Deck 47: Immune System

Question 1

Client teaching related to systemic lupus erythematosus (SLE)would include which of these aspects?

A)Eat in a sitting position or with the head of the bed elevated.
B)Report joint pain to health care provider immediately.
C)Increase medication when symptoms increase in severity.
D)Direct sun exposure may increase symptoms and is contraindicated.

Answer 1

Direct sun exposure may increase symptoms and is contraindicated.

Question 2

When educating a client who has human immunodeficiency virus (HIV),the nurse should include the information that it is possible to remain asymptomatic for:

A)up to 2 years
B)up to 5 years
C)up to 10 years
D)10 or more years

Answer 2

10 or more years

Question 3

A client who has myasthenia gravis (MG)exhibits increased muscle weakness,difficulty swallowing,and respiratory distress.Cholinergic crisis is diagnosed and is medically treated by:

A)administrating atropine
B)conducting a Tensilon test
C)providing oxygen by a mask
D)performing a tracheotomy

Answer 3

administrating atropine

Question 4

A client who has myasthenia gravis (MG)has all of the following nursing diagnoses.Which would reflect the greatest threat to the client?

A)Risk for aspiration
B)Impaired verbal communication
C)Knowledge deficit related to disease process
D)Altered urinary elimination

Question 5

A client who has previously required blood transfusions is admitted for another transfusion.Four hours after a unit of blood infuses,the client develops fever,chills,nausea,and headache.The nurse should suspect the client is experiencing which type of transfusion reaction?

A)acute hemolytic
B)allergic urticarial
C)delayed hemolytic
D)febrile nonhemolytic

Question 6

A client has been cleaning window screens for the past 2 days and has now developed sneezing;thin,watery nasal discharge;and redness and itching of the eyes.Which type of allergic reaction should the nurse suspect?

A)allergic rhinitis
B)anaphylaxis
C)animal dander hypersensitivity
D)contact dermatitis

Question 7

The nurse is caring for a client who is taking immunosuppressive medications.The nurse recognized that this client is especially prone to which of the following adverse reactions?

A)developing infection
B)elevated glucose levels
C)hypotension
D)muscle wasting

Question 8

How is active acquired immunity obtained?

A)by antibodies produced by another human being or an animal
B)by exposure to a disease itself or its vaccine
C)by innate resistance to illnesses specific to other species
D)by transmission of antibodies through fetal circulation

Question 9

The client who is suspected of having an acute hemolytic transfusion reaction would receive all of the following emergency treatments.Which one should the nurse initiated FIRST?

A)Start an IV of normal saline.
B)Administer emergency drugs intravenously as ordered.
C)Maintain an airway.
D)Stop the transfusion.

Question 10

Which of these statements about systemic lupus erythematosus (SLE)is true?

A)It occurs most commonly in young white males.
B)It is characterized by periods of exacerbation and remission.
C)It can be cured with prescribed medications.
D)It is diagnosed by computerized tomography.

Question 11

The nurse is teaching the client with myasthenia gravis (MG)about living with the disease.The nurse would include which of these aspects in the teaching?

A)Eat a diet high in fiber.
B)Get plenty of aerobic exercise.
C)Suction secretions as needed.
D)Wear a protective mask when going outside.

Question 12

The nurse is caring for a client who just had an intravenous pyelogram (IVP).The client suddenly develops severe urticaria,angioedema,dyspnea,and cyanosis.Which of these actions should the nurse take first?

A)Administer epinephrine subcutaneously.
B)Maintain the airway and administer oxygen via mask.
C)Notify the health care provider for medication orders.
D)Start an IV line of D5W.

Question 13

The nurse recognizes that which statement about myasthenia gravis (MG)is TRUE?

A)It is a chronic,progressive,incurable autoimmune disease affecting multiple body organs.
B)It involves the body's inability to transmit nerve impulses to voluntary muscles,causing extreme muscle weakness and fatigue.
C)It is a hypersensitive immune response.
D)It is an inadequate immunological response by the body.

Question 14

A coworker who has just completed an aseptic client procedure is now flushed and wheezing and complains of chest tightness and shortness of breath.Vital signs are heart rate 76,respiratory rate 24,and blood pressure 86/67.The nurse should suspect the coworker is experiencing which of the following?

A)anaphylactic shock
B)hypersensitivity to the antiseptic used in the procedure
C)hypoglycemic shock
D)latex allergy

Question 15

Education for the client with rheumatoid arthritis would include which of the following?

