administered.)
The nurse is preparing to administer IVIG to a patient who has an immunodeficiency.
What nursing guideline should the nurse apply?
(Feedback:
The nurse should administer pretreatment acetaminophen and diphenhydramine as
prescribed 30 minutes before the start of the infusion. The patient should be weighed
prior to the treatment and the IV infusion rate should not exceed 200 mL/hour. The
nurse should stop the transfusion in the event of any signs of a reaction.)
IVIG has been ordered for the treatment of a patient with an immunodeficiency. Which
of the following actions should the nurse perform before administering this blood
product?
(Feedback:
The nurse should obtain height and weight before treatment to verify accurate dosing.
IVIG can be administered through a peripheral line. Diuretics are not normally given
prior to administration, and IVIG is not mixed with normal saline.)
A patient with a diagnosis of common variable immunodeficiency begins to develop
thick, sticky, tenacious sputum. The patient has a history of episodes of pneumonia at
least one time per year for the last 10 years. What does the nurse suspect the patient is
developing?
A) Pulmonary edema
B) A pulmonary neoplasm
C) Bronchiectasis
D) Emphysema
C
(Feedback:
Frequent respiratory tract infections in patients with CVID typically lead to chronic
progressive bronchiectasis and pulmonary failure. Pulmonary edema is often a result of
vascular insufficiency. A patient suffering from CVID is likely to develop gastric cancer,
not lung cancer. The patient is not at risk for emphysema.)
A nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis.
Which of the following nursing diagnoses should the nurse include in the patient's plan
of care?
(Feedback:
Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder
characterized by cerebellar ataxia (loss of muscle coordination), telangiectasia (vascular
lesions caused by dilated blood vessels), and immune deficiency. Decreased
coordination is likely to constitute a risk for falls. The patient does not characteristically
lose tactile sensation or experience pernicious anemia or constipation.)
A 20-year-old patient with an immunodeficiency is admitted to the unit with an acute
episode of upper airway edema. This is the fifth time in the past 3 months that the
patient has had such as episode. As the nurse caring for this patient, you know that the
patient may have a deficiency of what?
A) Interferons
B) C1esterase inhibitor
C) IgG
D) IgA
B
(Feedback:
Hereditary angioneurotic edema results from the deficiency of C1esterase inhibitor,
which opposes the release of inflammatory mediators. The clinical picture of this
autosomal dominant disorder includes recurrent attacks of edema. A patient with this
diagnosis does not lack interferons, IgG, or IgA.)
A patient with Wiskott-Aldrich syndrome is admitted to the medical unit. The nurse
caring for the patient should prioritize which of the following?
A) Protective isolation
B) Fresh-frozen plasma administration
C) Chest physiotherapy
D) Nutritional supplementation
A
(Feedback:
Patients with Wiskott-Aldrich syndrome (WAS) are at a grave risk for infection; infection
prevention is a priority aspect of nursing care. Nutritional supplementation may be
necessary, but infection prevention is paramount. Chest physiotherapy and FFP
administration are not indicated.)
The nurse is admitting a patient to the unit with a diagnosis of ataxia-telangiectasia. The
nurse's assessment should reflect the patient's increased risk for what complication?
A) Peripheral edema
B) Cancer
C) Anaphylaxis
D) Gastrointestinal bleeds
B
(Feedback:
Frequent causes of death in patients with ataxia-telangiectasiaare chronic pulmonary
disease and malignancy. Peripheral edema, anaphylaxis, and GI bleeding are not noted
to be common among patients with ataxia-telangiectasia.)
The nurse is working with the interdisciplinary team to care for a patient who has
recently been diagnosed with severe combined immunodeficiency disease (SCID).
What treatment is likely of most benefit to this patient?
(Feedback:
Treatment options for SCID include stem cell and bone marrow transplantation, but
HSCT is the definitive therapy for the disease and supersedes the importance of
antibiotics. CSFs, radiation therapy, and chemotherapy are not indicated.)
A patient has been admitted with a phagocytic cell disorder and the nurse is reviewing
the most common health problems that accompany these disorders. The nurse should
identify which of the following? Select all that apply.
(Feedback:
Patients with phagocytic cell disorders experience recurrent cutaneous abscesses,
chronic eczema, bronchitis, pneumonia, chronic otitis media, and sinusitis. Irritable
bowel syndrome and cognitive deficits are atypical.)
A nurse is caring for a patient with a phagocytic cell disorder. The patient states, "My
specialist says that I will likely be cured after I get my treatment tomorrow." To what
treatment is the patient most likely referring?
(Feedback:
Hematopoietic stem cell transplantation (HSCT), another form of cell therapy, has
proven to be a successful curative modality. Treatment with GM-CSF or G-CSF is not
curative. Brachytherapy is not a treatment for immunodeficiency.)
A patient's primary immunodeficiency disease is characterized by the inability of white
blood cells to initiate an inflammatory response to infectious organisms. What is this
patient's most likely diagnosis?
(Feedback:
In one rare type of phagocytic disorder, hyperimmunoglobulinemia E syndrome
(formerly known as Job syndrome), white blood cells cannot initiate an inflammatory
response to infectious organisms. The other listed health problems do not have this
pathology.)
A nurse educator is explaining that patients with primary immunodeficiencies are living
longer than in past decades because of advances in medical treatment. This increased
longevity is associated with an increased risk of what?
(Feedback:
Advances in medical treatment have meant that patients with primary
immunodeficiencies live longer, thus increasing their overall risk of developing cancer. It
does not mean that they are at increased risk of COPD, dementia, or pulmonary
fibrosis.)
The nurse educator is differentiating primary immunodeficiency diseases from
secondary immunodeficiencies. What is the defining characteristic of primary
immunodeficiency diseases?
(Feedback:
Primary immunodeficiency diseases are genetic in origin and result from intrinsic
defects in the cells of the immune system. Primary immunodeficiency diseases do not
always need IVIG as treatment, and they are not communicable. Primary
immunodeficiencies do not result from intrauterine infection.)
A nurse has created a plan of care for an immunodeficient patient, specifying that care
providers take the patient's pulse and respiratory rate for a full minute. What is the
rationale for this aspect of care?
(Feedback:
Pulse rate and respiratory rate should be counted for a full minute, because subtle
changes can signal deterioration in the patient's clinical status. The rationale for this
action is not because of the relationship between heart rate and respirations. These
patients do not have a greatly increased risk of hemodynamic instability or
dysrhythmias.)
A nurse is providing health education regarding self-care to a patient with an
immunodeficiency. What teaching point should the nurse emphasize?
(Feedback:
Many patients develop oral manifestations and need education about promoting good
dental hygiene to diminish the oral discomfort and complications that frequently result in
inadequate nutritional intake. Alcohol cleansers do not necessarily need to be avoided
and nail care is not a central concern. Acne care is not a main focus of education, since
it is not relevant to many patients.)
The nurse is applying standard precautions in the care of a patient who has an
immunodeficiency. What are key elements of standard precautions? Select all that
apply.
(Feedback:
Some of the key elements of standard precautions include performing hand hygiene;
using appropriate personal protective equipment, depending on the expected type of
exposure; and using safe injection practices. Isolation is an infection control strategy but
is not a component of standard precautions.)
The nurse is caring for a patient with an immunodeficiency who has experienced
sudden malaise. The nurse's colleague states, "I'm pretty sure that it's not an infection,
because the most recent blood work looks fine." What principle should guide the nurse's
response to the colleague?
A) Immunodeficient patients will usually exhibit subtle and atypical signs of infection.
B) Infections in immunodeficient patients have a slower onset but a more severe
course.
C) Laboratory blood work is often inaccurate in immunodeficient patients.
D) Immunodeficient patients do not develop symptoms of infection.
A
(Feedback:
Immunodeficient patients often lack the typical objective and subjective signs and
symptoms of infection. However, this does not mean that they wholly lack symptoms.
Infections do not normally have a slower onset. Blood work may not be a reliable
diagnostic tool, but that does not mean that the results are inaccurate.)
A nurse is caring for a patient who has an immunodeficiency. What assessment finding
should prompt the nurse to consider the possibility that the patient is developing an
infection?
A) Uncharacteristic aggression
B) Persistent diarrhea
C) Pruritis (itching)
D) Constipation
B
(Feedback:
Persistent diarrhea is among the varied signs and symptoms that may suggest infection
in an immunocompromised patient. Aggression, pruritis, and constipation are less
suggestive of an infectious etiology.)
A patient with a diagnosis of primary immunodeficiency informs the nurse that he has
been experiencing a new onset of a dry cough and occasional shortness of breath. After
determining that the patient's vital signs are within reference ranges, what action should
the nurse take?
(Feedback:
Dyspnea and cough are among the many signs and symptoms that may suggest
infection in an immunocompromised patient. There is no indication for suctioning or the
use of nebulizers. Deep breathing and coughing exercises do not address the patient's
complaints or the likely etiology.)
A home health nurse is reinforcing health education with a patient who is
immunosuppressed and his family. What statement best suggests that the patient has
understood the nurse's teaching?
A) "My family needs to understand when I can go get the seasonal flu shot."
B) "I need to know how to treat my infections in a home setting."
C) "I need to understand how to give my platelet transfusions."
D) "My family needs to understand that I'll probably need lifelong treatment."
D
(Feedback:
The patient must be made aware that all health-related instructions are lifelong.
Immunizations may be contraindicated and infection usually requires inpatient
treatment. Platelet transfusions are not indicated for most patients who have
immunodeficiencies.)
A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a
diagnosis of severe combined immunodeficiency disease (SCID). What medication
should the nurse administer prior to initiating the infusion?
A) Diphenhydramine
B) Ibuprofen
C) Hydromorphone
D) Fentanyl
A
(Feedback:
Diphenhydramine and acetaminophen are administered 30 minutes prior to an IVIG
infusion.)
An immunocompromised patient is being treated in the hospital. The nurse's
assessment reveals that the patient's submandibular lymph nodes are swollen, a finding
that represents a change from the previous day. What is the nurse's most appropriate
action?
(Feedback:
Swollen lymph nodes are suggestive of infection and warrant prompt medical
assessment and treatment. Acetaminophen is an ineffective response. The nurse
should monitor the patient's vital signs closely, but the physician should also be
informed. Standard precautions should be in place regardless of the patient's status.)
A nurse caring for a patient who has an immunosuppressive disorder knows that
continual monitoring of the patient is critical. What is the primary rationale behind the
need for continual monitoring?
(Feedback:
Continual monitoring of the patient's condition is critical, so that early signs of impending
infection may be detected and treated before they seriously compromise the patient's
status. Continual monitoring is not primarily motivated by the patient's functional needs
or medication schedule. The nurse's documentation is important, but less than infection
control.)
A nurse is planning the care of a patient who requires immunosuppression to ensure
engraftment of depleted bone marrow during a transplantation procedure. What is the
most important component of infection control in the care of this patient?
A) Administration of IVIG
B) Antibiotic administration
C) Appropriate use of gloves and goggles
D) Thorough and consistent hand hygiene
D
(Feedback:
Hand hygiene is usually considered the most important aspect of infection control. IVIG
and antibiotics are not considered infection control measures, though they enhance
resistance to infection and treat infection. Gloves and goggles are sometimes indicated
but are less effective than hand hygiene.)
A home health nurse is caring for a patient who has an immunodeficiency. What is the
nurse's priority action to help ensure successful outcomes and a favorable prognosis?
A) Encourage the patient and family to be active partners in the management of the
immunodeficiency.
B) Encourage the patient and family to manage the patient's activity level and activities
of daily living effectively.
C) Make sure that the patient and family understand the importance of monitoring fluid
balance.
D) Make sure that the patient and family know how to adjust dosages of the medications
used in treatment.
A
(Feedback:
Encouraging the patient and family to be active partners in the management of the
immunodeficiency is the key to successful outcomes and a favorable prognosis. This
transcends the patient's activity and functional status. Medications should not be
adjusted without consultation from the primary care provider. Fluid balance is not
normally a central concern.)
A nurse is preparing to discharge a patient with an immunodeficiency. When preparing
the patient for self-infusion of IVIG in the home setting, what education should the nurse
prioritize?
(Feedback:
The patient who is to receive IVIG at home will need information about adverse
reactions and their management. A patient would not start a new IV site independently
and the patient does not calculate changes in dose independently. Medications are not
added to IVIG.)
A home health nurse will soon begin administering IVIG to a new patient on a regular
basis. What teaching should the nurse provide to the patient?
(Feedback:
The patient who is to receive IVIG at home will need information about the expected
benefits and outcomes of the treatment as well as expected adverse reactions and their
management. The home environment cannot be sterile and complementary alternatives
to IVIG have not been identified. Fluid management is not a central concern.)
The home health nurse is assessing a patient who is immunosuppressed following a
liver transplant. What is the most essential teaching for this patient and the family?
(Feedback:
They must be informed of the need for continuous monitoring for subtle changes in the
patient's physical health status and of the importance of seeking immediate health care
if changes are detected. Nutrition is important, but infection control is the priority.
