NCLEX Review about Immune System Disorders (11-15)

--> NCLEX Review about Immune System Disorders

11. The 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 nor yet been achieved?

a) client limits fluid intake
b) client has clear breath sounds
c) client expectorates secretions easily
d) client is free of complaints of shortness of breath

12. 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?

a) the presence of tiny red vesicles
b) an autoimmune disease that causes blistering in the epidermis
c) the presence of skin vesicles found along the nerve caused by a virus
d) the presence of red, raised papules and large plaques covered by silvery scales

13. The nurse is providing dietary instructions to the client with systemic lupus erythematosus. Which of the following dietary items would the nurse instruct the client to avoid?

a) steak
b) turkey
c) broccoli
d) cantaloupe

14. A client calls the nurse in the emergency room and tells the nurse that he was just stung by a bee 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:

a) advise the client to soak the site in hydrogen peroxide
b) ask the client if ever sustained a bee sting in the past
c) tell the client to call an ambulance for transport to the emergency room
d) tell the client no to worry about the sting unless difficulty with breathing occurs

15. The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that an immunization will provide:

a) protection from all disease
b) innate immunity from disease
c) natural immunity from disease
d) acquired immunity from disease






NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

11) A

- The status of the client with a diagnosis of Impaired gas exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include the client stating that breathing is easier and is coughing 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.

12) B

- 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 A describes eczema, option C describes herpes zoster, and option D describes psoriasis.

13) A

- The client with systemic lupus erythematosus (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 salt, fat, and cholesterol intake.

14) B

- In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever received a bee sting in the past. Option A is not appropriate advice. Option C is unnecessary. The client should not be told “not to worry.”

15) D

- 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.




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