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immune nclex

Terms in this set (104)

A 55 year old female patient is receiving cyclosporine (Neoral, Sandimmune) after a heart transplant. The patient exhibits a white blood cell count of 12,000 cells/mm3, a sore throat, fatigue, and a low-grade fever. The nurse suspects:
1. transplant rejection
2. heart failure
3. dehydration
4. infection
4. infection

Rationale: Due to immune system suppression by the medication, infections are common
Which of the following statements by a patient taking cyclosporine (Neoral, Sanimmune) would indicate the need for more teaching by the nurse?
1. "I will report any reduction in urine output to my physician"
2. "I will my wash my hands frequently"
3. "I will take my blood pressure at home every day"
4. "I will take my cyclosporine at breakfast with a glass of grapefruit juice"
4. "I will take my cyclosporine at breakfast with a glass of grapefruit juice"

Rationale: Grapefruit juice increases cyclosporine levels 50% to 200%, resulting in drug toxicity. Hand washing is important to prevent infection. Renal Toxicity and hypertension are adverse effects of cylcosporine therapy
The nurse should monitor a transplant patient for the major adverse effect of cyclosproine (Neoral, Sandimmune) therapy by assessing which lab test?
1. CBC
2. Serum creatinine
3. Liver enzymes
4. Electrolytes
2. Serum creatinine

Rationale: 75% of patients on cyclosporine experience decreased renal output because of physiological changes in the kidneys, such as microcalcification and interstitial fibrosis. The serum creatinine test is a good indicator of renal fucntion
The nurse would question an order for immunostimulant therapy if the patient had which of following conditions? (Select all that apply)
1. Pregnancy
2. Renal disease
3. Infection
4. Liver disease
5. Metastatic cancer
1. Pregnancy
2. Renal disease
4. Liver disease
5. Metastatic cancer

Rationale: Pregnancy, renal or liver disease, and metastatic cancer are contraindications to the use of immunostimulant drugs. Infection, immunodeficiency disease, and cancer are indications for use of these drugs
The type of immunity achieved through the administration of vaccine is called:
1. active immunity
2. passive immunity
3. titer
4. vaccine
1. Active Immunity

Rationale: Active Immunity occurs when the patient has received the vaccine. Passive immunity is achieved by directly administering antibodies to a patient. A titer is a measurement of the amount of antibody produced after a vaccine.
A 5-year-old child is due for prekindergarten immunizations. After interviewing her mother, which of the following response may indicate a possible contraindication for giving this preschooler a live vaccine (e.g MMR) at this visit and would require further exploration by the nurse?
1. Her cousin has the flu
2. The mother has just finished her series of hepatitis B vaccines
3. Her arm got really sore after her last tetanus shot
4. They are caring for her grandmother who has just finished her second chemotherapy treatment for breast cancer.
4. They are caring for her grandmother who has just finished her second chemotherapy treatment for breast cancer.

Rationale: Live vaccines may be contraindicated when patients present an exposure risk of the infections agent to immunocompromised patients such as those on chemotherapy or immunsuprressant therapy. The patient's cousin having the flu is not a potential contraindication, assuming the cousin has a normal and active immune system. the mother would not be at risk since she has received recent vaccinations, assessment of her immune system would have been completed at that time. Soreness of the injected arm is a potential (mild) adverse effects of immunizations and can be managed symptomatically
1. A 60-year-old patient has osteoarthritis (OA) of the left knee. A finding that the nurse would expect to be present on examination of the patient's knee is
a. Heberden's nodules.
b. redness and swelling of the knee joint.
c. pain upon joint movement.
d. stiffness that increases with movement.
Answer: C
Rationale: Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is worse right after the patient rests and decreases with joint movement.
A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous?
1. Weight gain
2. Subnormal temperature
3. Elevated red blood cell count
4. Rash on the face across the bridge of the nose and on the cheeks
Answer: 4
Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.
1. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions?
1. "I should take hot baths because they are relaxing."
2. "I should sit whenever possible to conserve my energy."
3. "I should avoid long periods of rest because it causes joint stiffness."
4. "I should do some exercises, such as walking, when I am not fatigued."
1. "I should take hot baths because they are relaxing."
Rationale:
To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.
A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which of the following descriptions of this condition?
1. The presence of tiny red vesicles
2. An autoimmune disease that causes blistering in the epidermis
3. The presence of skin vesicles found along the nerve caused by a virus
4. The presence of red, raised papules and large plaques covered by silvery scales
Answer: 2
Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.
The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care?
1. Protecting the client from infection
2. Providing emotional support to decrease fear
3. Encouraging discussion about lifestyle changes
4. Identifying factors that decreased the immune function
Answer: 1
Rationale: The client with immune deficiency has inadequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.
A client calls the office of his primary care health care provider and tells the nurse that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction, because the client's neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to:
1. Advise the client to soak the site in hydrogen peroxide.
2.Ask the client if he ever sustained a bee sting in the past.
3. Tell the client to call an ambulance for transport to the emergency room.
4. Tell the client not to worry about the sting unless difficulty with breathing occurs.
Answer: 2
Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."
The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that immunization provides which of the following?1. Protection from all diseases
2. Innate immunity from disease
3. Natural immunity from disease
4. Acquired immunity from disease
Answer: 4
Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases.
The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is:
1. A local rash that occurs as a result of allergy
2. A disease caused by overexposure to sunlight
3. An inflammatory disease of collagen contained in connective tissue
4. A disease caused by the continuous release of histamine in the body
Answer: 3
Rationale: SLE is an inflammatory disease of collagen contained in connective tissue. Options 1, 2, and 4 are not associated with this disease.
