Immune System Practice Test (46-50)

Welcome to Immune System Practice Test. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

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46. A client with acquired immunodeficiency syndrome (AIDS) has a nursing diagnosis of Imbalanced nutrition: less than body requirements. The nurse plans which of the following goals with this client?

a)  consume foods and beverages that are high in glucose
b) plan large menus and cook meals in advance
c) eat low-calorie snacks between meals
d) eat small, frequent meals throughout the day

47. A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse include in the plan of care to assist the client in performing activities of daily living?

a) provide supportive care with hygiene needs
b) provide meals and snacks with high-protein, high calorie, and high-nutritional value
c) provide small, frequent meals
d) offer low microbial foods

48. A client who was tested for human immunodeficiency virus (HIV) after a recent exposure had a negative result. During the post-test counseling session, the nurse tells the client which of the following?

a) the test should be repeated in 6 months
b) this ensures that the client is not infected with the HIV virus
c) the client no longer needs to protect himself from sexual partners
d) the client probably has immunity to the acquired immunodeficiency virus

49. A client is diagnosed with late stage human immunodeficiency virus (HIV), and the client and family are extremely upset about the diagnosis. The priority psychosocial nursing intervention for the client and family is to:

a) tell the client and family to stop smoking because it will predispose the client to respiratory infections
b) tell the client and family that raw or improperly washed foods can produce microbes
c) encourage the client and family to discuss their feelings about the disease
d) advise the client to avoid becoming pregnant because of the risk of transmission of the infection

50. A client is diagnosed  with human immunodeficiency virus (HIV) infection. The nurse prepares a care plan for the client, knowing that HIV is primarily a condition in which:

a) immunosuppression occurs and is indicated by a T4 lymphocyte count of less than 200/mm3
b) bacterial infection occurs, causing weakness
c) fungal infection occurs, causing a rash and pruritus
d) protozoan infection occurs, causing a fever and nonproductive cough





Immune System Practice Test 
Answers and Rationale

46) D

- The client should eat small, frequent meals throughout the day. The client also should take in nutrient-dense and high-calorie meals and snacks rather than those that are high in glucose only. The client is encouraged to eat favorite foods to keep intake up and plan meals that are easy to prepare. The client can also avoid taking fluids with meals to increase food intake before satiety sets in.

47) A
- 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 B, C, and D are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option B will assist the client in maintaining appropriate weight and proper nutrition. Option C will assist the client in tolerating meals better. Option D will decrease the client's risk of infection.

48) A

- A negative test result indicates that no HIV antibodies were detected in the blood sample. A repeated test in 6 months is recommended because false-negative test results have occurred early in the infection. Options B, C, and D are incorrect.

49) C

- The priority psychosocial nursing intervention for the client and family is to encourage the client and family to discuss their feelings about the disease. Options A, B, and D identify physiological not psychosocial concerns.

50) A

- HIV infection causes immunosuppression and is indicated by a T4 lymphocyte count of less than 200/mm3. Although bacterial, fungal, and protozoal infection can occur, these occur as opportunistic infections as a result of the immunosuppression.


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Immune System Practice Test (1-5)

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NCLEX Review about Immune System Disorders 41-45

Welcome to NCLEX Review about Immune System Disorders. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.


41. A nurse is monitoring a client with herpes simplex virus who is receiving intravenous (IV) acyclovir (Zovorax). Which of the following laboratory results would be of concern as a possible adverse effect of this medication?

a) blood urea nitrogen (BUN) of 36 mg/dL
b) platelet count of 300,000 cells/mm3
c) white blood cell count of 6000 cells/mm3
d) red blood cell count of 5.2 million cells/mm3

42. A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovor (Cytovene). The nurse takes which priority nursing action in caring for this client?

a) ensuring that the client uses an electric razor for shaving
b) administering the medication with an antacid
c) monitoring for signs of hyperglycemia
d) administering the medication without food

43. A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine also called azidothymidine (AZT)(Retrovir). The nurse monitors the results of which laboratory blood study for adverse effects of therapy?

a) complete blood count (CBC)
b) blood urea nitrogen (BUN) level
c) creatinine level
d) potassium concentration

44. A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine (Videx). The nurse reviewing the client's laboratory results should most closely monitor serum levels of:

a) cholesterol
b) amylase
c) glucose
d) protein

45. A client is receiving zalcitabine (Hivid). The nurse plans to monitor the results of which study to determine the effectiveness of this medication?

a) enzyme-linked immunosorbent assay (ELISA)
b) western blot
c) CD4+ cell count
d) complete blood cell (CBC) count with differential





NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

41) A

- Although the most common adverse reactions with this medication are phlebitis and inflammation at the IV site, reversible nephrotoxicity evidenced by an elevated serum creatinine and BUN levels can occur in some clients. The cause of nephrotoxicity is deposition of acyclovir in the renal tubules. The risk of renal injury is increased by dehydration and by the use of other nephrotoxic medications. The values identified in options B, C, and D are within normal limits.

