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."
A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which description 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 scales2. An autoimmune disease that causes blistering in the epidermis
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan?
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 function1. Protecting the client from infection
A client calls the nurse in the emergency department and states that he was just stung by a bumble bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which nursing action should the nurse take?
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 department.
4. Tell the client not to worry about the sting unless difficulty with breathing occurs.2. Ask the client if he ever sustained a bee sting in the past.
The community health nurse is conducting a research study and is identifying clients in the community 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 home1. Hairdressers
Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.
1. Use nonlatex gloves.
2. Use medications from glass ampules.
3. Place the client in a private room only.
4. Keep a latex-safe supply cart available in the client's area.
5. Avoid the use of medication vials that have rubber stoppers.
6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.- 1. Use nonlatex gloves.
- 2. Use medications from glass ampules.
- 4. Keep a latex-safe supply cart available in the client's area.
- 5. Avoid the use of medication vials that have rubber stoppers.
The camp nurse prepares to instruct a group of children about Lyme disease. Which information should 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 caused by the inhalation of spores from bird droppings.
4. Lyme disease can be contagious through skin contact with an infected individual.1. Lyme disease is caused by a tick carried by deer.
A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed?
1. Maintain bed rest as much as possible.
2. Administer corticosteroids as prescribed for inflammation.
3. Advise the client to remain supine for 1 to 2 hours after meals.
4. Keep the room temperature warm during the day and cool at night.2. Administer corticosteroids as prescribed for inflammation.
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 nursing actions aremost appropriate? Select all that apply.
1. Tell the client that testing is not necessary unless arthralgia develops.
2. Tell the client to avoid any woody, grassy areas that may contain ticks.
3. Instruct the client to immediately start to take the antibodies that are prescribed.
4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease.
5. Tell the client if this happens again to never remove the tick but vigorously scrub the area with an antiseptic.- 2. Tell the client to avoid any woody, grassy areas that may contain ticks.
- 3. Instruct the client to immediately start to take the antibodies that are prescribed.
- 4.Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease.
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 finding?
1. Swelling in the genital area
2. Swelling in the lower extremities
3. Positive punch biopsy of the cutaneous lesions
4. Appearance of reddish-blue lesions noted on the skin3. Positive punch biopsy of the cutaneous lesions
The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate for the nurse to perform? Select all that apply.
1. Record site, date, and time of the test.
2. Give the client a list of potential allergens if identified.
3. Estimate the size of the wheal and document the finding.
4. Tell the client to return to have the site inspected only if there is a reaction.
5. Have the client wait in the waiting room for at least 1 to 2 hours after injection.- 1. Record site, date, and time of the test.
- 2. Give the client a list of potential allergens if identified.
The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item?
1. Eggs
2. Milk
3. Yogurt
4. Bananas4. Bananas
A client with acquired immunodeficiency syndrome is receiving ganciclovir (Cytovene). The nurse should take which priority action in caring for this client?
1. Monitor for signs of hyperglycemia.
2. Administer the medication without food.
3. Administer the medication with an antacid.
4. Ensure that the client uses an electric razor for shaving.4. Ensure that the client uses an electric razor for shaving.
The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection?
1. Fever, hypotension, and polyuria
2. Hypertension, polyuria, and thirst
3. Fever, hypertension, and graft tenderness
4. Hypotension, graft tenderness, and hypothermia3. Fever, hypertension, and graft tenderness
A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine (Retrovir). The nurse should monitor the results of which laboratory blood study for adverse effects of therapy?
1. Creatinine level
2. Potassium concentration
3. Complete blood count (CBC)
4. Blood urea nitrogen (BUN) level3. Complete blood count (CBC)
A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine (Videx). When the nurse reviews the client's laboratory test results, which result should be most closely monitored?
1. Protein
2. Glucose
3. Amylase
4. Cholesterol3. Amylase
A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication?
1. Western blot
2. CD4+ cell count
3. Enzyme-linked immunosorbent assay (ELISA)
4. Complete blood cell (CBC) count with differential2. CD4+ cell count
A client who has been receiving pentamidine (Pentam 300) intravenously now has a fever with a temperature of 102° F. Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition?
1. Inadequate thermoregulation
2. Insufficient medication dosing
3. Toxic nervous system effects from the medication
4. Infection caused by leukopenic effects of the medication4. Infection caused by leukopenic effects of the medication
A client is diagnosed with stage I Lyme disease, and the nurse assesses the client for disease manifestations. Which should the nurse expect to note as the hallmark characteristic of this stage?