The camp nurse prepares to instruct a group of children about Lyme disease. Which of the following information would the nurse include in the instructions?
1. Lyme disease is caused by a tick carried by deer.
2. Lyme disease is caused by contamination from cat feces.
3. Lyme disease can be contagious by skin contact with an infected individual.
4. Lyme disease can be caused by the inhalation of spores from bird droppings.
Answer: 1
Rationale: Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by Ixodes ticks can be infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings.
The client is diagnosed with stage I of Lyme disease. The nurse assesses the client for which characteristic of this stage?
1. Arthralgias
2. Flu-like symptoms
3. Enlarged and inflamed joints
4. Signs of neurological disorders
Answer: 2
Rationale: The hallmark of stage I is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bullseye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Neurological deficits occur in stage II. Arthralgias and joint enlargements are most likely to occur in stage III.
A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which of the following nursing actions is appropriate?
1. Refer the client for a blood test immediately.
2. Inform the client that there is not a test available for Lyme disease.
3. Tell the client that testing is not necessary unless arthralgia develops.
4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.
Answer: 4
Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Options 1, 2, and 3 are incorrect.
A Cub Scout leader who is a nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions?
1. "I need to bring a hat to wear during the trip."
2. "I should wear long-sleeved tops and long pants."
3. "I should not use insect repellent because it will attract the ticks."
4. "I need to wear closed shoes and socks that can be pulled up over my pants."
Answer: 3
Rationale: In the prevention of Lyme 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. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, one should avoid heavily wooded areas or areas with thick underbrush. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.
The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of the following?
1. Swelling in the genital area
2. Swelling in the lower extremities
3. Punch biopsy of the cutaneous lesions
4. Appearance of reddish-blue lesions on the skin
Answer: 3
Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.
Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply.
1. Use non-latex gloves.
2. Use medications from glass ampules.
3. Place the client in a private room only.
4. Do not puncture rubber stoppers with needles.
5. Keep a latex-safe supply cart available in the client's area.
6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.
Answer: 1 2 4 5
Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use non-latex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with a rubber stopper that requires puncture with a needle. It is not necessary to place the client in a private room.
A nurse is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?
1. Children in day care centers
2. Individuals with spina bifida
3. Individuals with cardiac disease
4. Individuals living in a group home
Answer: 2
Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work with manufacturing latex products; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, passion fruit, avocados, and chestnuts.
The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed?
1. Antibiotic
2. Antidiarrheal
3. Corticosteroid
4. Opioid analgesic
Answer: 3
Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. The incorrect options are not standard components of medication therapy for this disorder.
The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. Which client population is at most risk for developing this type of allergy?
1. Hairdressers
2. The homeless
3. Children in day care centers
4. Individuals living in a group home
Answer: 1
Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; individuals having multiple surgeries; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts.
The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food item?
1. Eggs
2. Milk
3. Yogurt
4. Bananas
Answer: 4
Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy.
A nurse is assigned to care for a client who returned home from the emergency department following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should:
1. Contact the health care provider (HCP).
2. Cover the crutch pads with cloth.
3. Call the local medical supply store, and ask for a cane to be delivered.
4. Tell the client that the crutches must be removed immediately from the house.
Answer: 2
Rationale: The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 4 is inappropriate and may alarm the client. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may not be appropriate, considering this client's injury. No reason exists to contact the HCP at this time.
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?
1. Elastic bandages
2. Adhesive bandages
3. Brown Ace bandages
4. Cotton pads and silk tape
Answer: 4
Rationale: Cotton pads and plastic or silk tape are latex-free products. The items identified in the incorrect options are products that contain latex.
A nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse understands that which problem is a priority for the client?
1. Infection
2. Inability to cope
3. Lack of information about the disease
4. Feeling uncomfortable about body changes
Answer: 1
Rationale: The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority problem is infection. The question presents no data indicating that options 2, 3, or 4 are a problem.
A client calls the emergency department and tells the nurse that he received a bee sting to the arm while weeding a garden. The client states that he has received bee stings in the past and is not allergic to bees. The client states that the site is painful and asks the nurse for advice to alleviate the pain. The nurse tells the client to first:
1. Take two acetaminophen (Tylenol).
2. Place a heating pad to the site.
3. Apply ice and elevate the site.
4. Lie down and elevate the arm.
Answer: 3
Rationale: When a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. Pain may be alleviated by the application of an ice pack and elevating the site. A heating pad will increase discomfort at the site. Acetaminophen may be taken by the client to assist in alleviating discomfort, but this would not treat the injury at a local level. Lying down and elevating the arm may have some effect on reducing edema at the site but will not directly assist in alleviating the pain at the site of injury.
A client with human immunodeficiency virus (HIV) who has contracted tuberculosis (TB) asks the nurse how long the medication therapy lasts. The nurse responds that the duration of therapy would likely be for at least:
1. 6 total months and at least 1 month after cultures convert to negative
2. 6 total months and at least 3 months after cultures convert to negative
3. 9 total months and at least 3 months after cultures convert to negative
4. 9 total months and at least 6 months after cultures convert to negative
Answer: 4
Rationale: The client with tuberculosis who is coinfected with HIV requires that antitubercular therapy last longer than usual. The prescription is usually for a total of 9 months and at least 6 months after sputum cultures convert to negative.
A client who is human immunodeficiency virus (HIV) positive has had a Mantoux skin test. The results show a 7-mm area of induration. The nurse evaluates that this result is:
1. Negative
2. Borderline
3. Uncertain
4. Positive
Answer: 4
Rationale: The client with HIV is considered to have positive results on Mantoux skin testing with an area of 5 mm of induration or greater. The client without HIV is positive with induration greater than 10 or 15 mm if the client is at low risk. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is also possible for the client infected with HIV to have false negative readings because of the immunosuppression factor.