Patients and families do not choose antibiotics independently. Vaccinations are often
contraindicated in immunocompromised patients.)
Family members of an immunocompromised patient have asked the nurse why
antibiotics are not being given to the patient in order to prevent infection. How should
the nurse best respond?
(Feedback:
Although prophylactic drug treatment effectively prevents some bacterial and fungal
infections, it must be used with caution because it has been implicated in the
emergence of resistant organisms. Use of antibiotics does not directly increase the risk
of viral infections.)
A 6-month-old infant has been diagnosed with X-linked agammaglobulinemia and the
parents do not understand why their baby did not develop an infection during the first
months of life. The nurse should describe what phenomenon?
What is immunodeficiency?
the inability to produce a normal complement of antibodies or immunologically
sensitized T cells, especially in response to specific antigens
symptoms include
1. scleroderma-like appearance
2. dry lacrimal ducts
3. dry oral mucosa
What is allograft or homograft transplant?
cells and tissue obtained from the same species (i.e. close relative or unrelated donor
with a similar type of cell compatibility)
What is histocompatibility testing?
done to determine the similarities and differences in the complex set of proteins on the
surface membranes of all human nucleated cells, tissues, & blood cells (except RBCs)
What is the treatment for the variety of hematological, malignant, & nonmalignant
disorders?
bone marrow transplant
What is a syngeneic transplant?
use of bone marrow cells donated by an identical twin w/no detectable tissue
incompatibility
What is autologous transplant?
removal of bone marrow cells from the individual - treated and stored - then returned
after the individual receives intensive chemotherapy or radiation
What can the blood from the umbilical cord and placenta used for?
rapid therapy for leukemia, lymphoma, & many other life-threatening diseases
process of removing plasma that is causing the disease and replacing it with normal
saline, lactated Ringer's, frozen plasma, or albumen
a needle is inserted into the arm, the blood is circulated through a cell separator that
separates the blood and plasma; remainder of contents are returned via needle into the
opposite arm
1. oral contraceptives
2. isoniazid
3. procainamide
4. methyldopa
What are the risk factors for SLE?
1. gender (female)
2. age (15-40)
3. race (African-American, Hispanic, Asian, Native American)
What are the possible effects of SLE on pregnancy?
1. hx of miscarriages or preterm births
2. increased risk for fetal or newborn deaths when there is kidney damage or HTN
3. pre-eclampsia
4. blood clots in the placenta
5. hyperglycemia
What are the clinical manifestations of SLE?
1. polyarthritis (involving many joints)
2. polyarthralgia (pain in many joints)
3. lethargy
4. malaise
5. fever
6. weight loss
7. butterfly rash on face
8. pleural effusion
9. basilar pneumonia
10. generalized lymphadenopathy
11. pericarditis
12. hepatosplenomegaly
Severe cases
1. delirium
2. convulsions
3. psychosis
4. coma
What is progressive systemic sclerosis (scleroderma)?
rare connective tissue disease that involves excess collagen deposition & changes in
both the humoral and cellular immunity
What is a morphea type skin lesion in sleroderma?
hard, oval, and white w/a purple ring surrounding them
What does a skin lesion in linear scleroderma look like?
thick line of skin on the arms, legs, or forehead that can become fixated to the
subdermal structures including the fascia that covers tendon sheaths & muscles
What body systems are involved in the general form of scleroderma?
skin and many internal organs
What body systems are involved in the subcutaneous scleroderma form of
scleroderma?
involves the skin, the synovium, digital arteries, parenchyma, and small arteries in
internal organs
What body systems are involved in the diffuse subcutaneous form (CREST) of
scleroderma?
skin, muscles, joints, lungs, esophagus, heart, digestive system, and kidneys
What are the clinical manifestations of scleroderma (CREST)?
Calcinosis - development of small white calcium deposits under the skin; chalky fluid
drains when lumps break open
heart, kidney, or lung involvement is severe & tends to occur early in the disease;
has high mortality rate
What is the treatment for scleroderma?
supportive & tailored to clinical manifestations; primary goal to promote remission
1. steroids
2. immunosuppressants
During the early stages of a chronic disease, clients tend to focus on:
1. Medication schedule
2. Interpretation of symptoms
Rationale: Clients tend to focus on lifestyle changes in the early stages of a chronic
disease.
The goal of HAART is to:
Rationale: The goal of HAART is to avoid viral resistance for each drug.
Early clinical manifestations of GVHD include:
Rationale: The early clinical manifestations of GVHD are skin rash and pruritus.
Monoclonal antibodies are:
Rationale: The reversible form of SLE is because of a reaction to drugs, such as oral
contraceptives (e.g., Levora).
Cell-mediated immunity is initiated by:
Rationale: Passive immunity involves inoculation with vaccine containing live or killed
infectious organisms.
Sero-conversion is the presence of antibodies of HIV in the blood and are detected by
diagnostic studies within:
When the nurse administers intravenous gamma-globulin infusion, she recognizes that
which symptom, if reported by the client, may indicate an adverse effect of the infusion?
Tightness in the chest pg. 991
T-cell deficiency occurs when which gland fails to develop normally during
embryogenesis?
Thymus pg. 992
Nursing students are reviewing information about the various types of primary
immunodeficiencies. The students demonstrate understanding of the material when
they identify which of the following as an example of a primary immunodeficiency
involving B-lymphocyte dysfunction?
IgA deficiency pg. 987
The nurse is aware that the most prevalent cause of immunodeficiency worldwide is
Malnutrition pg. 994
A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for
complaints of abdominal pain. Ten minutes after receiving the medication, the client's
eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure
should the nurse prepare to do?
Administer epinephrine. pg. 1037
A client received 2 units of packed red blood cells while in the hospital with rectal
bleeding. Three days after discharge, the client experienced an allergic response and
began to itch and break out with hives. What type of reaction does the nurse understand
could be occurring?
Delayed hypersensitivity response pg. 1038
A client calls the clinic and asks the nurse if using oxymetazoline nasal spray would be
alright to relieve the nasal congestion he is experiencing due to seasonal allergies.
What instructions should the nurse provide to the client to avoid complications?
Do not overuse the medication as rebound congestion can occur. pg. 1040
A nurse is assessing a client with a primary immunodeficiency. Afterward the nurse
documents that the client displayed ataxia. The nurse makes this documentation
because the client has
uncoordinated muscle movements. pg. 992
A client with chronic mucocutaneous candidiasis, an autosomal recessive disorder, asks
the nurse, "Will my children have this disease?" Which response by the nurse is
appropriate?
"All of your children will be carriers of the recessive gene but may not develop the
disease." pg. 990
Reproductive health education for women who are HIV-positive includes recommending
which of the following contraceptives?
The female condom pg. 1000
What treatment option does the nurse anticipate for the patient with severe combined
immunodeficiency disease (SCID)?
Bone marrow transplantation pg. 992
A patient is suspected to have an immunodeficiency disorder. The physician orders a
nitroblue tetrazolium reductase (NTR) test to diagnose this patient. What does the nurse
suspect that this disorder is related to?
Phagocytic cells pg. 988
The nurse is working with a parent whose child has just been diagnosed with selective
immunoglobulin A deficiency. The parent asks the nurse, "Does this mean that my child
is going to die?" How should the nurse respond?
"Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin
A, a type of antibody that protects against infections of the lining the mouth and
digestive tract." pg. 987
Which adverse effect(s) should the nurse closely monitor in a client who has secondary
immunodeficiencies due to immunosuppressive therapy?
Respiratory or urinary system infections pg. 994
A client presents to the clinic with complaints that he began to itch and break out in
hives after taking an aspirin this morning. What medication does the nurse anticipate
administering that blocks histamine receptors?
Diphenhydramine pg. 1047
A client has been having joint pain and swelling in the left foot and is diagnosed with
rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and
the client has significant joint destruction. What type of disease is this considered?
Autoimmune pg. 1054
A client presents at the clinic with an allergic disorder. The client asks the nurse what an
"allergic disorder" means. What would be the nurse's best response?
"It is a hyperimmune response to something in the environment that is usually
harmless." pg. 1030
A client is prescribed antihistamines, and asks the nurse about administration and
adverse effects. The nurse should advise the client to avoid:
Avoid alcohol pg. 1041
A majority of clients with CVID develop which type of anemia?
Pernicious pg. 990
Ataxia refers to
uncoordinated muscle movement. pg. 992
The nurse is caring for a young client who has agammaglobulinemia. The nurse is
teaching the family how to avoid infection at home. Which statement by the family
indicates that additional teaching is needed?
"I can take my child to the beach, as long as we play in the sand rather than swim in the
water." pg. 995
The majority of patient with primary immunodeficiency are in which age group?
Younger than 20 pg. 987
When administering intravenous gamma globulin infusion, the nurse recognizes that
which of the following complaints, if reported by the client, may indicate an adverse
effect of the infusion?
Flank pain pg. 991
Telangiectasia is the term that refers to
Vascular lesions caused by dilated blood vessels pg. 992
A nurse knows that more than 50% of clients with CVID develop the following disorder.
pernicious anemia pg. 990
A client is diagnosed with common variable immunodeficiency (CVID). When assessing
the client for possible infection, which of the following would the nurse identify as a least
likely cause?
Pneumocystis jiroveci pneumonia pg. 990
A nurse educator is preparing to discuss immunodeficiency disorders with a group of
fellow nurses. What would the nurse identify as the most common secondary
immunodeficiency disorder?
AIDS pg. 994
More than 50% of individuals with this disease develop pernicious anemia:
Common variable immunodeficiency (CVID) pg. 990
A treatment option for severe combined immune deficiency (SCID) includes
a stem cell transplant. pg. 992
A nurse is providing discharge teaching to a client who is immunosuppressed. Which
statement by the client indicates the need for additional teaching?
"I can eat whatever I want as long as it's low in fat." pg. 995
A client with common variable immunodeficiency (CVID) comes to the ED reporting
tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic
diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of
reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen
as well as gastric atrophy. Based on these findings, what common secondary problem
has this client developed?
Pernicious anemia pg. 988
A client with lupus has had antineoplastic drugs prescribed. Why would the physician
prescribe antineoplastic drugs for an autoimmune disorder?
For their immunosuppressant effects pg. 982
A client has begun sensitivity testing to determine the allergen which caused an
anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more
sensitive to allergens?
back pg. 1035
The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. A
clinical manifestation is telangiectasia. The nurse would recognize that the client is
exhibiting telangiectasia when assessing the presence of what?
Vascular lesions caused by dilated blood vessels pg. 992
A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to
stop the infusion if the client experiences which of the following symptoms? Choose all
that apply.
• Shaking chills
• Flank pain
• Tightness in the chest pg. 991
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell
transplant. Which of the following would the nurse expect to be started?
Immunosuppressive agents pg. 992
Which assessment finding would the nurse expect to document for a client with ataxia-
telangiectasis?
Vascular lesions pg. 992
A child has just been diagnosed with a primary immune deficiency. The parents state,
"Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?
"Although AIDS is an immune deficiency, your child's condition is different from AIDS."
pg. 994
A mother brings her young child to the clinic for an evaluation of an infection. The
mother states, "He's been taking antibiotics now for more than 2 months and still doesn't
seem any better. It's like he's always sick." During the history and physical examination,
which of the following would alert the nurse to suspect a primary immunodeficiency?
Ten ear infections in the past year pg. 989
A nurse is preparing an in-service presentation about primary immunodeficiencies.
When describing these conditions, which of the following would the nurse need to
integrate into the presentation?
Most cases are typically diagnosed in infancy pg. 987
There are major differences between primary and secondary immunodeficiencies.
Select the most accurate statement the nurse would use to explain the cause of a
secondary immunodeficiency.
"Your immune system was most likely affected by an underlying disease process." pg.
994
The nurse is teaching the client who has an immunodeficiency disorder how to avoid
infection at home. Which statement indicates that additional teaching is needed?
"I will be sure to eat lots of fresh fruits and vegetables every day." pg. 995
A nurse is reviewing treatment options with parents of an infant born with severe
combined immunodeficiency disease (SCID). The nurse recognizes that the parents
understand the teaching based on which statement?
"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a
human leukocyte antigen-identical sibling." pg. 992
A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The
client asks the nurse about the infusion's administration and its adverse effects. Which
condition should the nurse instruct this client to report immediately?
Tickle in the throat pg. 991
A client with rheumatoid arthritis informs the nurse that since he has been in remission
and not having any symptoms, he doesn't need to take his medication any longer. What
is the best response by the nurse?
"It is important that you continue to take your medication to avoid an acute
exacerbation." pg. 1056
Which allergic reaction is potentially life threatening?
angioedema pg. 1048
A client is presenting an anaphylactic response to unknowingly ingesting nuts at a
family celebration. What type of hypersensitivity did this client exhibit?
Type I pg. 1032
When a nurse infuses gamma globulin intravenously, the rate should not exceed
3 mL/min. pg. 991
A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client
would expect to see what included in the treatment regimen?
