Question 1

The nurse is reviewing data collected on several patients.Which patient should the nurse identify as being most likely to exhibit signs and symptoms of systemic lupus erythematosus?

Accepted Answer

Systemic lupus erythematosus tends to develop in young women of child-bearing years and occurs in the African American and Hispanic populations more frequently.A.C.D.These individuals are less likely to develop manifestations of systemic lupus erythematosus.

Question 2

The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus.Which adverse effect should the nurse encourage the patient to report when taking this medication?

Accepted Answer

The patient should have an ophthalmologic examination completed before starting this medication because vision changes can occur.A.C.D.These are not identified adverse effects for this medication.

Question 3

The nurse recommends the diagnosis Disturbed Body Image for a patient with systemic lupus erythematosus.What would be an appropriate long-term outcome for this patient?

Accepted Answer

The ultimate outcome is for the patient to return to previous social involvement in spite of body image issues such as the butterfly rash.A.B.D.These outcomes would be short-term for the patient with systemic lupus erythematosus.

Question 4

The nurse is caring for a patient who had a kidney transplant 5 days ago.The patient had been very outgoing and jovial,but this morning the patient is very quiet and refusing breakfast,and ambulation.What would be the most appropriate nursing action at this time?

Accepted Answer

Psychological support is important for transplant patients.Patients need time to verbalize feelings and understand that feelings of guilt are normal and diminish with time.A.B.C.These actions are not appropriate for the patient at this time.

Question 5

The nurse is reinforcing teaching about potential triggers with a patient experiencing allergic rhinitis.What should the nurse include in the teaching? (Select all that apply.)

Accepted Answer

Allergic rhinitis causative antigens are environmental and airborne.Frequent home vacuuming and dusting are recommended.B.E.F.Penicillin,topical lotion,and oral multivitamins are not identified as being triggers for allergic rhinitis.

Question 6

A patient is being started on a blood transfusion.For how many minutes should the nurse stay with the patient during this transfusion?

Accepted Answer

The nurse should stay at the bedside with a patient for the first 15 minutes of any blood transfusion to detect signs of a reaction.A.B.The nurse needs to stay longer than 5 or 10 minutes.D.The nurse does not need to stay beyond 15 minutes.

Question 7

A patient with lupus erythematosis is prescribed a corticosteroid.What side effects of this medication should the nurse review with the patient? (Select all that apply.)

Accepted Answer

Corticosteroids can cause weight gain,increased facial hair,acne,round "moon" face,mood changes,irritability,depression,increased appetite,increased weight,poor wound healing,headache,peptic ulcers,and osteoporosis.A.F.Tinnitus,rash,and pruritus are not adverse effects of corticosteroid therapy.

Question 8

The nurse is contributing to a staff education program about nursing care for hypersensitivity reactions.Which should the nurse include as examples of type I hypersensitivity reactions? (Select all that apply.)

Accepted Answer

Type I hypersensitivity reactions include conditions such as allergic rhinitis and allergic asthma,atopic dermatitis,anaphylaxis,angioedema.hemolytic transfusion reactions,measles,and transplant rejections.C.E.F.These health problems are not considered type I hypersensitivity reactions.

Question 9

The nurse notes that a patient has an elevated lactate dehydrogenase,fragmented RBCs seen on microscopic examination,and low RBC count,hematocrit (Hct),and hemoglobin (Hgb)levels.For which health problem should the nurse consider planning care for this patient?

Accepted Answer

In idiopathic autoimmune hemolytic anemia,the RBC count and Hgb and Hct levels are low,with fragmented RBCs and elevated lactate dehydrogenase because of RBC destruction and tissue ischemia.A.B.C.These manifestations are not seen in serum sickness,pernicious anemia,or hemolytic transfusion reactions.

Question 10

The nurse has been caring for a patient with pernicious anemia.Which finding should indicate to the nurse that treatment has been successful?

Accepted Answer

Macrocytic (enlarged RBCs)anemia,and low vitamin B₁₂ levels are indicators of pernicious anemia,so increased vitamin B₁₂ levels and decreased enlarged RBCs would indicate successful treatment.A.B.D.These findings would not support treatment for pernicious anemia as being successful.

Question 11

A patient comes into the emergency department with a fear of developing poison ivy after falling while walking through a wooded area earlier in the day.What should the nurse instruct the patient to do if exposure to poison ivy occurs again?

Accepted Answer

The patient should be instructed to wash the area with a brown soap (e.g.,Fels-Naptha)or,if unavailable,any soap when contact with the offending agent is suspected.This removes the offending agent from the skin.A.Cold water is not going to remove the agent from the skin.B.C.Wrapping the area with a towel or gauze is going to trap the offending agent on the skin and make the skin reaction worse.

