IMMUNE SYSTEM DISORDERS COMPREHENSIVE EXAMINATION

Transcription

1 2504_h13_ qxd 11/4/10 9:50 PM Page 561 HPTER 13 IMMUNE SYSTEM ISORERS IMMUNE SYSTEM ISORERS OMPREHENSIVE EXMINTION 1. The client is prescribed a prick epicutaneous test to determine the cause of hypersensitivity reactions. Which result indicates the client is hypersensitive to the allergen? 1. The client complains of shortness of breath. 2. The skin is dry, intact, and without redness. 3. The pricked blood tests positive for allergens. 4. pruritic wheal and erythema occur. 2. Which area of the body should the nurse assess to identify symptoms to support the early diagnosis of Guillain-arré syndrome? Which referral should the nurse implement for a client with severe multiple allergies? 1. Registered dietitian. 2. Occupational therapist. 3. Recreational therapist. 4. Social worker. 4. The client diagnosed with an anaphylactic reaction is admitted to the emergency room. Which assessment data indicate the client is not responding to the treatment? 1. The client has a urinary output of 120 ml in two (2) hours. 2. The client has an P of 110 and a P of 90/ The client has clear breath sounds and an RR of The client has hyperactive bowel sounds. 5. Which signs/symptoms should the nurse expect to assess in the client diagnosed with Sjögren s syndrome? 1. omplaints of dry mouth and eyes. 2. omplaints of peripheral joint pain. 3. omplaints of muscle weakness. 4. omplaints of severe itching. 561

2 562 ME-SURG SUESS 6. Which intervention should the nurse implement for the client diagnosed with systemic sclerosis (scleroderma)? 1. Instill artificial tears four (4) times a day. 2. pply moisturizers to the skin frequently. 3. Instruct the client on how to apply braces. 4. Encourage the client to decrease smoking. 7. The nurse is caring for a client with suspected fibromyalgia. Which diagnostic test confirms the diagnosis of fibromyalgia? 1. There is no diagnostic test to confirm fibromyalgia. 2. positive antinuclear antibody test. 3. magnetic resonance imaging (MRI) shows fibrosis. 4. negative erythrocyte sedimentation rate (ESR). 8. The primary nurse is administering medications to the assigned clients. Which client situation requires immediate intervention by the charge nurse? 1. The client with congestive heart failure with an apical pulse of 64 who received mg digoxin, a cardiac glycoside. 2. The client with essential hypertension who received a beta blocker and has a blood pressure of 114/ The client with myasthenia gravis who received the anticholinesterase medication 30 minutes late. 4. The client with IS who received trimethoprim-sulfamethoxazole, an antibiotic, and has a 4 cell count of less than Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply. 1. Recommend the client not to engage in unprotected sexual activity. 2. Instruct the client not to inform past sexual partners of HIV status. 3. Tell the client to not donate blood, organs, or tissues. 4. Suggest the client not get pregnant. 5. Explain the client does not have to tell health-care personnel of HIV status. 10. Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-arré syndrome? 1. ecreasing deep tendon reflexes. 2. rooping of the eyelids has resolved. 3. positive abinski s reflex. 4. escending increase in muscle strength.

3 HPTER 13 IMMUNE SYSTEM ISORERS The client is diagnosed with systemic lupus erythematosus (SLE). Which area of the body should the nurse assess for a butterfly rash? Which nursing intervention should the nurse include when teaching the client diagnosed with polymyositis? 1. Explain the care of a percutaneous endoscopic gastrostomy tube. 2. iscuss the need to take corticosteroids every day. 3. Instruct to wear long-sleeved shirts when exposed to sunlight. 4. Teach the importance of strict hand washing. 13. The client recently diagnosed with rheumatoid arthritis is prescribed aspirin, a nonsteroidal anti-inflammatory medication. Which comment by the client warrants immediate intervention by the nurse? 1. I always take the aspirin with food. 2. If I have dark stools, I will call my HP. 3. spirin will not cure my arthritis. 4. I am having some ringing in my ears. 14. Which sign/symptom makes the nurse suspect the client has ankylosing spondylitis? 1. Low back pain at night relieved by activity in the morning. 2. scending paralysis of the lower extremities up to the spinal cord. 3. deep ache and stiffness in the hip joints radiating down the legs. 4. ifficulty changing from lying to sitting position, especially at night. 15. The client diagnosed with multiple sclerosis is having trouble maintaining balance. Which intervention should the nurse discuss with the client? 1. iscuss obtaining a motorized wheelchair for the client. 2. Teach the client to stand with the feet slightly apart. 3. Encourage the client to narrow his or her base of support. 4. Explain the need to balance activity with rest. 16. The nurse is caring for the client diagnosed with acquired immunodeficiency syndrome (IS) dementia. Which action by the unlicensed assistive personnel (UP) requires immediate intervention by the nurse? 1. The UP is helping the client to sit on the bedside chair. 2. The UP is wearing sterile gloves when bathing the client. 3. The UP is helping the client shave and brush the teeth. 4. The UP is providing a back massage to the client.