A client with acquired immunodeficiency syndrome (AIDS) is taking zidovudine (Retrovir) 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. Which of the following would the nurse anticipate to be prescribed for the client?
1. Reduction in the medication dosage
2. Discontinuation of the medication
3. The administration of prednisone concurrent with the therapy
4. Administration of epoetin alfa (Epogen)
Answer: 2
Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.
A client with acquired immunodeficiency syndrome (AIDS) is taking didanosine (Videx). The client calls the nurse at the health care provider's office and reports nausea, vomiting, and abdominal pain. Which of the following instructions would the nurse provide to the client?
1. This is an expected side effect of the medication.
2. Come to the office to be seen by the health care provider.
3. Take crackers and milk with the administration of the medication.
4. Decrease the dose of the medication until the next health care provider's visit.
Answer: 2
Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of developing pancreatitis, which include increased serum amylase in association with increased serum triglycerides, decreased serum calcium, and nausea, vomiting, or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. The client should be seen by the health care provider.
Indinavir (Crixivan) is prescribed for a client with human immunodeficiency virus (HIV). The nurse has provided instructions to the client regarding ways to maximize absorption of the medication. Which of the following, if stated by the client, indicates an adequate understanding of the use of this medication?
1. "I need to take the medication with my large meal of the day."
2. "I need to store the medication in the refrigerator."
3. "I need to take the medication with water but on an empty stomach."
4. "I need to take the medication with a high-fat snack."
Answer: 3
Rationale: To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal such as cornflakes with skim milk and sugar. It is not to be administered with a large meal. The medication should be stored at room temperature and protected from moisture because moisture can degrade the medication.
A nurse is assisting in developing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention should the nurse suggest including in the plan of care to manage this symptom?
1. Keep the call bell within reach for the client.
2. Administer a sedative at bedtime.
3. Administer an antipyretic at bedtime.
4. Provide a back rub and comfort measures before bedtime.
Answer: 3
Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer an antipyretic at bedtime. It is also helpful to keep a change of bed linens and night clothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Options 1, 2, and 4 are important interventions but they are unrelated to the subject of fever and night sweats.
A nurse is assisting in preparing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure should the nurse include in the plan?
1. Dairy products with each snack and meal
2. Red meat daily
3. Adding spices to food to make the taste more palatable
4. Foods that are at room temperature
Answer: 4
Rationale: The client with AIDS experiencing nausea should avoid fatty products, such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous foods should be avoided because they aggravate nausea. Foods are best tolerated either cold or at room temperature.
A nurse is assisting in developing a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which of the following is the priority concern for this client?
1. Inability to care for self at home
2. Development of an infection
3. Lack of available support services
4. Isolation
Answer: 2
Rationale: Acquired immunodeficiency syndrome decreases the body's immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body's defense system. Opportunistic infections are a primary cause of death in people affected with AIDS. Therefore preventing infection is a priority of nursing care. Although the concerns in options 1, 3, and 4 may need to be addressed at some point in the care of the client, these are not the priority.
The nurse is assessing a client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection?
1. "Did you have chicken pox as a child?"
2. "How many sexual partners have you had?"
3. "Did you use an electric blanket on your side?"
4. "Why don't you try docosanol cream (Abreva) on your lesions?"
Answer: 1
Rationale: The client has the symptoms of herpes zoster, or shingles, which is caused by the same organism as chicken pox. Asking about sexual partners is inappropriate for this disorder. An electric blanket use does not cause this type of lesions. Abreva is used on herpes simplex I (cold sores).
A client who is prescribed zidovudine (Retrovir) has been diagnosed with severe neutropenia. The nurse anticipates which intervention will be implemented?\
1. The medication dose will be reduced.
2. The medication will be temporarily discontinued.
3. Prednisone will be added to the medication regimen.
4. Epoetin alfa (Epogen) will be added to the medication regimen.
Answer: 2
Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or neutropenia develops, treatment should be interrupted until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.
6. A patient with hip pain is diagnosed with osteoarthritis (OA). The nurse may need to teach the patient about the use of
a. prednisone (Deltasone).
b. capsaicin cream (Zostrix).
c. sulfasalazine (Azulfidine).
d. doxycycline (Vibramycin).
Answer: B
Rationale: Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.
7. A 71-year-old obese patient has bilateral osteoarthritis (OA) of the hips. The nurse teaches the patient that the most beneficial measure to protect the joints is to
a. use a wheelchair to avoid walking as much as possible.
b. sit in chairs that do not cause the hips to be lower than the knees.
c. use a walker for ambulation to relieve the pressure on the hips.
d. eat according to a weight-reduction diet to obtain a healthy body weight.
Answer: D
Rationale: Because the patient's major risk factor is obesity, the nurse should teach the patient that weight loss is the best way to reduce stress on the hips. Avoiding activity by sitting in a wheelchair would likely increase the patient's weight; moderate activity is recommended for patients with OA. Sitting with the hips higher than the knees and using a walker would be recommended but are not as helpful as weight loss for this obese patient.
9. A patient with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers, wrists, and feet with swelling, redness, and limited movement of the joints. When developing the plan of care, the nurse recognizes that the most appropriate patient outcome at this time is to
a. maintain a positive self-image.
b. perform activities of daily living independently.
c. achieve satisfactory control of pain.
d. make a successful adjustment to disease progression.
Answer: C
Rationale: The focus during an acute exacerbation of RA is to manage pain effectively. The other outcomes are appropriate long-term outcomes.
