NCLEX Review About Immune System Disorders 24

8/20/2019 NCLEX Review About Immune System Disorders 24

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NCLEX Review about Immune System

Disorders

1. An older adult with no known cognitive

impairment residing in a long-term care

facility suddenly becomes disoriented andconfused. There are no signs of extremity

weakness or other neurological changes.

Based on these observations, the nursewould focus the assessment in which

priority body systems?

a) pulmonary and renal systems

b reproductive and endocrine systemc integumentary and neurological systems

d cardiovascular and gastrointestinal

systems

1) A - !hanges in mental status andconfusion are commonly associated with

infections in the older adult. Assessments of

the pulmonary and renal systems would be

the priority. The older adult is at risk for pneumonia. The lungs should be auscultated

for decreased breath sounds and other

adventitious sounds. "rinary tract infectionsare also common in older adults, especially

women. #lank pain with fre$uency and

urgency are symptoms. The urine should bemonitored for cloudiness, odor, and other

changes indicating hematuria. Based on the

data in the $uestion, the body systemsidentified in options B, !, and % are not the

priority.

. A female client arrives at the health careclinic and tells the nurse that she was &ust

bitten by a tick and would like to be tested

for 'yme disease. The client tells the nursethat she removed the tick and flushed it

down the toilet. (hich of the following

nursing actions is most appropriate?a refer the client for blood test immediately

b inform the client that there is no test

available for 'yme disease

c tell the client that testing is not necessaryunless arthralgia develops

d) instru!t t"e !lient to return in # to $

wee%s to be tested be!ause testin& be'ore

t"is time is not reliable

) D - A blood test is available to detect

'yme disease) however, the test is not

reliable if performed before * to + weeksfollowing the tick bite. Antibody formation

takes place in the following manner.mmunoglobulin is detected to * weeks

after 'yme disease onset, peaks at + to /

weeks, and then gradually disappears)

immunoglobulin 0 is detected 1 to monthsafter infection and may remain elevated for

years. 2ptions A, B, and ! are incorrect.

(. #ollowing diagnosis of stage 'yme

disease, the nurse would anticipate that

which of the following will be part of thetreatment plan for the client?

a no treatment unless symptoms develop

b) a (wee% !ourse o' oral antibioti!

t"erapy

c daily oatmeal baths for 1 weeks

d treatment with intravenously administeredantibiotics

() * - 3revention, public education, and

early diagnosis are vital to the control andtreatment of 'yme disease. A -week course

of oral antibiotic therapy is recommended

during stage . 'ater stages of 'yme diseasemay re$uire therapy with intravenously

administered antibiotics, such as penicillin

0. 2ptions A and ! are incorrect.

#. A !ub 4cout leader, who is a nurse

preparing a group of !ub 4couts for an

overnight camping trip, instructs the scoutsabout the methods to prevent 'yme disease.

(hich statement by one of the !ub 4couts

indicates a need for further instructions?a need to bring a hat to wear during the

trip

b should wear long-sleeved tops and long

pants

!) I s"ould not use inse!t repellents

be!ause it will attra!t t"e ti!%s


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d need to wear closed shoes and socks that

can be pulled up over my pants

#) C - n the prevention of 'yme disease,individuals need to be instructed to use an

insect repellent on the skin and clothes when

in an area where ticks are likely to be found.'ong-sleeved tops and long pants, closed

shoes, and a hat or cap should be worn. f

possible, heavily wooded areas or areas withthick underbrush should be avoided. 4ocks

can be pulled up and over the pant legs to

the prevent ticks from entering under

clothing.

+. The client with ac$uired

immunodeficiency syndrome is diagnosed

with cutaneous 5aposi6s sarcoma. Based on

this diagnosis, the nurse understands thatthis has been confirmed by which of the

following?a swelling in the genital area

b swelling in the lower extremities

!) pun!" biopsy o' t"e !utaneous lesions

d appearance of reddish-blue lesions noted

on the skin

+) C - 5aposi7s sarcoma lesions begin as

red, dark blue, or purple macules on the

lower legs that change into pla$ues. Theselarge pla$ues ulcerate or open and drain.

The lesions spread by metastasis through the

upper body and then to the face and oralmucosa. They can move to the lymphatic

system, lungs, and gastrointestinal tract.

'ate disease results in swelling and pain in

the lower extremities, penis, scrotum, orface. %iagnosis is made by punch biopsy of

cutaneous lesions and biopsy of pulmonary

and gastrointestinal lesions.