4 564 ME-SURG SUESS 17. Which assessment data should make the nurse suspect the client has chronic allergies? 1. Jaundiced sclera and jaundiced palms of hands. 2. Pale, boggy, edematous nasal mucosa. 3. Lacy white plaques on the oral mucosa. 4. Purple or blue patches on the face. 18. The client has had an anaphylactic reaction to insect venom, a bee sting. Which discharge instruction should the nurse discuss with the client? 1. Take a corticosteroid dose pack when stung by a bee. 2. Take antihistamines prior to outdoor activities. 3. Use a cromolyn sodium (Intal) inhaler prophylactically. 4. arry a bee sting kit, especially when going outside. 19. The client with acquired immunodeficiency syndrome (IS) dementia is referred to hospice. Which intervention has highest priority when caring for the client in the home? 1. ssess the client s social support network. 2. Identify the client s usual coping methods. 3. Have consistent uninterrupted time with the client. 4. iscuss and complete an advance directive. 20. The client with multiple sclerosis is prescribed the muscle relaxant baclofen (Lioresal). Which statement by the client indicates the client needs more teaching? 1. This medication may cause drowsiness so I need to be careful. 2. I should not drink any type of alcohol or take any antihistamines. 3. I will increase the fiber in my diet and increase fluid intake. 4. I stopped taking the medication because I can t afford it. 21. Which intervention has the highest priority when caring for a client diagnosed with rheumatoid arthritis? 1. Encourage the client to ventilate feelings about the disease process. 2. iscuss the effects of disease on the client s career and other life roles. 3. Instruct the client to perform most important activities in the morning. 4. Teach the client the proper use of hot and cold therapy to provide pain relief. 22. Which statement indicates the female client with systemic lupus erythematosus (SLE) understands the discharge instructions? 1. I should wear sunscreen with at least a 5 SPF. 2. I am not going to any activities with large crowds. 3. I should not get pregnant because I have SLE. 4. I must avoid using hypoallergenic products. 23. Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction? 1. dminister parenteral epinephrine, an adrenergic agonist. 2. Prepare for immediate endotracheal intubation. 3. Provide a calm assurance when caring for the client. 4. Establish and maintain a patent airway. 24. Which discharge instruction should the nurse implement for the client newly diagnosed with myasthenia gravis (MG)? 1. Identify specific measures to help avoid fatigue and undue stress. 2. Instruct the client to pad bony prominences, especially the sacral area. 3. iscuss complementary therapies to help manage pain. 4. Explain the possibility of having a splenectomy to help control the symptoms.

5 25. Which signs/symptoms make the nurse suspect the most common opportunistic infection in the female client diagnosed with acquired immunodeficiency syndrome (IS)? 1. Fever, cough, and shortness of breath. 2. Oral thrush, esophagitis, and vaginal candidiasis. 3. bdominal pain, diarrhea, and weight loss. 4. Painless violet lesions on the face and tip of nose. 26. The client is experiencing an anaphylactic reaction to bee venom. Which interventions should the nurse implement? List in order of priority. 1. Establish a patent airway. 2. dminister epinephrine, an adrenergic agonist, IVP. 3. Start an IV with 0.9% saline. 4. Teach the client to carry an EpiPen when outside. 5. dminister diphenhydramine (enadryl), an antihistamine, IVP. HPTER 13 IMMUNE SYSTEM ISORERS 565