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Nursing A Concept Based Approach to Learning Volume I 2nd Edition Test Bank

ISBN-13: 978-0132934268

ISBN-10: 0132934264

 

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Nursing A Concept Based Approach to Learning Volume I 2nd Edition Test Bank

ISBN-13: 978-0132934268

ISBN-10: 0132934264

 

 

 

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Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

Module 8   Immunity

 

The Concept of Immunity

1) The nurse is caring for a client who is hospitalized on a medical unit for a systemic infection. The client asks the nurse what defenses the body has against infection. The nurse responds that which physiological barrier helps defend the body against microorganisms?

Select all that apply.

  1. A) Moisturizing the skin
  2. B) Adequate urinary output
  3. C) Intact skin
  4. D) Occasional smoking
  5. E) A surgical incision

Answer:  B, C

Explanation:  A) Voiding a sufficient quantity of urine is a form of barrier protection that helps the body to defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. Moisturizing the skin and a surgical incision can both allow microorganisms to enter the body.

  1. B) Voiding a sufficient quantity of urine is a form of barrier protection that helps the body to defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. Moisturizing the skin and a surgical incision can both allow microorganisms to enter the body.
  2. C) Voiding a sufficient quantity of urine is a form of barrier protection that helps the body to defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. Moisturizing the skin and a surgical incision can both allow microorganisms to enter the body.
  3. D) Voiding a sufficient quantity of urine is a form of barrier protection that helps the body to defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. Moisturizing the skin and a surgical incision can both allow microorganisms to enter the body.

 

  1. E) Voiding a sufficient quantity of urine is a form of barrier protection that helps the body to defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. Moisturizing the skin and a surgical incision can both allow microorganisms to enter the body.

Page Ref: 444

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  1. Summarize the physiology of the immune system related to wellness promotion and disease prevention.

 

2) A client, who has been given a yellow fever vaccine before traveling to the Amazon Basin, asks the nurse to explain how the elements of the immune system will now provide protection. Which is the appropriate response by the nurse?

Select all that apply.

  1. A) “Human macrophages engulf the weakened vaccine virus as if it is dangerous and antigens stimulate the immune system to attack it.”
  2. B) “In the lymph nodes, part of the lymphoid system, the macrophages present yellow fever antigens to T cells and B cells.”
  3. C) “A response from yellow fever-specific T cells is activated. B cells secrete yellow fever antibodies.”
  4. D) “The body’s immune system eats away at the protective sheath (myelin) that covers the nerves.”
  5. E) “The initial weak infection is eliminated and the client is left with a supply of memory T and B cells for future protection against yellow fever.”

Answer:  A, B, C, E

Explanation:  A) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.

  1. B) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.
  2. C) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.
  3. D) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.

 

  1. E) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present.

Page Ref: 442

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Client Need Sub:  Reduction of Risk Potential

Nursing Process:  Analysis

Learning Outcome:  2. Examine the relationship between immunity and other concepts/systems.

 

3) A nurse is volunteering in a health screening booth at the state fair. The nurse has assessed several clients and determines that which client demonstrates the decline in responsiveness of the immune system of an older adult?

  1. A) An 88-year-old client with pneumonia who has a temperature of 99.5°F
  2. B) A 70-year-old client who has swelling and redness around an abdominal incision from an open appendectomy
  3. C) A 58-year-old client who complains of redness and itching after developing a rash from contact with poison ivy
  4. D) A 56-year-old client who has 8 mm induration at the site of a PPD skin test 72 hours earlier

Answer:  A

Explanation:  A) The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration.

  1. B) The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration.
  2. C) The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration.
  3. D) The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration.

Page Ref: 445

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  3. Identify commonly occurring alterations in immunity and their related therapies.

 

4) A client who has been diagnosed with untreated HIV comes in complaining of fatigue and weight loss. What are some important elements of the physical exam for evaluating the client’s AIDS status?

Select all that apply.

  1. A) Assess the general appearance.
  2. B) Assess skin color, temperature, and moisture.
  3. C) Assess hair loss.
  4. D) Inspect the skin for evidence of rashes or lesions.
  5. E) Inspect the mouth for lesions.

Answer:  A, B, D, E

Explanation:  A) Assess height, weight, and body type for apparent weight loss or wasting. Pallor may indicate bone marrow suppression with accompanying immunodeficiency. Skin lesions may be indicative of Kaposi sarcoma. Hair loss is not usually related to AIDS. Mouth lesions, which may have a “cottage cheese” appearance, may indicate candida.

  1. B) Assess height, weight, and body type for apparent weight loss or wasting. Pallor may indicate bone marrow suppression with accompanying immunodeficiency. Skin lesions may be indicative of Kaposi sarcoma. Hair loss is not usually related to AIDS. Mouth lesions, which may have a “cottage cheese” appearance, may indicate candida.
  2. C) Assess height, weight, and body type for apparent weight loss or wasting. Pallor may indicate bone marrow suppression with accompanying immunodeficiency. Skin lesions may be indicative of Kaposi sarcoma. Hair loss is not usually related to AIDS. Mouth lesions, which may have a “cottage cheese” appearance, may indicate candida.
  3. D) Assess height, weight, and body type for apparent weight loss or wasting. Pallor may indicate bone marrow suppression with accompanying immunodeficiency. Skin lesions may be indicative of Kaposi sarcoma. Hair loss is not usually related to AIDS. Mouth lesions, which may have a “cottage cheese” appearance, may indicate candida.
  4. E) Assess height, weight, and body type for apparent weight loss or wasting. Pallor may indicate bone marrow suppression with accompanying immunodeficiency. Skin lesions may be indicative of Kaposi sarcoma. Hair loss is not usually related to AIDS. Mouth lesions, which may have a “cottage cheese” appearance, may indicate candida.

Page Ref: 447

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Assessment

Learning Outcome:  4. Differentiate common assessment procedures used to examine immune health across the life span.

 

5) The nurse is caring for a client being seen at an urgent care clinic because of an infected arm. The client tells the nurse he was bitten by a raccoon on a recent camping trip. The nurse expects treatment for this client to include which of the following?

  1. A) An injection of immunoglobulin
  2. B) A tetanus toxoid injection
  3. C) Mother’s breast milk with antibodies in it
  4. D) An immunization for rabies

Answer:  D

Explanation:  A) Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples but would not be used in the case of an animal bite. Mother’s breast milk is another example of passive immunity, but would not be used in the case of an animal bite.

  1. B) Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples but would not be used in the case of an animal bite. Mother’s breast milk is another example of passive immunity, but would not be used in the case of an animal bite.
  2. C) Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples but would not be used in the case of an animal bite. Mother’s breast milk is another example of passive immunity, but would not be used in the case of an animal bite.
  3. D) Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples but would not be used in the case of an animal bite. Mother’s breast milk is another example of passive immunity, but would not be used in the case of an animal bite.

Page Ref: 450

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  6. Explain management of immune health and prevention of infection and disease.

 

6) The nurse is caring for a client in an allergy clinic. The nurse believes the client is having a reaction to a specific antigen. Which lab test would the nurse assess in order to determine the possibility of a hypersensitivity reaction?

  1. A) Indirect Coombs’ showing no agglutination
  2. B) Patch test with a 1-inch area of erythema
  3. C) 2% eosinophils in the WBC count
  4. D) Rh antigen with negative results

Answer:  B

Explanation:  A) A patch test assesses a 1-inch area impregnated with the allergen, which is applied for 48 hours. Absence of a response indicates a negative result. Positive responses are graded from mild (erythema in the exposed area) to severe (papules, vesicles, or ulcerations). Direct Coombs’ test detects antibodies in the client’s RBC that damage and destroy the cells. This is used following a suspected transfusion reaction to detect antibodies coating the transfused RBCs. This is also part of the crossmatch of a blood type and crossmatch. Indirect Coombs’ test detects the presence of circulating antibodies against RBCs. The eosinophil count is 1% to 4%, which is within normal range.

  1. B) A patch test assesses a 1-inch area impregnated with the allergen, which is applied for 48 hours. Absence of a response indicates a negative result. Positive responses are graded from mild (erythema in the exposed area) to severe (papules, vesicles, or ulcerations). Direct Coombs’ test detects antibodies in the client’s RBC that damage and destroy the cells. This is used following a suspected transfusion reaction to detect antibodies coating the transfused RBCs. This is also part of the crossmatch of a blood type and crossmatch. Indirect Coombs’ test detects the presence of circulating antibodies against RBCs. The eosinophil count is 1% to 4%, which is within normal range.
  2. C) A patch test assesses a 1-inch area impregnated with the allergen, which is applied for 48 hours. Absence of a response indicates a negative result. Positive responses are graded from mild (erythema in the exposed area) to severe (papules, vesicles, or ulcerations). Direct Coombs’ test detects antibodies in the client’s RBC that damage and destroy the cells. This is used following a suspected transfusion reaction to detect antibodies coating the transfused RBCs. This is also part of the crossmatch of a blood type and crossmatch. Indirect Coombs’ test detects the presence of circulating antibodies against RBCs. The eosinophil count is 1% to 4%, which is within normal range.
  3. D) A patch test assesses a 1-inch area impregnated with the allergen, which is applied for 48 hours. Absence of a response indicates a negative result. Positive responses are graded from mild (erythema in the exposed area) to severe (papules, vesicles, or ulcerations). Direct Coombs’ test detects antibodies in the client’s RBC that damage and destroy the cells. This is used following a suspected transfusion reaction to detect antibodies coating the transfused RBCs. This is also part of the crossmatch of a blood type and crossmatch. Indirect Coombs’ test detects the presence of circulating antibodies against RBCs. The eosinophil count is 1% to 4%, which is within normal range.

Page Ref: 490

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  5. Describe diagnostic and laboratory tests to determine the individual’s immune status.

7) The nurse is teaching a group of young parents at the local elementary school health fair about immunity and the importance of vaccination. The nurse is giving the group an example of how active immunity is acquired. Which scenario would provide a client with active immunity?