$. (hich of the following individuals isleast likely at risk for the development of

5aposi6s sarcoma?

a A kidney transplant client

b a male with a history of same-gender partners

c a client receiving anti-neoplastic

medications

d) an individual wor%in& in an

environment in w"i!" "e or s"e is e,posed

to asbestos

$) D - 5aposi7s sarcoma is a vascular

malignancy that presents as a skin disorder

and is a common ac$uiredimmunodeficiency syndrome indicator.

alignancy is seen most fre$uently in men

with a history of same-gender partners.Although the cause of 5aposi7s sarcoma is

not known, it is considered to be caused by

an alteration or failure in the immune

system. The renal transplantation client andthe client receiving antineoplastic

medications are at risk for

immunosuppression. 8xposure to asbestos is

not related to the development of 5aposi7ssarcoma.

-. The nurse prepares to give a bath andchange the bed linens on a client with

cutaneous 5aposi6s sarcoma lesions. The

lesions are open and draining a scant amountof serous fluid. (hich of the following

would the nurse incorporate into the plan

during the bathing of this client?

a wearing gloves

b) wearin& a &own and &loves

c wearing a gown, gloves, and a mask

d wear a gown and gloves to change the bed linens and gloves only for the bath

-) * - 0owns and gloves are re$uired if the

nurse anticipates contact with soiled itemssuch as those with wound drainage or is

caring for a client who is incontinent with

diarrhea or a client who has an ileostomy or

colostomy. asks are not re$uired unlessdroplet or airborne precautions are

necessary. 9egardless of the amount of

wound drainage, a gown and gloves must beworn.

. A client is suspected of having systemic

lupus erythematosus. The nurse monitors theclient, knowing that which of the following

is one of the initial characteristic signs of

systemic lupus erythematosus?

a weight gain


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b subnormal temperature

c elevated red blood cell count

d) ras" on t"e 'a!e a!ross t"e brid&e o'

t"e nose and on t"e !"ee%s

) D

- 4kin lesions or rash on the face across the bridge of the nose and on the cheeks is an

initial characteristic sign of systemic lupus

erythematosus :4'8. #ever and weight lossmay also occur. Anemia is most likely to

occur later in 4'8.

/. The nurse provides home care instructions

to a client with systemic lupus

erythematosus and tells the client aboutmethods to manage fatigue. (hich

statement by the client indicates a need for

further instructions?

a) I s"ould ta%e "ot bat"s be!ause t"ey

are rela,in&

b should sit whenever possible to

conserve my energyc should avoid long periods of rest

because it causes &oint stiffness

d should do some exercises, such aswalking, when am not fatigued

/) A - To help reduce fatigue in the client

with systemic lupus erythematosus, thenurse should instruct the client to sit

whenever possible, avoid hot baths :because

they exacerbate fatigue, schedule moderatelow-impact exercises when not fatigued, and

maintain a balanced diet. The client is

instructed to avoid long periods of rest

because it promotes &oint stiffness.

10. The client with ac$uired

immunodeficiency syndrome has raised,

dark purplish-colored lesions on the trunk of the body. The nurse anticipates that which of

the following procedures will be done to

confirm whether these lesions are caused by5aposi6s sarcoma?

a) s%in biopsy

b lung biopsy

c western blotd en;yme-linked immunosorbent assay

10) A - The skin biopsy is the procedure of

choice to diagnose 5aposi7s sarcoma, which

fre$uently complicates the clinical picture of

the client with ac$uired immunodeficiencysyndrome. 'ung biopsy would confirm

3neumocystis &iroveci infection. The

en;yme-linked immunosorbent assay and(estern blot are tests to diagnose human

immunodeficiency virus status.

11. The client with ac$uired

immunodeficiency syndrome has a

respiratory infection from 3neumocystis &iroveci and a nursing diagnosis of mpaired

0as 8xchange written in the plan of care.

(hich of the following indicates that theexpected outcome of care has nor yet been

achieved?

a) !lient limits 'luid inta%e

b client has clear breath sounds

c client expectorates secretions easily

d client is free of complaints of shortness of

breath

11) A - The status of the client with a

diagnosis of mpaired gas exchange would

be evaluated against the standard outcomecriteria for this nursing diagnosis. These

would include the client stating that

breathing is easier and is coughing upsecretions effectively, and has clear breath

sounds. The client should not limit fluid

intake because fluids are needed to decreasethe viscosity of secretions for expectoration.