8. The health care provider prescribes methotrexate (Rheumatrex) for a 28-year-old woman with stage II moderate rheumatoid arthritis (RA). When obtaining a health history from the patient, the most important information for the nurse to communicate to the health care provider is that the patient has
a. a history of infectious mononucleosis as a teenager.
b. a family history of age-related macular degeneration of the retina.
c. been trying to have a baby before her disease becomes more severe.
d. been using large doses of vitamins and health foods to treat the RA.
Answer: C
Rationale: Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.
11. When teaching range-of-motion exercises to a patient who is having an acute exacerbation of rheumatoid arthritis (RA) with joint pain and swelling in both hands, the nurse teaches the patient that
a. affected joints should not be exercised when pain is present.
b. cold applications before exercise will decrease joint pain.
c. exercises should be performed passively by someone other than the patient.
d. regular walking may substitute for range-of-motion (ROM) exercises on some days.
Answer: B
Rationale: Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.
10. A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes and a dry mouth. Which action by the nurse is most appropriate?
a. Have the patient withhold the daily methotrexate (Rheumatrex) until talking with the health care provider.
b. Reassure the patient that dry eyes and mouth are very common with RA.
c. Teach the patient to use an antiseptic mouth wash tid.
d. Suggest that the patient start using over-the-counter (OTC) artificial tears.
Answer: D
Rationale: The patient's dry eyes and oral mucous membranes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes and mouth are not side effects of methotrexate. Although dry eyes and mouth are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. Rinsing the mouth to decrease oral dryness is appropriate, but the frequent use of antiseptic mouthwashes is not appropriate unless the patient has oral symptoms that require this.
13. When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to
a. stand rather than sit when performing household chores.
b. avoid activities that require continuous use of the same muscles.
c. strengthen small hand muscles by wringing sponges or washcloths.
d. protect the knee joints by sleeping with a small pillow under the knees.
Answer: B
Rationale: Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee ROM.
14. When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex), which information is most important to communicate to the health care provider?
a. The platelet count is 130,000/μl.
b. The white blood cell count (WBC) is 1500/μl.
c. The blood glucose is 130 mg/dl.
d. The potassium is 5.2 mEq/L.
Answer: B
Rationale: Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The other laboratory values are also abnormal but are not far from normal values and would not have any immediate serious consequences.
15. When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with
a. a warm bath followed by a short rest.
b. a 10-minute routine of isometric exercises.
c. stretching exercises to relieve joint stiffness.
d. active range-of-motion (ROM) exercises.
Answer: A
Rationale: Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.
16. The biologic agent anakinra (Kineret) is prescribed for a patient who has moderately severe rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about
a. symptoms of gastrointestinal (GI) irritation or bleeding.
b. self-administration of subcutaneous injections.
c. taking the medication with at least 8 oz of fluid.
d. avoiding concurrently taking aspirin or NSAIDs.
Answer: B
Rationale: Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs and these should not be discontinued.
12. Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. When the patient has a follow-up visit 1 month later, the nurse recognizes that the patient's response to the treatment may be best evaluated by
a. blood glucose testing.
b. liver function tests.
c. serum electrolyte levels.
d. C-reactive protein level.
Answer: D
Rationale: C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids.
25. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes the information that SLE is a(n)
a. hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant.
b. autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body.
c. disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression.
d. disease that causes production of antibodies that bind with cellular estrogen receptors, causing an inflammatory response.
Answer: C
Rationale: SLE has an unpredictable course, even with appropriate treatment. Women are more at risk for SLE, but it is not confined exclusively to women. Clinical symptoms may worsen during pregnancy but are not confined to pregnancy or the perinatal period. All nucleated cells are not destroyed by the antinuclear antibodies. The inflammation in SLE is not caused by antibody binding to cellular estrogen receptors.
18. In teaching a patient with ankylosing spondylitis (AS) about the management of the condition, the nurse instructs the patient to
a. sleep on the side with hips flexed.
b. take slow, long walks as a form of exercise.
c. perform daily deep-breathing exercises.
d. take frequent naps during the day.
Answer: C
Rationale: Deep-breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.
17. A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate?"
a. "Your family may need some help to understand the impact of your rheumatoid arthritis."
b. "You may need to see a family therapist for some help."
c. "Perhaps it would be helpful for you and your family to get involved in a support group."
d. "Tell me more about the situations that are causing stress."
Answer: D
Rationale: The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.
26. A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care?
a. Institute seizure precautions.
b. Reorient to time and place PRN.
c. Monitor intake and output.
d. Place on cardiac monitor.
Answer: C
Rationale: Lupus nephritis is a common complication of SLE, and when the patient is taking corticosteroids, it is especially important to monitor renal function. There is no indication that the patient is experiencing any nervous system or cardiac problems with the SLE.
27. A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I hate the way I look! I never go anyplace except here to the health clinic." An appropriate nursing diagnosis for the patient is
a. activity intolerance related to fatigue and inactivity.
b. impaired skin integrity related to itching and skin sloughing.
c. social isolation related to embarrassment about the effects of SLE.
d. impaired social interaction related to lack of social skills.
Answer: C
Rationale: The patient's statement about not going anyplace because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.
28. A patient with polyarthralgia with joint swelling and pain is being evaluated for systemic lupus erythematosus (SLE). The nurse knows that the serum test result that is the most specific for SLE is the presence of
a. rheumatoid factor.
b. anti-Smith antibody (Anti-Sm).
c. antinuclear antibody (ANA).
d. lupus erythematosus (LE) cell prep.
Answer: B
Rationale: The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE
29. Following instruction for a patient with newly diagnosed systemic lupus erythematosus (SLE), the nurse determines that teaching about the disease has been effective when the patient says,
a. "I should expect to have a low fever all the time with this disease."
b. "I need to restrict my exposure to sunlight to prevent an acute onset of symptoms."
c. "I should try to ignore my symptoms as much as possible and have a positive outlook."
d. "I can expect a temporary improvement in my symptoms if I become pregnant."