1. Skin rash
2. Arthralgias
3. Neurological deficits
4. Enlarged and inflamed joints1. Skin rash
Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage?
1. Arthralgias
2. Joint enlargement
3. Erythematous rash
4. Cardiac conduction deficits4. Cardiac conduction deficits
The clinic nurse reads the chart of a client just seen by the health care provider (HCP) and notes that the HCP has documented that the client has stage III Lyme disease. Which clinical manifestation should the nurse expect to note in this client?
1. A generalized skin rash
2. A cardiac dysrhythmia
3. Complaints of joint pain
4. Paralysis of the affected extremity3. Complaints of joint pain
A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. The client reports that he removed the tick and flushed it down the toilet. The nurse should take which nursing action?
1. Refer the client for a blood test immediately.
2. Ask the client about the size and color of the tick.
3. Tell the client to return to the clinic in 4 to 6 weeks.
4. Inform the client that the tick is needed to perform a test.3. Tell the client to return to the clinic in 4 to 6 weeks.
A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention 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 therapy4. A 3- to 4-week course of oral antibiotic therapy
The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess that also is indicative of SLE?
1. Ascites
2. Emboli
3. Facial rash
4. Two hemoglobin S genes3. Facial rash
A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of his enzyme-linked immunosorbent assay (ELISA) has been positive. The nurse should formulate a response based on which information?
1. A Western blot will be done to confirm these findings.
2. The client probably will have a bone marrow biopsy done.
3. A CD4+ cell count will be done to measure T-helper lymphocytes.
4. The client will be diagnosed definitively as positive for HIV infection at this point.1. A Western blot will be done to confirm these findings.
The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation?
1. Fever
2. Cough
3. Dyspnea at rest
4. Dyspnea on exertion2. Cough
A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding?
1. The histoplasmosis is resolving.
2. The client has disseminated histoplasmosis infection.
3. This is a side effect of the medications given to treat AIDS.
4. The client probably has another infection that is developing.2. The client has disseminated histoplasmosis infection.
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention would be the least helpful in managing this symptom?
1. Keep liquids at the bedside.
2. Make sure the pillow has a plastic cover.
3. Keep a change of bed linens nearby in case they are needed.
4. Administer an antipyretic after the client has a spike in temperature.4. Administer an antipyretic after the client has a spike in temperature.
A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan?
1. Provide large, nutritious meals.
2. Serve foods while they are hot.
3. Add spices to food for added flavor.
4. Remove dairy products and red meat from the meal.4. Remove dairy products and red meat from the meal.
The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity?
1. Sunlight
2. Going to parties
3. The use of latex condoms
4. Outdoor activities as much as possible3. The use of latex condoms
A client is diagnosed with Goodpasture's syndrome. The nurse determines that this client's renal disease is caused by which response?
1. A type I hypersensitivity response
2. A type II hypersensitivity response
3. A type III hypersensitivity response
4. A type IV hypersensitivity response2. A type II hypersensitivity response
The nursing instructor asks a nursing student to identify the components of natural resistance as it relates to the immune system. Which statement by the nursing student indicates a need for further research?
1. "It also is called inherited immunity."
2. "It is that immunity with which a person is born."
3. "It does not require previous exposure to the antigen."
4. "It includes all antigen-specific immunities a person develops during a lifetime."4. "It includes all antigen-specific immunities a person develops during a lifetime."
The nursing student is planning to conduct a clinical conference on the immune system. In creating a handout for the conference, what should the student include as the function of B lymphocytes (B cells)?
1. Activate T cells.
2. Make antibodies.
3. Initiate phagocytosis.
4. Attack and kill target cells directly.2. Make antibodies.
The nurse has been assigned to care for a client with an immune disorder. In developing a plan of care for this client, the nurse incorporates knowledge that the immune system consists of specific major types of cells. Which types of cells are associated with the immune system? Select all that apply.
1. Dendritic cells
2. B lymphocytes
3. Red blood cells
4. Helper T lymphocytes
5. Cytolytic T lymphocytes- 1. Dendritic cells
- 2. B lymphocytes
- 4. Helper T lymphocytes
- 5. Cytolytic T lymphocytes
The nurse mentor is describing the phases of the immune response to a recent nursing graduate. The mentor determines that the graduate needs additional information if the graduate states that which is a phase of the immune response?
