NCLEX Review about Immune System Disorders (21-25)

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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)

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    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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      Linkbait - Magic Keyword "NCLEX Practice Test"

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      NCLEX Review about Immune System Disorders (11-15)

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      --> 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)

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        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)

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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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            NCLEX Review about Ear Infection 36-40

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            NCLEX Review about Ear Infection

            36. A nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair. The nurse plans to incorporate which important concept regarding hearing loss in the presentation?

            a) siting near loud music is not harmful
            b) ear plugs or other protectors are necessary only when use of power tools
            c) prolonged ringing in the ears after loud noises is normal
            d) cup the hands over the ears if loud noise is expected suddenly

            37. A nurse instructs a client in the use of a hearing aid. The nurse includes which of the following in the instructions?

            a) check the battery to ensure that it is working before use
            b) leave the hearing aid in place while showering
            c) hearing aids do not require any care
            d) a water-soluble lubricant is used on the hearing aid before insertion

            38. A nurse has given a client at risk for motion sickness suggestions about medications that can prevent an occurrence. The nurse determines that the client has correctly learned the information if the client states to take medication at what time before the triggering event?

            a) at least 1/2 day before
            b) at least 1 hour before
            c) at least the day before
            d) at least 2 days before

            39. An adult client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse would ask about which of the following as a risk factor related to infection of the ears?

            a) exposure to loud noise
            b) use of drilling and other power tools
            c) congenital abnormalities
            d) occupational noise

            40. A nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Teaching for this client will include which of the following statements?

            a) drive only when feelings of dizziness have not been experienced for several hours
            b) go to the bedroom and lie down when vertigo is experienced
            c) remove throw rugs and clutter in the home
            d) turn the head slowly when spoken to





            NCLEX REVIEW ABOUT EAR INFECTION:
            ANSWERS AND RATIONALE

            36) D
            - A variety of ear protective devices are available commercially. These include disposable and reusable plugs, headbands, and foam-filled muffs. They should be used around any type of loud noise, such as from power tools, machinery, lawn mowers, chain saws, or other equipment. Sitting near loud music should be avoided whenever possible. If a loud noise is suddenly anticipated, the ears should be covered for protection. The client should see a physician for tinnitus or hearing loss after exposure to a loud noise.

            37) A
            - The battery of the hearing aid should be checked before use. The hearing aid should be removed for showering, because it should not get wet. It also should be put away in its case at night. It should be cleaned according to manufacturer’s directions, which usually consist of washing with warm soapy water, followed by thorough drying. Lubricants or other solvents are not used on the hearing aid.

            38) B
            - To be maximally effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event. Medications that are commonly used for this purpose include dimenhydrinate (Dramamine), scopolamine (Transderm-Scop), promethazine (Phenergan), and prochlorperazine (Compazine). Options A, C, and D are incorrect.

            39) C
            - Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the eustachian tube. Risk factors include a young age (usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. Options A, B, and D can cause hearing loss. Hearing loss can occur as a result of an acute loud noise (acoustic trauma) or by the chronic exposure to loud noise (noise-induced hearing loss).

            40) C
            - The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. To further prevent vertigo attacks, the client should change positions slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of furniture. The client should maintain the home without throw rugs and in a state that is free of clutter, because the effort of trying to regain balance after slipping could trigger the onset of vertigo.



            After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

            NCLEX Review about Ear Infection 1-5


            Or proceed to the next set of questions:

            NCLEX Review about Ear Infection 41-45

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