  1. A) Receiving a rabies shot after being bitten by a rabid dog
  2. B) Having measles
  3. C) Receiving an injection of gamma globulin
  4. D) Becoming ill with tetanus and receiving tetanus toxoid

Answer:  B

Explanation:  A) When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.

  1. B) When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.
  2. C) When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.
  3. D) When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.

Page Ref: 450

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  6. Explain management of immune health and prevention of infection and disease.

 

8) The nurse is caring for a client who is taking an immunosuppressant agent for the treatment of an autoimmune disorder. Which client statement shows that teaching has not been effective?

  1. A) “I should drink plenty of water to keep from getting dehydrated.”
  2. B) “I should drink a lot of grapefruit juice while on these medications.”
  3. C) “If I experience any joint pain, I should take ibuprofen for the pain as needed every 4 hours.”
  4. D) “I know to call the physician if I start experiencing a lot of bruising.”

Answer:  B

Explanation:  A) Immunosuppressive agents inhibit T cell development and activation. They are given concurrently with glucocorticoids and in combination with other immunosuppressants, and inhibit immune system activity and organ rejection. Nursing responsibilities include monitoring BUN and creatinine for evidence of nephrotoxicity. The client should avoid grapefruit juice, which can raise cyclosporine levels by 50% to 200% and increase the risk of toxicity. Fluids should be increased to maintain good hydration and urinary output. Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with cytotoxic agents.

  1. B) Immunosuppressive agents inhibit T cell development and activation. They are given concurrently with glucocorticoids and in combination with other immunosuppressants, and inhibit immune system activity and organ rejection. Nursing responsibilities include monitoring BUN and creatinine for evidence of nephrotoxicity. The client should avoid grapefruit juice, which can raise cyclosporine levels by 50% to 200% and increase the risk of toxicity. Fluids should be increased to maintain good hydration and urinary output. Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with cytotoxic agents.
  2. C) Immunosuppressive agents inhibit T cell development and activation. They are given concurrently with glucocorticoids and in combination with other immunosuppressants, and inhibit immune system activity and organ rejection. Nursing responsibilities include monitoring BUN and creatinine for evidence of nephrotoxicity. The client should avoid grapefruit juice, which can raise cyclosporine levels by 50% to 200% and increase the risk of toxicity. Fluids should be increased to maintain good hydration and urinary output. Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with cytotoxic agents.
  3. D) Immunosuppressive agents inhibit T cell development and activation. They are given concurrently with glucocorticoids and in combination with other immunosuppressants, and inhibit immune system activity and organ rejection. Nursing responsibilities include monitoring BUN and creatinine for evidence of nephrotoxicity. The client should avoid grapefruit juice, which can raise cyclosporine levels by 50% to 200% and increase the risk of toxicity. Fluids should be increased to maintain good hydration and urinary output. Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with cytotoxic agents.

Page Ref: 503

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  6. Explain management of immune health and prevention of infection and disease.

 

9) A nurse working with a 52-year-old woman who has been prescribed NSAIDs as part of her treatment for rheumatoid arthritis should assist the client by:

Select all that apply.

  1. A) Monitoring for signs of allergic reaction.
  2. B) Assuring the client that there is no relationship between NSAIDs and heart disease.
  3. C) Encouraging the client to take with a full glass of water, milk, or small snack to help avoid GI distress.
  4. D) Monitoring for signs of renal problems.
  5. E) Advising against abrupt discontinuation of drugs.

Answer:  A, C, D, E

Explanation:  A) An aspirin allergy or sensitivity, or a reaction to NSAIDs, can cause symptoms that range from mild to severe, especially in people with asthma. NSAIDs have been linked to heart failure. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects.

  1. B) An aspirin allergy or sensitivity, or a reaction to NSAIDs, can cause symptoms that range from mild to severe, especially in people with asthma. NSAIDs have been linked to heart failure. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects.
  2. C) An aspirin allergy or sensitivity, or a reaction to NSAIDs, can cause symptoms that range from mild to severe, especially in people with asthma. NSAIDs have been linked to heart failure. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects.
  3. D) An aspirin allergy or sensitivity, or a reaction to NSAIDs, can cause symptoms that range from mild to severe, especially in people with asthma. NSAIDs have been linked to heart failure. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects.
  4. E) An aspirin allergy or sensitivity, or a reaction to NSAIDs, can cause symptoms that range from mild to severe, especially in people with asthma. NSAIDs have been linked to heart failure. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow can permanently damage your kidneys and it can eventually lead to kidney failure and require dialysis. Abrupt discontinuation can have serious side effects.

Page Ref: 501

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Client Need Sub:  Pharmacological and Parenteral Therapies

Nursing Process:  Implementation

Learning Outcome:  8. Compare and contrast common independent and collaborative interventions for clients with alterations in immune function.

10) A nurse is caring for a client with leukocytosis. Which action by the nurse is most appropriate when caring for this client?

  1. A) Instruct the client on the use of an electric razor and soft toothbrush.
  2. B) Assess for bleeding and bruising.
  3. C) Assess for source of infection.
  4. D) Place the patient in reverse isolation precautions.

Answer:  C

Explanation:  A) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm3). In the presence of an attack such as an infection, additional WBCs are released from the bone marrow, and as WBCs move out of the bone marrow into the blood, the bone marrow increases its production of additional leukocytes, leading to leukocytosis. Instructing the client on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a client with decreased platelet levels, or thrombocytopenia. Placing the patient in reverse isolation precautions would be appropriate for the client with neutropenia, a decrease in the number of neutrophils.

  1. B) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm3). In the presence of an attack such as an infection, additional WBCs are released from the bone marrow, and as WBCs move out of the bone marrow into the blood, the bone marrow increases its production of additional leukocytes, leading to leukocytosis. Instructing the client on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a client with decreased platelet levels, or thrombocytopenia. Placing the patient in reverse isolation precautions would be appropriate for the client with neutropenia, a decrease in the number of neutrophils.
  2. C) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm3). In the presence of an attack such as an infection, additional WBCs are released from the bone marrow, and as WBCs move out of the bone marrow into the blood, the bone marrow increases its production of additional leukocytes, leading to leukocytosis. Instructing the client on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a client with decreased platelet levels, or thrombocytopenia. Placing the patient in reverse isolation precautions would be appropriate for the client with neutropenia, a decrease in the number of neutrophils.
  3. D) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm3). In the presence of an attack such as an infection, additional WBCs are released from the bone marrow, and as WBCs move out of the bone marrow into the blood, the bone marrow increases its production of additional leukocytes, leading to leukocytosis. Instructing the client on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a client with decreased platelet levels, or thrombocytopenia. Placing the patient in reverse isolation precautions would be appropriate for the client with neutropenia, a decrease in the number of neutrophils.

Page Ref: 438

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Client Need Sub:  Reduction of Risk Potential

Nursing Process:  Planning

Learning Outcome:  5. Describe diagnostic and laboratory tests to determine the individual’s immune status.

 

11) A nurse is educating a group of pregnant clients regarding infant immunity. Which statements will the nurse include in the teaching?

Select all that apply.

  1. A) IgM is the only immunoglobulin that crosses the placental barrier.
  2. B) IgA and IgE are present at birth.
  3. C) In the infant, maternal IgG disappears by 6-8 months.
  4. D) Infants and children have differing amounts of some immunoglobulins.
  5. E) A newborn’s levels of IgG differ widely from those of the mother.

Answer:  C, D

Explanation:  A) In regard to newborn and infant immunity, IgG is the only immunoglobulin that crosses the placental barrier. Because of this, a newborn’s level of IgG is similar to that of the mother. The maternal IgG disappears by the time the infant is 6-8 months old. IgA and IgE are not present at birth. Infants and children have differing amounts of some immunoglobulins.

  1. B) In regard to newborn and infant immunity, IgG is the only immunoglobulin that crosses the placental barrier. Because of this, a newborn’s level of IgG is similar to that of the mother. The maternal IgG disappears by the time the infant is 6-8 months old. IgA and IgE are not present at birth. Infants and children have differing amounts of some immunoglobulins.
  2. C) In regard to newborn and infant immunity, IgG is the only immunoglobulin that crosses the placental barrier. Because of this, a newborn’s level of IgG is similar to that of the mother. The maternal IgG disappears by the time the infant is 6-8 months old. IgA and IgE are not present at birth. Infants and children have differing amounts of some immunoglobulins.
  3. D) In regard to newborn and infant immunity, IgG is the only immunoglobulin that crosses the placental barrier. Because of this, a newborn’s level of IgG is similar to that of the mother. The maternal IgG disappears by the time the infant is 6-8 months old. IgA and IgE are not present at birth. Infants and children have differing amounts of some immunoglobulins.
  4. E) In regard to newborn and infant immunity, IgG is the only immunoglobulin that crosses the placental barrier. Because of this, a newborn’s level of IgG is similar to that of the mother. The maternal IgG disappears by the time the infant is 6-8 months old. IgA and IgE are not present at birth. Infants and children have differing amounts of some immunoglobulins.

Page Ref: 442

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing Process:  Planning

Learning Outcome:  7. Demonstrate the nursing process in providing culturally competent and caring interventions across the life span for individuals with common alterations in immune function.

 

Exemplar 8.1  HIV and AIDS

 

1) HIV infects and destroys CD4 cells. List the following events in the order in which they occur.

  1. Virus invades cell with CD4 antigen.
  2. Viral RNA converts with reverse transcriptase to viral DNA.
  3. Viral DNA integrates with host cell DNA.
  4. Virus remains latent, or actively replicates.
  5. Virus sheds protein coat.

Answer:  1, 3, 4, 5, 2

Explanation:  The HIV virus gains entry into helper T cells, uses the cell DNA to replicate, interferes with normal function of the T cells, and destroys the normal cells.

Page Ref: 457

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Analysis

Learning Outcome:  1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS).