1. Effector phase
2. Memory phase
3. Activation phase
4. Recognition phase2. Memory phase
A client is admitted to the hospital with a diagnosis of parasitic worms. The nurse should plan care knowing that which cells are the primary cell types that attack these foreign particles?
1. Basophils
2. Neutrophils
3. Eosinophils
4. Dendritic cells3. Eosinophils
The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an altered immune system. What should the student tell the instructor when asked to describe the properties of interferon?
1. Is produced only by B lymphocytes
2. Is effective only against specific viruses
3. Is effective against a wide variety of viruses
4. Inactivates viruses that are found only outside cells3. Is effective against a wide variety of viruses
The nursing student is assigned to care for a client with an immune disorder. The student is reviewing information related to the immune response and the classes of human antibodies. The student should plan care knowing that what is the major serum antibody?
1. Immunoglobulin E (IgE)
2. Immunoglobulin G (IgG)
3. Immunoglobulin A (IgA)
4. Immunoglobulin M (IgM)2. Immunoglobulin G (IgG)
The nursing instructor is evaluating a nursing student for knowledge of antibody classes. What should the student state when asked which antibody is the first produced in response to an antigen?
1. Immunoglobulin G (IgG)
2. Immunoglobulin A (IgA)
3. Immunoglobulin D (IgD)
4. Immunoglobulin M (IgM)4. Immunoglobulin M (IgM)
The nursing student who is enrolled in an anatomy and physiology course is studying the immune system. The student understands that a nonspecific immune response can include physical barriers and chemical barriers. What should the student identify as an example of a chemical barrier?
1. The skin
2. The mucous membranes
3. The cilia lining the respiratory tract
4. Acids and enzymes found in body fluids4. Acids and enzymes found in body fluids
Tetanus toxoid is prescribed for a client who sustained a foot laceration from a piece of metal while walking barefoot on the beach. When preparing the injection, the nurse understands that which accurately describes the prescribed toxoid?
1. A non-attenuated virus
2. An attenuated bacterium
3. A specific antibody that will prevent infection
4. A toxin produced by bacteria that has been altered so that it is no longer toxic4. A toxin produced by bacteria that has been altered so that it is no longer toxic
The nursing student is conducting a clinical conference on immunity. In discussing active versus passive immunity, what should the student emphasize about active immunity?
1. Has a half-life of about 30 days
2. Provides protection immediately
3. Lasts much longer than passive immunity
4. Is less effective at preventing subsequent infections3. Lasts much longer than passive immunity
A nursing instructor is reviewing information on the organs of the immune system. The instructor asks a nursing student to name the location of Kupffer cells. What is the accurate student response?
1. The liver
2. The spleen
3. The tonsils
4. Bone marrow1. The liver
The nursing instructor asks a nursing student to identify the location of Peyer patches. What should be the correct response by the student?
1. The liver
2. The spleen
3. The tonsils
4. The small intestine4. The small intestine
The nursing student is reviewing information related to the inflammatory reaction. What should the student understand is the primary purpose of neutrophils in the inflammatory response?
1. Dilate the blood vessels.
2. Increase fluids at the site of injury.
3. Allow permeability of the blood vessels.
4. Phagocytize any potentially harmful agents.4. Phagocytize any potentially harmful agents.
The nursing instructor asks a nursing student to define the process of phagocytosis. What should the student tell the instructor that phagocytosis is?
1. Required for the production of antibodies
2. The initial reaction in the inflammatory response
3. A protein produced in response to a viral infection
4. A process by which a particle is ingested and digested by a cell4. A process by which a particle is ingested and digested by a cell
The nursing student is describing the differences between specific and nonspecific immunity. What should the student correctly identify as specific immunity?
1. Present and functioning at birth
2. The first line of defense against infection
3. The second line of defense against infection
4. The type of immunity that reacts the same to all antigens3. The second line of defense against infection
A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis. What does this test assess for the presence of?
1. Inflammation
2. Antigens of IgA
3. Infection in the body
4. Unusual antibodies of the IgG and IgM type4. Unusual antibodies of the IgG and IgM type
A nurse is reviewing the diagnostic tests prescribed for an assigned client and notes that a lupus cell preparation (LE cell prep) has been prescribed. The nurse understands that this test is used to screen primarily for which disorder?
