Online Nursing Practice Test about Immune System Disorders (1-5)

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NCLEX Review about Immune System Disorders

1. An older adult with no known cognitive impairment residing in a long-term care facility suddenly becomes disoriented and confused. There are no signs of extremity weakness or other neurological changes. Based on these observations, the nurse would focus the assessment in which priority body systems?

a) pulmonary and renal systems
b) reproductive and endocrine system
c) integumentary and neurological systems
d) cardiovascular and gastrointestinal systems

2. 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 most appropriate?

a) refer the client for blood test immediately
b) inform the client that there is no test available for Lyme disease
c) tell the client that testing is not necessary unless arthralgia develops
d) instruct the client to return in 4 to 6 weeks to be tested because testing before this time is not reliable

3. Following diagnosis of stage I Lyme disease, the nurse would anticipate that which of the following will be part of the treatment plan for the client?

a) no treatment unless symptoms develop
b) a 3-week course of oral antibiotic therapy
c) daily oatmeal baths for 2 weeks
d) treatment with intravenously administered antibiotics

4. A Cub Scout leader, who is a nurse preparing a group of Cub Scouts for an overnight camping trip, instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions?

a) I need to bring a hat to wear during the trip
b) I should wear long-sleeved tops and long pants
c) I should not use insect repellents because it will attract the ticks
d) I need to wear closed shoes and socks that can be pulled up over my pants

5. 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?

a) swelling in the genital area
b) swelling in the lower extremities
c) punch biopsy of the cutaneous lesions
d) appearance of reddish-blue lesions noted on the skin






NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

1) A
- Changes in mental status and confusion are commonly associated with infections in the older adult. Assessments of the pulmonary and renal systems would be the priority. The older adult is at risk for pneumonia. The lungs should be auscultated for decreased breath sounds and other adventitious sounds. Urinary tract infections are also common in older adults, especially women. Flank pain with frequency and urgency are symptoms. The urine should be monitored for cloudiness, odor, and other changes indicating hematuria. Based on the data in the question, the body systems identified in options B, C, and D are not the priority.

2) D
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 A, B, and C are incorrect.

3) B
- Prevention, public education, and early diagnosis are vital to the control and treatment of Lyme disease. A 3-week course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with intravenously administered antibiotics, such as penicillin G. Options A and C are incorrect.

4) C
- 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, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over the pant legs to the prevent ticks from entering under clothing.

5) C
- 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.


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