IV gamma globulin administration pg. 992
Ataxia-telangiectasia is a disorder characterized by the following. Choose all that apply.
Neurologic symptoms that usually occur before 5 years of age
IgA deficiency in 40% of individuals pg. 992
You should avoid taking naproxen with any other NSAIDs, such as aspirin because this
can increase the risk for bleeding and gastrointestinal ulceration
A nurse is reinforcing discharge teaching with a partner of a client who has acquired
immune deficiency syndrome(AIDS). Which of the following statements by the client
partner indicates the need for further teaching?
I'll clean up blood spills immediately with hot water.
A nurse is teaching an assistive personnel about standard precautions when caring for
a client who has vancomycin resistant Enterococcus of the urine. Which of the following
images of personal protection equipment should the nurse recommend the AP to use
when caring for this client?
The nurse should don clean gloves when caring for a client who has vancomycin-
resistant enterococcus of the urine. This protects the nurse form coming in contact with
bodily fluids contaminated with the bacteria of the client.
A nurse is teaching a client who has genital herpes about self-management. Which of
the following instructions should the nurse include in the teaching?
"Apply a warm compress to the lesions."
A nurse is planning discharge teaching for a client who has systemic lupus
erythematosus (SLE). Which of the following instructions should the nurse plan to
include?
"Monitor your body temperature and report any elevations promptly."
A nurse is providing discharge teaching to a client who has AIDS about preventing
infection while at home. Which of the following instructions should the nurse include in
the teaching.
"Wash your genitalia using an antimicrobial soap"
A nurse is caring for a client who had radioallergosorbent (RAST) testing completed due
to seasonal allergies. The nurse should anticipate and elevation in which of the
following laboratory tests?
IgE (immunoglobulin E)
A nurse is preparing to administer a Mantoux skin test to a client. The nurse should
inform the client that the purpose of a Mantoux skin test using purified protein derivative
(PPD) is to do which of the following actions?
Identify if a client has been infected with mycobacterium tuberculosis
A nurse in a provider's office is providing teaching to a client who has a recent diagnosis
of rheumatoid arthritis and has a new prescription for naproxen tablets. Which of the
following statements by the client requires further teaching?
"I can take this medication with aspirin."
A nurse is caring for a client who has human immunodeficiency virus (HIV). The client
asks the nurse, "should I tell my partner that I am HIV positive?" Which of the following
statements should the nurse give?
"It sounds like you are unsure what to say to your partner."
A nurse is teaching a client who has Raynaud's disease. Which of the following
information should the nurse include in the teaching?
Protect against the cold by wearing layers of clothing.
A nurse is reviewing the laboratory results for a client who reports bilateral pain and
swelling in her finger joints, with stiffness in the morning. The nurse should recognize
that an increase in which of the following laboratory tests can indicate arthritis?
Rheumatoid factor
A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is
concerned abouth the skin lesions on her face and neck. The client asks the nurse,
"What should I do about these spots?" Which of following responses should the nurse
give?
"Apply moisturizer after bathing the lesions with warm water."
A nurse is teaching a female client who has a new diagnosis of systemic lupus
erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse
should determine that the client needs more teaching when she identifies which of the
following as a factor that can exacerbate SLE?
Exercise
A nurse is caring for a client who is 2 days postoperative. Which of the following findings
should alert the nurse that the client is developing an infection?
Erythema at the incision site
A nurse is monitoring a newly licensed nurse who is caring for a client. The client has
active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled
for a chest x-ray. The nurse should instruct the newly licensed nurse to take which of
the following actions?
Have the client wear a surgical mask
A nurse is providing discharge instructions to a client who is being treated for genital
warts. Which of the following statements indicates that the client understands how to
prevent transmission of the sexually transmitted infection (STI)?
"I will bring my sexual partner in for treatment."
A nurse is teaching a client who has AIDS about the transmission of Pneumocystis
jiroveci pneumonia (PCP). Which of the following information should the nurse include
in the teaching?
"PCP results from an impaired immune system."
A nurse is teaching a client about manifestations of an allergic reaction. The nurse
should explain that histamine release causes which of the following reactions?
Increased mucus secretion
A nurse is teaching a client who has tuberculosis about a new prescription for rifampin.
Which of the following statements by the client indicates an understanding of the
teaching?
"I can expect this medication to turn my skin orange."
A nurse is caring for a client who is concerned about the possibility of contracting Lyme
disease after receiving a tick bite. For which of the following early manifestations of
Lyme disease should the nurse assess the client?
A progressive, circular rash
A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the
following manifestations of the client's skin should the nurse expect?
Unilateral, localized, nodular skin lesions
A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings
should the nurse expect?
Reddish-purple skin lesions
A nurse is assessing a client who has systemic scleroderma. Which of the following
findings should the nurse expect?
Finger contractures
A nurse is teaching a client who has tested positive for an allergy to dust. The nurse
should determine that the client understands how to reduce her exposure to this
allergen when she states which of the following?
"I will apply a mattress cover to my bed."
A nurse is teaching a client who has human immunodeficiency virus about how the virus
is transmitted. Which of the following statements should the nurse include the teaching?
"HIV can be transmitted to anyone who has had contact with the infected blood."
A nurse is teaching a client who has human immunodeficiency virus about the early
manifestations of acquired immune deficiency syndrome. Which of the following
statements should the nurse include in the teaching?
"You can expect a persistent fever and swollen glands."
A nurse is providing teaching to a client who has a diagnosis of Hepatitis A. Which of
the following statements by the client indicates an understanding of the teaching?
"I should stop eating raw clams."
A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid
arthritis. The nurse should anticipate that the client's affected joints will requires which of
the following treatments?
Heat paraffin therapy applied to the client's joints
A nurse is teaching a client who was recently diagnosed with Raynaud's disease about
preventing the onset of manifestations. Which of the following statements by the client
indicates an understanding of the teaching?
I should not smoke.
A nurse is caring for client who has human immunodeficiency virus. Which of the
following types of isolation should the nurse implement to prevent transmission of HIV?
Standard Precautions
A nurse is providing discharge teaching to the partner of a client who has acquired
immune deficiency syndrome. Which of the following statements by the client's partner
indicate the need for further teaching?
"I'll clean up blood spills immediately with hot water."
a nurse is caring for a client who has human immunodeficiency virus (HIV). which of the
following types of isolation should the nurse implement to prevent the transmission of
HIV
a. protective isolation
b. droplet precaution
c. standard precautions
d. airborne precaution
standard precautions
a burse is performing a preoperative assessment of a client about to undergo a
cholecystectomy. the nurse should identify a risk for a latex allergy when the client
reports an allergy to which of the following foods
a. cabbage
b. oatmeal
c. milk
d. banana
banana
a nurse is providing discharge teaching to the partner of a client who has acquired
immune deficiency syndrome (AIDS). which of the following statements by the client's
partner indicates a need for further teaching
i will clean up blood spills immediately with hot water
a nurse is teaching a client who has raynaud's disease. which of the following pieces of
information should the nurse include in the teaching
protect against the cold by wearing layers of clothing
a nurse is planning care for a client who has acute systemic lupus erythematosus (SLE)
and is scheduled to begin treatment for systemic manifestations. which of the following
types of medications should the nurse plan to administer
a. corticosteroids
b. antimalarials
c. antidepressants
d. opioids
corticosteroids
a nurse is caring for a client who underwent radioallergosorbent (RAST) testing due to
seasonal allergies. the nurse should anticipate an elevation in which of the following
immunoglobulin laboratory values?
a. IgM
b. IgA
c. IgG
d. IgE
IgE
A nurse is assessing a 66 year old client during a routine physical examination. this is
the client's first clinic visit, and she does not have her medical records. when the nurse
asks if she has received the pneumococcal immunization, the client replies, i am not
sure, but it's been at least 5 years since I have had any immunization which of he
following responses should the nurse provide?
a. in case you had the immunization before, we can't give you another one
b. you will need a series of 3 injections
c. this immunization is unsafe for people over the age of 65 years old
d. let's go ahead and give you this immunization
let's go ahead and give you this immunization
a nurse is planning care for a client. which of the following interventions should the
nurse include in the plan
a. advance diet to soft
b. perform active and passive range-of-motion (ROM) exercises twice daily
c. apply compression garments 23 hr daily
d. restrict visitors
restrict visitors
a nurse is providing discharge instructions to a male client who is being treated for
genital warts. which of the following statements indicates that the client understands
how to prevent the transmission of this sexually transmitted infection (STI)
I will bring my sexual partner for treatment
a nurse is providing teaching to a client who has a diagnosis of hepatitis A. which of the
following statements by the client indicates an understanding of the teaching.
a. i am unable to donate blood
b. i will need to get a booster shot of serum globulin every year
c. i should stop eating raw clams
d. i can develop this disease by getting a tattoo
i should stop eating raw clams
a nurse is planning an educational program for a group of young adults about reducing
the risk of cervical cancer. which of the following interventions should the nurse include
get the human papillomavirus (HPV) immunization
a nurse is providing discharge teaching about foot care to a client who has diabetic
neuropathy. which of the following statements by the client demonstrates an
understanding of the teaching
i will wash my feet daily and apply lotion expect between my toes
a nurse is caring for a client who has pseudomembranous colitis due to a clostridium of
difficile infection. which of the following interventions is the nurse priority
a. performing hand hygiene before and after contact with the client
b. reducing client anxiety due to isolation procedures .
c. assisting the client in making nutritional choices
d. monitoring the client's intake and output
performing hand hygiene before and after contact with the client
a nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hr ago.
the nurse finds 10mm of induration with slight redness. which of the following
conclusions should the nurse make.
a. the client has active tuberculosis
b. the client had an exposure to tuberculosis
c. the nurse must re-evaluate the result in 24 hr
d. the test is negative for tuberculosis
the client had an exposure to tuberculosis
a nurse is providing discharge teaching to a client who has a new diagnosis of systemic
lupus erythematosus (SLE). which of the following statement by the client indicates an
understanding of the teaching
I will need to take methotrexate even if i'm in remission
a nurse is planning discharge teaching for a client who has systemic lupus
erythematosus (SLE). which of the following instructions should the nurse include
a. avoid the use of NSAIDS
b. stop taking the corticosteroids when your symptoms resolves
c. exposure to ultraviolet light will help control the skin rashes
d. monitor your temperature and report any elevations promptly
monitor your temperature and report any elevations promptly
a nurse in a provider's office is teaching a client with a recent diagnosis of rheumatoid
arthritis who has a new prescription for naproxen tablets. which of the following
statements by the client indicates the need for further teaching
a. after taking tis medication for 4 weeks i will start to notice relief in my joint
b. i can take an antacid with this medication for indigestion
c. i can take this medication with aspirin
d. the naproxen goes down easier when i crush it and put it in applesauce
i can take this medication with aspirin
a nurse is teaching a client who was recently diagnosed with Raynaud's disease about
preventing the onset of manifestations. which of the following statements by the client
indicates an understanding of the teaching
a. i should limit my exposure to sunlight
b. i should avoid drinking alcohol
c. i should not smoke
d. i should limit of intake of foods that are high in purinesc
i should not smoke
a nurse is caring for a client who is concerned about the possibility of contracting lyme
disease after receiving a tick bite. for which of the following early manifestations of lyme
disease should the nurse assess the client
a. diffuse maculopapular rash
b. dyspnea
c. double vision
d. progressive circular rash
progressive circular rash
a nurse is teaching a client with systemic lupus erythematosus who has a new
prescription for prednisone. the nurse should instruct the client to monitor for which of
the following adverse effects of this medication
a. hypoglycemia
b. tendinitis
c. infection
d. weight loss
infection
a nurse is planning care for a client who has AIDS and has developed stomatitis. which
of the following interventions should the nurse include in the plan of care
a. rinse the mouth with chlorhexidine solution every 2 hr
b. limit fluid intake with meal
c. provide oral hygiene with a firm-bristled toothbrush after each meal
d. avoid salty foods
avoid salty foods
a nurse is teaching a female client with a new diagnosis of systemic lupus
erythematosus (SLE) about factors that can trigger an exacerbations of SLE. the nurse
should determine that the client requires further teaching if she identifies which of the
following as an exacerbation factor
a. exercise
b. pregnancy
c. infection
d. sunlight
exercise
a nurse is teaching a client who has genital herpes about self-management. which of
the following instructions should the nurse include in the teaching
a. use an alcohol-based soap to clean lesions
b. wear a condom during sexual activity when leisions are present
c. take sitz bath once per day
d. apply a warm compress to the lesions
apply a warm compress to the lesions
a nurse is caring for a male client who reports a thick urethral discharge. which of the
following actions should the nurse take
a. contact the client sexual partners
b. obtain a urethral specimen for culture
c. prepare to administer penicillin to the client
d. obtain blood for a rapid plasma reagin test
obtain a urethral specimen for culture
a nurse is assessing a client who has an exacerbation of herpes zoster. which of the
following manifestations of the client skin should the nurse expect
a. confluent, honey-colored, crusted lesions
b. a large, tender nodule located on a hair follicle
c. unilateral, localized nodular skin lesions
d. a fluid-filled vesicular rash in the genital region
unilateral localized nodular skin lesions
a nurse health nurse is planning care for a client who is receiving chemotherapy and
has neutropenia. which of the following foods should the nurse include in the client's
plan of care
a. soft-boiled egg
b. brie cheese made with unpasteurized milk
c. cold deli-meat sandwiches
d. baked chicken
baked chicken
a nurse is providing dietary teaching for a client with AIDS who has stomatitis of the
mouth. which of the following instructions should the nurse include in the teaching
a. you can suck on popsicles to numb your mouth
b. season food with spices instead of salt
c. avoid the use of a straw to drink liquids
d. eat foods at hot temperature
you can suck on popsicles to numb your mouth
a nurse is reviewing the laboratory data of a client who reports manifestations
suggesting systemic lupus erythematosus (SLE). the nurse should expect an increase
in which of the following parameters for client who has SLE
a. platelet count
b. RBC count
c. Hct
d. erythrocyte sedimentation rate (ESR)
erythrocytes sedimentation rate (ESR)
a nurse is caring for a client who is suspected to have tuberculosis. which of the
following findings should the nurse expect
a. recent weight gain
b. high fever
c. rhinitis
d. blood-streaked sputum
blood-streaked sputum
a nurse is teaching a client who has human immunodeficiency virus (HIV) about how
the virus is transmitted. which of the following statements should the nurse include in
the teaching
HIV can be transmitted to anyone who has had contact with infected blood
a nurse is teaching a client who has human immunodeficiency virus (HIV) about the
early manifestations of acquired immune deficiency syndrome (AIDS). which of the
following statements should the nurse include in the teaching
a. you can expect a persistent fever and swollen glands
b. you can expect an elevated white blood cell count---decrease
c. you can expect increased blood pressure and edema--hypotension
d. you can expect weight gain--weight loss
you can expect a persistent fever and swollen glands
a nurse is monitoring a newly licensed nurse who is caring for a client. the client has
active pulmonary tuberculosis, was places on airborne precautions, and is scheduled for
a chest x-ray. the nurse should instruct the newly licensed nurse to take which of the
following actions
a. have the client wear a surgical mask
b. wear a gown for protection from the client's infection
c. ask the radiology staff to perform a portable chest x-ray in the client's room
d. place an N-95 respirator on the client--- the nurse should wear this
have the client wear a surgical mask
a nurse is preparing to administer a mantoux skin test to a client. what is the purpose of
a mantoux skin test using purified protein derivative ?