Answer: B
Rationale: Sun exposure is associated with SLE exacerbation, and patients should use sunscreen with an SPF of at least 15 and stay out of the sun between 11:00 AM and 3:00 PM. Low-grade fever may occur with an exacerbation but should not be expected all the time. A positive attitude may decrease the incidence of SLE exacerbations, but patients are taught to self-monitor for symptoms that might indicate changes in the disease process. Symptoms may worsen during pregnancy and especially during the postpartum period.
30. A 19-year-old patient who is taking azathioprine (Imuran) for systemic lupus erythematosus has a check-up before leaving home for college. The health care provider writes all of these orders. Which one should the nurse question?
a. Naproxen (Aleve) 200 mg BID
b. Give measles-mumps-rubella (MMR) immunization
c. Draw anti-DNA titer
d. Famotidine (Pepcid) 20 mg daily
Answer: B
Rationale: Live virus vaccines, such as rubella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.
31. A patient has systemic sclerosis manifested by the CREST syndrome. During assessment of the patient, the nurse would expect to find
a. bony ankylosis of the small joints in the feet.
b. a recent history of significant weight gain.
c. burning, itching, and photosensitivity of the eyes.
d. a history of numbness and tingling in the fingers.
Answer: D
Rationale: Raynaud's phenomenon is one aspect of the CREST syndrome. Bony ankylosis is not a symptom of systemic sclerosis, which does not affect bone. Weight loss occurs with CREST syndrome as a result of esophageal scarring. Burning, itching, and photosensitivity of the eyes are not associated with systemic sclerosis.
32. The nurse teaches a patient diagnosed with progressive systemic sclerosis about health maintenance activities. The nurse determines that additional instruction is needed when the patient says,
a. "I should lie down for an hour after meals."
b. "Lotions will help if I rub them in for a long time."
c. "I should perform range-of-motion exercises daily."
d. "Paraffin baths can be used to help my hands."
Answer: A
Rationale: Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective
19. A patient who had arthroscopic surgery of the left knee 5 days previously is admitted with a red, swollen, and hot-to-touch knee. Which of these assessment data obtained by the nurse should be reported to the health care provider immediately?
a. The white blood cell count is 14,200/μl.
b. The patient rates the knee pain at 9 on a 10-point pain scale.
c. The patient has recently taken ibuprofen (Motrin).
d. The oral temperature is 104.1° F degrees.
Answer: D
Rationale: The elevated temperature suggests that the patient may have an infection and be in danger of developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately life-threatening problems.
20. A 22-year-old patient hospitalized with severe pain in the knees and a fever and shaking chills is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient
a. has a parent who has reactive arthritis.
b. recently returned from a trip to South America.
c. is sexually active and has multiple partners.
d. had several sports-related knee injuries as a teenager.
Answer: C
Rationale: Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.
21. A concerned parent who lives in an area endemic for Lyme disease asks the nurse what precautions should be taken for the disease. The nurse will teach the parent that
a. early treatment of the infection with antiviral agents can prevent the development of cardiac and neurologic manifestations.
b. if Lyme disease is transmitted by a tick, symptoms of nausea, vomiting, and diarrhea occur before the onset of joint pain.
c. transmission of the disease can be prevented by covering ticks attached to the skin with oil to suffocate them.
d. an early sign of Lyme disease is a lesion at the bite site that increases in size and has a red border and clear center.
Answer: D
Rationale: Erythema migrans is the typical early lesion associated with a tick bite causing Lyme disease. Treatment with antibiotics can prevent the later stages of Lyme disease. The initial symptoms are headache, chills, stiff neck, fatigue, and joint and muscle pain. Ticks should be removed with tweezers.
33. A patient hospitalized for IV corticosteroid therapy to treat polymyositis has joint pain, an erythematosus facial rash with eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is
a. risk for aspiration related to dysphagia.
b. acute pain related to inflammation.
c. risk for impaired skin integrity related to scratching.
d. disturbed visual perception related to eyelid swelling.
Answer: A
Rationale: The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses are also appropriate but are not as high a priority as the maintenance of the patient's airway.
34. A patient is hospitalized for onset of diffuse erythema of the upper body with periorbital edema. The health care provider suspects dermatomyositis. In planning care for the patient, the nurse anticipates that the collaborative care of the patient will involve
a. instillation of artificial tears.
b. local steroid injections of skin lesions.
c. administration of high-dose corticosteroids.
d. electromyelographic (EMG) evaluation for meningeal inflammation.
Answer: C
Rationale: Dermatomyositis is initially treated with high-dose steroids. Eye dryness is not a manifestation of dermatomyositis and artificial tears are not routinely needed. Topical corticosteroids may be used to treat the skin rash. EMG evaluation is done because this disease involves muscle changes, not neurologic changes.
35. A patient with fibromyalgia syndrome (FMS) tells the nurse, "I don't know why the doctor has prescribed amitriptyline (Elavil) for me. I don't feel depressed, just tired and achy." The most appropriate response by the nurse is, "The Elavil
a. is ordered to prevent depression from occurring."
b. will improve the quality of your sleep at night."
c. relaxes your muscles and helps prevent spasm."
d. has antiinflammatory actions to reduce joint pain."
Answer: B
Rationale: Elavil is ordered to improve sleep, to decrease stress and fatigue, and as an adjuvant medication for pain control. It would not be ordered to prevent depression, although it might be ordered to treat depression in a patient with FMS. Elavil is not a muscle relaxant or an antiinflammatory drug, although medications from these categories are used in treating FMS.