Question 12

The nurse is caring for a patient with severe ankylosing spondylitis.What nursing action would be most appropriate?

Accepted Answer

The patient should not stay in any one position for any length of time to reduce stiffness and pain.A.B.D.These actions are not specifically identified to help the patient with severe ankylosing spondylitis.

Question 13

The nurse is reinforcing teaching provided to a patient with pernicious anemia.Which patient statement indicates that teaching has been effective?

Accepted Answer

If vitamin B₁₂ injections are prescribed,the patient must understand that this is a lifelong need to prevent the return of symptoms.A.C.Patients should not miss injections.D.Injections are not taken as needed for fatigue.

Question 14

The nurse is contributing to the teaching plan for a patient diagnosed with Hashimoto's thyroiditis who has progressed to hypothyroidism with a goiter.Which self-care instructions should the nurse recommend? (Select all that apply.)

Accepted Answer

If the patient has a goiter,a soft diet may be necessary for comfort.Frequent rest periods may be necessary as well as slowly increasing patient activity.Anti-embolic stockings may help prevent venous stasis during the low-energy,decreased-activity phase.E.During the hyperthyroidism phase,a diet high in protein and carbohydrates encourages weight gain.D.The patient will be sensitive to cold,so room temperature will need to be increased for comfort.C.Foods high in iodine should be avoided.

Question 15

The nurse is participating in a teaching plan to address Risk for Impaired Skin Integrity for a patient with contact dermatitis.Which information should the nurse recommend be included in this plan? (Select all that apply.)

Accepted Answer

The patient should be instructed to avoid scratching the skin to prevent the spread of dermatitis and infection development.Ease itching with cool washcloths and oatmeal baths,and keep fingernails short to avoid injury to skin if scratching occurs.Oil-in-water lubricants tend to be the most effective for skin dryness.D.E.Rubbing the skin and avoiding brown soap will not help the patient with contact dermatitis.

Question 16

The nurse is assisting in an educational seminar on common allergens.What should the nurse include as the most common irritant causing contact dermatitis? (Select all that apply.)

Accepted Answer

Poison ivy and poison oak are the most common irritants causing contact dermatitis.A.B.C.These items are not known to cause contact dermatitis.

Question 17

The nurse is assisting in the care of a patient with ankylosing spondylitis.What should the nurse expect to find in the patient's collaborative plan of care? (Select all that apply.)

Accepted Answer

Nursing care focuses on patient education and administration and evaluation of prescribed medications.Pain management,rest periods,and assistance with activities of daily living (ADLs)are provided.B.Sitz baths are not indicated for this health problem.

Question 18

A patient is suspected as having a blood transfusion reaction.Which laboratory test should the nurse expect to be done to confirm this diagnosis?

Accepted Answer

The direct Coombs' test confirms the diagnosis of transfusion reaction.In the laboratory,a small amount of the patient's RBCs is washed to remove any unattached antibodies.Antihuman globulin is added to see if agglutination (clumping)of the RBCs results.If agglutination occurs,an immune reaction such as a hemolytic transfusion reaction is taking place.A.Skin testing is used to determine the presence of a type I hypersensitivity reaction.C.D.These tests might be done to determine the presence of serum sickness.

Question 19

The nurse is contributing to the plan of care for a patient with systemic lupus erythematosus (SLE).Which interventions should the nurse recommend for this patient? (Select all that apply.)

Accepted Answer

Fatigue during activities of daily living is minimized through the use of a daily personal schedule.Additionally,a minimum of 8 hours of sleep per night with naps as necessary are important to combat fatigue.Because the majority of patients with SLE develop transitory arthralgia,maintaining fitness and joint range of motion through a regular fitness program while decreasing activity during flares is vital.Warm baths may help with morning stiffness.Because renal disease is a major complication of SLE,patients must learn the signs of impending problems that need to be relayed to the physician immediately.These are such findings as facial puffiness and "foamy" urine or "coke-colored" urine indicative of proteinuria and hematuria,respectively.Eating a well-balanced diet will also influence level of fatigue and weight gain from the corticosteroids.C.Cool showers will not help relieve the pain and stiffness associated with this disorder.D.Rest is beneficial for this disorder.E.Exercise should be reduced during flare-ups.

Question 20

The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how the disease process occurred.What should the nurse explain to the mother?

Accepted Answer

Hypogammaglobulinemia is either a hereditary congenital disorder or acquired after childhood from unknown causes.It is characterized by the absence or deficiency of one or more of the five classes of immunoglobulins (IgG,IgM,IgA,IgD,and IgE)from defective B-cell function.The lack of normal function of these antibodies makes the patient prone to infections.A.The congenital form of this disorder affects males.B.It is not linked to pesticide exposure.C.It did not develop because the infant was premature.

Quiz 19: Nursing Care of Patients With Immune Disorders