1. A client with pemphigus is being seen in

the clinic regularly. The nurse plans care

based on which of the following descriptionsof this condition?

a the presence of tiny red vesicles

b) an autoimmune disease t"at !auses

blisterin& in t"e epidermis

c the presence of skin vesicles found along

the nerve caused by a virusd the presence of red, raised papules and

large pla$ues covered by silvery scales

1) *

- 3emphigus is an autoimmune disease thatcauses blistering in the epidermis. The client

has large flaccid blisters :bullae. Because


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the blisters are in the epidermis, they have a

thin covering of skin and break easily,

leaving large denuded areas of skin. 2ninitial examination, clients may have

crusting areas instead of intact blisters.

2ption A describes ec;ema, option !describes herpes ;oster, and option %

describes psoriasis.

1(. The nurse is providing dietary

instructions to the client with systemic lupus

erythematosus. (hich of the followingdietary items would the nurse instruct the

client to avoid?

a) stea%

b turkey

c broccoli

d cantaloupe

1() A - The client with systemic lupus

erythematosus :4'8 is at risk for

cardiovascular disorders such as coronary

artery disease and hypertension. The clientis advised of lifestyle changes to reduce

these risks, which include smoking cessation

and prevention of obesity andhyperlipidemia. The client is advised to

reduce salt, fat, and cholesterol intake.

1#. A client calls the nurse in the emergencyroom and tells the nurse that he was &ust

stung by a bee while gardening. The client is

afraid of a severe reaction because theclient6s neighbor experienced such a reaction

&ust < week ago. The appropriate nursing

action is to=

a advise the client to soak the site inhydrogen peroxide

b) as% t"e !lient i' ever sustained a bee

stin& in t"e past

c tell the client to call an ambulance for

transport to the emergency room

d tell the client no to worry about the stingunless difficulty with breathing occurs

1#) * - n some types of allergies, a reaction

occurs only on second and subse$uent

contacts with the allergen. The appropriateaction, therefore, would be to ask the client

if he ever received a bee sting in the past.

2ption A is not appropriate advice. 2ption !

is unnecessary. The client should not be told

>not to worry.

1+. The nurse is assisting in administering

immuni;ations at a health care clinic. The

nurse understands that an immuni;ation will provide=

a protection from all disease

b innate immunity from diseasec natural immunity from disease

d) a!uired immunity 'rom disease

1+) D - Ac$uired immunity can occur by

receiving an immuni;ation that causes

antibodies to a specific pathogen to form. @atural :innate immunity is present at birth.

@o immuni;ation protects the client from all

diseases.

1$. The nurse is assigned to care for a client

with systemic lupus erythematosus. Thenurse plans care, knowing that this disorder

is a:n=

a local rash that occurs as a result of allergy b disease caused by overexposure to

sunlight

!) in'lammatory disease o' !olla&en

!ontained in !onne!tive tissue

d disease caused by the continuous releaseof histamine in the body

1$) C - 4ystemic lupus erythematosus is aninflammatory disease of collagen in

connective tissue. 2ptions A, B, and % are

not associated with this disease.

1-. The nurse is assigned to care for a client

admitted to the hospital with a diagnosis of

systemic lupus erythematosus. The nursereviews the physician6s orders, expecting to

note that which type of medication is

prescribed?a antibiotic

b antidiarrheal

!) !orti!osteroid

d opioid analgesic

1-) C - Treatment of systemic lupus

erythematosus is based on the systems

involved and symptoms. Treatment normally


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consists of anti-inflammatory drugs,

corticosteroids, and immunosuppressants.

2ptions A, B, and % are not standardcomponents of medication therapy.

1. The community health nurse is

conducting a research study and isidentifying clients in the community at risk

for latex allergy. (hich client population is

at most risk for developing this type ofallergy?

a) "airdressers

b the homeless

c children in day care centersd individuals living in a group home

1) A - ndividuals at risk for developing a

latex allergy include health care workers,

individuals who work in the rubber industryor those who have had multiple surgeries,

have spina bifida, wear gloves fre$uently,such as food handlers, hairdressers, and auto

mechanics, or are allergic to kiwis, bananas,

pineapples, tropical fruits, grapes, avocados, potatoes, ha;elnuts, and water chestnuts.

1/. The home care nurse is performing an

assessment on a client who has been

diagnosed with an allergy to latex. ndetermining the client6s risk factors

associated with the allergy, the nurse

$uestions the client about an allergy towhich food item?

a eggs

b milk c yogurt

d) bananas

1/) D - ndividuals who are allergic to

kiwis, bananas, pineapples, tropical fruits,grapes, avocados, potatoes, ha;elnuts, and

water chestnuts are at risk for developing a

latex allergy. This is thought to be to theresult of a possible cross-reaction between

the food and the latex allergen. 2ptions A,

B, and ! are unrelated to latex allergy.