to identify if a client has been infected with mycobacterium tuberculosis
a nurse is providing discharge teaching to a client who has HIV. which of the
instructions about infection prevention should the nurse include
a. avoid large gatherings of people
b. clean toothbrush by running through the dishwasher
c. change pet litter boxes with disposable gloves
d. consume fresh fruit and raw vegetables
e. avoid digging in the garden
avoid large gathering of people
clean toothbrush by running through the dishwasher
avoid digging in the garden
a nurse is caring for a client with clostridium defficile who has contact-isolation
precaution in place. which of the following actions should the nurse perform
use dedicated equipment for the client
a nurse is assessing a client who has kaposi sarcoma. which of the following findings
should the nurse expect
reddish -purple skin lesions
a nurse is teaching a client about the manifestations of allergic reactions. the release of
histamine causes which of the following reaction
a. increased mucus secretion
b. bronchial dilation
c. bradycardia
d. vertigo
increased mucus secretion
a nurse is teaching a client who has AIDS about the transmission of pneumocystis
jiroveci pneumonia (PCP). which of the following pieces of information should the nurse
include in the teaching
PCP results from an impaired immune system
a nurse is reviewing the laboratory result for a client who reports bilateral pain and
swelling in her finger joints, with stiffness in the morning. the nurse should recognize
that an increase in which of the following laboratory values can indicate arthritis
a. reticulocyte count
b. rheumatoid factor
c. direct Coomb's test
d. platelet count
rheumatoid factor
a nurse is providing teaching about foot care to a client who has diabetes mellitus.
which of the following pieces of information should the nurse include in the teaching
wash your feet daily using lukewarm water and saop
a nurse is providing discharge teaching to a client who has AIDS about preventing
infection while at home. which of the following instructions should the nurse include in
the teaching
wash your genitalia using an antimicrobial soap
wash toothbrush in dish washer ones per week
a nurse is working with an assistive personnel (AP) who is assigned to bathe a client
with hepes zoster. the AP asks the nurse if hepes zoster is contagious. which of the
following responses should the nurse make
herpes zoster is not contagious to people who have had chickenpox
a nurse is conducting dietary teaching for a client who has AIDS. which of the following
instructions should the nurse include in the teaching
a. discard leftover after 8 hrs
b. use a separate cutting board for poultry
c. thaw frozen foods at room temperature
d. store cold foods at 10 degree (50 degree) or less
use a separate cutting board for poultry
a nurse is teaching a client about preventing the transmission of hepatitis A. the nurse
should identify that hepatitis A is transmitted by which of the following routea
a. maternal-fatal
b. fecal-oral contamination
c. genital sexual contact
d. blood to blood
fecal-oral contamination
a nurse is teaching a client who has tuberculosis about a new prescription for rifampin.
which of the following statements by the client indicates an understanding of the
teaching
i can expect this medication to turn my skin orange
a nurse is caring for a client who has human immunodeficiency virus (HIV). the client
ask the nurse, should i tell my partner that i am HIV positive? which of the following
statements should the nurse provide
it sounds like you are unsure what to say to your partner
a nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid
arthritis. the nurse should anticipate that the client's affected joints will require which of
the following treatment
a. an assistive device when the client is ambulating
b. heat paraffin therapy applied to the client's joint
c. gentle massage of the client hand
d. active range-of-motion exercises on the client's affected joint
heat paraffin therapy applied to the client's joint
a nurse is caring for a client who has systemic lupus erythematosus (SLE) and is
concerned about skin lesions on her face and neck. the client asks the nurse, what
should i do about these spot? which of the following responses should the nurse give
apply moisturizer after bathing the lesions with warm water
apply topical corticosteroids
pat dry lesions with washcloths to dry after washing
a nurse is admitting a client who has manifestations that suggest tuberculosis. which of
the following actions is the nurse's priority
a. initiate airborne precautions
b. administer antimicrobial therapy
c. tell the client that the infection will be communicable for 2-3 weeks from the start of
medication therapy
d. teach the client about the manifestations of tuberculosis
initiate airborne precautions
a nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks
ago. which of the following findings should the nurse report to the provider immediately
a. headache and fatigue
b. swollen lymph nodes in the neck
c. abdominal pain in the left upper quadrant
d. fever and sore throat
abdominal pain in the left upper quadrant
a nurse is providing teaching to a client who has a new prescription for alprazolam.
which of the following items is a priority for teaching
this medication can affect your ability to drive or handle mechanical equipment
a nurse is caring for a client who is 2 days postoperative. which of the following findings
indicate the client is developing an infection
a. temperature 37.8 (100)
b. erythema at the incision site
c. WBC count 9000/mm3
d. pain reported a 6 on a scale of 0-10
erythema at the incision site
a nurse is teaching a client who tested positive for an allergy to dust. the nurse should
determine that the client understands how to reduce her exposure to this allergen
through which of the following statments
i will put a mattress cover on my bed
a nurse is assessing a client who has systemic scleroderma. which of the following
findings should the nurse expect
a. excessive salivation
b. finger contracture
c. periorbital edema
d. alopecia
finger contracture
A nurse is collecting data from a client who is concerned about the possibility of the
contracting Lyme disease after being bitten by a tick. For which of the following early
manifestations of Lyme disease should the nurse monitor the client?
A progressive, circular rash
A nurse is reinforcing teaching with a client who has AIDS about preventing infection
while at home. Which of the following instructions should the nurse include in the
teaching?
Wash genitalia using an antimicrobial soap
A nurse is reinforcing discharge teaching with the partner of a client who has acquired
immune deficiency syndrome (AIDS). Which of the following statements by the client's
partner indicates the need for further teaching?
I'll clean up blood spills immediately with hot water.
A nurse is collecting data from a client who has Kaposi's sarcoma. Which of the
following findings should the nurse expect with this condition?
Reddish-purple skin lesions
A nurse is reinforcing teaching with a client who has a recent diagnosis of Raynaud's
disease about preventing the onset of manifestations. Which of the following statements
by the client indicates an understanding of the teaching?
I should not smoke
A nurse in a provider's office is reinforcing teaching with a client who has a new
diagnosis of rheumatoid arthritis and a new prescription for naproxen tablets. Which of
the following statements by the client requires further teaching?
I can take this medication with Aspirin
A nurse is reinforcing teaching with a client who is HIV positive about the early
manifestations of acquired immune deficiency syndrome (AIDS). Which of the following
statements should the nurse include in the teaching?
You can expect a persistent fever and swollen glands
A nurse is caring for a client who test positive for the human immunodeficiency virus.
The client asks the nurse, "Should i tell my partner that i HIV positive?" Which of the
following is an appropriate nursing response?
It sounds like you are unsure what to say to your partner
A nurse is collecting data from a client who is experiencing an acute exacerbation of
rheumatoid arthritis. The nurse should anticipate that the client's affected joints will
require which of the following treatments?
Heat paraffin therapy applied to the client's hands
A nurse is reinforcing teaching with a client who is being treated for genital warts. Which
of the following statements indicates that the client understands how to prevent
transmission of his sexually transmitted infection (STI)?
I will bring my sexual partner in for treatment
A nurse is assisting with the care of a client who is 2 days postoperative. Which of the
following findings should alert the nurse that the client is developing an infection?
Erythema at the incision site
A nurse is assisting with the care of a client who has systemic lupus erythematosus
(SLE). The client asks the nurse, "What should i do to care for my dry skin?" Which of
the following responses should the nurse make?
Apply lotion twice per day to dry skin
A nurse is reinforcing teaching with a client about the manifestations of an allergic
reaction. The nurse should explain that histamine release causes which of the following
reactions?
Increased mucus secretion
A nurse is collecting data from a client who had radioallergosorbent (RAST) testing
completed due to seasonal allergies. The nurse should anticipate an elevation in which
of the following laboratory values?
IgE (immunoglobulin E)
A nurse is reinforcing teaching with a client who has AIDS about the transmission of
Pnuemocystis jiroveci pneumonia (PCP). Which of the following information should the
nurse include in the teaching?
PCP results from an impaired immune system
A nurse is reinforcing teaching with a client who has systemic lupus erythematosus
(SLE). Which of the following instructions should the nurse plan to include in the
teaching?
Monitor your body temperature and report any elevations promptly
A nurse is reinforcing teaching with an assistive personnel about standard precautions
when caring for a client who has vancomycin resistant Enterococcus of the urine. Which
of the following of personal protection equipment should the nurse recommend the AP
to use when caring for this client?
Gloves
A nurse is collecting data from a client who has systemic scleroderma. Which of the
following findings should the nurse expect?
Skin tightening
A nurse is reinforcing teaching with a client who has Raynaud's disease. Which of the
following information should the nurse include in the teaching?
Protect against the cold by wearing layers of clothing
A nurse is reviewing the laboratory results for a client who reports bilateral pain and
swelling in her finger joints, with stiffness in the morning. The nurse should recognize
that an increase in which of the following laboratory values can indicate arthritis?
Rheumatoid factor
A nurse is reinforcing teaching with a client who has genital herpes about self-
management. Which of the following instructions should the nurse include in the
teaching?
Pour running water over the lesions when urinating
A nurse is reinforcing teaching with a client who has tested positive for an allergy to dust
about how to reduce her exposure to the allergen. The nurse should determine that the
client understands how to reduce her exposure to the allergen when she states which of
the following?
I will install an electrostatic filter in my furnace
A nurse is reinforcing teaching with a client who has tuberculosis about a new
prescription for rifampin. Which of the following statements by the client indicates an
understanding of the teaching?
I can expect this medication to turn my skin orange
A nurse is reinforcing teaching with a client who has a diagnosis of hepatitis A. Which of
the following statements by the client indicates an understanding of the teaching?
I should stop eating raw clams
A nurse is collecting data from a client who has an exacerbation of herpes zoster.
Which of the following manifestations of the client's skin should the nurse expect to
see?
Unilateral, localized, nodular skin lesions
A nurse is reinforcing teaching with a female client who has a new diagnosis of systemic
lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The
nurse should determine that the client requires further teaching when she identifies
which of the following as a factor that can exacerbate SLE?
Exercise
A nurse is reinforcing teaching with an assistive personnel (AP) who is caring for a client
who has active pulmonary tuberculosis, was placed on airborne precautions, and is
scheduled for a chest x-ray. Which of the following instructions should the nurse include
in the teaching?