42) A

- Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication does not have to be taken on an empty stomach or without food and should not be taken with an antacid. The medication may cause hypoglycemia, but not hyperglycemia.

43) A

- Common adverse effects of this medication are agranulocytopenia and anemia. The nurse monitors the CBC results for these changes. BUN, creatinine, and potassium are unrelated to this medication.

44) B

- This medication is toxic to both the pancreas and the liver. A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis and may be potentially fatal in the client with AIDS. Therefore, the nurse monitors the results of amylase and liver function studies closely. Options A, C, and D are unrelated to this medication.

45) C

- Zalcitabine slows the progression of acquired immunodeficiency syndrome (AIDS) by improving the CD4+ cell count. A CBC with differential may be done as part of an ongoing monitoring of the status of the client with AIDS, and to detect adverse effects of other medications. The ELISA and the Western blot are performed to diagnose AIDS initially.


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NCLEX Review about Immune System Disorders (46-50)

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NCLEX Review about Immune System Disorders 36-40

NCLEX Review about Immune System Disorders

36. A 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?

a) I need to avoid long periods of rest
b) I need to sit whenever possible
c) I should take a hot bath every evening
d) I should engage in moderate low-impact exercise when I am not tired

37. A nurse is reviewing the results of serum laboratory studies for a client with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the physician if which of the following laboratory test results is significantly elevated?

a) serum cholesterol level
b) serum amylase level
c) blood glucose concentration
d) serum protein concentration


38. A client with acquired immunodeficiency syndrome (AIDS) who is taking zidovudine (Retrovir) 200 mg orally three times daily has severe neutropenia noted on the follow-up laboratory studies. The nurse interprets that which of the following is likely to occur at this point?

a) prednisone (Deltasone) probably will be added to the medication regimen
b) epoetin (Epogen) probably will be added to the medication regimen
c) the medication dose probably will be reduced
d) the medication probably will be discontinued until laboratory results indicated bone marrow recovery

39. A client with human immunodeficiency virus (HIV) infection is taking indinavir (Crixivan). The nurse plans to tell the client which of the following when providing instructions about the use of this medication?

a) take the medication with water on an empty stomach
b) take the medication with a high-fat snack
c) take the medication with the large meal of the day
d) store the medication in the refrigerator

40. A client is receiving acyclovir (Zovirax) by the intravenous (IV) route for treatment of cytomegalovirus (CMV) infection. After reconstituting the powder dispensed by the pharmacy, the nurse administers this medication by:

a) continuous IV infusion over 12 hours
b) continuous IV infusion over 24 hours
c) rapid IV bolus over 5 minutes
d) slow IV infusion over 1 hour






NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

36) C

- To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, to avoid hot baths, to schedule moderate low-impact exercises when not fatigued, and to maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness.

37) B

- A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis from the medication, which can be potentially fatal. The medication may have to be discontinued. The medication also is hepatotoxic, which can result in liver failure. Options A, C, and D are not associated with this medication.

38) B

- 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 evidence of bone marrow recovery is noted. 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 administered to clients experiencing anemia.

39) A

- 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. It is not administered with a large meal. The medication should be stored at room temperature and protected from moisture, because moisture can degrade the medication.

40) D

- Acyclovir is dispensed as a powder to be reconstituted for IV administration and is administered by slow IV infusion over 1 hour. It is not given as an IV bolus or continuous infusion or by intramuscular or subcutaneous injection. To minimize the risk of renal damage, the client should be hydrated during the infusion and for 2 hours after the infusion.


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NCLEX Review about Immune System Disorders (31-35)

NCLEX Review about Immune System Disorders

31. The client with acquired immunodeficiency syndrome has begun therapy with zidovudine (Retrovir, azidothymidine, AZT, ZDV). The nurse carefully monitors which of the following laboratory results during treatment with this medication?

a) blood culture
b) blood glucose level
c) blood urea nitrogen level
d) complete blood count

32. The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that he client may have the medication discontinued by the physician if which of the following significantly elevated results is noted?

a) serum protein level
b) blood glucose level
c) serum amylase level
d) serum creatinine level

33. The nurse is caring for a post-renal transplantation client taking cyclosporin (Sandimmune, Gengraf, Neoral). Th nurse notes an increase in one of he client's vital signs and the client is complaining of a headache. What is the vital sign that is most likely increased?