A)Wear protective clothing and sunscreen when going out in the sun.
B)Stay in bed most of the day to maintain strength.
C)Take a warm shower to relieve joint stiffness and pain.
D)Do isometric exercises throughout the day.

Question 16

Which of these medications is usually prescribed initially for the client who has rheumatoid arthritis?

A)antimalarials
B)corticosteroids
C)nonsteroidal anti-inflammatory drugs (NSAIDs)
D)salicylates

Question 17

The nurse is caring for a client who is having an anaphylactic reaction.Which of these medications does the nurse know is usually administered FIRST to a client who has an anaphylactic reaction?

A)aminophylline
B)ampicillin
C)dopamine hydrochloride
D)epinephrine

Question 18

The nurse is teaching a client who had a liver transplant to observe for signs of rejection.The client's understanding is verified when what sign is listed?

A)nausea and vomiting
B)altered mental status
C)fever
D)weight loss

Question 19

Which body system is at highest risk for tissue destruction in a large percentage of clients who have systemic lupus erythematosus (SLE)?

A)cardiac
B)neurological
C)pulmonary
D)renal

Question 20

In addition to careful observation for signs of rejection,which of these nursing interventions is appropriate for clients who have undergone a heart transplant?

A)weighing the client weekly
B)supporting frequent visits from family members
C)encouraging intake of fresh fruits and vegetables
D)placing the client in reverse isolation

Question 21

The nurse is usually responsible for which of the following actions prior to a client being tested for human immunodeficiency virus (HIV)?

A)explaining venipuncture to client and obtaining specimen for testing
B)obtaining a signed consent only
C)pretest counseling and ensuring a signed consent is completed
D)pretest counseling only

Question 22

The nurse caring for a client with systemic lupus erythematosus (SLE)provides teaching about measures to avoid fatigue.The nurse recognizes that the client needs additional teaching if the client states he or she should:

A)Avoid long periods of rest.
B)Perform activities sitting whenever possible.
C)Take a hot shower.
D)Engage in low-impact exercise when well rested.

Question 23

Mycobacterium avium complex (MAC)initially infects which system in persons who have AIDS?

A)bone marrow
B)central nervous system
C)gastrointestinal (GI)tract
D)lymphatic

Question 24

Early signs and symptoms of acquired immunodeficiency syndrome (AIDS)dementia complex include:

A)psychotic behaviors
B)depression
C)hyperactive behavior
D)inability to concentrate

Question 25

Which of these statements about the medical treatment for cryptosporidiosis is TRUE?

A)It is aimed at palliative treatment.
B)It consists of antibiotic therapy such as penicillin G IV over a period of 14 to 21 days.
C)It consists of antifungal therapy IV for a period of 6 weeks.
D)It consists of radiation therapy for the gastrointestinal (GI)tract.

Question 26

As the disease progresses,symptoms of human immunodeficiency virus (HIV)become evident when which of the cells of the immune system decrease?

A)B cells
B)macrophages
C)neutrophils
D)CD4 T cells

Question 27

When is a health care worker at greatest risk of being exposed to tuberculosis (TB)?

A)during and after procedures that induce coughing in clients with TB
B)when handling blood products of a client with HIV
C)when caring for clients at risk for developing TB,such as clients who are HIV-positive
D)when caring for clients who have come to the United States from other countries

Question 28

The nurse recognizes the MOST common opportunistic infection occurring in over half of clients with acquired immunodeficiency syndrome (AIDS)is:

A)Kaposi's sarcoma
B)mycobacterium avium complex (MAC)
C)non-Hodgkin's lymphoma
D)Pneumocystis carinii pneumonia

Question 29

A client is undergoing drug treatment for human immunodeficiency virus (HIV)with nucleoside analog reverse transcriptase inhibitors (NRTIs).The nurse is aware that the outcomes of this treatment is:

A)delayed onset of opportunistic infection
B)prolonged progression of HIV in early symptomatic stage
C)prevention of transmission to others
D)increase of viral load

Question 30

What oral fungal infection produces symptoms such as creamy,white intraoral lesions;mucosal tenderness;and painful swallowing in clients who are immunocompromised?

A)cryptosporidium colitis
B)Epstein-Barr virus
C)oral candidiasis
D)oral hairy leukoplakia

Question 31

When caring for a client with a diagnosis of human immunodeficiency virus (HIV),the nurse understands that HIV is transmitted by:

A)airborne droplets
B)exchange of body fluids
C)exposure to infected animals or their waste products
D)sexual activity only

Question 32

A nurse is clarifying information for a client whose ELISA test is negative.After reviewing the test results with the client,which aspect should be included?