36. A patient who has had fatigue and muscle weakness for several years is diagnosed with chronic fatigue syndrome. The patient expresses anger at the health care professional for not offering relief of the symptoms and also anger at family members for saying "snap out of it and get busy." Based on the patient's statements, the nurse identifies a nursing diagnosis of
a. activity intolerance related to fatigue.
b. powerlessness related to lack of control over illness.
c. altered family process related to illness of family member.
d. situational low self-esteem related to inability to meet role expectation.
Answer: B
Rationale: The patient's statements support the problem and etiology of powerlessness related to lack of control. The patient does not complain about activity intolerance. Although the patient may have risk for altered family process, but there are not enough data to support this diagnosis. The patient is not expressing low self-esteem or feelings of inadequacy regarding meeting role expectations.
37. The health care provider plans to prescribe methotrexate (Rheumatrex) to a patient with newly diagnosed rheumatoid arthritis (RA). The patient tells the nurse, "That drug has too many side effects; I would rather wait until my joint problems are worse before beginning any drugs." The most appropriate response by the nurse is
a. "You should tell the doctor how you feel so the two of you can make a decision together."
b. "It is important to start methotrexate early in order to decrease the joint damage."
c. "Methotrexate is not expensive and will be cheaper to take than other possible drugs."
d. "Methotrexate is very effective and has no more side effects than the other available drugs."
Answer: B
Rationale: Disease-modifying anti-rheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.
38. A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication?
a. The patient has experienced a recent 5-pound weight loss.
b. The patient's erythrocyte sedimentation rate (ESR) has increased.
c. The patient's blood glucose is 166 mg/dl.
d. The patient has no improvement in symptoms.
Answer: C
Rationale: Hyperglycemia is a side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication.
39. The home health nurse is doing a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed?
a. The patient sleeps with two pillows under the head.
b. The patient has been taking 16 aspirins daily.
c. The patient requires a 2 hour midday nap.
d. The patient sits on a stool when preparing meals.
Answer: A
Rationale: The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective.
40. A patient with an acute attack of gout in the left great toe has a new prescription for probenecid (Benemid). Which information about the patient's home routine indicates a need for teaching regarding gout management?
a. The patient takes one aspirin a day prophylactically to prevent angina.
b. The patient sleeps about 8 to 10 hours every night.
c. The patient generally drinks about 3 quarts of juice and water daily.
d. The patient usually eats beef once or twice a week.
Answer: A
Rationale: Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.
41. When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider?
a. Elevated blood urea nitrogen (BUN) and creatinine
b. Positive lupus erythematosus cell prep
c. Positive antinuclear antibodies (ANA)
d. Decreased C-reactive protein (CRP)
Answer: A
Rationale: The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive LE cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.
1. During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the patient to report (Select all that apply.)
a. sleep disturbances.
b. multiple tender points.
c. urinary frequency and urgency.
d. cardiac palpitations and dizziness.
e. multijoint pain with inflammation and swelling.
f. widespread bilateral, burning musculoskeletal pain.
Answer: A, B, C, F
Rationale: These symptoms are commonly described by patients with FMS. Cardiac involvement and joint inflammation are not typical of FMS.
A client with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine (Videx) therapy. The clinic nurse emphasizes what instruction to this client?
1. Take crackers and milk with each dose of the medication.
2. Come to the health care clinic to be seen by the health care provider.
3. Decrease the dose of the medication until the next clinic visit.
4. This is an uncomfortable but expected side effect of the medication.
Answer: 2
Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine (Videx). The client should be seen by the health care provider and be monitored for indications of developing pancreatitis. The reported symptoms are not the primary subject, and so the options directed toward explaining or managing them are not correct. The nurse should not encourage the client to alter the medication dose without first notifying the health care provider.
The nurse interprets that the client who is prescribed zalcitabine (Hivid) is experiencing an adverse effect of this medication when which event is reported by the client?
1. Diarrhea
2. Tinnitus
3. Burning with urination
4. Numbness in the legs
Answer: 4
Rationale: Peripheral neuropathy is an adverse effect associated with the use of zalcitabine, which manifests initially as numbness and burning sensations in the extremities. They may progress to sharp shooting pains or severe continuous burning if the medication is not withdrawn. The other options are not associated with use of this medication.
A client is diagnosed with stage 1 Lyme disease. The nurse checks the client for which hallmark characteristic of this stage?
1. Signs of neurological disorders
2. Enlarged and inflamed joints
3. Headache
4. Skin rash
Answer: 4
Rationale: The hallmark of stage 1 is the development of a skin rash that occurs within 2 to 30 days of infection, generally at the site of the tick bite. The remaining options are not initially related to this pathology.
A client diagnosed with Lyme disease says to the nurse, "I heard this disease can affect the heart. Is this true?" The nurse should make which response to the client?
1. "Where did you get your information?"
2. "Yes, that's true but it rarely ever occurs."
3. "It can, but you will be monitored closely for cardiac complications."
4. "It primarily affects the joints with the occasional facial paralysis."
Answer: 3
Rationale: Stage 2 of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. The serious problems that occur in this stage include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. The remaining options are either untrue or do not effectively address the client's concern.
A nurse reads the chart of a client who has been diagnosed with stage 3 Lyme disease. Which clinical manifestation supports this diagnosis?
1. A generalized skin rash
2. A cardiac dysrhythmia
3. Complaints of joint pain
4. Paralysis of a facial muscle
Answer: 3
Rationale: Stage 3 develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage 2. A rash occurs in stage 1. Paralysis of the extremity where the tick bite occurred is not a characteristic of Lyme disease.