a) pulse
b) respiration
c) blood pressure
d) pulse oximetry

34. Ketoconazole (Nizoral) is prescribed for a client with a diagnosis of candidiasis. Select the interventions that the nurse includes when administering this medication. Select all that apply

a) restrict fluid intake
b) instruct the client to avoid alcohol
c) monitor liver function studies
d) administer the medication with a antacid
e) instruct the client to avoid exposure to the sun
f) administer the medication on an empty stomach

35. The nurse has an order to begin administering foscarnet (Foscavir) to the client with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS). The nurse assesses the latest results of which laboratory study prior to administering the dose?

a) serum albumin level
b) serum creatinine level
c) CD4 count
d) lymphocyte count





NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

31) D

- Common side effects of this medication therapy are leukopenia and anemia. The nurse monitors the complete blood count results for these changes. Options A, B, and C are unrelated to the use of this medication.

32) C

- Didanosine (Videx) can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

33) C

- Hypertension can occur in a client taking cyclosporine (Sandimmune, Gengraf, Neoral) and, because this client is also complaining of a headache, the blood pressure is the vital sign to be monitoring most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options A, B, and D are unrelated to the use of this medication.

34) B, C, E

- Ketoconazole (Nizoral) is an antifungal medication. It is administered with food (not on an empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure absorption. The medication is hepatotoxic and the nurse monitors liver function studies. The client is instructed to avoid exposure to the sun because the medication increases photosensitivity. The client is also instructed to avoid alcohol. There is no reason for the client to restrict fluid intake. In fact, this could be harmful to the client.

35) B

- Foscarnet (Foscavir) is very toxic to the kidneys. The serum creatinine level is monitored prior to therapy, two or three times weekly during induction therapy, and at least weekly during maintenance therapy. It also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels are also measured with the same frequency.

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NCLEX Review about Immune System Disorders (26-30)

NCLEX Review about Immune System Disorders

26. The client who is human immunodeficiency virus seropositive has been taking zalcitabine (ddC, Hivid) as a component of treatment. The nurse plans to monitor which of the following most closely while the client is taking this medication?

a) platelet count
b) glucose level
c) red blood cell count
d) liver function studies

27. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet (Foscavir), an antiviral. The nurse checks the latest results of which of the following laboratory studies while the client is taking this medication?

a) CD4 cell count
b) serum albumin level
c) serum creatinine level
d) lymphocyte count

28. The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine (Pentam 300). The client develops a temperature of 101F. The nurse does further monitoring of the client, knowing that his sign would most likely indicate that the:

a) dose of the medication is too low
b) client is experiencing toxic effects of the medication
c) client has developed inadequacy of thermoregulation
d) result of another infection caused by leukopenic effects of the medication

29. Saquinavir (Invirase) is prescribed for the client who is seropositive for human immunodeficiency virus. The nurse reinforces medication instructions and tells the client to:

a) avoid sun exposure
b) eat low-calorie foods
c) eat foods that are low in fat
d) take the medication on an empty stomach

30. The client who is human immunodeficiency virus seropositive has been taking Stavudine (d4t, Zerit). The nurse monitors which of the following most closely while the client is taking this medication?

a) gait
b) appetite
c) level of consciousness
d) gastrointestinal function





NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

26) D

- Zalcitabine (ddC, Hivid) is an antiretroviral (nucleoside reverse transcriptase inhibitor) used to manage human immunodeficiency virus infection in combination with other antiretrovirals. Zalcitabine also has been used as a single agent in clients who are intolerant of other regimens. Zalcitabine can cause serious liver damage, and liver function studies should be monitored closely. Options A, B, and C are not associated specifically with the use of this medication.

27) C

- Foscarnet (Foscavir) is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency.

28) D

- Frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

29) A

- Saquinavir is an antiretroviral (protease inhibitor) used with other antiretroviral medications to manage human immunodeficiency virus infection. Saquinavir is administered with meals and is best absorbed if the client consumes high-calorie, high-fat meals. Saquinavir can cause photosensitivity, and the nurse should instruct the client to avoid sun exposure.

30) A

- Stavudine (d4t, Zerit) is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client’s gait closely and ask the client about paresthesia.



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NCLEX Review about Immune System Disorders (21-25)

NCLEX Review about Immune System Disorders

21. 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?

a) elastic bandages
b) adhesive bandages
c) brown ace bandages
d) cotton pads and silk tape

22. 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?

a) Lyme disease is caused by tick carried by deer
b) Lyme disease is caused by contamination from cat feces
c) Lyme disease can be contagious through skin contact with an infected individual
d) Lyme disease can be caused by the inhalation of spores from bird droppings

23. The client is diagnosed with stage I Lyme disease. The nurse assesses the client for which characteristic of this stage?

a) arthralgias
b) flu-like symptoms
c) enlarged and inflamed joints
d) signs of neurological disorders

24. Select the interventions that would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply

a) use non-latex gloves
b) use medications from glass ampules
c) place the client in a private room only
d) do not puncture rubber stoppers with needles
e) keep a latex-safe supply cart available in the client's area
f) use a blood pressure cuff from an electronic device only to measure the blood pressure

25. Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the physician immediately if which of the following occurs?

a) nausea
b) lethargy
c) hearing loss
d) muscle aches





NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

21) D

- Cotton pads and plastic or silk tape are latex-free products. The items identified in options A, B, and C are products that contain latex.