 

2) The nurse is caring for a client with AIDS who is taking an antiretroviral medication. The client complains of nausea, fever, severe diarrhea, and anorexia. Which of the following medications would the nurse determine to be most effective to relieve the anorexia, as well as to stimulate the client’s appetite?

Select all that apply.

  1. A) Dronabinol (Marinol)
  2. B) Zidovudine (Retrovir, AZT)
  3. C) Abacavir (Ziagen)
  4. D) Ciprofloxacin (Cipro)
  5. E) Megestrol (Megace)

Answer:  A, E

Explanation:  A) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase the client’s appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.

  1. B) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase the client’s appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.
  2. C) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase the client’s appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.
  3. D) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase the client’s appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.
  4. E) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase the client’s appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.

Page Ref: 478

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with HIV/AIDS.

 

3) A new graduate nurse is performing an admission assessment on a client with symptoms that indicate the client may have HIV. Which question does the nurse ask to identify a major risk factor for contracting HIV?

  1. A) “Has your partner been experiencing these symptoms?”
  2. B) “Do you always practice safe sex?”
  3. C) “Have you had any fever, diarrhea, or chills over the last 48 hours?”
  4. D) “Have you ever experimented with intravenous drugs?”

Answer:  D

Explanation:  A) Use of recreational drugs, such as intravenous drugs, is a risk factor for contracting HIV. Asking about safe sexual practices is important, but intravenous drug use would put the client at greater risk for contracting HIV. The nurse cannot ask about the partner without the partner’s consent; however, if the partner were present and positive, it would be a risk factor. Recent symptoms are not a risk factor.

  1. B) Use of recreational drugs, such as intravenous drugs, is a risk factor for contracting HIV. Asking about safe sexual practices is important, but intravenous drug use would put the client at greater risk for contracting HIV. The nurse cannot ask about the partner without the partner’s consent; however, if the partner were present and positive, it would be a risk factor. Recent symptoms are not a risk factor.
  2. C) Use of recreational drugs, such as intravenous drugs, is a risk factor for contracting HIV. Asking about safe sexual practices is important, but intravenous drug use would put the client at greater risk for contracting HIV. The nurse cannot ask about the partner without the partner’s consent; however, if the partner were present and positive, it would be a risk factor. Recent symptoms are not a risk factor.
  3. D) Use of recreational drugs, such as intravenous drugs, is a risk factor for contracting HIV. Asking about safe sexual practices is important, but intravenous drug use would put the client at greater risk for contracting HIV. The nurse cannot ask about the partner without the partner’s consent; however, if the partner were present and positive, it would be a risk factor. Recent symptoms are not a risk factor.

Page Ref: 458

Cognitive Level:  Applying

Client Need:  Psychosocial Integrity

Nursing Process:  Implementation

Learning Outcome:  2. Identify risk factors and prevention methods associated with HIV/AIDS.

 

4) The nurse is discharging an HIV-positive pediatric client who has recently developed AIDS. The nurse is teaching the client’s mother about health promotion activities for the child. It is important for the nurse to tell the mother that the client should not receive which immunizations due to HIV/AIDS status?

  1. A) Varicella vaccine
  2. B) Haemophilus influenzae type B (HIB conjugate vaccine)
  3. C) Hepatitis B vaccine (hep B)
  4. D) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

Answer:  A

Explanation:  A) A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.

  1. B) A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.
  2. C) A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.
  3. D) A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule.

Page Ref: 476

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing Process:  Implementation

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with HIV/AIDS.

 

5) A nurse is developing a plan of care for a client who was recently diagnosed with HIV. The client admits to being sexually active and states that he will remain sexually active. Which would be a priority nursing diagnosis for this client based on this information?

  1. A) Risk for Infection related to immunodeficiency
  2. B) Death Anxiety
  3. C) Deficient Knowledge related to preventing transmission of HIV
  4. D) Social Isolation related to fear of AIDS

Answer:  C

Explanation:  A) All options are potential nursing diagnoses for this client. Deficient knowledge related to preventing transmission of HIV would be the priority diagnosis for this client due to his statement of wanting to remain sexually active. The client will need to be educated on safer sex practices to decrease the risk of transmission to potential sexual partners.

  1. B) All options are potential nursing diagnoses for this client. Deficient knowledge related to preventing transmission of HIV would be the priority diagnosis for this client due to his statement of wanting to remain sexually active. The client will need to be educated on safer sex practices to decrease the risk of transmission to potential sexual partners.
  2. C) All options are potential nursing diagnoses for this client. Deficient knowledge related to preventing transmission of HIV would be the priority diagnosis for this client due to his statement of wanting to remain sexually active. The client will need to be educated on safer sex practices to decrease the risk of transmission to potential sexual partners.
  3. D) All options are potential nursing diagnoses for this client. Deficient knowledge related to preventing transmission of HIV would be the priority diagnosis for this client due to his statement of wanting to remain sexually active. The client will need to be educated on safer sex practices to decrease the risk of transmission to potential sexual partners.

Page Ref: 474

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  4. Formulate priority nursing diagnoses appropriate for an individual with HIV/AIDS.

 

6) The nurse is caring for a client who is newly diagnosed with HIV. The client asks the nurse if there are ways to protect the client’s sexual partner. Which client statement indicates the need for further instruction?

  1. A) “I know to use an oil-based lubricant to prevent spread of the disease to my partner.”
  2. B) “I know I can’t donate blood anymore, as I have HIV.”
  3. C) “I will not share my toothbrush or razor with my partner.”
  4. D) “I know I have to practice safe sex with my partner by using a latex condom.”

Answer:  A

Explanation:  A) The nurse should educate the client regarding the prevention of the spread of HIV. The client will need further education when he states that he will use an oil-based lubricant. The client should be educated to use latex condoms for oral, vaginal, or anal intercourse and to avoid natural or animal skin condoms, which allow passage of HIV. The client should use only water-based lubricants–not oil-based, such as petroleum jelly, which can result in condom damage. The client is correct in stating that it is not an acceptable practice to share toothbrushes or razors. The client is also correct in stating that blood donation is prohibited.

  1. B) The nurse should educate the client regarding the prevention of the spread of HIV. The client will need further education when he states that he will use an oil-based lubricant. The client should be educated to use latex condoms for oral, vaginal, or anal intercourse and to avoid natural or animal skin condoms, which allow passage of HIV. The client should use only water-based lubricants–not oil-based, such as petroleum jelly, which can result in condom damage. The client is correct in stating that it is not an acceptable practice to share toothbrushes or razors. The client is also correct in stating that blood donation is prohibited.
  2. C) The nurse should educate the client regarding the prevention of the spread of HIV. The client will need further education when he states that he will use an oil-based lubricant. The client should be educated to use latex condoms for oral, vaginal, or anal intercourse and to avoid natural or animal skin condoms, which allow passage of HIV. The client should use only water-based lubricants–not oil-based, such as petroleum jelly, which can result in condom damage. The client is correct in stating that it is not an acceptable practice to share toothbrushes or razors. The client is also correct in stating that blood donation is prohibited.
  3. D) The nurse should educate the client regarding the prevention of the spread of HIV. The client will need further education when he states that he will use an oil-based lubricant. The client should be educated to use latex condoms for oral, vaginal, or anal intercourse and to avoid natural or animal skin condoms, which allow passage of HIV. The client should use only water-based lubricants–not oil-based, such as petroleum jelly, which can result in condom damage. The client is correct in stating that it is not an acceptable practice to share toothbrushes or razors. The client is also correct in stating that blood donation is prohibited.

Page Ref: 478

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  6. Plan evidence-based care for an individual with HIV/AIDS and his or her family in collaboration with other members of the healthcare team.

 

7) The nurse is planning care for a pediatric client with HIV. The nurse selects Risk for Infection as a priority nursing diagnosis for this client. Which interventions are appropriate for a child with this diagnosis?

Select all that apply.

  1. A) Give frequent baths to the family dog.
  2. B) Teach proper food-handling techniques to the family.
  3. C) Provide ample fresh fruits and vegetables to bolster the immune system.
  4. D) Assess the health status of all visitors.
  5. E) Teach hand-washing techniques to the family.

Answer:  B, D, E

Explanation:  A) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. If there are pets, they should be kept outside, as they are a source of infection to the child. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.

  1. B) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. If there are pets, they should be kept outside, as they are a source of infection to the child. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.
  2. C) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. If there are pets, they should be kept outside, as they are a source of infection to the child. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.
  3. D) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. If there are pets, they should be kept outside, as they are a source of infection to the child. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.
  4. E) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. If there are pets, they should be kept outside, as they are a source of infection to the child. Fresh fruits and vegetables are not recommended for a client with a depressed immune system.

Page Ref: 475-476

Cognitive Level:  Analyzing

Client Need:  Safe and Effective Care Environment

Nursing Process:  Implementation

Learning Outcome:  6. Plan evidence-based care for an individual with HIV/AIDS and his or her family in collaboration with other members of the healthcare team.

 

8) The nurse is reviewing the laboratory values of a client who has been newly diagnosed with AIDS. Which laboratory values would the nurse report to the physician?

Select all that apply.

  1. A) CD4 cell count 1,100/mm3
  2. B) T4 cell count 150
  3. C) CD4 lymphocytes 12%
  4. D) Viral load 11,500 copies/mL
  5. E) WBC 6,500

Answer:  B, C, D

Explanation:  A) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range (4,500-10,000).

  1. B) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range (4,500-10,000).
  2. C) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range (4,500-10,000).
  3. D) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range (4,500-10,000).
  4. E) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range (4,500-10,000).

Page Ref: 468

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with HIV/AIDS.

 

9) A home health nurse has just received the list of clients who need to be seen during the shift. Which client should the nurse plan to see first?