A client arrives at the health care clinic requesting to be tested for Lyme disease. The client tells the nurse that he removed the tick and flushed it down the toilet. Which nursing action is appropriate?
1. Refer the client for a blood test immediately.
2. Inform the client that the tick is needed to perform a test.
3. Arrange for the client to return in 4 to 6 weeks to be tested.
4. Ask the client to describe the size, shape, and color of the tick.
Answer: 3
Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. Options 1, 2, and 4 are inaccurate.
A client is positively diagnosed with stage 1 Lyme disease. The client asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which of the following will be part of the treatment plan?
1. Ultraviolet light therapy
2. No treatment unless symptoms develop
3. Treatment with intravenous (IV) penicillin G
4. A 3- to 4-week course of oral antibiotic therapy
Answer: 4
Rationale: A 3- to 4-week course of oral antibiotic therapy is recommended during stage 1. Later stages of Lyme disease may require therapy with intravenous antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.
A nurse is collecting data on a client with rheumatoid arthritis. The nurse looks at the client's hands and notes the characteristic hand deformity in which the swelling of the metacarpophalangeal joints (the big knuckles at the base of the fingers) causes fingers to become displaced, tending towards the little finger. The nurse identifies this deformity as:
1. Ulnar drift
2. Rheumatoid nodules
3. Swan neck deformity
4. Boutonniere deformity
Answer: 1
Rationale: All of the conditions identified in the options can occur in rheumatoid arthritis. Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints.
A nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse further checks for which of the following that is also indicative of the presence of SLE?
1. Emboli
2. Ascites
3. Two hemoglobin S genes
4. Butterfly rash on cheeks and bridge of nose
Answer: 4
Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE. Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many conditions but are not associated with SLE.
A health care provider aspirates synovial fluid from a knee joint of a client with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to indicate which finding?
1. Cloudy synovial fluid
2. Presence of organisms
3. Bloody synovial fluid
4. Presence of irate crystals
Answer: 1
Rationale: Cloudy synovial fluid is diagnostic of rheumatoid arthritis. Organisms present in the synovial fluid are characteristic of a septic joint condition. Bloody synovial fluid is seen with trauma. Urate crystals are found in gout.
Which client is at the highest risk for systemic lupus erythematous (SLE)?
1. An Asian male
2. A white female
3. An African-American male
4. An African-American female
Answer: 4
Rationale: SLE affects females more commonly than males. It is more common in African-American females than in white females.
A client calls the health care clinic and tells the nurse that he was bitten by a tick. The client is concerned and asks the nurse about the first signs of Lyme disease. The nurse informs the client that stage 1 of Lyme disease is characterized by:
1. Skin rash
2. Painful joints
3. Tremors and weakness
4. Headaches and blurred vision
Answer: 1
Rationale: The hallmark of stage 1 of Lyme disease is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bullseye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage 1, most infected people develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. Options 2, 3, and 4 are not the first symptoms related to Lyme disease.
A client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which of the following questions should the nurse ask next?
1. "Was the tick small or large?"
2. "When were you bitten by the tick?"
3. "Did you save the tick for inspection?"
4. "Did the tick bite anyone else in the family?"
Answer: 2
Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. The appropriate question by the nurse should elicit information related to when the tick bite occurred.
A nurse is doing discharge teaching with a client who has sickle cell disease. The nurse instructs the client to avoid which factor that could precipitate a sickle cell crisis?
1. Infection
2. Mild exercise
3. Fluid overload
4. Warm weather
Answer: 1
Rationale: The client should avoid infections, which can increase metabolic demand and cause dehydration, precipitating a sickle cell crisis. The client should also avoid dehydration from other causes. Warm weather and mild exercise do not need to be avoided, but the client should take measures to avoid dehydration during these conditions. Fluids are important to prevent dehydration. Finally, the client should avoid being in areas of high altitude, or flying in a nonpressurized aircraft because of lesser oxygen tension in these areas.
A client with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client verbalized to increase intake of foods such as:
1. Raw fruits and vegetables
2. Hot soup
3. Peanut butter
4. Puddings
Answer: 4
Rationale: The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables. The client is encouraged to take in foods that are mild, nonabrasive, and easy to swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs, and desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating.
A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse suggest to assist the client in performing activities of daily living?
1. Provide supportive care with hygiene needs.
2. Provide meals and snacks with high protein, high calorie, and high nutritional value.
3. Provide small, frequent meals.
4. Offer low microbial food.
Answer: 1
Rationale: Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options 2, 3, and 4 are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option 2 will assist the client in maintaining appropriate weight and proper nutrition. Option 3 will assist the client in tolerating meals better. Option 4 will decrease the client's risk of infection.
A nurse is reviewing the medical record of a young female client who is suspected of having systematic lupus erythematosus (SLE). Which of the following would the nurse expect to note documented in the record that is related to this diagnosis?
1. Presence of two hemoglobin S genes in the blood cell report
2. Ascites noted in the abdomen
3. Recurrent emboli
4. Butterfly rash on cheeks and bridge of the nose
Answer: 4
Rationale: SLE primarily occurs in females 10 to 35 years of age and is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE. Option 1 is found in sickle cell anemia. Options 2 and 3 are found in many conditions but are not usually noted in SLE.
A nurse determines that the neutropenic client needs further discharge teaching if which of the following statements is made by the client?
1. "I will include plenty of fresh fruits in my diet."
2. "If I develop a fever over 100° F, I will call my doctor."
3. "Petting my dog is fine as long as I wash my hands after doing so."
4. "My husband will just have to take over cleaning the cat's litter box."
Answer: 1
Rationale: Fresh fruits and vegetables are eliminated from the diet to avoid the introduction of pathogens. Fever of 100.4° F or greater should be reported immediately. Feeding and petting cats and dogs are fine as long as handwashing follows. Handling pet excrement must be avoided to avoid exposure to pathogens.