1. Histoplasmosis
2. Progressive systemic sclerosis
3. Systemic lupus erythematosus (SLE)
4. Human immunodeficiency virus (HIV)3. Systemic lupus erythematosus (SLE)
A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse suspects that which finding will be reported with this blood test?
1. Increased neutrophils
2. Increased red blood cell count
3. Increased white blood cell count
4. Decreased numbers of all cell types4. Decreased numbers of all cell types
The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse should recognize that which is a least likely early clinical manifestation of this disorder?
1. Anorexia
2. Weight gain
3. Complaints of fatigue
4. Complaints of generalized weakness2. Weight gain
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has begun to experience multiple opportunistic infections. Which laboratory test would be most helpful in assessing the client's need for reassessment of treatment?
1. Western blot
2. B-lymphocyte count
3. CD4+ cell or T-lymphocyte count
4. Enzyme-linked immunosorbent assay (ELISA)3. CD4+ cell or T-lymphocyte count
A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine (Retrovir). The nurse assesses the complete blood count (CBC), knowing that which is an adverse effect of this medication?
1. Polycythemia
2. Leukocytosis
3. Thrombocytosis
4. Agranulocytopenia4. Agranulocytopenia
A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE?
1. Fever
2. Fatigue
3. Skin lesions
4. Elevated red blood cell count3. Skin lesions
The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about measures to manage fatigue. Which statement by the client indicates the need for further instruction?
1. "I need to sit whenever possible."
2. "I need to avoid long periods of rest."
3. "I should take a hot bath every evening."
4. "I should engage in moderate low-impact exercise when I am not tired."3. "I should take a hot bath every evening."
A client seen in an ambulatory clinic has a facial rash that is present on both cheeks. The nurse interprets that this finding is consistent with manifestations of which disorder?
1. Hyperthyroidism
2. Pernicious anemia
3. Cardiopulmonary disorders
4. Systemic lupus erythematosus (SLE)4. Systemic lupus erythematosus (SLE)
A client asks a nurse about obtaining a home test kit to test for human immunodeficiency virus (HIV) status. What should the nurse tell the client?
1. Home test kits are not available for testing at this time.
2. Home test kits are reliable for determining the HIV status.
3. Home test kits may not be as reliable as laboratory blood tests.
4. Home test kits should not be used; rather, it is important to contact the health care provider (HCP) with concerns about the HIV status.3. Home test kits may not be as reliable as laboratory blood tests.
A client reports to the health care clinic for testing for human immunodeficiency virus (HIV) immediately after being exposed to HIV. The test results are negative, and the client tells the nurse that he is relieved that he has not contracted HIV. What should the nurse emphasize when explaining the test results to the client?
1. No further testing is needed.
2. The test should be repeated in 1 month.
3. A negative HIV test result is considered accurate.
4. A negative HIV test result is not considered accurate immediately after exposure.4. A negative HIV test result is not considered accurate immediately after exposure.
A client is tested for human immunodeficiency virus (HIV) infection with an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. What should the nurse tell the client?
1. HIV infection has been confirmed.
2. The client probably has a gastrointestinal infection.
3. The test will need to be confirmed with a Western blot.
4. A positive test result is normal and does not mean that the client has acquired HIV.3. The test will need to be confirmed with a Western blot.
A CD4+ lymphocyte count is performed in a client with human immunodeficiency virus (HIV) infection. The nurse plans care, knowing that which is the reason for the count?
1. Establish the stage of HIV infection.
2. Confirm the presence of HIV infection.
3. Identify the cell-associated proviral DNA.
4. Determine the presence of HIV antibodies in the bloodstream.1. Establish the stage of HIV infection.
A CD4 T-cell count is measured in a client newly diagnosed with human immunodeficiency virus (HIV). The nurse understands that which is accurate regarding the CD4 T-cell count? Select all that apply.
1. Falls in response to a declining viral load
2. Is a primary marker of immunocompetence
3. Plays a role in the cell-mediated immune response
4. Is a direct measure of the magnitude of HIV replication
5. Guides decision making regarding timing of initiation of treatment- 2. Is a primary marker of immunocompetence
- 3. Plays a role in the cell-mediated immune response
- 5. Guides decision making regarding timing of initiation of treatment
A client with human immunodeficiency virus (HIV) infection has a fever, and histoplasmosis is suspected. The nurse should prepare the client for which diagnostic test to confirm the presence of histoplasmosis?