  1. A) A client with AIDS who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count
  2. B) A client with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath
  3. C) A client with wasting syndrome who has end-stage AIDS who needs modifications and education regarding dietary changes
  4. D) A client with a long history of AIDS who is receiving IV antibiotics daily for toxoplasmosis

Answer:  B

Explanation:  A) The home health nurse should see the client with PCP because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain vital signs and perform a respiratory assessment.

  1. B) The home health nurse should see the client with PCP because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain vital signs and perform a respiratory assessment.
  2. C) The home health nurse should see the client with PCP because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain vital signs and perform a respiratory assessment.
  3. D) The home health nurse should see the client with PCP because of the complaint of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain vital signs and perform a respiratory assessment.

Page Ref: 463

Cognitive Level:  Applying

Client Need:  Safe and Effective Care Environment

Nursing Process:  Implementation

Learning Outcome:  6. Plan evidence-based care for an individual with HIV/AIDS and his or her family in collaboration with other members of the healthcare team.

 

10) The mother of an Anna, an 8-year-old girl infected with HIV, is describing Anna’s condition and activities to the nurse. Which statements would indicate positive outcomes for the child?

Select all that apply.

  1. A) “Anna is attending school and doing well in her class.”
  2. B) “Anna seems somewhat isolated and doesn’t have any real friends.”
  3. C) “Anna has a good appetite and eats regular meals.”
  4. D) “Anna hasn’t shown any sign of infection.”
  5. E) “Anna attends a weekly support group for kids with HIV.”

Answer:  A, C, D, E

Explanation:  A) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.

  1. B) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.
  2. C) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.
  3. D) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.
  4. E) Positive outcomes for an HIV client would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school.

Page Ref: 479

Cognitive Level:  Analyzing

Client Need:  Health Promotion and Maintenance

Nursing Process:  Evaluation

Learning Outcome:  7. Evaluate expected outcomes for an individual with HIV/AIDS.

 

11) A nurse in the Intensive Care Unit (ICU) is assigned a client diagnosed with AIDS. The type of precautions the nurse will adhere to in caring for this client is:

  1. A) Droplet.
  2. B) Reverse.
  3. C) Standard.
  4. D) Contact.

Answer:  C

Explanation:  A) Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the healthcare professionals treat all clients alike, eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.

  1. B) Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the healthcare professionals treat all clients alike, eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.
  2. C) Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the healthcare professionals treat all clients alike, eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.
  3. D) Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the healthcare professionals treat all clients alike, eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.

Page Ref: 461

Cognitive Level:  Applying

Client Need:  Safe and Effective Care Environment

Nursing Process:  Planning

Learning Outcome:  2. Identify risk factors and prevention methods associated with HIV/AIDS.

 

12) A nurse working in the pediatric intensive care unit (PICU) is caring for a pediatric client with HIV. The client is severely symptomatic with the additional diagnoses of lymphoma and wasting syndrome. The nurse understands that the client is in which clinical stage of HIV?

  1. A) Category N
  2. B) Category C
  3. C) Category A
  4. D) Category B

Answer:  B

Explanation:  A) The 1994 Revised HIV Pediatric Classification System remains the standard for determining clinical staging and related treatment for children with HIV. The client described is Category C, a severely symptomatic client with lymphoma and wasting syndrome. The other choices are incorrect.

  1. B) The 1994 Revised HIV Pediatric Classification System remains the standard for determining clinical staging and related treatment for children with HIV. The client described is Category C, a severely symptomatic client with lymphoma and wasting syndrome. The other choices are incorrect.
  2. C) The 1994 Revised HIV Pediatric Classification System remains the standard for determining clinical staging and related treatment for children with HIV. The client described is Category C, a severely symptomatic client with lymphoma and wasting syndrome. The other choices are incorrect.
  3. D) The 1994 Revised HIV Pediatric Classification System remains the standard for determining clinical staging and related treatment for children with HIV. The client described is Category C, a severely symptomatic client with lymphoma and wasting syndrome. The other choices are incorrect.

Page Ref: 469

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Client Need Sub:  Physiological Adaptation

Nursing Process:  Assessment

Learning Outcome:  1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS).

 

Exemplar 8.2  Hypersensitivity

 

1) A nurse is caring for a client who is to receive an outclient infusion of intravenous immunoglobulin (IVIG) for the treatment of a combined immunodeficiency disease. The nurse is aware that the infusion should be stopped if the child experiences:

  1. A) A mild headache.
  2. B) Shaking, chills, and fever.
  3. C) Clear, yellow urine when voiding.
  4. D) Extreme thirst.

Answer:  B

Explanation:  A) Hypersensitivity reaction can result from IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but is not a severe reaction which would warrant the transfusion to be stopped. Voiding clear, yellow urine is a normal finding. Thirst is not an indication of a reaction.

  1. B) Hypersensitivity reaction can result from IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but is not a severe reaction which would warrant the transfusion to be stopped. Voiding clear, yellow urine is a normal finding. Thirst is not an indication of a reaction.
  2. C) Hypersensitivity reaction can result from IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but is not a severe reaction which would warrant the transfusion to be stopped. Voiding clear, yellow urine is a normal finding. Thirst is not an indication of a reaction.
  3. D) Hypersensitivity reaction can result from IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but is not a severe reaction which would warrant the transfusion to be stopped. Voiding clear, yellow urine is a normal finding. Thirst is not an indication of a reaction.

Page Ref: 487

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of hypersensitivity.

 

2) The nurse is providing education for a pregnant client who is at 20 weeks’ gestation. The client has not decided on a feeding method for her infant. The client tells the nurse she has heard that how she feeds her baby can impact the baby’s ability to fight infection. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which client statement indicates effective teaching?

  1. A) “My baby will have a lower risk of food allergies if I breastfeed.”
  2. B) “Breast milk cannot be stored; it has to be thrown away after pumping.”
  3. C) “Formula-feeding will give my baby protection from infections.”
  4. D) “Breastfeeding is more expensive than formula-feeding.”

Answer:  A

Explanation:  A) Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children. Formula does not provide the baby with protection from infections as much as breast milk does. Breast milk can be refrigerated or frozen after pumping. Formula must be purchased and, therefore, is more expensive than breastfeeding.

  1. B) Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children. Formula does not provide the baby with protection from infections as much as breast milk does. Breast milk can be refrigerated or frozen after pumping. Formula must be purchased and, therefore, is more expensive than breastfeeding.
  2. C) Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children. Formula does not provide the baby with protection from infections as much as breast milk does. Breast milk can be refrigerated or frozen after pumping. Formula must be purchased and, therefore, is more expensive than breastfeeding.
  3. D) Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children. Formula does not provide the baby with protection from infections as much as breast milk does. Breast milk can be refrigerated or frozen after pumping. Formula must be purchased and, therefore, is more expensive than breastfeeding.

Page Ref: 442

Cognitive Level:  Analyzing

Client Need:  Health Promotion and Maintenance

Nursing Process:  Implementation

Learning Outcome:  2. Identify risk factors and prevention methods associated with hypersensitivity.

 

3) The nurse is admitting a 6-year-old child to the hospital with a VP shunt malfunction. The client’s family speaks very little English. The interpreter has arrived and the nurse is obtaining a health history from the parents. Which product should the nurse avoid placing in the room of this child whose shunt was placed at birth after a repair of a meningocele?

  1. A) Vinyl gloves
  2. B) Powder-free gloves
  3. C) Polyethylene products
  4. D) Oil-based hand lotions

Answer:  D

Explanation:  A) Using oil-based hand creams and lotions before putting on latex gloves can break down the latex. Clients with a history of meningocele may have severe latex allergies. Vinyl gloves are an alternative for latex. Polyethylene products can substitute for latex products. Powder can have high amounts of latexRemember, powder-free gloves are recommended.

  1. B) Using oil-based hand creams and lotions before putting on latex gloves can break down the latex. Clients with a history of meningocele may have severe latex allergies. Vinyl gloves are an alternative for latex. Polyethylene products can substitute for latex products. Powder can have high amounts of latexRemember, powder-free gloves are recommended.
  2. C) Using oil-based hand creams and lotions before putting on latex gloves can break down the latex. Clients with a history of meningocele may have severe latex allergies. Vinyl gloves are an alternative for latex. Polyethylene products can substitute for latex products. Powder can have high amounts of latexRemember, powder-free gloves are recommended.
  3. D) Using oil-based hand creams and lotions before putting on latex gloves can break down the latex. Clients with a history of meningocele may have severe latex allergies. Vinyl gloves are an alternative for latex. Polyethylene products can substitute for latex products. Powder can have high amounts of latexRemember, powder-free gloves are recommended.

Page Ref: 486

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with hypersensitivity.

 

4) The nurse is caring for a client in an allergy clinic. The nurse has just completed a client history and selects the nursing diagnosis of Risk for Shock based on which of the following items?

  1. A) Anaphylactic reaction to shellfish
  2. B) A drug reaction to penicillin causing a rash
  3. C) Glomerulonephritis
  4. D) Dermatitis resulting from a response to changing laundry detergent

Answer:  A

Explanation:  A) Type I hypersensitivities occur immediately and may be life-threatening. This is the case with an anaphylactic reaction. A rash caused by a drug reaction is a type II hypersensitivity, which occurs 15-30 minutes postexposure to the allergen. Glomerulonephritis is an example of a type III hypersensitivity in which antigen-antibody complexes circulate within the blood and tissue, causing cellular and tissue injury. This reaction occurs 10-14 days after the exposure. In the case of glomerulonephritis, the kidney is damaged from immune complex deposits that occur in response to toxins produced in a streptococcal infection. Dermatitis is a type IV hypersensitivity, which is delayed hypersensitivity.