Have the client wear surgical mask
A nurse is reinforcing teaching with a client who has human immunodeficiency virus
about how the virus is transmitted. Which of the following statements should the nurse
include in the teaching?
HIV can be transmitted to anyone who has had contact with infected blood
A nurse is assisting with the care of a client who has human immunodeficiency virus.
Which of the following types of isolate should the nurse implement to prevent
transmission of HIV
Standard precautions
A nurse is preparing to administer a Mantoux skin test to a client. The nurse should
inform the client that the purpose of a Mantoux skin test using purified protein derivative
(PPD) is to do which of the following actions?
Identify if a client has been infected with mycobacterium tuberculosis.
A nurse is caring for a client who has human immunodeficiency virus (HIV). The client
asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following
statements should the nurse give?
a. "This is your decision alone."
b. "I would if I were you."
c. "It sounds like you are unsure what to say to your partner."
d. 'Your provider is required by law to notify your partner."
c. "It sounds like you are unsure what to say to your partner."
Rationale - This response uses the therapeutic communication tools of clarifying and
restatement. It identifies that the client is unsure about if or how to approach the issue of
being HIV positive with his partner, a common concern of clients due to fear of rejection.
This response shows that the nurse is open to further communication with the client and
encourages his expression of feelings.
A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings
should the nurse expect?
a. A nonproductive cough, fever, and shortness of breath
b. lesions of the retina that produce blurred vision.
c. Onset of progressive dementia.
d. Reddish-purple skin lesions.
d. Reddish-purple skin lesions
Rationale - Kaposi's sarcoma is commonly associated with AIDS and manifests as
hyper-pigmentated multi centric lesions that can be firm, flat, raised, or nodular.
Following biopsy, the lesions are treated with radiation and/or chemotherapy.
A nurse is caring for a client who had radioallergosorbent (RAST) testing completed due
to seasonal allergies. The nurse should anticipate an elevation in which of the following
laboratory tests?
a. IgM
b. IgA
c. IgG
d. IgE
d. IgE
Rationale - RAST testing involves measuring the quantity of IgE present in serum after
exposure to specific antigens selected on a basis of the client's symptom history. An
elevated IgE indicates a positive response and is common among clients who have a
history of allergic manifestations, anaphylaxis, and asthma.
A nurse is caring for a client who is 2 days postoperative. Which of the following findings
should alert the nurse that the client is developing an infection?
a. Temperature 37.8 C (100 F)
b. Erythema at the incision site
c. WBC count 9,000/mm^3
d. Pain reported as 6 on a scale of 0 to 10.
b. Erythema at the incision site.
Rationale - Redness, or erythema, at the incision site is an initial sign of a wound
infection and requires intervention by the nurse.
A nurse is teaching a client who was recently diagnosed with Raynaud's disease about
preventing the onset of manifestations. Which of the following statements by the client
indicates an understanding of the teaching?
a. "I should limit my exposure to sunlight."
b. "I should avoid drinking alcohol."
c. "I should not smoke."
d. "I should limit my intake of foods high in purine."
c. "I should not smoke."
Rationale - Raynaud's disease is a disorder of the blood vessels that supply blood to the
skin and cause the distal extremities to feel numb and cool in response to cold
temperatures or stress. During a Raynaud's attack, these arteries narrow, limiting blood
circulation to affected areas. Strong emotion or exposure to the cold causes these areas
to become white, due to a lack of blood flow in the area. They then turn blue, as tiny
blood vessels dilate to allow more blood to remain in the tissues. When the flow of blood
returns, the area becomes red and then later returns to normal color. This can cause
tingling, swelling, and painful throbbing. The attacks can last from minutes to hours. If
the condition progresses, blood flow to the area could become permanently decreased,
causing the fingers to become thin and tapered, with smooth, shiny skin and slow-
growing nails. If an artery becomes blocked completely, gangrene or ulceration of the
skin can occur. Smoking cessation, not just reduction, is an action the client should take
to prevent the onset of the manifestations of Raynaud's disease.
A nurse is assessing a client who has systemic scleroderma. Which of the following
findings should the nurse expect?
a. Excessive salivation
b. Finger contractures
c. Periorbital edema
d. Alopecia
b. Finger contractures
Rationale - Scleroderma is a chronic disease that can cause thickening, hardening, or
tightening of the skin, blood vessels, and internal organs. There are two types of
scleroderma: localized scleroderma, which mainly affects the skin, and systemic
scleroderma, which can affect internal organs. The manifestations include skin changes,
Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With
scleroderma, the body produces and deposits too much collagen, causing thickening
and hardening. In addition to the client's skin and subcutaneous tissues becoming
increasingly hard and rigid, the extremities stiffen and lose mobility. Contractors develop
with advanced systemic scleroderma unless clients follow a regimen of range-of-motion
and muscle-strengthening exercises.
A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is
concerned about the skin lesions on her face and neck. The client asks the nurse,
"What should I do about these spots?" Which of the following responses should the
nurse give?
a. "Keep the lesions covered with a light sterile dressing when going outside."
b. "Rub lesions with a washcloth to dry after washing."
c. "Apply moisturizer after bathing the lesions with warm water."
d. "Apply antibiotic cream twice per day until scabs form on the lesions."
c. "Apply moisturizer after bathing the lesions with warm water."
Rationale - The nurse should instruct the client to clean, dry, and moisturize the skin
using warm (not hot) water, along with an unscented lotion.
A nurse teaching a client who has human immunodeficiency virus about how the virus is
transmitted. Which of the following statements should the nurse include in the teaching?
a. "HIV can be transmitted as soon as a person develops manifestations."
b. "HIV can be transmitted to anyone who has had contact with the infected blood."
c. "HIV is transmitted through the respiratory route through droplets."
d. "HIV is transmitted only during the active phase of the virus."
b. "HIV can be transmitted to anyone who has had contact with the infected blood."
Rationale - The concentration of the virus is highest in blood but also has been isolated
in other body fluids, including sputum, saliva, cerebrospinal fluid, urine and semen.
Clients who have HIV are cautioned to practice safe sex, avoid donating blood, and
abstain from sharing needles with others.
A nurse is caring for a client who has human immunodeficiency virus. Which of the
following types of isolation should the nurse implement to prevent transmission of HIV?
a. Protective isolation
b. Droplet isolation
c. Standard isolation
d. Airborne isolation
c. Standard isolation
Rationale - Standard precautions should be implemented with every client, to prevent
the spread of infection transmitted by direct or indirect contact with infectious blood or
body fluids. Because HIV is spread through blood and bodily fluid, standard precautions
are appropriate.
A nurse is teaching a client who has tested positive for an allergy to dust. The nurse
should determine that the client understands how to reduce her exposure to this
allergen when she states which of the following?
a. "I will begin vacuuming once a week."
b. Carpeting the entire hose will be very expensive, but it will be worth it."
c. I will apply a mattress cover to my bed."
d. "Installing curtains on my windows will help control the dust in the house."
c. "I will apply a mattress cover to my bed."
Rationale - The nurse should instruct the client to apply a hypoallergenic mattress cover
that can be zipped over her bed to control the amount of dust. The client should remove
the mattress cover periodically and machine wash to clean.
A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid
arthritis. The nurse should anticipate that the client's affected joints will require which of
the following treatments?
a. An assistive device to use when the client is ambulating.
b. Heat paraffin therapy applied to client's joints.
c. Gentle massage of the client's hands.
d. Active range-of-motion exercises on the client's affected joints.
b. Heat paraffin therapy applied to client's joints.
Rationale - The nurse should anticipate the use of heat paraffin to be prescribed as a
non-pharmacologic intervention. The elevated ESR indicates an acute inflammatory
process due to client's rheumatoid arthritis. The use of the warm paraffin relieves the
stiffness of the client's joints and provides comfort.
A nurse is providing discharge teaching to a client who has AIDS about preventing
infection while at home. Which of the following instructions should the nurse include in
the teaching?
a. "Wash your genitalia using an antimicrobial soap."
b. "Rinse your dishes with cold water."
c. "Clean your toothbrush once per month."
d. "Incorporate raw fruits and vegetables into your diet."
a. "Wash your genitalia using an antimicrobial soap."
Rationale - The nurse should instruct the client to bathe daily using an antimicrobial
soap to prevent the spread of infection. If bathing is not possible, washing the genitalia
using an antimicrobial soap is recommended.
A nurse is teaching a client who has tuberculosis about a new prescription for rifampin.
Which of the following statements by the client indicates an underling of the teaching?
a. "I should take this medication with food."
b. "I need to take B-complex vitamin while taking this medication."
c. "I can expect this medication to turn my skin orange."
d. I can expect this medication to make my vision blurry."
c. "I can expect this medication to turn my skin orange."
Rationale - The nurse should instruct the client to expect his skin and urine to turn a
reddish-orange tinge which taking rifampin.
A nurse is providing discharge teaching to the partner of a client who has acquired
immune deficiency syndrome. Which of the following statements by the client's partner
indicates the need for further testing?
a. "I will dispose soiled tissues in separate plastic bags."
b. "I'll clean up blood spills immediately with hot water."
c. "I know that hand washing is an important preventive measure."
d. "I will wash soiled clothes in hot water
b. "I'll clean up blood spills immediately with hot water."
Rationale - The client's partner should clean blood or potentially contaminated body
substances with a bleach solution and wear gloves when coming into contact with blood
products.
A nurse is caring for a client who is concerned about the possibility of contracting lyme
disease after receiving a tick bite. For which of the following early manifestations of
Lyme disease should the nurse asses the client?
a. A diffuse maculopapular rash
b. Dyspnea
c. Double vision
d. A progressive, circular rash
d. A progressive, circular rash
Rationale - Early Lyme Disease is characterized by fever, influenza-like manifestations,
and erythema migraines, a distinct progressive circular or bulls-eye rash that often
develops at the bite site, but can also develop at other sites, such as the thighs and
knees.
A nurse is providing teaching to a client who has a diagnosis of Hepatitis A. Which of
the following statements by the client indicates an understanding of the teaching?
a. "I am unable to donate blood."
b. "I will need to get a booster shot of immune serum globulin every year."
c. "I should stop eating raw clams."
d. "I can get this disease by getting a tattoo."
c. "I should stop eating raw clams."
Rationale - Hepatitis A is transmitted via the fecal-oral route through consumption of
contaminated fruits, vegetables, water, milk, or uncooked shellfish. Individuals who eat
raw or steamed shellfish are at increased risk for acquiring hepatitis A.
A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the
following manifestations of the client's skin should the nurse expect?
a. Confluent, honey-colored, crusted lesions
b. Large, tender nodules located on a hair follicle
c. Unilateral, localized, nodular skin lesions
d. A fluid-filled vesicular rash in the genital region
c. Unilateral, localized, nodular skin lesions.
Rationale - Herpes zoster, or shingles, results from the reactivation of a dormant
varicella virus, It is the acute, unilateral inflammation of the dorsal root ganglion. The
infection typically develops in adults and produces localized vesicular lesions confined
to a dermatome. It produces unilateral, localized, nodular skin lesions.
A nurse is teaching a client who has AIDS about the transmission of Pneumocystis
jiroveci pneumonia (PCP). Which of the following information should the nurse include
in the teaching?
a. "PCP is sexually transmitted from person to person."
b. "You were most likely exposed to a contaminated surface, such as a drinking glass."
c. "PCP results from an impaired immune system."
d. "You may have contracted PCP from a family pet."
c. "PCP results from an impaired immune system."
Rationale - The nurse should explain that the organism that causes PCP exists as part
of the normal flora of the lungs and develops into a fungus. It becomes an aggressive
pathogen when the immune system is compromised and the infection results from an
impaired immune system.
A nurse is teaching a client about manifestations of an allergic reaction. The nurse
should explain that histamine release causes which of the following reactions?
a. Increased mucus secretion
b. Bronchial dilation
c. Bradycardia
d. Vertigo
a. Increased mucus secretion
Rationale - The nurse should instruct the client that increased mucus secretion is a
manifestation of histamine release. Histamine is the neurotransmitter the body produces
during an allergic reaction.
A nurse is teaching a client who has HIV about the early manifestations of AIDS. Which
of the following statements should the nurse include in the teaching?
a. "You can expect a persistent fever and swollen glands."
b. "You can expect an elevated white blood cell count."
c. "You can expect an increase in blood pressure and edema."
d. "You can expect weight gain."
a. "You can expect a persistent fever and swollen glands."
Rationale - Clients who have AIDS can have persistent fever, swollen glands, diarrhea,
weight loss, and fatigue. These manifestations indicate the onset of AIDS.
A nurse is teaching a client who has genital herpes about self-management. Which of
the following instructions should the nurse include in the teaching?
a. Use an alcohol-based to clean lesions.
b. Wear a condom during sexual activity when lesions are present.
c. Take a sitz bath once per day.
d. Apply a warm compress to the lesions.
d. Apply a warm compress to the lesions.
Rationale - The nurse should instruct the client to apply a warm compares to the lesions
to relieve discomfort.