1. Skin biopsy
2. Sputum culture
3. Western blot test
4. Upper gastrointestinal series2. Sputum culture
A client with human immunodeficiency virus infection has signs and symptoms of cryptosporidiosis. The nurse should prepare the client for which test that will assist in confirming the diagnosis?
1. Stool culture
2. Bronchoscopy
3. Sputum culture
4. Chest x-ray study1. Stool culture
-
A nurse reviews the record of an assigned client and notes that the client has a diagnosis of oral candidiasis (thrush). Which objective finding would the nurse expect to note in the client?
1. Hyperactive bowel sounds
2. Complaints of watery diarrhea
3. Red lesions locate on the upper arms
4. Creamy white curdlike patches noted on the oral mucosa4. Creamy white curdlike patches noted on the oral mucosa
A nurse is assigned to care for a client suspected of having Kaposi's sarcoma. The nurse should prepare the client for which test to confirm this diagnosis?
1. Skin biopsy
2. Blood culture
3. Bone marrow biopsy
4. Magnetic resonance imaging1. Skin biopsy
A nurse is assigned to care for a client with human immunodeficiency virus infection. The nurse reviews the client's health care record and notes documentation of toxoplasmosis. On the basis of this information, the nurse would assess for which sign or symptom?
1. Lesions on the skin
2. Mental status changes
3. Changes in bowel pattern
4. Lesions on the oral mucosa2. Mental status changes
A fluorescent antinuclear antibody titer (FANA) is performed in a client suspected of having rheumatoid arthritis (RA). The nurse reviews the laboratory findings and determines that the test result is positive if which value is noted?
1. 0:5
2. 0:8
3. 1:5
4. 1:204. 1:20
A rheumatoid factor assay is performed in a client with a diagnosis of rheumatoid arthritis. The nurse understands that this test is done to detect which finding?
1. The presence of inflammation
2. The presence of antigens of IgA
3. The presence of infection in the body
4. The presence of unusual antibodies of the immunoglobulin G (IgG) and IgM types4. The presence of unusual antibodies of the immunoglobulin G (IgG) and IgM types
An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test?
1. Determines the presence of antigens
2. Identifies which additional tests need to be performed
3. Confirms the diagnosis of a connective tissue disorder
4. Confirms the presence of inflammation or infection in the body4. Confirms the presence of inflammation or infection in the body
A nurse is reviewing the diagnostic tests performed in an adult with a connective tissue disorder. The erythrocyte sedimentation rate (ESR) is reported as 35 mm/hr. How should the nurse interpret this finding?
1. Normal
2. Indicating mild inflammation
3. Indicating severe inflammation
4. Indicating moderate inflammation2. Indicating mild inflammation
A nurse is reviewing the diagnostic tests prescribed for an assigned client and notes that an "LE cell prep" has been prescribed. The nurse understands that this test is used to screen primarily for which disorder?
1. Histoplasmosis
2. Progressive systemic sclerosis
3. Systemic lupus erythematosus (SLE)
4. Human immunodeficiency virus infection3. Systemic lupus erythematosus (SLE)
A complete blood cell count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE?
1. Decreased platelets only
2. Increased red blood cell count
3. Increased white blood cell count
4. Decreased number of all cell types4. Decreased number of all cell types
A nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA?
1. Anemia
2. Anorexia
3. Amenorrhea
4. Night sweats2. Anorexia
A client with human immunodeficiency virus infection is diagnosed with herpes simplex. The nurse should prepare the client for which diagnostic test to determine the presence of herpesvirus infection?
1. Chest x-ray
2. Viral culture
3. Stool culture
4. Neurological exam2. Viral culture
A nurse is assigned to care for a client with human immunodeficiency virus infection. The nurse notes recent documentation of herpes simplex in the client's medical record. On assessment, the nurse would expect to note which type of lesion?
1. Macular lesions
2. Ecchymotic lesions
3. Creamy-white patches
4. Vesicular lesions that rupture4. Vesicular lesions that rupture
A nurse is caring for a client with human immunodeficiency virus infection and notes a diagnosis of cryptococcosis in the client's medical record. The nurse understands that this opportunistic infection most likely was diagnosed by which test?