A)Assess the client's risk behavior and strategies for reducing risk.
B)Make a follow-up appointment for further testing.
C)Review the symptoms of disease progression.
D)Discuss the medication regimen.

Question 33

The nurse is aware that when caring for the client who is human immunodeficiency virus (HIV)positive,once initial treatment for acute cryptococcal meningitis is completed,interventions should include:

A)avoiding fresh juice and fruit
B)being reevaluated every 2 to 4 weeks for reoccurrence
C)recognizing the signs and symptoms of meningitis,so any reoccurrence can be identified soon
D)beginning lifelong suppressive therapy

Question 34

What is the name of the vascular malignancy that can occur anywhere in the body,but whose first lesions often appear on the face or oral cavity in clients with acquired immunodeficiency syndrome (AIDS)?

A)Kaposi's sarcoma
B)oral candidiasis
C)oral hairy leukoplakia
D)non-Hodgkin's lymphoma

Question 35

The nurse caring for a client who is HIV positive notes the client is experiencing an explained weight loss of more than 10% of body weight that is associated with chronic diarrhea or fever.The nurse plans care,knowing that this condition is:

A)anorexia
B)histoplasmosis
C)HIV-wasting syndrome
D)malabsorption syndrome

Question 36

The nurse is caring for a client who is human immunodeficiency virus (HIV)positive with a diagnosis of toxoplasmosis.Confirmation the diagnosis of toxoplasmosis in the client is made by which of these signs?

A)recent onset of neurological abnormality
B)presence of CD4 T cells
C)presence of white patches on tongue or oral mucosa
D)evidence of elevated protein level in cerebrospinal fluid

Question 37

What is the MOST common initial infection occurring in women who are human immunodeficiency virus (HIV)positive?

A)candidiasis
B)cryptosporidium
C)Epstein-Barr virus
D)hairy leukoplakia

Question 38

Which of these conditions belongs to the herpes virus group and lies dormant in tissues waiting to be reactivated in the immunocompromised client?

A)cryptosporidium enteritis
B)cytomegalovirus
C)Pneumocystis carinii pneumonia
D)tuberculosis

Question 39

The majority of clients who have oral hairy leukoplakia receive which kind of treatment?

A)none
B)acyclovir sodium
C)nystatin suspension
D)oral fluconazole

Question 40

The nurse caring for a client with human immunodeficiency virus (HIV)understands that a client is considered to have acquired immunodeficiency syndrome (AIDS)when which of the following occurs?

A)appearance of flulike symptoms
B)CD4 T cell count of less than 200 cells/mm3 and one defined clinical condition
C)enlarged lymph nodes for more than 3 months
D)one positive enzyme-linked immunosorbent assay (ELISA)test

Question 41

A client has received testing for human immunodeficiency virus (HIV).The client's results of two enzyme-linked immunosorbent assay (ELISA)tests have been positive.In explaining the next step,the nurse's response is based on the understanding that:

A)the client will have a bone marrow biopsy to confirm the diagnosis
B)a Western blot test will be done to confirm the diagnosis
C)a CD4+ cell count will be obtained to measure T-helper lymphocytes
D)the client will be diagnosed as HIV-positive and begin medical treatment

Question 42

The nurse is caring for a client with a diagnosis of human immunodeficiency virus (HIV).The nurse understands that the therapeutic management of the client does NOT include:

A)using antiretrovirals to prolong the HIV stage
B)preventing opportunistic infections from occurring
C)radiation to inhibit HIV replication
D)medications to treat opportunistic infections

Question 43

The nurse is caring for a client with systemic lupus erythematosus (SLE).The nurse plans care for this client,knowing that this disorder is which of the following? (Select all that apply. )

A)a local rash that occurs as a result of allergy
B)an inflammatory disease of collagen contained in connective tissue
C)a disease frequently affecting women of childbearing age
D)a disease caused by the continuous release of histamine in the body

Question 44

Which interventions would apply when caring for a client at high risk for an allergic response to a latex allergy? (Select all that apply. )

A)Use nonlatex gloves.
B)Keep a latex-free supply cart available for the client's use.
C)Only use a blood pressure cuff from an electronic device to measure the blood pressure.
D)Use medications from glass ampoules.
E)Do not puncture rubber stoppers with needles.

Question 45

The nurse is educating the client with histoplasmosis about prevention methods for future exposure.The nurse evaluates that the client needs future instruction if the client states that the possible sources include which of the following?

A)cleaning bird cages
B)chicken coops
C)fruit trees
D)mushroom cellars