A nurse in a provider's office is providing teaching to a client who has a recent diagnosis
of rheumatoid arthritis and has a new prescription for naproxen tablets. Which of the
following statements by the client requires further teaching?
a. "This medication will take 4 weeks for me to notice relief in my joints."
b. "I can take an antacid with this medication for indigestion."
c. "I can take this medication with aspirin."
d. "The naproxen goes down easier when i crush it and put it in applesauce."
c. "I can take this medication with aspirin."
Rationale - The nurse should instruct the client to avoid taking this medication with any
other NSAIDs, such as aspirin, because this can increase the risk for bleeding and
gastrointestinal ulceration.
A nurse is preparing to administer a Mantoux skin test to a client. The nurse should
inform the client that the purpose of a Mantoux skin test using purified protein derivative
(PPD) is to do which of the following actions?
a. Identify if a client lacks immunity to tuberculosis
b. Find out if a client has active tuberculosis
c. Decrease the hypersensitivity of the client's reaction to PPD
d. Identify if a client has been infected with mycobacterium tuberculosis.
d. Identify if a client has been infected with mycobacterium tuberculosis.
Rationale - The nurse should inform the client that the Mantoux skin test is used to
identify individuals who have been infected with mycobacterium tuberculosis.
A nurse is teaching a female client who has a new diagnosis of system lupus
erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse
should determine that the client needs more teaching when she identifies which of the
following as a factor that can exacerbate SLE?
a. Exercise
b. Pregnancy
c. Infection
d. Sunlight
a. Exercise
Rationale - SLE is a chronic autoimmune disease that develops when the immune
system becomes hyperactive and attacks healthy body tissue. This attack results in
generalized inflammation and the manifestations associated with the specific involved
tissues. Most clients who have SLE can follow an exercise program to increase the
aerobic capacity of cells and improve immune function, and the client should develop
such a program with her provider's assistance. This client needs additional teaching
about the importance of exercise to keep her muscles and joints active.
A nurse is providing discharge instructions to a client who is being treated for genital
warts. Which of the following statements indicates that the client understands how to
prevent transmission of the STI?
a. "I will bring my sexual partner in for treatment."
b. "Now that I've had my first dose of medicine, I can resume sexual activity"
c. "Once I have been treated, it is no longer necessary to use condoms."
d. Once treatment is completed and I am free of symptoms, I don't have to return to the
clinic."
a. "I will bring my sexual partner in for treatment."
Rationale - The client should bring his partner in to be screened for genital warts and
treated.
A nurse is planning discharge teaching for a client who has systemic lupus
erythematosus (SLE). Which of the following instructions should the nurse plan to
include.
a. "Avoid the use of NSAIDs
b. "Stop taking the corticosteroids when your symptoms resolve."
c. "Exposure to ultraviolet light with help control the skin rashes.
d. "Monitor your body temperature and report any elevations promptly."
d. "Monitor your body temperature and report any elevations promptly."
Rationale - SLE is a chronic autoimmune disorder the can affect any organ of the body.
With SLE, the body's immune system becomes hyperactive, forming antibodies that
attack tissues and organs, including the skin, joints, kidneys, brain, heart, lungs, and
blood. SLE is characterized by periods of exacerbation and remissions. The nurse
should teach the client to monitor body temperature and report any elevations promptly,
as fever can suggest either an exacerbation or a potentially life-threatening infection.
A nurse is monitoring a newly licensed nurse who is caring for a client. The client has
active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled
for a chest x-ray. The nurse should instruct the newly licensed nurse to take which of
the following actions?
a. Have the client wear a surgical mask
b. Wear gown for protection from the client's infection.
c. Ask the radiology staff to perform a portable chest x-ray in the client's room.
d. Place an N95 respirator on the client.
a. Have the client wear a surgical mask.
Rationale - The nurse should instruct the client to wear a surgical mask. The mask will
protect anyone who comes into contact with the client, including the nurse.
The nurse is reviewing the laboratory results for a client who reports bilateral pain and
swelling in her finger joints, with stiffness in the morning. The nurse should recognize
that an increase in which of the following laboratory tests can indicate arthritis?
a. Reticulocyte count
b. Rheumatoid factor
c. Direct Coomb's test
d. Platelet count
b. Rheumatoid factor
Rationale - An increase in the client's rheumatoid factor can indicate rheumatoid arthritis
or other connective tissue diseases.
A nurse is teaching a client who has Raynaud's disease. Which of the following
information should the nurse include in the teaching?
a. Protect against the cold by wearing layers of clothing
b. Beging an exercise program of 2-mile walks once per week
c. Increase vitamin A in the diet
a. Protect against the cold by wearing layers of clothing.
Rationale - Clients who have Raynaud's disease are prone to attacks during cold
weather. Extreme cold can lead to tissue damage. Therefore, the client needs to be
protected with layers of clothing to promote warmth and increase circulation to the
extremities.
Which statement by a patient with systemic lupus erythematosus (SLE) indicates that
the patient has understood the nurse's teaching about the condition?
a. "I will exercise even if I am tired."
b. "I will use sunscreen when I am outside."
c. "I should take birth control pills to keep from getting pregnant."
d. "I should avoid aspirin or nonsteroidal antiinflammatory drugs."
ANS: B
Severe skin reactions can occur in patients with SLE who are exposed to the sun.
Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral
contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs
are used to treat the musculoskeletal manifestations of SLE.
A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial
rash and alopecia tells the nurse, "I never leave my house because I hate the way I
look." An appropriate nursing diagnosis for the patient is
a. activity intolerance related to fatigue and inactivity.
b. impaired social interaction related to lack of social skills.
c. impaired skin integrity related to itching and skin sloughing.
d. social isolation related to embarrassment about the effects of SLE.
ANS: D
The patient's statement about not going anywhere because of hating the way he or she
looks supports the diagnosis of social isolation because of embarrassment about the
effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but
the information about this patient does not support this as a diagnosis. The rash with
SLE is nonpruritic. There is no evidence of lack of social skills for this patient.
A new clinic patient with joint swelling and pain is being tested for systemic lupus
erythematosus. Which test will provide the most specific findings for the nurse to
review?
a. Rheumatoid factor (RF)
b. Antinuclear antibody (ANA)
c. Anti-Smith antibody (Anti-Sm)
d. Lupus erythematosus (LE) cell prep
ANS: C
The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also
used in screening but are not as specific to SLE
The health care provider has prescribed the following collaborative interventions for a
patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which
order will the nurse question?
a. Draw anti-DNA blood titer.
b. Administer varicella vaccine.
c. Naproxen (Aleve) 200 mg BID.
d. Famotidine (Pepcid) 20 mg daily.
ANS: B
Live virus vaccines, such as varicella, are contraindicated in a patient taking
immunosuppressive drugs. The other orders are appropriate for the patient
Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most
important for the nurse to communicate to the health care provider?
a. Decreased C-reactive protein (CRP)
b. Elevated blood urea nitrogen (BUN)
c. Positive antinuclear antibodies (ANA)
d. Positive lupus erythematosus cell prep
ANS: B
The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for
a change in therapy to avoid further renal damage. The positive lupus erythematosus
(LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows
an improvement in the inflammatory process.
Which nursing action can the registered nurse (RN) delegate to unlicensed assistive
personnel (UAP) who are assisting with the care of a patient with scleroderma?
a. Monitor for difficulty in breathing.
b. Document the patient's oral intake.
c. Check finger strength and movement.
d. Apply capsaicin (Zostrix) cream to hands.
ANS: B
Monitoring and documenting patients' oral intake is included in UAP education and
scope of practice. Assessments for changes in physical status and administration of
medications require more education and scope of practice, and should be done by
licensed nurses
In teaching a patient with SLE about the disorder, the nurse knows that the
pathophysiology of SLE includes
a. circulating immune complexes formed from IgG autoantibodies reacting with IgG
b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin
layer
c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles
d. the production of a variety of autoantibodies directed against components of the cell
nucleus
Correct answer: d
Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of
many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA),
erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins.
Autoimmune reactions characteristically are directed against constituents of the cell
nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune
complexes containing antibody against DNA are deposited in the basement membranes
of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and
inflammation occurs. The overaggressive antibody response is also related to activation
of B and T cells. The specific manifestations of SLE depend on which cell types or
organs are involved. SLE is a type III hypersensitivity response.
A female patient's complex symptomatology over the past year has culminated in a
diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following
statements demonstrates the need for further teaching about the disease?
A client is suspected of having systemic lupus erythematous. The nurse monitors the
client, knowing that which of the following is one of the initial characteristic sign of
systemic lupus erythematous?
1. Weight gain
2. Subnormal temperature
3. Elevated red blood cell count
4. Rash on the face across the bridge of the nose and on the cheeks
Answer: 4
Rationale: Skin lesions or rash on the face across the bridge of the nose and on the
cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever
and weight loss may also occur. Anemia is most likely to occur later in SLE.
The nurse is assisting in planning care for a client with a diagnosis of immune
deficiency. The nurse would incorporate which of the following as a priority in the plan of
care?
1. Protecting the client from infection
2. Providing emotional support to decrease fear
3. Encouraging discussion about lifestyle changes
4. Identifying factors that decreased the immune function
Answer: 1
Rationale: The client with immune deficiency has inadequate or absent immune bodies
and is at risk for infection. The priority nursing intervention would be to protect the client
from infection. Options 2, 3, and 4 may be components of care but are not the priority.
The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The
nurse plans care knowing that this disorder is:
1. A local rash that occurs as a result of allergy
2. A disease caused by overexposure to sunlight
3. An inflammatory disease of collagen contained in connective tissue
4. A disease caused by the continuous release of histamine in the body
Answer: 3
Rationale: SLE is an inflammatory disease of collagen contained in connective tissue.
Options 1, 2, and 4 are not associated with this disease.
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 of the following medications would the nurse expect to be
prescribed?
1. Antibiotic
2. Antidiarrheal
3. Corticosteroid
4. Opioid analgesic
Answer: 3
Rationale: Treatment of SLE is based on the systems involved and symptoms.
Treatment normally consists of anti-inflammatory drugs, corticosteroids, and
immunosuppressants. The incorrect options are not standard components of medication
therapy for this disorder.
A 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 of the following
that is also indicative of the presence of SLE?
1. Emboli
2. Ascites
3. Two hemoglobin S genes
4. Butterfly rash on cheeks and bridge of nose
Answer: 4
Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A
butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE.
Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many
conditions but are not associated with SLE.
Which client is at the highest risk for systemic lupus erythematous (SLE)?
1. An Asian male
2. A white female
3. An African-American male
4. An African-American female
1. An Asian male
2. A white female
3. An African-American male
4. An African-American female
Answer: 4
Rationale: SLE affects females more commonly than males. It is more common in
African-American females than in white females.
A nurse is reviewing the medical record of a young female client who is suspected of
having systematic lupus erythematosus (SLE). Which of the following would the nurse
expect to note documented in the record that is related to this diagnosis?
1. Presence of two hemoglobin S genes in the blood cell report
2. Ascites noted in the abdomen
3. Recurrent emboli
4. Butterfly rash on cheeks and bridge of the nose
Answer: 4
Rationale: SLE primarily occurs in females 10 to 35 years of age and is a chronic
inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks
and the bridge of the nose is a characteristic sign of SLE. Option 1 is found in sickle cell
anemia. Options 2 and 3 are found in many conditions but are not usually noted in SLE.
The nurse provides 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 instructions?
1. "I should take hot baths because they are relaxing."
2. "I should sit whenever possible to conserve my energy."
3. "I should avoid long periods of rest because it causes joint stiffness."
4. "I should do some exercises, such as walking, when I am not fatigued."
Answer: 1
Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the
nurse should instruct the client to sit whenever possible, avoid hot baths (because they
exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and
maintain a balanced diet. The client is instructed to avoid long periods of rest because it
promotes joint stiffness.
A complete blood cell count is performed on a client with systemic lupus erythematosus
(SLE). The nurse would suspect that which of the following findings will be reported
from this blood test?
1. Increased red blood cell count
2. Decrease of all cell types
3. Increased white blood cell count
4. Increased neutrophils
Answer: 2
Rationale: In the client with SLE, a complete blood count commonly shows
pancytopenia, a decrease of all cell types, probably caused by a direct attack of all
blood cells or bone marrow by immune complexes. The other options are incorrect.
A client is diagnosed with an immune deficiency. The nurse focuses on which of the
following as the highest priority when providing care to this client?
1. Encouraging discussion about emotional impact of the disorder
2. Identifying historical factors that placed the client at risk
3. Providing emotional support to decrease fear
4. Protecting the client from infection
Answer: 4
Rationale: The client with immune deficiency has inadequate immune bodies and is at
risk for infection. The priority nursing intervention would be to protect the client from
infection. The other options are also part of the plan of care but are not the highest
priority.
1. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus
(SLE) involving her joints. In teaching the patient about the disease, the nurse includes
the information that SLE is a(n):
A. Hereditary disorder of women but usually does not show clinical symptoms unless a
woman becomes pregnant.