  1. B) Type I hypersensitivities occur immediately and may be life-threatening. This is the case with an anaphylactic reaction. A rash caused by a drug reaction is a type II hypersensitivity, which occurs 15-30 minutes postexposure to the allergen. Glomerulonephritis is an example of a type III hypersensitivity in which antigen-antibody complexes circulate within the blood and tissue, causing cellular and tissue injury. This reaction occurs 10-14 days after the exposure. In the case of glomerulonephritis, the kidney is damaged from immune complex deposits that occur in response to toxins produced in a streptococcal infection. Dermatitis is a type IV hypersensitivity, which is delayed hypersensitivity.
  2. C) Type I hypersensitivities occur immediately and may be life-threatening. This is the case with an anaphylactic reaction. A rash caused by a drug reaction is a type II hypersensitivity, which occurs 15-30 minutes postexposure to the allergen. Glomerulonephritis is an example of a type III hypersensitivity in which antigen-antibody complexes circulate within the blood and tissue, causing cellular and tissue injury. This reaction occurs 10-14 days after the exposure. In the case of glomerulonephritis, the kidney is damaged from immune complex deposits that occur in response to toxins produced in a streptococcal infection. Dermatitis is a type IV hypersensitivity, which is delayed hypersensitivity.
  3. D) Type I hypersensitivities occur immediately and may be life-threatening. This is the case with an anaphylactic reaction. A rash caused by a drug reaction is a type II hypersensitivity, which occurs 15-30 minutes postexposure to the allergen. Glomerulonephritis is an example of a type III hypersensitivity in which antigen-antibody complexes circulate within the blood and tissue, causing cellular and tissue injury. This reaction occurs 10-14 days after the exposure. In the case of glomerulonephritis, the kidney is damaged from immune complex deposits that occur in response to toxins produced in a streptococcal infection. Dermatitis is a type IV hypersensitivity, which is delayed hypersensitivity.

Page Ref: 492

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Assessment

Learning Outcome:  4. Formulate priority nursing diagnoses appropriate for an individual with hypersensitivity.

5) The nurse is preparing to assess a client when one of the client’s family members begins showing symptoms of a latex sensitivity. What is the best action for the nurse?

  1. A) Ask the family member to leave the unit.
  2. B) Transfer the client to a department that does not use latex products.
  3. C) Wait until Monday to report the problem to the supervisor of the unit.
  4. D) Obtain latex-free products for the client’s room.

Answer:  D

Explanation:  A) When symptoms of sensitivity to latex occur on exposure, latex-free products should be supplied. Transferring the client to a department that does not use latex products is not realistic because the family member might experience exposure on another unit. (No hospital unit can be latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client’s right’s.

  1. B) When symptoms of sensitivity to latex occur on exposure, latex-free products should be supplied. Transferring the client to a department that does not use latex products is not realistic because the family member might experience exposure on another unit. (No hospital unit can be latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client’s right’s.
  2. C) When symptoms of sensitivity to latex occur on exposure, latex-free products should be supplied. Transferring the client to a department that does not use latex products is not realistic because the family member might experience exposure on another unit. (No hospital unit can be latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client’s right’s.
  3. D) When symptoms of sensitivity to latex occur on exposure, latex-free products should be supplied. Transferring the client to a department that does not use latex products is not realistic because the family member might experience exposure on another unit. (No hospital unit can be latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client’s right’s.

Page Ref: 486

Cognitive Level:  Applying

Client Need:  Safe and Effective Care Environment

Nursing Process:  Implementation

Learning Outcome:  6. Plan evidence-based care for an individual with hypersensitivity and his or her family in collaboration with other members of the healthcare team.

 

6) The nurse is caring for a client who is experiencing anaphylactic shock following the administration of a medication. The nurse knows that the client should be placed in which position in order to obtain the best outcome?

  1. A) Trendelenburg position
  2. B) Flat, with legs slightly elevated
  3. C) Supine position
  4. D) High Fowler position

Answer:  D

Explanation:  A) The Trendelenburg position elevates the foot of the bed and is no longer recommended for the treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. Lying flat is not recommended. A person in a supine position may not be able to maintain an open airway. Placing the client in Fowler or high Fowler position allows optimal lung expansion and ease of breathing.

  1. B) The Trendelenburg position elevates the foot of the bed and is no longer recommended for the treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. Lying flat is not recommended. A person in a supine position may not be able to maintain an open airway. Placing the client in Fowler or high Fowler position allows optimal lung expansion and ease of breathing.
  2. C) The Trendelenburg position elevates the foot of the bed and is no longer recommended for the treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. Lying flat is not recommended. A person in a supine position may not be able to maintain an open airway. Placing the client in Fowler or high Fowler position allows optimal lung expansion and ease of breathing.
  3. D) The Trendelenburg position elevates the foot of the bed and is no longer recommended for the treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. Lying flat is not recommended. A person in a supine position may not be able to maintain an open airway. Placing the client in Fowler or high Fowler position allows optimal lung expansion and ease of breathing.

Page Ref: 492

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with hypersensitivity.

 

7) The nurse is caring for a client with a history of latex allergies. The client develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which intervention is considered priority for this client?

  1. A) Teach the client regarding using a kit that contains treatment for allergic reactions.
  2. B) Administer diphenhydramine (Benadryl) by mouth every 4 hours per the healthcare provider’s orders.
  3. C) Administer epinephrine 1:1,000 by subcutaneous injection per the healthcare provider’s orders.
  4. D) Collect a detailed history from the client regarding the history of latex allergies.

Answer:  C

Explanation:  A) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client’s signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.

  1. B) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client’s signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.
  2. C) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client’s signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.

 

  1. D) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client’s signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.

Page Ref: 492

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with hypersensitivity.

 

 

8) A nurse is working in a summer camp for children. One of the children comes to the clinic stating that she has been stung by several bees. The nurse plans to inject the child with epinephrine (EpiPen) if which symptoms are present?

Select all that apply.

  1. A) Skin that is cold and clammy to the touch
  2. B) Skin that is warm and dry to the touch
  3. C) The child is hyperactive and hyperverbal.
  4. D) Complaints of thirst
  5. E) Restlessness and confusion

Answer:  A, D, E

Explanation:  A) General symptoms of shock include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.

  1. B) General symptoms of shock include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.
  2. C) General symptoms of shock include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.
  3. D) General symptoms of shock include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.
  4. E) General symptoms of shock include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.

Page Ref: 493

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  6. Plan evidence-based care for an individual with hypersensitivity and his or her family in collaboration with other members of the healthcare team.

 

9) A nurse has been providing a 22-year-old woman with hypersensitivity with instructions on the correct methods for using an EpiPen. Which client statement indicates understanding of the proper technique?

Select all that apply.

  1. A) “It’s fine to leave the EpiPen out in the sun”
  2. B) “I frequently check the expiration date”
  3. C) “I make sure the EpiPen is always available.”
  4. D) “No one else in my family knows how to use the EpiPen.”
  5. E) “I don’t need a medical alert tag.”

Answer:  B, C

Explanation:  A) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the clientRemember,meone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.

  1. B) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the clientRemember,meone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.
  2. C) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the clientRemember,meone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.
  3. D) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the clientRemember,meone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.
  4. E) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The client and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the client studies, works, or plays. In addition to the clientRemember,meone else should always know how to use the kit as well. The client should be encouraged to wear a medical alert bracelet or tag.

Page Ref: 493

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Evaluation

Learning Outcome:  7. Evaluate expected outcomes for an individual with hypersensitivity.

 

10) A pediatric client has been diagnosed with a hypersensitivity reaction requiring an EpiPen to treat an anaphylactic reaction. The nurse caring for this client will include which statements when teaching the client and parent regarding this medication?

Select all that apply.

  1. A) “It is recommended that the client wear a medical alert bracelet.”
  2. B) “This medication does not come pre-filled and must be measured.”
  3. C) “Keep the medication in the car at all times.”
  4. D) “Frequently check the expiration date of the medication.”
  5. E) “Keep the medication in one location that is easy to remember.”

Answer:  A, D

Explanation:  A) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.

  1. B) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.
  2. C) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.
  3. D) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.

 

  1. E) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.

Page Ref: 493

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Planning

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with hypersensitivity.

 

11) A nurse is caring for a client with seasonal hypersensitivity. What teaching would the nurse provide to improve this client’s comfort?

Select all that apply.

  1. A) Keep doors and windows open on high-allergen days to circulate air.
  2. B) Remain indoors if possible on high-allergen days.
  3. C) Maintain a clean, dust-free environment.
  4. D) Take antihistamine and leukotriene medication as ordered.
  5. E) Stop taking oral corticosteroids immediately once symptoms disappear.

Answer:  B, C

Explanation:  A) A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.

  1. B) A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.
  2. C) A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.
  3. D) A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.
  4. E) A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include instruction on taking antihistamine and anti-leukotriene medication, not leukotriene. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.

Page Ref: 488

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with hypersensitivity.

Exemplar 8.3  Rheumatoid Arthritis

 

1) A 43-year-old woman, recently diagnosed with RA, asks the nurse whether she might have concerns beyond the problems with her joints. The nurse informs her that RA may also involve:

Select all that apply.

  1. A) The respiratory system.
  2. B) The cardiovascular system.
  3. C) The exocrine system.
  4. D) The reproductive system.
  5. E) The hematologic system.

Answer:  A, B, C, E

Explanation:  A) RA can result in pleural effusion (collection of fluid in the pleural space). Individuals with RA have an increased risk of developing coronary heart disease. RA is a systemic disease of connective tissue that can affect exocrine glands, resulting most frequently in dry eyes and mouth. Properly managed, rheumatoid arthritis is not considered to be a danger for pregnant women or their babies. Patients with RA may suffer from a variety of hematologic disorders, particularly anemia.