The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions?
1. "I should take hot baths because they are relaxing."
2. "I should sit whenever possible to conserve my energy."
3. "I should avoid long periods of rest because it causes joint stiffness."
4. "I should do some exercises, such as walking, when I am not fatigued."
Answer: 1
Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.
The client with acquired immunodeficiency syndrome has raised, dark purplish 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 due to Kaposi's sarcoma?
1. Skin biopsy
2. Lung biopsy
3. Western blot
4. Enzyme-linked immunosorbent assay
Answer: 1
Rationale: The skin biopsy is the procedure of choice to diagnose Kaposi's sarcoma, which frequently complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay and Western blot are tests to diagnose human immunodeficiency virus status.
A client with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a nursing diagnosis of Impaired Gas Exchange written in the plan of care. Which of the following indicates that the expected outcome of care has not yet been achieved?
1. The client limits fluid intake.
2. The client has clear breath sounds.
3. The client expectorates secretions easily.
4. The client is free of complaints of shortness of breath.
Answer: 1
Rationale: The status of the client with a nursing diagnosis of Impaired Gas Exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include that the client breathes easier, coughs up secretions effectively, and has clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.
A nurse is providing dietary instructions to a client with systemic lupus erythematosus. Which of the following dietary items would the nurse instruct the client to avoid?
1. Steak
2. Turkey
3. Broccoli
4. Cantaloupe
Answer: 1
Rationale: The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake.
A client is diagnosed with stage I of Lyme disease. In addition to the rash, the nurse would check the client for which manifestation?
1. Arthralgias
2. Flulike symptoms
3. Neurologic deficits
4. Enlarged and inflamed joints
Answer: 2
Rationale: The hallmark of stage I is the development of a skin rash at the tick bite site. The rash develops into a concentric ring that has a bullseye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. The other options listed occur in stage II (neurological deficits) or stage III (arthralgias and enlarged, inflamed joints).
A client reports to the health care clinic to obtain testing regarding human immunodeficiency virus (HIV) status after being exposed to an individual who is HIV positive. The test results are reported as negative, and the client tells the nurse that he feels so much better knowing that he had not contracted HIV. The nurse explains the test results to the client, telling the client that:
1. There is no further need for testing.
2. A negative HIV test is considered accurate.
3. A negative HIV test is not considered accurate during the first 6 months after exposure.
4. The test should be repeated in 1 week.
Answer: 3
Rationale: A test done for HIV should be repeated. There might be a lag period after the infection occurs and before antibodies appear in the blood. Therefore a negative HIV test is not considered accurate during the first 6 months after exposure.
A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse would suspect that which of the following findings will be reported from this blood test?
1. Increased red blood cell count
2. Decrease of all cell types
3. Increased white blood cell count
4. Increased neutrophils
Answer: 2
Rationale: In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease of all cell types, probably caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.
A clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse assesses for an early manifestation of Pneumocystis jiroveci infection by monitoring for which of the following at each client visit?
1. Fever
2. Cough
3. Dyspnea on exertion
4. Dyspnea at rest
Answer: 2
Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.
A nurse is providing instructions to a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. The nurse advises the client to do which of the following to increase comfort while minimizing symptoms?
1. Remove the plastic cover on the pillow.
2. Keep liquids on the nightstand at home.
3. Reduce fluid intake before bedtime.
4. Take an antipyretic after the fever spikes.
Answer: 2
Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to keep liquids on the nightstand at home. The client should keep a plastic cover on the pillow and place a towel over the pillowcase if needed also. The client should not decrease fluid intake, and the client should take an antipyretic before going to sleep and before the fever spikes.
A nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse would inform the students that which of the following is an unsafe behavior?
1. Abstinence
2. Mutual monogamy
3. Use of latex condoms
4. Use of natural skin condoms
Answer: 4
Rationale: The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through. Abstinence is the safest way to avoid HIV infection. The next most reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of the HIV virus as long as the condom is used properly and remains in place and intact.
A nurse is providing information to a client with systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which of the following foods?
1. Chicken
2. Beef
3. Melons
4. Cauliflower
Answer: 2
Rationale: The client with SLE is at risk for cardiovascular disorders, such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce intake of salt, fat, and cholesterol.
A client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse would focus on which of the following first until additional help arrives?
1. Preparing a dose of epinephrine (Adrenalin)
2. Preparing a dose of a corticosteroid
3. Maintaining a patent airway
4. Telling the client to obtain a Medic-Alert bracelet
Answer: 3
Rationale: The initial priority of the nurse would be to maintain a patent airway. Once additional helps arrives, the client would likely receive epinephrine and corticosteroids. The topic of the Medic-Alert bracelet should be deferred until the client is stable.
A client is diagnosed with an immune deficiency. The nurse focuses on which of the following as the highest priority when providing care to this client?
1. Encouraging discussion about emotional impact of the disorder
2. Identifying historical factors that placed the client at risk
3. Providing emotional support to decrease fear
4. Protecting the client from infection
Answer: 4
Rationale: The client with immune deficiency has inadequate immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. The other options are also part of the plan of care but are not the highest priority.
A nurse is assisting in the care of a client diagnosed with systemic lupus erythematosus (SLE). The nurse should administer which of the following prescribed medications that is needed to manage the condition?
1. Antidiarrheal
2. Corticosteroid
3. Antibiotic
4. Opioid analgesic
Answer: 2
Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory medications, corticosteroids, and immunosuppressants. The other options are not standard components of medication therapy for this disorder.
THIS SET IS OFTEN IN FOLDERS WITH...