0. The home care nurse is assigned to visit

a client who has returned home from the

emergency room following treatment for a

sprained ankle. The nurse notes that the

client as sent home with crutches that have

rubber axillary pads and needs instructions

regarding crutch walking. 2n admissionassessment, the nurse discovers that the

client has an allergy to latex. Before

providing instructions regarding crutchwalking, the nurse should=

a contact the physician

b) !over t"e !rut!" pads wit" !lot"

c call the local medical supply store and ask

for a cane to be delivered

d tell the client that the crutches must be

removed from the house immediately

0) * - The rubber pads used on crutchesmay contain latex. f the client re$uires the

use of crutches, the nurse can cover the pads

with a cloth to prevent cutaneous contact.2ption * is inappropriate and may alarm the

client. The nurse cannot order a cane for a

client. Additionally, this type of assistive

device may not be appropriate, consideringthis client7s in&ury. @o reason exists to

contact the physician at this time.

1. The home care nurse is ordering dressing

supplies for a client who has an allergy to

latex. The nurse asks the medical supply personnel to deliver which of the following?

a elastic bandages

b adhesive bandagesc brown ace bandages

d) !otton pads and sil% tape

1) D - !otton pads and plastic or silk tape

are latex-free products. The items identifiedin options A, B, and ! are products that

contain latex.

. The camp nurse prepares to instruct agroup of children about 'yme disease.

(hich of the following information would

the nurse include in the instructions?

a) Lyme disease is !aused by ti!% !arried

by deer

b 'yme disease is caused by contamination

from cat fecesc 'yme disease can be contagious through

skin contact with an infected individual


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d 'yme disease can be caused by the

inhalation of spores from bird droppings

) A - 'yme disease is a multisysteminfection that results from a bite by a tick

carried by several species of deer. 3ersons

bitten by the xodesscapularis or . pacificustick can become infected with the spirochete

Borrelia burgdorferi. 'yme disease cannot

be transmitted from one person to another.istoplasmosis is caused by the inhalation

of spores from bat or bird droppings.

Toxoplasmosis is caused by the ingestion of

cysts from contaminated cat feces.

(. The client is diagnosed with stage

'yme disease. The nurse assesses the client

for which characteristic of this stage?

a arthralgiasb) 'luli%e symptomsc enlarged and inflamed &ointsd signs of neurological disorders

() * - The hallmark of stage 'yme

disease is the development of a rash within 1to days of infection, generally at the site

of the tick bite. The rash develops into a

concentric ring, giving it a bull7s-eye

appearance. The lesion enlarges up to C to+ cm, and smaller lesions develop farther

away from the original tick bite. n stage ,

most infected persons develop flu-likesymptoms that last D to


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d) liver 'un!tion studies

$) D - Ealcitabine :dd!, ivid is an

antiretroviral :nucleoside reversetranscriptase inhibitor used to manage

human immunodeficiency virus infection in

combination with other antiretrovirals.Ealcitabine also has been used as a single

agent in clients who are intolerant of other

regimens. Ealcitabine can cause serious liver damage, and liver function studies should be

monitored closely. 2ptions A, B, and ! are

not associated specifically with the use of

this medication.

-. The nurse is assigned to care for a client

with cytomegalovirus retinitis and ac$uired

immunodeficiency syndrome who is

receiving foscarnet :#oscavir, an antiviral.The nurse checks the latest results of which

of the following laboratory studies while theclient is taking this medication?

a !%* cell count

b serum albumin level

!) serum !reatinine level

d lymphocyte count

-) C - #oscarnet :#oscavir is toxic to the

kidneys. The serum creatinine level ismonitored before therapy, two or three times

per week during induction therapy, and at

least weekly during maintenance therapy.#oscarnet also may cause decreased levels

of calcium, magnesium, phosphorus, and

potassium. Thus, these levels also aremeasured with the same fre$uency.

. The client with ac$uired

immunodeficiency syndrome and

3neumocystis &iroveci infection has beenreceiving pentamidine :3entam . The

client develops a temperature of


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(1. The client with ac$uired

immunodeficiency syndrome has begun

therapy with ;idovudine :9etrovir,a;idothymidine, AET, E%F. The nurse

carefully monitors which of the following

laboratory results during treatment with thismedication?

a blood culture

b blood glucose levelc blood urea nitrogen level

d) !omplete blood !ount

(1) D - !ommon side effects of this

medication therapy are leukopenia andanemia. The nurse monitors the complete

blood count results for these changes.