B. Autoimmune disease of women in which antibodies are formed that destroy all
nucleated cells in the body.
C. Disorder of immune function, but it is extremely variable in its course, and there is no
way to predict its progression.
D. Disease that causes production of antibodies that bind with cellular estrogen
receptors, causing an inflammatory response.
1. Answer: C
Rationale: SLE has an unpredictable course, even with appropriate treatment. Women
are more at risk for SLE, but it is not confined exclusively to women. Clinical symptoms
may worsen during pregnancy but are not confined to pregnancy or the perinatal period.
All nucleated cells are not destroyed by the antinuclear antibodies. The inflammation in
SLE is not caused by antibody binding to cellular estrogen receptors.
2. A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is
hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The
health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which
nursing action should be included in the plan of care?
A. Rheumatoid factor.
B. Anti-Smith antibody (Anti-Sm).
C. Antinuclear antibody (ANA).
D. Lupus erythematosus (LE) cell prep.
4. Answer: B
Rationale: The anti-Sm is antibody found almost exclusively in SLE. The other blood
tests are also used in screening but are not as specific to SLE.
5. Following instruction for a patient with newly diagnosed systemic lupus
erythematosus (SLE), the nurse determines that teaching about the disease has been
effective when the patient says:
A. "I should expect to have a low fever all the time with this disease."
B. "I need to restrict my exposure to sunlight to prevent an acute onset of symptoms."
C. "I should try to ignore my symptoms as much as possible and have a positive
outlook."
D. "I can expect a temporary improvement in my symptoms if I become pregnant."
5. Answer: B
Rationale: Sun exposure is associated with SLE exacerbation, and patients should use
sunscreen with an SPF of at least 15 and stay out of the sun between 11:00 AM and
3:00 PM. Low-grade fever may occur with an exacerbation but should not be expected
all the time. A positive attitude may decrease the incidence of SLE exacerbations, but
patients are taught to self-monitor for symptoms that might indicate changes in the
disease process. Symptoms may worsen during pregnancy and especially during the
postpartum period.
6. A 19-year-old patient who is taking azathioprine (Imuran) for systemic lupus
erythematosus has a check-up before leaving home for college. The health care
provider writes all of these orders. Which one should the nurse question?
A. Weight gain
B. Subnormal temperature
C. Elevated red blood cell count
D. Rash on the face across the bridge of the nose
7. Answer: D
Rationale: Skin lesions or rash on the face across the bridge of the nose and on the
cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever
and weight loss may also occur. Anemia is most likely to occur later in SLE.
8. The nurse is assigned to care for a client with systemic lupus erythematosus (SLE).
The nurse plans care knowing that this disorder is:
A. Antibiotic
B. Antidiarrheal
C. Corticosteroid
D. Opioid analgesic
9. Answer: C
Rationale: Treatment of SLE is based on the systems involved and symptoms.
Treatment normally consists of anti-inflammatory drugs, corticosteroids, and
immunosuppressants. The incorrect options are not standard components of medication
therapy for this disorder.
10. A 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 of the following
that is also indicative of the presence of SLE?
A. Emboli
B. Ascites
C. Two hemoglobin S genes
D. Butterfly rash on cheeks and bridge of nose
10. Answer: D
Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A
butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE.
Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many
conditions but are not associated with SLE.
11. Which client is at the highest risk for systemic lupus erythematous (SLE)?
A. An Asian male
B. A white female
C. An African-American male
D. An African-American female
11. Answer: D
An African-American female
12. The nurse monitors a patient to have Systemic Lupus Erythematosus. Which of the
following symptoms is characteristic of this diagnosis?
A. Circulating immune complexes formed from IgG autoantibodies reacting with IgG
B. An autoimmune T-cell reaction that results in destruction of the deep dermal skin
layer
C. Immunologic dysfunction leading to chronic inflammation in the cartilage and
muscles
D. The production of a variety of autoantibodies directed against components of the cell
nucleus
13. Answer: D
Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of
many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA),
erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins.
Autoimmune reactions characteristically are directed against constituents of the cell
nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune
complexes containing antibody against DNA are deposited in the basement membranes
of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and
inflammation occurs. The overaggressive antibody response is also related to activation
of B and T cells. The specific manifestations of SLE depend on which cell types or
organs are involved. SLE is a type III hypersensitivity response.
14. A female patient's complex symptomatology over the past year has culminated in a
diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following
statements demonstrates the need for further teaching about the disease?
A. Increased RBCs
B. Decreased ESR
C. Decreased anti-DNA
D. Increased complement
17. Answer: C
Decreased anti-DNA
18. Teaching that the nurse will plan for the patient with SLE includes:
25. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus
(SLE) involving her joints. In teaching the patient about the disease, the nurse includes
the information that SLE is a(n)
a. hereditary disorder of women but usually does not show clinical symptoms unless a
woman becomes pregnant.
b. autoimmune disease of women in which antibodies are formed that destroy all
nucleated cells in the body.
c. disorder of immune function, but it is extremely variable in its course, and there is no
way to predict its progression.
d. disease that causes production of antibodies that bind with cellular estrogen
receptors, causing an inflammatory response.
Answer: C
Rationale: SLE has an unpredictable course, even with appropriate treatment. Women
are more at risk for SLE, but it is not confined exclusively to women. Clinical symptoms
may worsen during pregnancy but are not confined to pregnancy or the perinatal period.
All nucleated cells are not destroyed by the antinuclear antibodies. The inflammation in
SLE is not caused by antibody binding to cellular estrogen receptors.
1. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus
(SLE) involving her joints. In teaching the patient about the disease, the nurse includes
the information that SLE is a(n):
A. Hereditary disorder of women but usually does not show clinical symptoms unless a
woman becomes pregnant.
B. Autoimmune disease of women in which antibodies are formed that destroy all
nucleated cells in the body.
C. Disorder of immune function, but it is extremely variable in its course, and there is no
way to predict its progression.
D. Disease that causes production of antibodies that bind with cellular estrogen
receptors, causing an inflammatory response.
1. Answer: C
Rationale: SLE has an unpredictable course, even with appropriate treatment. Women
are more at risk for SLE, but it is not confined exclusively to women. Clinical symptoms
may worsen during pregnancy but are not confined to pregnancy or the perinatal period.
All nucleated cells are not destroyed by the antinuclear antibodies. The inflammation in
SLE is not caused by antibody binding to cellular estrogen receptors.
2. A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is
hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The
health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which
nursing action should be included in the plan of care?
A. Institute seizure precautions.
B. Reorient to time and place PRN.
C. Monitor intake and output.
D. Place on cardiac monitor.
2. Answer: C
Rationale: Lupus nephritis is a common complication of SLE, and when the patient is
taking corticosteroids, it is especially important to monitor renal function. There is no
indication that the patient is experiencing any nervous system or cardiac problems with
the SLE.
3. A patient with systemic lupus erythematosus (SLE) who has a facial rash and
alopecia tells the nurse, "I hate the way I look! I never go anyplace except here to the
health clinic." An appropriate nursing diagnosis for the patient is:
A. Rheumatoid factor.
B. Anti-Smith antibody (Anti-Sm).
C. Antinuclear antibody (ANA).
D. Lupus erythematosus (LE) cell prep.
4. Answer: B
Rationale: The anti-Sm is antibody found almost exclusively in SLE. The other blood
tests are also used in screening but are not as specific to SLE.
5. Following instruction for a patient with newly diagnosed systemic lupus
erythematosus (SLE), the nurse determines that teaching about the disease has been
effective when the patient says:
A. "I should expect to have a low fever all the time with this disease."
B. "I need to restrict my exposure to sunlight to prevent an acute onset of symptoms."
C. "I should try to ignore my symptoms as much as possible and have a positive
outlook."
D. "I can expect a temporary improvement in my symptoms if I become pregnant."
5. Answer: B
Rationale: Sun exposure is associated with SLE exacerbation, and patients should use
sunscreen with an SPF of at least 15 and stay out of the sun between 11:00 AM and
3:00 PM. Low-grade fever may occur with an exacerbation but should not be expected
all the time. A positive attitude may decrease the incidence of SLE exacerbations, but
patients are taught to self-monitor for symptoms that might indicate changes in the
disease process. Symptoms may worsen during pregnancy and especially during the
postpartum period.
6. A 19-year-old patient who is taking azathioprine (Imuran) for systemic lupus
erythematosus has a check-up before leaving home for college. The health care
provider writes all of these orders. Which one should the nurse question?
A. Weight gain
B. Subnormal temperature
C. Elevated red blood cell count
D. Rash on the face across the bridge of the nose
7. Answer: D
Rationale: Skin lesions or rash on the face across the bridge of the nose and on the
cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever
and weight loss may also occur. Anemia is most likely to occur later in SLE.
8. The nurse is assigned to care for a client with systemic lupus erythematosus (SLE).
The nurse plans care knowing that this disorder is:
A. Emboli
B. Ascites
C. Two hemoglobin S genes
D. Butterfly rash on cheeks and bridge of nose
10. Answer: D
Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A
butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE.
Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many
conditions but are not associated with SLE.
11. Which client is at the highest risk for systemic lupus erythematous (SLE)?
A. An Asian male
B. A white female
C. An African-American male
D. An African-American female
11. Answer: D
An African-American female
12. The nurse monitors a patient to have Systemic Lupus Erythematosus. Which of the
following symptoms is characteristic of this diagnosis?
A. Circulating immune complexes formed from IgG autoantibodies reacting with IgG
B. An autoimmune T-cell reaction that results in destruction of the deep dermal skin
layer
C. Immunologic dysfunction leading to chronic inflammation in the cartilage and
muscles
D. The production of a variety of autoantibodies directed against components of the cell
nucleus
13. Answer: D
Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of
many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA),
erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins.
Autoimmune reactions characteristically are directed against constituents of the cell
nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune
complexes containing antibody against DNA are deposited in the basement membranes
of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and
inflammation occurs. The overaggressive antibody response is also related to activation
of B and T cells. The specific manifestations of SLE depend on which cell types or
organs are involved. SLE is a type III hypersensitivity response.
14. A female patient's complex symptomatology over the past year has culminated in a
diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following
statements demonstrates the need for further teaching about the disease?
A. You can plan to have a near-normal life since SLE rarely causes death
B. It is difficult to tell because to disease is so variable in its severity and progression
C. Life span is shortened somewhat in people with SLE, but the disease can be
controlled with long-term use of corticosteroids
D. Most people with SLE have alternating periods of remissions and exacerbations with
rapid progression to permanent organ damage
16. Answer: B
It is difficult to tell because to disease is so variable in its severity and progression
17. During an acute exacerbation, a patient with SLE is treated with corticosteroids. The
nurse would expect the steroids to begin to be tapered when serum laboratory results
indicate:
A. Increased RBCs
B. Decreased ESR
C. Decreased anti-DNA
D. Increased complement
17. Answer: C
Decreased anti-DNA
18. Teaching that the nurse will plan for the patient with SLE includes:
inflammation of the kidneys (lupus nephritis), which can affect the body's ability to filter
waste from the blood and can be so damaging that dialysis or kidney transplant may be
needed
an increase in blood pressure in the lungs (pulmonary hypertension)
inflammation of the nervous system and brain, which can cause memory problems,
confusion, headaches, and strokes
SLE Triggers
While a person's genes may increase the chance that he or she will develop lupus, it
takes some kind of environmental trigger to set off the illness or to bring on a flare.
Examples include:
• ultraviolet rays from the sun
• ultraviolet rays from fluorescent light bulbs
• sulfa drugs, which make a person more sensitive to the sun, such as: Bactrim® and
Septra® (trimethoprim-sulfamethoxazole); sulfisoxazole (Gantrisin®); tolbutamide
(Orinase®); sulfasalazine (Azulfidine®); diuretics
• sun-sensitizing tetracycline drugs such as minocycline (Minocin®)
• penicillin or other antibiotic drugs such as: amoxicillin (Amoxil®); ampicillin (Ampicillin
Sodium ADD-Vantage®); cloxacillin (Cloxapen®)
• an infection
• a cold or a viral illness
• exhaustion
• an injury
• emotional stress, such as a divorce, illness, death in the family, or other life
complications
• anything that causes stress to the body, such as surgery, physical harm, pregnancy, or
giving birth
Although many seemingly unrelated factors can trigger the onset of lupus in a
susceptible person, scientists have noted some common features among many people
who have lupus, including:
• exposure to the sun
• an infection
• being pregnant
• giving birth
• a drug taken to treat an illness
Clients with active disease have an increased risk for
infections
Early manifestations include
Because lupus can affect so many different organs, a wide range of symptoms can
occur. These symptoms may come and go, and different symptoms may appear at
different times during the course of the disease.