22) A

- Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodesscapularis or I. pacificus tick can become infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces.

23) B

- The hallmark of stage I Lyme disease is the development of a 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 bull’s-eye 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.

24) A, B, D, E

- If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex 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, medications with a rubber stopper that requires puncture with a needle, latex-safe syringes, and latex-safe intravenous tubing. It is not necessary to place the client in a private room.

25) C

Amikacin (Amikin) is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems) confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the physician immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the physician immediately if nausea occurs. If nausea persists or results in vomiting, the physician should be notified.



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NCLEX Review about Immune System Disorders (16--20)

NCLEX Review about Immune System Disorders

16. The nurse is assigned to care for a client with systemic lupus erythematosus. The nurse plans care, knowing that this disorder is a(n):

a) local rash that occurs as a result of allergy
b) disease caused by overexposure to sunlight
c) inflammatory disease of collagen contained in connective tissue
d) disease caused by the continuous release of histamine in the body

17. The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus. The nurse reviews the physician's orders, expecting to note that which type of medication is prescribed?

a) antibiotic
b) antidiarrheal
c) corticosteroid
d) opioid analgesic

18. 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?

a) hairdressers
b) the homeless
c) children in day care centers
d) individuals living in a group home

19. 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 associated with the allergy, the nurse questions the client about an allergy to which food item?

a) eggs
b) milk
c) yogurt
d) bananas

20. The home care nurse is assigned to visit a client who has returned home from the emergency room following treatment for a sprained ankle. The nurse notes that the client as 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, the nurse should:

a) contact the physician
b) cover the crutch pads with cloth
c) call the local medical supply store and ask for a cane to be delivered
d) tell the client that the crutches must be removed from the house immediately






NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

16) C

- Systemic lupus erythematosus is an inflammatory disease of collagen in connective tissue. Options A, B, and D are not associated with this disease.

17) C

- Treatment of systemic lupus erythematosus is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. Options A, B, and D are not standard components of medication therapy.

18) A

- Individuals at risk for developing a latex allergy include health care workers, individuals who work in the rubber industry or those who have had multiple surgeries, have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts.

19) D

- 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 to the result of a possible cross-reaction between the food and the latex allergen. Options A, B, and C are unrelated to latex allergy.

20) B

- 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 order a cane for a client. Additionally, this type of assistive device may not be appropriate, considering this client’s injury. No reason exists to contact the physician at this time.




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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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NCLEX Review about Immune System Disorders (6-10)

NCLEX Review about Immune System Disorders

6. Which of the following individuals is least likely at risk for the development of Kaposis's sarcoma?

a) A kidney transplant client
b) a male with a history of same-gender partners
c) a client receiving anti-neoplastic medications
d) an individual working in an environment in which he or she is exposed to asbestos

7. The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate into the plan during the bathing of this client?

a) wearing gloves
b) wearing a gown and gloves
c) wearing a gown, gloves, and a mask
d) wear a gown and gloves to change the bed linens and gloves only for the bath

8. A client is suspected of having systemic lupus erythematosus. The nurse monitors the client, knowing that which of the following is one of the initial characteristic signs of systemic lupus erythematosus?

a) weight gain
b) subnormal temperature
c) elevated red blood cell count
d) rash on the face across the bridge of the nose and on the cheeks

9. 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?

a) I should take hot baths because they are relaxing
b) I should sit whenever possible to conserve my energy
c) I should avoid long periods of rest because it causes joint stiffness
d) I should do some exercises, such as walking, when I am not fatigued

10. The client with acquired immunodeficiency syndrome has raised, dark purplish-colored 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 caused by Kaposi's sarcoma?

a) skin biopsy
b) lung biopsy
c) western blot
d) enzyme-linked immunosorbent assay






NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

6) D

- Kaposi’s sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. Malignancy is seen most frequently in men with a history of same-gender partners. Although the cause of Kaposi’s sarcoma is not known, it is considered to be caused by an alteration or failure in the immune system. The renal transplantation client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi’s sarcoma.

7) B

- Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

8) D

- 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.

9) A

- 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.

10) A

- 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.



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

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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