  1. B) RA can result in pleural effusion (collection of fluid in the pleural space). Individuals with RA have an increased risk of developing coronary heart disease. RA is a systemic disease of connective tissue that can affect exocrine glands, resulting most frequently in dry eyes and mouth. Properly managed, rheumatoid arthritis is not considered to be a danger for pregnant women or their babies. Patients with RA may suffer from a variety of hematologic disorders, particularly anemia.
  2. C) RA can result in pleural effusion (collection of fluid in the pleural space). Individuals with RA have an increased risk of developing coronary heart disease. RA is a systemic disease of connective tissue that can affect exocrine glands, resulting most frequently in dry eyes and mouth. Properly managed, rheumatoid arthritis is not considered to be a danger for pregnant women or their babies. Patients with RA may suffer from a variety of hematologic disorders, particularly anemia.
  3. D) RA can result in pleural effusion (collection of fluid in the pleural space). Individuals with RA have an increased risk of developing coronary heart disease. RA is a systemic disease of connective tissue that can affect exocrine glands, resulting most frequently in dry eyes and mouth. Properly managed, rheumatoid arthritis is not considered to be a danger for pregnant women or their babies. Patients with RA may suffer from a variety of hematologic disorders, particularly anemia.
  4. E) RA can result in pleural effusion (collection of fluid in the pleural space). Individuals with RA have an increased risk of developing coronary heart disease. RA is a systemic disease of connective tissue that can affect exocrine glands, resulting most frequently in dry eyes and mouth. Properly managed, rheumatoid arthritis is not considered to be a danger for pregnant women or their babies. Patients with RA may suffer from a variety of hematologic disorders, particularly anemia.

Page Ref: 495

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Analysis

Learning Outcome:  1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of rheumatoid arthritis (RA).

2) A client has just recently been diagnosed with rheumatoid arthritis (RA). The client asks the nurse if RA always causes crippling deformities. The nurse tells the client that to decrease the likelihood of deformities, it is important to:

Select all that apply.

  1. A) Ignore pain as a warning signal.
  2. B) Type instead of hand-writing items if possible.
  3. C) Use stronger joints for most activity.
  4. D) Avoid stress to any current area of deformity.
  5. E) Stop an activity if it is beyond your ability to perform.

Answer:  B, C, D, E

Explanation:  A) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong gripRemember, typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.

  1. B) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong gripRemember, typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.
  2. C) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong gripRemember, typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.
  3. D) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong gripRemember, typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.
  4. E) The client with RA should never attempt to push a joint beyond its ability. Writing requires using a strong gripRemember, typing is preferable. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA should stop any activity that causes pain. When performing a task, the client should avoid stress in the area of the deformity to help prevent further deformities.

Page Ref: 505

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  2. Identify risk factors and prevention methods associated with RA.

 

3) A female client who was recently diagnosed with rheumatoid arthritis (RA) asks the nurse if the cause of the disease is the fact that her family is of Hispanic descent. Which is the most appropriate response by the nurse to this client?

  1. A) “RA affects those of German descent most often.”
  2. B) “RA is most prevalent in Caucasian females.”
  3. C) “RA is most prevalent in men under the age of 20 years.”
  4. D) “RA affects all races at the same rate.”

Answer:  D

Explanation:  A) RA affects 12% of the total population across all races. It affects women 3 times more than men, and the onset is usually between the ages of 20 and 40 years.

  1. B) RA affects 12% of the total population across all races. It affects women 3 times more than men, and the onset is usually between the ages of 20 and 40 years.
  2. C) RA affects 12% of the total population across all races. It affects women 3 times more than men, and the onset is usually between the ages of 20 and 40 years.
  3. D) RA affects 12% of the total population across all races. It affects women 3 times more than men, and the onset is usually between the ages of 20 and 40 years.

Page Ref: 496

Cognitive Level:  Applying

Client Need:  Psychosocial Integrity

Nursing Process:  Implementation

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with rheumatoid arthritis.

 

4) The nurse is collecting a health history for a client being seen in an outpatient clinic. The client complains of joint pain and swelling that have lasted for about 2 months. The nurse devises a plan of care based on the nursing diagnosis of Activity Intolerance based on which client statement?

  1. A) “I seem to get tired early in the day and require a nap.”
  2. B) “My joints are stiffest at night before I go to sleep.”
  3. C) “I find it difficult to move when I first get up in the morning.”
  4. D) “I take ibuprofen for the pain as needed.”

Answer:  A

Explanation:  A) One hallmark of RA is extreme fatigue, and the nurse would plan to teach the client about frequent rest periods during the day to conserve energy. The client with RA will be stiff early in the morning, but that would not interfere with activities later in the day. Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does not affect the ability for activity.

  1. B) One hallmark of RA is extreme fatigue, and the nurse would plan to teach the client about frequent rest periods during the day to conserve energy. The client with RA will be stiff early in the morning, but that would not interfere with activities later in the day. Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does not affect the ability for activity.
  2. C) One hallmark of RA is extreme fatigue, and the nurse would plan to teach the client about frequent rest periods during the day to conserve energy. The client with RA will be stiff early in the morning, but that would not interfere with activities later in the day. Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does not affect the ability for activity.
  3. D) One hallmark of RA is extreme fatigue, and the nurse would plan to teach the client about frequent rest periods during the day to conserve energy. The client with RA will be stiff early in the morning, but that would not interfere with activities later in the day. Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does not affect the ability for activity.

Page Ref: 505

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  4. Formulate priority nursing diagnoses appropriate for an individual with rheumatoid arthritis.

 

5) The nurse is completing a health screening for a school-age child with rheumatoid arthritis. The parents ask the nurse to recommend activities that will promote exercise for their child. Which is an appropriate recommendation by the nurse?

  1. A) Swimming
  2. B) Football
  3. C) Softball
  4. D) Basketball

Answer:  A

Explanation:  A) Swimming exercises all the extremities without putting undue stress on joints. Softball, football, or basketball could exacerbate joint discomfort.

  1. B) Swimming exercises all the extremities without putting undue stress on joints. Softball, football, or basketball could exacerbate joint discomfort.
  2. C) Swimming exercises all the extremities without putting undue stress on joints. Softball, football, or basketball could exacerbate joint discomfort.
  3. D) Swimming exercises all the extremities without putting undue stress on joints. Softball, football, or basketball could exacerbate joint discomfort.

Page Ref: 504

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing Process:  Implementation

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with RA.

 

6) A client with rheumatoid arthritis is being seen in the outpatient clinic for a progress check-up. The nurse is reviewing the client’s plan of care and determines that the client has met a goal of treatment when the client makes which statement?

  1. A) “I sleep for 10 hours at night.”
  2. B) “I have increased pain in my joints all the time now.”
  3. C) “I have delegated many household chores to my children and spouse.”
  4. D) “I do not perform household chores at all anymore.”

Answer:  C

Explanation:  A) One technique for reducing stress on the joints is to delegate household tasks to family members. The client does not need to refrain from all household chores. Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. Increased joint pain would indicate that goals have not been met.

  1. B) One technique for reducing stress on the joints is to delegate household tasks to family members. The client does not need to refrain from all household chores. Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. Increased joint pain would indicate that goals have not been met.
  2. C) One technique for reducing stress on the joints is to delegate household tasks to family members. The client does not need to refrain from all household chores. Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. Increased joint pain would indicate that goals have not been met.
  3. D) One technique for reducing stress on the joints is to delegate household tasks to family members. The client does not need to refrain from all household chores. Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. Increased joint pain would indicate that goals have not been met.

Page Ref: 507

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  7. Evaluate expected outcomes for an individual with RA.

 

7) The nurse is caring for a client who was diagnosed with rheumatoid arthritis last year. The client has recently been placed on prednisone for treatment. The nurse is teaching the client about safe medication administration. Which client statement indicates that the medication teaching was successful?

  1. A) “I will not have to limit my consumption of canned vegetables.”
  2. B) “I will take this medication on a full stomach to enhance absorption.”
  3. C) “I will not need to monitor my blood sugar more frequently while on this medication.”
  4. D) “I will take the ordered dose at the same time every day.”

Answer:  D

Explanation:  A) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day. Steroids are taken with food to minimize GI distress, not to enhance absorption. Steroids can cause fluid retentionRemember, sodium intake should be limited. A hidden source of sodium is canned vegetables. Steroids also increase blood sugarRemember, blood sugar may need to be monitored more frequently while on the medication regimen.

  1. B) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day. Steroids are taken with food to minimize GI distress, not to enhance absorption. Steroids can cause fluid retentionRemember, sodium intake should be limited. A hidden source of sodium is canned vegetables. Steroids also increase blood sugarRemember, blood sugar may need to be monitored more frequently while on the medication regimen.
  2. C) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day. Steroids are taken with food to minimize GI distress, not to enhance absorption. Steroids can cause fluid retentionRemember, sodium intake should be limited. A hidden source of sodium is canned vegetables. Steroids also increase blood sugarRemember, blood sugar may need to be monitored more frequently while on the medication regimen.
  3. D) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day. Steroids are taken with food to minimize GI distress, not to enhance absorption. Steroids can cause fluid retentionRemember, sodium intake should be limited. A hidden source of sodium is canned vegetables. Steroids also increase blood sugarRemember, blood sugar may need to be monitored more frequently while on the medication regimen.

Page Ref: 502

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with RA.

 

8) A nurse is caring for a client who was admitted to the hospital with an exacerbation of rheumatoid arthritis. The client states that her pain is a 3 on a scale from 1 to 10 today. What non-pharmacological interventions can the nurse provide?

Select all that apply.

  1. A) Discourage any position changes.
  2. B) Relaxation techniques
  3. C) Immobilize the extremity.
  4. D) Massage
  5. E) Provide diversion activities.

Answer:  B, D, E

Explanation:  A) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.

  1. B) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.
  2. C) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.
  3. D) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.
  4. E) Non-pharmacological activities for pain relief include massage, relaxation, and diversion. Position changes are encouraged along with supportive equipment. Immobilization would likely cause contractures in the joints.

Page Ref: 504

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  6. Plan evidence-based care for an individual with RA and his or her family in collaboration with other members of the healthcare team.

 

9) A nurse is caring for a pregnant client who has rheumatoid arthritis (RA). The nurse understands that this client may:

  1. A) Be at higher risk for preterm delivery.
  2. B) Not stop medication for RA, even if the client is in remission.
  3. C) Experience a relapse during pregnancy, often followed by a remission after delivery.
  4. D) Be anemic as a result of blood loss from salicylate therapy.