2ptions A, B, and ! are unrelated to the use

of this medication.(. The nurse is reviewing the results of

serum laboratory studies drawn on a clientwith ac$uired immunodeficiency syndrome

who is receiving didanosine :Fidex. The

nurse interprets that he client may have themedication discontinued by the physician if

which of the following significantly elevated

results is noted?

a serum protein level b blood glucose level

!) serum amylase level

d serum creatinine level

() C - %idanosine :Fidex can cause

pancreatitis. A serum amylase level that is

increased to


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c !%* count

d lymphocyte count

(+) * - #oscarnet :#oscavir is very toxic to

the kidneys. The serum creatinine level is

monitored prior to therapy, two or threetimes weekly during induction therapy, and

at least weekly during maintenance therapy.t also may cause decreased levels of

calcium, magnesium, phosphorus, and

potassium. Thus, these levels are also

measured with the same fre$uency.

($. A home care nurse provides instructions

to a client with systemic lupuserythematosus :4'8 about measures to

manage fatigue. (hich statement by the

client indicates the need for furtherinstruction?

a need to avoid long periods of rest

b need to sit whenever possible

!) I s"ould ta%e a "ot bat" every evenin&

d should engage in moderate low-impact

exercise when am not tired

($) C - To help reduce fatigue in the client

with 4'8, the nurse should instruct theclient to sit whenever possible, to avoid hot

baths, to schedule moderate low-impactexercises when not fatigued, and to maintain

a balanced diet. The client is instructed notto rest for long periods because it promotes

&oint stiffness.

(-. A nurse is reviewing the results of serumlaboratory studies for a client with ac$uired

immunodeficiency syndrome :A%4 who is

receiving didanosine :Fidex. The nurseinterprets that the client may have the

medication discontinued by the physician if

which of the following laboratory test resultsis significantly elevated?

a serum cholesterol level

b) serum amylase level

c blood glucose concentrationd serum protein concentration

(-) * - A serum amylase level that is

increased


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medication should be administered with

water on an empty stomach. The medication

can be taken < hour before a meal or 1 hoursafter a meal, or it can be administered with

skim milk, coffee, tea, or a low-fat meal. t

is not administered with a large meal. Themedication should be stored at room

temperature and protected from moisture,

because moisture can degrade themedication.

#0. A client is receiving acyclovir :Eovirax

by the intravenous :F route for treatment

of cytomegalovirus :!F infection. Afterreconstituting the powder dispensed by the

pharmacy, the nurse administers this

medication by=

a continuous F infusion over


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##. A client with ac$uired

immunodeficiency syndrome :A%4 is

receiving didanosine :Fidex. The nursereviewing the client6s laboratory results

should most closely monitor serum levels of=

a cholesterolb) amylasec glucose

d protein

##) * - This medication is toxic to both the

pancreas and the liver. A serum amylase

level that is increased


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post-test counseling session, the nurse tells

the client which of the following?

a) t"e test s"ould be repeated in $ mont"s

b this ensures that the client is not infected

with the F virus

c the client no longer needs to protecthimself from sexual partners

d the client probably has immunity to the

ac$uired immunodeficiency virus

#) A - A negative test result indicates that

no F antibodies were detected in the

blood sample. A repeated test in + months is

recommended because false-negative testresults have occurred early in the infection.

2ptions B, !, and % are incorrect.

#/. A client is diagnosed with late stage

human immunodeficiency virus :F, andthe client and family are extremely upset

about the diagnosis. The priority psychosocial nursing intervention for the

client and family is to=

a tell the client and family to stop smoking because it will predispose the client to

respiratory infections

b tell the client and family that raw or

improperly washed foods can producemicrobes

!) en!oura&e t"e !lient and 'amily to

dis!uss t"eir 'eelin&s about t"e disease

d advise the client to avoid becoming

pregnant because of the risk of transmission

of the infection

#/) C - The priority psychosocial nursing

intervention for the client and family is toencourage the client and family to discuss

their feelings about the disease. 2ptions A,

B, and % identify physiological not psychosocial concerns.

+0. A client is diagnosed with human

immunodeficiency virus :F infection.

The nurse prepares a care plan for the client,knowing that F is primarily a condition in

which=

a) immunosuppression o!!urs and is

indi!ated by a :# lymp"o!yte !ount o'

less t"an 007mm(

b bacterial infection occurs, causingweakness

c fungal infection occurs, causing a rash

and pruritus

d proto;oan infection occurs, causing afever and nonproductive cough

+0) A - F infection causes

immunosuppression and is indicated by a T*lymphocyte count of less than 1Gmm.

Although bacterial, fungal, and proto;oal

infection can occur, these occur asopportunistic infections as a result of the

immunosuppression.

NCLEX Review About Immune System Disorders 24

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