1. Skin biopsy
2. Viral culture
3. Sputum culture
4. Bone marrow biopsy3. Sputum culture
A client with acquired immunodeficiency syndrome (AIDS) is experiencing fatigue. The nurse should plan to teach the client which strategy to conserve energy after discharge from the hospital?
1. Bathe before eating breakfast.
2. Sit for as many activities as possible.
3. Stand in the shower instead of taking a bath.
4. Group all tasks to be performed early in the morning.2. Sit for as many activities as possible.
The nurse instructs a client with candidiasis (thrush) of the oral cavity how to care for the disorder. Which client statement indicates the need for further instruction?
1. "I need to eat foods that are liquid or pureed."
2. "I need to eliminate spicy foods from my diet."
3. "I need to eliminate citrus juices and hot liquids from my diet."
4. "I need to rinse my mouth four times daily with a commercial mouthwash."4. "I need to rinse my mouth four times daily with a commercial mouthwash."
A client is suspected of having stage I Lyme disease. The nurse anticipates that which will be part of the treatment plan for the client?
1. Daily oatmeal baths for 2 weeks
2. No treatment unless symptoms develop
3. A 3-week course of oral antibiotic therapy
4. Treatment with intravenously administered antibiotics3. A 3-week course of oral antibiotic therapy
A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas exchange. Which finding indicates that the expected outcome of care has yet to be 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.1. The client limits fluid intake.
A nurse is assisting in administering immunizations at a health care clinic. What should the nurse understand that an immunization provides?
1. Protection from all diseases
2. Innate immunity from disease
3. Natural immunity from disease
4. Acquired immunity from disease4. Acquired immunity from disease
A home care nurse is assigned to visit a client who has 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 admission assessment, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, what action should the nurse take?
1. Cover the crutch pads with cloth.
2. Contact the health care provider (HCP).
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 from the house immediately.1. Cover the crutch pads with cloth.
A home care nurse is prescribing dressing supplies for a client who has an allergy to latex. Which item should the nurse ask the medical supply personnel to deliver?
1. Elastic bandages
2. Adhesive bandages
3. Brown Ace bandages
4. Cotton pads and silk tape4. Cotton pads and silk tape
A client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse should take?
1. Place the client on 100% oxygen and prepare for intubation.
2. Assess for anaphylaxis and prepare for emergency treatment.
3. Obtain an arterial blood gas and immunoglobulin E (IgE) blood level.
4. Teach the client about the relationship between asthma and allergies.2. Assess for anaphylaxis and prepare for emergency treatment.
The nurse is preparing to care for a client with immunodeficiency. The nurse should plan to address which problem as the priority?
1. Anxiety
2. Fatigue
3. Risk for infection
4. Need for social isolation3. Risk for infection
A nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. The nurse understands that in cases in which the recipient rejects transplanted organs, the cells of the transplanted organs are seen by the body as which?
1. T cell
2. B cell
3. Antibody
4. Foreign antigen4. Foreign antigen
A client is admitted to the hospital with a diagnosis of parasitic worms. The nurse understands that the primary cell type that will attack these foreign particles is which?
1. Basophils
2. Neutrophils
3. Eosinophils
4. Dendritic cells3. Eosinophils
Tetanus toxoid is prescribed for a client who has sustained a foot laceration from a piece of metal while walking barefoot on the beach. The nurse understands that a toxoid is which?
1. A nonattenuated virus
2. An attenuated bacterium
3. Toxin produced by bacteria that has been altered so that it is no longer toxic
4. Specific antibody that will prevent infection through an antigen-antibody reaction3. Toxin produced by bacteria that has been altered so that it is no longer toxic
A nursing instructor is questioning a nursing student about the organs of the immune system and asks the student where Kupffer's cells are located. The student responds correctly by stating that these types of cells are located in which location?
1. Liver
2. Tonsils
3. Spleen
4. Bone marrow1. Liver
A nurse teaches a client that the primary purpose of neutrophils in the inflammatory response is to promote which response?
1. Dilate the blood vessels.
2. Increase fluids at the site of injury.
3. Produce permeability of the blood vessels.
4. Phagocytize any potentially harmful agents.4. Phagocytize any potentially harmful agents.
A nurse teaches a client that the process of phagocytosis is which?
1. The initial reaction in the inflammatory response
2. A protein produced in response to a viral infection
3. A process required for the production of antibodies
4. A process whereby a particle is ingested and digested by a cell4. A process whereby a particle is ingested and digested by a cell