Answer:  D

Explanation:  A) The pregnant client with RA may have prolonged gestations and often experience a remission during pregnancy and relapse after delivery. The pregnant client with RA that is in remission may stop medication. This client may be anemic as a result of blood loss from salicylate therapy.

  1. B) The pregnant client with RA may have prolonged gestations and often experience a remission during pregnancy and relapse after delivery. The pregnant client with RA that is in remission may stop medication. This client may be anemic as a result of blood loss from salicylate therapy.
  2. C) The pregnant client with RA may have prolonged gestations and often experience a remission during pregnancy and relapse after delivery. The pregnant client with RA that is in remission may stop medication. This client may be anemic as a result of blood loss from salicylate therapy.
  3. D) The pregnant client with RA may have prolonged gestations and often experience a remission during pregnancy and relapse after delivery. The pregnant client with RA that is in remission may stop medication. This client may be anemic as a result of blood loss from salicylate therapy.

Page Ref: 497

Cognitive Level:  Analyzing

Client Need:  Health Promotion and Maintenance

Nursing Process:  Planning

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with RA.

 

10) A nurse is caring for a client who has been newly diagnosed with rheumatoid arthritis (RA). The client asks the nurse what the difference is between rheumatoid arthritis and osteoarthritis (OA). The nurse’s best response includes:

Select all that apply.

  1. A) “The onset of OA is gradual while the onset of RA may be rapid.”
  2. B) “With OA, multiple joints are symmetrically affected; RA affects one joint at a time.”
  3. C) “The affected joints in RA feel cold to the touch while the joints affected by OA are warm or hot to the touch.”
  4. D) “OA is slowly progressive while RA is characterized by exacerbations and remissions.”
  5. E) “The pain and stiffness with RA is with activity; OA pain and stiffness is predominant upon arising.”

Answer:  A, D

Explanation:  A) The onset of OA is gradual while the onset of RA may be rapid. RA affects multiple joints symmetrically while OA affects one joint at a time. The affected joints in OA feel cold to the touch while the joints affected by RA are warm or hot to the touch. OA is slowly progressive while RA has exacerbations and remissions. Pain associated with RA is predominant upon arising versus the pain in OA, which is with activity.

  1. B) The onset of OA is gradual while the onset of RA may be rapid. RA affects multiple joints symmetrically while OA affects one joint at a time. The affected joints in OA feel cold to the touch while the joints affected by RA are warm or hot to the touch. OA is slowly progressive while RA has exacerbations and remissions. Pain associated with RA is predominant upon arising versus the pain in OA, which is with activity.
  2. C) The onset of OA is gradual while the onset of RA may be rapid. RA affects multiple joints symmetrically while OA affects one joint at a time. The affected joints in OA feel cold to the touch while the joints affected by RA are warm or hot to the touch. OA is slowly progressive while RA has exacerbations and remissions. Pain associated with RA is predominant upon arising versus the pain in OA, which is with activity.
  3. D) The onset of OA is gradual while the onset of RA may be rapid. RA affects multiple joints symmetrically while OA affects one joint at a time. The affected joints in OA feel cold to the touch while the joints affected by RA are warm or hot to the touch. OA is slowly progressive while RA has exacerbations and remissions. Pain associated with RA is predominant upon arising versus the pain in OA, which is with activity.
  4. E) The onset of OA is gradual while the onset of RA may be rapid. RA affects multiple joints symmetrically while OA affects one joint at a time. The affected joints in OA feel cold to the touch while the joints affected by RA are warm or hot to the touch. OA is slowly progressive while RA has exacerbations and remissions. Pain associated with RA is predominant upon arising versus the pain in OA, which is with activity.

Page Ref: 495

Cognitive Level:  Understanding

Client Need:  Physiological Integrity

Nursing Process:  Assessment

Learning Outcome:  1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of rheumatoid arthritis (RA).

 

Exemplar 8.4  Systemic Lupus Erythematosus

 

1) The client enters the outpatient clinic and states to the triage nurse, “I think I have the flu. I’m so tired, I have no appetite, and everything hurts.” The triage nurse assesses the client and finds a butterfly rash over the bridge of nose and on the cheeks. Which diagnosis does the nurse expect?

  1. A) Systemic lupus erythematosus
  2. B) Fibromyalgia
  3. C) Lyme disease
  4. D) Gout

Answer:  A

Explanation:  A) The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE), although not every client diagnosed with this disorder will have this rash. While fibromyalgia, Lyme’s disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks.

  1. B) The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE), although not every client diagnosed with this disorder will have this rash. While fibromyalgia, Lyme’s disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks.
  2. C) The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE), although not every client diagnosed with this disorder will have this rash. While fibromyalgia, Lyme’s disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks.
  3. D) The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE), although not every client diagnosed with this disorder will have this rash. While fibromyalgia, Lyme’s disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks.

Page Ref: 510

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of systemic lupus erythematosus.

 

2) A female client asks the nurse if there are any conditions that can exacerbate systemic lupus erythematosus (SLE). Which is the best nurse response?

  1. A) “Conditions that cause hypotension can often exacerbate SLE.”
  2. B) “GI upset is often associated with SLE exacerbation.”
  3. C) “Pregnancy is often associated with an SLE exacerbation.”
  4. D) “Fever is a known trigger for an SLE exacerbation.”

Answer:  C

Explanation:  A) Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels. Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.

  1. B) Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels. Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.
  2. C) Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels. Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.
  3. D) Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels. Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.

Page Ref: 510

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  2. Identify risk factors and prevention methods associated with systemic lupus erythematosus.

 

 

3) The nurse is providing health education to a diverse group at a neighborhood community center. Why does the nurse plan to include signs and symptoms of systemic lupus erythematosus (SLE)?

  1. A) The neighborhood is composed of many young female children.
  2. B) The audience has asked the nurse to include the information.
  3. C) The audience is mainly composed of Caucasian women.
  4. D) The audience is mainly females of Asian-American descent.

Answer:  D

Explanation:  A) Among women who are of child-bearing age, SLE is seen in more African-Americans, Hispanics, and Asian-Americans than Caucasians. There is no evidence that the audience asked for the information.

  1. B) Among women who are of child-bearing age, SLE is seen in more African-Americans, Hispanics, and Asian-Americans than Caucasians. There is no evidence that the audience asked for the information.
  2. C) Among women who are of child-bearing age, SLE is seen in more African-Americans, Hispanics, and Asian-Americans than Caucasians. There is no evidence that the audience asked for the information.
  3. D) Among women who are of child-bearing age, SLE is seen in more African-Americans, Hispanics, and Asian-Americans than Caucasians. There is no evidence that the audience asked for the information.

Page Ref: 510

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with systemic lupus erythematosus.

 

4) The nurse is caring for a client who is hospitalized due to an exacerbation of systemic lupus erythematosus (SLE). The nurse is reviewing the client’s lab work and finds the white blood cell count (WBC) is shifted to the left. Based on this information, which is a priority nursing diagnosis for this client?

  1. A) Ineffective Protection
  2. B) Ineffective Health Maintenance
  3. C) Ineffective Individual Coping
  4. D) Risk for Impaired Skin Integrity

Answer:  A

Explanation:  A) All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in the WBC count indicates an increased risk for infection. A shift to the left in a WBC differential is indicative of a large number of immature cells, suggesting infection, and is therefore the priority for the client with the diagnosis Ineffective Protection.

  1. B) All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in the WBC count indicates an increased risk for infection. A shift to the left in a WBC differential is indicative of a large number of immature cells, suggesting infection, and is therefore the priority for the client with the diagnosis Ineffective Protection.
  2. C) All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in the WBC count indicates an increased risk for infection. A shift to the left in a WBC differential is indicative of a large number of immature cells, suggesting infection, and is therefore the priority for the client with the diagnosis Ineffective Protection.
  3. D) All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in the WBC count indicates an increased risk for infection. A shift to the left in a WBC differential is indicative of a large number of immature cells, suggesting infection, and is therefore the priority for the client with the diagnosis Ineffective Protection.

Page Ref: 516

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  4. Formulate priority nursing diagnoses appropriate for an individual with systemic lupus erythematosus.

 

5) A client with SLE is being treated with immunosuppressant drugs and corticosteroids. Which precautions should the nurse provide this client?

Select all that apply.

  1. A) Avoid large crowds.
  2. B) Don’t get a flu shot.
  3. C) Use contraception to prevent pregnancy
  4. D) Refrain from taking aspirin or ibuprofen.
  5. E) Report signs of infection to the physician.

Answer:  A, C, D, E

Explanation:  A) Crowds may increase exposure to infection. Annual influenza vaccination is recommended but clients with significant immunosuppression should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects. Aspirin or ibuprofen may increase the risk of bleeding. Chills, feverRemember,re throat, fatigue, or malaise should be reported.

  1. B) Crowds may increase exposure to infection. Annual influenza vaccination is recommended but clients with significant immunosuppression should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects. Aspirin or ibuprofen may increase the risk of bleeding. Chills, feverRemember,re throat, fatigue, or malaise should be reported.
  2. C) Crowds may increase exposure to infection. Annual influenza vaccination is recommended but clients with significant immunosuppression should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects. Aspirin or ibuprofen may increase the risk of bleeding. Chills, feverRemember,re throat, fatigue, or malaise should be reported.
  3. D) Crowds may increase exposure to infection. Annual influenza vaccination is recommended but clients with significant immunosuppression should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects. Aspirin or ibuprofen may increase the risk of bleeding. Chills, feverRemember,re throat, fatigue, or malaise should be reported.
  4. E) Crowds may increase exposure to infection. Annual influenza vaccination is recommended but clients with significant immunosuppression should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects. Aspirin or ibuprofen may increase the risk of bleeding. Chills, feverRemember,re throat, fatigue, or malaise should be reported.