The most common symptoms of lupus, which are the same for females and males, are:
• extreme fatigue (tiredness)
• headaches
• painful or swollen joints
• fever
• anemia (low numbers of red blood cells or hemoglobin, or low total blood volume)
• swelling (edema) in feet, legs, hands, and/or around eyes
• pain in chest on deep breathing (pleurisy)
• butterfly-shaped rash across cheeks and nose
• sun- or light-sensitivity (photosensitivity)
• hair loss
• abnormal blood clotting
• fingers turning white and/or blue when cold (Raynaud's phenomenon)
• mouth or nose ulcers
Approximately 50% of people with SLE experience renal manifestations
Proteinuria, cellular casts, nephritic syndromes
Up to 10% renal failure
Hematologic abnormalities
Anemia,
leukopenia,
thrombocytopenia
Cardiovascular
Pericarditis,
vascultitis
Many clients with SLE develop transient nervous system involvement
Decline in intellect, memory loss, disorientation
Psychosis, seizures, depression, stroke
Ocular
Conjunctivitis,
photophobia,
transient blindness due to retinal vasculitis
GI
o Anorexia
o Nausea
o Abdominal pain
o Diarrhea
o hepatomegaly
Lung
o Pleurisy
o Pleural effusion
o pneumonitis
o interstitial fibrosis
Brain
o Neuropathies
o Seizures
o Depression
o Psychosis
o Stroke
Skin
o Butterfly rash on face
o Photosensitivity
o Maculopapular rash on expose body surfaces
o Discoid lesions
o Erythematous fingertip lesions
o Splinter hemorrhages
o Alopecia
o Ulcers (lips, mouth, nose
Sensory System
o Conjunctivitis
o Photophobia
o Retinal vasculitis with transient blindness
o Cotton-wool spots on retina
Diagnostic test
• Anti-DNA antibody testing
• Erythrocyte sedimentation rate::Typically elevated
• Serum complement levels::Usually decreased
• CBC::Anemia, leukopenia, lymphocytopenia, thrmocytopenia
• Urinalysis::Renal function: BUN, Serum Creatinine
• Kidney biopsy
Medications
hydroxychloroguine
Aspirin
Prednisone
Immunosuppressive agents such as cyclophosphamide or azathiprine
Low levels of WBC's and platelets?
Prednisone
Risk for infection R/T compromised immune system
• Prophylactic antibiotics
• Yearly influence vaccine
• Hand hygine
The white blood cell (WBC) count of a client with systemic lupus erythematosus (SLE)
shows a shift to the left. What is the highest priority nursing diagnosis for the nurse
caring for this client?
GI upset
Fever
Hypotension
Pregnancy
Pregnancy
Rationale:
Pregnancy can be associated with exacerbation because of increased estrogen levels.
Hypotension, fever, and GI upset do not cause exacerbation of SLE.
The nurse would assess which of the following in a client who is being evaluated for
systemic lupus erythematosus (SLE)?
Fever
Rash on the face across the nose
Elevated red blood cell count
Fatigue
Rash on the face across the nose
Rationale:
Rash on the face across the nose is the classic sign of SLE. Fever and fatigue are
symptoms that occur during exacerbations. The client with SLE is apt to be anemic.
The nurse, instructing a client with systemic lupus erythematosus (SLE) about the
management of fatigue during an exacerbation, would determine that learning outcomes
need reinforcement if the client states a plan to:
Turkey
Steak
Broccoli
Bacon
Cantaloupe
Bacon
Steak
Rationale:
The client with SLE is at risk for cardiovascular disorders. The client should be
instructed on nutritional lifestyle changes to prevent these disorders. The client should
be instructed to reduce fat (steak, bacon), salt (bacon), and to quit smoking. The other
food choices are part of a healthy diet.
The nurse, caring for a teen diagnosed with systemic lupus erythematosus (SLE),
should instruct the family about which of the following challenges?
Planning meals
Planning family vacations
Violence from the client
Adherence to treatment
Adherence to treatment
Rationale:
Consistent with this developmental stage, the teen client is apt to rebel more strongly
and deny the disease. Adherence to a plan of treatment, medications, and the fact that
this will differentiate them from the peer group can cause nonadherence. Anger at
having the disease could turn to violence, but this is not typical. Planning meals and
vacations should not pose problems for the family.
A client with systemic lupus erythematosus (SLE) asks the nurse if getting a flu vaccine
in the fall is important. The nurse responds with which of the following?
a) weight gain
b) subnormal temperature
c) elevated red blood cell count
d) rash on the face across the bridge of the nose and on the cheeks
D
- Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an
initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss
may also occur. Anemia is most likely to occur later in SLE.
The nurse provides 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 instructions?
a) antibiotic
b) antidiarrheal
c) corticosteroid
d) opioid analgesic
C
- Treatment of systemic lupus erythematosus is based on the systems involved and
symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and
immunosuppressants. Options A, B, and D are not standard components of medication
therapy.
The nurse is teaching a client with Systemic lupus erythematosus (SLE) about self care.
Which of the following teaching points is most important for the nurse to review with the
client?
Encourage the client to apply suntan lotion SPF 8 and higher to skin before exposure.
Encourage the client to verbalize feelings of anxiety related to the diagnosis.
Encourage the client to perform good hand washing after using the bathroom and
before eating.
Encourage the client to utilize clean technique in caring for any wound care.
Encourage the client to perform good hand washing after using the bathroom and
before eating.
Rationale: # 1 is incorrect because suntan lotion of an SPF 15, 30 or higher should be
used since sun exposure can bring on a flare. # 2 is incorrect because psychological
needs do not precede physical needs. # 3 is correct. Hand washing is the most
important client needs because hand washing reduces the risk of infection with
endogenous organisms. # 4 is incorrect because clean technique is not indicated. The
use of strict aseptic technique in caring for intravenous lines and indwelling urinary
catheters or performing any wound care is indicated. Aseptic technique offers protection
against external and resident host microorganisms.
The nurse is caring for a client with systemic lupus erythematosis (SLE). The major
complication associated with systemic lupus erythematosis is:
a. Nephritis
b. Cardiomegaly
c. Desquamation
d. Meningitis
Answer A is correct.
The major complication of SLE is lupus nephritis, which results in end-stage renal
disease. SLE affects the musculoskeletal, integumentary, renal, nervous, and
cardiovascular systems, but the major complication is renal involvement; therefore,
answers B and D are incorrect. Answer C is incorrect because the SLE produces a
"butterfly" rash, not desquamation.
A patient is diagnosed with a systematic lupus erythematous (SLE). SLE primarily
attacks which tissues?
a. Heart
b. Lung
c. Nerve
d. Connective
D
A classic sign of SLE is:
a. Rashes over the cheeks and nose
b. Weight loss
c. Vomiting
d. Difficulty urinating
A
A sign of neurologic involvement in SLE is manifested by:
a. CVA
b. Infection
c. Psychosis
d. Facial tic
B
A laboratory test result that supports the diagnosis of SLE is:
a. Leukocytosis, elevated BUN and CREA
b. Pancytopenia, elevated antinuclear antibody (ANA) titer
c. Thrombocytosis, elevated ESR
d. None of these
B
Which of the following statements when made by the client with systemic lupus
erythematosus (SLE) indicates the need for further teaching?
A client is suspected of having systemic lupus erythematous. The nurse monitors the
client, knowing that which of the following is one of the initial characteristic sign of
systemic lupus erythematous?
Weight gain
Subnormal temperature
Rash on the face across the bridge of the nose and on the cheeks
Rash on the face across the bridge of the nose and on the cheeks
Rationale:
Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an
initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss
may also occur. Anemia is most likely to occur later in SLE.
...
Test-Taking Strategy:
Use the process of elimination and note the strategic words "characteristic sign."
Recalling the characteristic butterfly rash associated with SLE will direct you to the
correct option. If you are unfamiliar with this disorder, review this content.
...
A client with pemphigus is being seen in the clinic regularly. The nurse plans care based
on which of the following descriptions of this condition?
The presence of skin vesicles found along the nerve caused by a virus
The presence of red, raised papules and large plaques covered by silvery scales
An autoimmune disease that causes blistering in the epidermis
Pemphigus
emphigus is an autoimmune disease that causes blistering in the epidermis. The client
has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a
thin covering of skin and break easily, leaving large denuded areas of skin. On initial
examination, clients may have crusting areas instead of intact blisters. Option 1
describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.
The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The
nurse plans care knowing that this disorder is:
A local rash that occurs as a result of allergy
Antidiarrheal
Corticosteroid
Opioid analgesic
Corticosteroid
Rationale:
Treatment of SLE is based on the systems involved and symptoms. Treatment normally
consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. The
incorrect options are not standard components of medication therapy for this disorder.
...
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 most risk
for developing this type of allergy?
Hairdressers
The homeless
Milk
Yogurt
Bananas
Bananas
Rationale:
Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes,
avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex
allergy. This is thought to be due to a possible cross-reaction between the food and the
latex allergen. The incorrect options are unrelated to latex allergy.
...
Test-Taking Strategy:
Use the process of elimination and knowledge regarding the food items related to a
latex allergy. Eliminate the incorrect options because they are comparable or alike and
relate to dairy products. Review the food items that are associated with a risk for latex
allergy if you had difficulty with this question.
...
A 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 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:
Contact the health care provider (HCP).
Call the local medical supply store, and ask for a cane to be delivered.
Tell the client that the crutches must be removed immediately from the house.
Cover the crutch pads with cloth.
Rationale:
The rubber pads used on crutches may contain latex. If the client requires the use of
crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact.
Option 4 is inappropriate and may alarm the client. The nurse cannot prescribe a cane
for a client. In addition, this type of assistive device may not be appropriate, considering
this client's injury. No reason exists to contact the HCP at this time.
...
Test-Taking Strategy:
Use the process of elimination and knowledge regarding the alternative resources for a
client with an allergy to latex. No data in the question support the need to contact the
HCP. The nurse should not prescribe assistive devices for the client. Option 4 is not a
therapeutic action. Review care to the client with a latex allergy if you had difficulty with
this question.
...
The home care nurse is ordering dressing supplies for a client who has an allergy to
latex. The nurse asks the medical supply personnel to deliver which of the following?
Elastic bandages
Adhesive bandages
Infection
Inability to cope
A client with human immunodeficiency virus (HIV) who has contracted tuberculosis (TB)
asks the nurse how long the medication therapy lasts. The nurse responds that the
duration of therapy would likely be for at least:
6 total months and at least 1 month after cultures convert to negative
Decrease the dose of the medication until the next health care provider's visit.
Come to the office to be seen by the health care provider.
Rationale:
Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the
administration of didanosine. Clients should be monitored for indications of developing
pancreatitis, which include increased serum amylase in association with increased
serum triglycerides, decreased serum calcium, and nausea, vomiting, or abdominal
pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. The
client should be seen by the health care provider.
...
Focus on the data in the question. Recalling that nausea, vomiting, and abdominal pain
are signs of pancreatitis and that pancreatitis is associated with the use of this
medication should direct you to the correct option. Review the adverse effects of this
medication if you had difficulty with this question.
...
A 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?
Keep the call bell within reach for the client.
Development of an infection
Isolation
Development of an infection
Rationale:
Acquired immunodeficiency syndrome decreases the body's immune response, making
the infected person susceptible to infections. AIDS affects helper T lymphocytes, which
are vital to the body's defense system. Opportunistic infections are a primary cause of
death in people affected with AIDS. Therefore preventing infection is a priority of nursing
care. Although the concerns in options 1, 3, and 4 may need to be addressed at some
point in the care of the client, these are not the priority.
...
Test-Taking Strategy:
Note the strategic word, "priority." Use Maslow's Hierarchy of Needs theory to eliminate
options 1, 3, and 4. Also, recalling that AIDS affects the body's immune system will
direct you to option 2. Review the priority concerns related to the client with AIDS if you
had difficulty with this question.
...
Study Mode
Question 31 of 64
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?"
Tinnitus
Rheumatoid nodules
Boutonniere deformity
Ulnar drift
Rationale:
All of the conditions identified in the options can occur in rheumatoid arthritis. Ulnar drift
occurs when synovitis stretches and damages the tendons, and eventually the tendons
become shortened and fixed. This damage causes subluxation (drift) of the joints.
...
A 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 of the following
that is also indicative of the presence of SLE?
Emboli
Ascites
Presence of organisms
A white female
An African-American male
An African-American female
An African-American female
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 verbalized to increase intake
of foods such as:
Raw fruits and vegetables
Hot soup
Peanut butter
Puddings
Puddings
Rationale:
The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client
also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables.
The client is encouraged to take in foods that are mild, nonabrasive, and easy to
swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs, and
desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or
cookies may be softened in milk or another beverage before eating.
...
Test-Taking Strategy:
Use the process of elimination, and focus on the subject of difficulty swallowing.
Evaluate each of the foods listed in terms of how easily they are swallowed. The rough,
hot, and sticky foods in options 1, 2, and 3, respectively, help you to choose option 4 as
the correct option. Review nutritional concepts for the AIDS client if you had difficulty
with this question.
...
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 meals and snacks with high protein, high calorie, and high nutritional value.
A negative HIV test is not considered accurate during the first 6 months after exposure.