Page Ref: 516

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with systemic lupus erythematosus.

 

6) A nurse is caring for a client with systemic lupus erythematosus (SLE). The client begins to cry and tells the nurse that she is afraid that her skin will be disfigured with lesions. Which intervention does the nurse plan to teach this client to minimize skin infections associated with SLE?

Select all that apply.

  1. A) Use sunscreen with an SPF of 15 or greater.
  2. B) Remain indoors on sunny days.
  3. C) Avoid swimming in a pool or the ocean.
  4. D) Avoid sun exposure between 10:00 a.m. and 3:00 p.m.
  5. E) Decrease sun exposure between 3:00 p.m. and 5:00 p.m.

Answer:  A, D

Explanation:  A) The nurse teaches the client to live a normal life with a few extra precautions. There is a relationship between sun exposure and infectionRemember, the client is taught to use sunscreen with an SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The client may swim but should reapply sunscreen after swimming. The client does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m.

  1. B) The nurse teaches the client to live a normal life with a few extra precautions. There is a relationship between sun exposure and infectionRemember, the client is taught to use sunscreen with an SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The client may swim but should reapply sunscreen after swimming. The client does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m.
  2. C) The nurse teaches the client to live a normal life with a few extra precautions. There is a relationship between sun exposure and infectionRemember, the client is taught to use sunscreen with an SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The client may swim but should reapply sunscreen after swimming. The client does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m.
  3. D) The nurse teaches the client to live a normal life with a few extra precautions. There is a relationship between sun exposure and infectionRemember, the client is taught to use sunscreen with an SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The client may swim but should reapply sunscreen after swimming. The client does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m.
  4. E) The nurse teaches the client to live a normal life with a few extra precautions. There is a relationship between sun exposure and infectionRemember, the client is taught to use sunscreen with an SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The client may swim but should reapply sunscreen after swimming. The client does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m.

Page Ref: 513

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  6. Plan evidence-based care for an individual with systemic lupus erythematosus and his or her family in collaboration with other members of the healthcare team.

 

7) The nurse is caring for a client who has been diagnosed with discoid lupus erythematosus. The nurse is collaborating with the client to set goals for the nursing plan of care. What is an appropriate goal for this client?

  1. A) Work through the stages of death and dying.
  2. B) Comply 100% of the time with a sun protection plan.
  3. C) Gain weight to within 10 pounds of normal for height.
  4. D) Report pain no higher than four on a scale of 1-10.

Answer:  B

Explanation:  A) Discoid lupus erythematosus is an autoimmune disorder of the skinRemember, the client must protect against the sun to avoid skin cancers and other complications. It is not fatal, is not related to weight, and is rarely painful unless complications arise.

  1. B) Discoid lupus erythematosus is an autoimmune disorder of the skinRemember, the client must protect against the sun to avoid skin cancers and other complications. It is not fatal, is not related to weight, and is rarely painful unless complications arise.
  2. C) Discoid lupus erythematosus is an autoimmune disorder of the skinRemember, the client must protect against the sun to avoid skin cancers and other complications. It is not fatal, is not related to weight, and is rarely painful unless complications arise.
  3. D) Discoid lupus erythematosus is an autoimmune disorder of the skinRemember, the client must protect against the sun to avoid skin cancers and other complications. It is not fatal, is not related to weight, and is rarely painful unless complications arise.

Page Ref: 515

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing Process:  Implementation

Learning Outcome:  7. Evaluate expected outcomes for an individual with systemic lupus erythematosus.

 

8) The nurse is planning care for an adolescent client who has systemic lupus erythematosus (SLE). The nurse knows that the treatment plan implemented by the healthcare team is appropriate for the situation when the client:

  1. A) Refuses to attend school.
  2. B) Does not want to attend any social functions.
  3. C) Discusses skin changes with the healthcare personnel.
  4. D) Discusses skin changes with a good friend.

Answer:  D

Explanation:  A) Peer interaction is important to teens. Being able to discuss the physical changes related to SLE with a friend indicates acceptance of the change in body image. Refusing to go to school or attend social functions indicates nonacceptance of the changes to body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to the body image changes.

  1. B) Peer interaction is important to teens. Being able to discuss the physical changes related to SLE with a friend indicates acceptance of the change in body image. Refusing to go to school or attend social functions indicates nonacceptance of the changes to body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to the body image changes.
  2. C) Peer interaction is important to teens. Being able to discuss the physical changes related to SLE with a friend indicates acceptance of the change in body image. Refusing to go to school or attend social functions indicates nonacceptance of the changes to body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to the body image changes.
  3. D) Peer interaction is important to teens. Being able to discuss the physical changes related to SLE with a friend indicates acceptance of the change in body image. Refusing to go to school or attend social functions indicates nonacceptance of the changes to body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to the body image changes.

Page Ref: 515

Cognitive Level:  Analyzing

Client Need:  Psychosocial Integrity

Nursing Process:  Implementation

Learning Outcome:  7. Evaluate expected outcomes for an individual with systemic lupus erythematosus.

 

9) The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which client statement indicates plan of care understanding?

  1. A) “I will take birth control pills while I am taking cytotoxic medications.”
  2. B) “I do not need to contact the doctor if I develop a fever or rash.”
  3. C) “I plan to go to the movies this weekend so that I get out of the house.”
  4. D) “I can take ibuprofen as indicated for pain.”

Answer:  A

Explanation:  A) Treatment for SLE can include cytotoxic drugs. The client is taught to avoid pregnancy by using contraceptives, as these drugs can cause birth defects. The client is taught to avoid crowds, as they are potential sources of infection. Client with SLE should contact their primary care providers should signs of infection occur, as the immune system is compromised. Aspirin and ibuprofen can cause bleeding and should be taken with extreme care.

  1. B) Treatment for SLE can include cytotoxic drugs. The client is taught to avoid pregnancy by using contraceptives, as these drugs can cause birth defects. The client is taught to avoid crowds, as they are potential sources of infection. Client with SLE should contact their primary care providers should signs of infection occur, as the immune system is compromised. Aspirin and ibuprofen can cause bleeding and should be taken with extreme care.
  2. C) Treatment for SLE can include cytotoxic drugs. The client is taught to avoid pregnancy by using contraceptives, as these drugs can cause birth defects. The client is taught to avoid crowds, as they are potential sources of infection. Client with SLE should contact their primary care providers should signs of infection occur, as the immune system is compromised. Aspirin and ibuprofen can cause bleeding and should be taken with extreme care.
  3. D) Treatment for SLE can include cytotoxic drugs. The client is taught to avoid pregnancy by using contraceptives, as these drugs can cause birth defects. The client is taught to avoid crowds, as they are potential sources of infection. Client with SLE should contact their primary care providers should signs of infection occur, as the immune system is compromised. Aspirin and ibuprofen can cause bleeding and should be taken with extreme care.

Page Ref: 514

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  7. Evaluate expected outcomes for an individual with systemic lupus erythematosus.

 

10) A nurse is caring for a client with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). The nurse understands that the primary concern with this drug is:

  1. A) Pulmonary fibrosis.
  2. B) Cushingoid effects.
  3. C) Retinal toxicity.
  4. D) Renal toxicity.

Answer:  C

Explanation:  A) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity and possible irreversible blindness. Cushingoid effects are a concern with corticosteroid therapy. Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil. Renal toxicity is not the primary concern with Plaquenil.

  1. B) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity and possible irreversible blindness. Cushingoid effects are a concern with corticosteroid therapy. Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil. Renal toxicity is not the primary concern with Plaquenil.
  2. C) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity and possible irreversible blindness. Cushingoid effects are a concern with corticosteroid therapy. Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil. Renal toxicity is not the primary concern with Plaquenil.
  3. D) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity and possible irreversible blindness. Cushingoid effects are a concern with corticosteroid therapy. Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil. Renal toxicity is not the primary concern with Plaquenil.

Page Ref: 514

Cognitive Level:  Analyzing

Client Need:  Physiological Integrity

Nursing Process:  Planning

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with systemic lupus erythematosus.

 

11) A nurse caring for a client with SLE on immunosuppressive therapy understands that careful teaching is required to make sure both clients and family members understand appropriate precautions against the threat of infection. Teaching points should include:

Select all that apply.

  1. A) Avoid large crowds and situations that increase exposure to infection.
  2. B) Report difficulty breathing or cough to the physician if taking cyclophosphamide.
  3. C) Use ibuprofen instead of acetaminophen if fever develops.
  4. D) Women may develop heavy menstrual bleeding during therapy.

Answer:  A, B

Explanation:  A) The nurse should teach the client and family regarding avoiding large crowds and situations that increase exposure to infection and to report difficulty breathing or cough. The client should report a fever if it develops, and ibuprofen should not be used, as this may increase the risk for bleeding. Women may have an absence of menstruation, not heavy bleeding, during therapy.

  1. B) The nurse should teach the client and family regarding avoiding large crowds and situations that increase exposure to infection and to report difficulty breathing or cough. The client should report a fever if it develops, and ibuprofen should not be used, as this may increase the risk for bleeding. Women may have an absence of menstruation, not heavy bleeding, during therapy.
  2. C) The nurse should teach the client and family regarding avoiding large crowds and situations that increase exposure to infection and to report difficulty breathing or cough. The client should report a fever if it develops, and ibuprofen should not be used, as this may increase the risk for bleeding. Women may have an absence of menstruation, not heavy bleeding, during therapy.
  3. D) The nurse should teach the client and family regarding avoiding large crowds and situations that increase exposure to infection and to report difficulty breathing or cough. The client should report a fever if it develops, and ibuprofen should not be used, as this may increase the risk for bleeding. Women may have an absence of menstruation, not heavy bleeding, during therapy.

Page Ref: 514

Cognitive Level:  Applying

Client Need:  Physiological Integrity

Nursing Process:  Implementation

Learning Outcome:  3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with systemic lupus erythematosus.

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