Deck 8: Immunity

Question 1

The nurse is teaching a group of parents at the local elementary school health fair about immunity and the importance of vaccination.Which scenario will the nurse provide as one in active immunity is acquired?

A) Receiving a rabies shot after being bitten by a rabid dog
B) Having measles
C) Receiving an injection of gamma globulin
D) Becoming ill with tetanus and receiving tetanus toxoid

Answer 1

Having measles

Question 2

The nurse is caring for a client who is newly diagnosed with human immunodeficiency virus (HIV).The client asks the nurse if there are ways to protect the client's life partner from getting the HIV virus.After educating the client,which statement indicates the need for further education?

A) "I know to use an oil-based lubricant to prevent spread of the disease to my partner."
B) "I can still kiss and hug my partner to show affection."
C) "I will not share my razor with my partner."
D) "I know I have to practice safer sex with my partner by using a latex condom."

Answer 2

"I know to use an oil-based lubricant to prevent spread of the disease to my partner."

Question 3

The nurse is providing care to a pediatric client who is HIV-positive.The client's mother is describing the child's current condition and activities to the nurse.Which statements by the mother indicate that the child is currently exhibiting positive outcomes related to the diagnosis? Select all that apply.

A) "My child attends school and doing well in class."
B) "My child seems somewhat isolated and doesn't have any real friends."
C) "My child has a good appetite and eats regular meals."
D) "My child hasn't shown any sign of infection."
E) "We attend a weekly support group for kids with HIV."

Answer 3

"My child attends school and doing well in class."
"My child has a good appetite and eats regular meals."
"My child hasn't shown any sign of infection."
"We attend a weekly support group for kids with HIV."

Question 4

A nurse is developing a plan of care for a client who was recently diagnosed with human immunodeficiency virus (HIV).The client states,"I don't plan on giving up sex just because I am HIV positive." Based on this data,which nursing diagnosis is the priority for this client?

A) Risk for Infection
B) Death Anxiety
C) Deficient Knowledge
D) Social Isolation

Question 5

The nurse is providing care to an adolescent client who presents at the clinic for a routine health assessment.Which immunizations does the nurse anticipate administering to the adolescent during this visit? Select all that apply.

A) MMR booster
B) Papillomavirus vaccine
C) TDaP booster
D) Meningococcal vaccine
E) Hepatitis B vaccine

Question 6

Human immunodeficiency virus (HIV)infects and destroys CD4 cells.List the following events in the order in which they occur for a client who is HIV-positive.

A) Virus invades helper T cell
B) Viral RNA converts with reverse transcriptase to viral DNA
C) Viral DNA integrates with host cell DNA.
D) Virus remains latent, or actively replicates.
E) Virus sheds protein coat.

Question 7

The nurse is caring for a client admitted to an urgent care clinic due to an arm infection.The client reports being bitten by a raccoon on a recent camping trip.Based on this data,which treatment option does the nurse anticipate for this client?

A) An injection of immunoglobulin.
B) A tetanus toxoid injection.
C) Mother's breast milk with antibodies in it.
D) An immunization for rabies.

Question 8

A nurse is caring for a client with who is experiencing leukocytosis.When providing care to this client,which action by the nurse is the most appropriate?

A) Instruct the client on the use of an electric razor and soft toothbrush.
B) Assess for bleeding and bruising.
C) Assess for source of infection.
D) Place the patient in reverse isolation precautions.

Question 9

A nurse working in the emergency department is providing care for a group of clients.Which client demonstrates a decline immune response that typically occurs with the aging process?

A) An 88-year-old client with pneumonia who has a temperature of 99.5°F
B) A 70-year-old client who has swelling and redness around an abdominal incision from an open appendectomy
C) A 58-year-old client who complains of redness and itching after developing a rash from contact with poison ivy
D) A 56-year-old client who has 8 mm induration at the site of a PPD skin test 72 hours earlier

Question 10

The nurse is providing care to a client with a compromised immune system.Which independent nursing intervention is appropriate for the nurse to include in the client's plan of care?

A) Educating on the importance of a nutritious diet
B) Administering corticosteroids, per order
C) Prescribing prophylactic antibiotic therapy
D) Recommending gene transfer therapy

Question 11

The nurse suspects that the client is experiencing a reaction to a specific antigen.Which laboratory result supports the conclusion made by the nurse?

A) Indirect Coombs' showing no agglutination
B) Patch test with a 1-inch area of erythema
C) 2% eosinophils in the WBC count
D) Rh antigen with negative results

Question 12

The nurse is planning care for a pediatric client diagnosed with human immunodeficiency virus (HIV).The nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric client.Based on this nursing diagnosis,which actions by the nurse are appropriate? Select all that apply.

A) Administering tuberculosis skin tests every six months
B) Teaching proper food-handling techniques to the family
C) Instructing on the importance of consuming ample fresh fruits and vegetables
D) Assessing the health status of all visitors
E) Monitoring hand-washing techniques used by the famly

Question 13

The nurse is providing care to a client who is receiving nonsteroidal anti-inflammatory drugs (NSAIDs)in the treatment of rheumatoid arthritis.When providing care to this client,which actions by the nurse are appropriate? Select all that apply.

A) Monitoring for signs of allergic reaction
B) Assuring the client that there is no relationship between NSAIDs and heart disease
C) Encouraging the client to take with a full glass of water, milk, or small snack to help avoid GI distress
D) Monitoring for signs of renal problems
E) Advising against abrupt discontinuation of drugs

Question 14

The nurse is conducting a physical assessment for a client with a compromised immune system.Which actions by the nurse are appropriate? Select all that apply.

A) Assessing general appearance
B) Recommending increased fluid intake
C) Inspecting the mucous membranes of the nose and mouth for color and condition
D) Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness
E) Checking joint range of motion (ROM), including that of the spine

Question 15

A client receives the yellow fever vaccine before traveling to the Amazon Basin and asks the nurse how the vaccine provides protection.Which responses by the nurse is the most appropriate? Select all that apply.

A) "Human macrophages engulf the weakened vaccine virus as if it is dangerous and antigens stimulate the immune system to attack it."
B) "In the lymph nodes, part of the lymphoid system, the macrophages present yellow fever antigens to T cells and B cells."
C) "A response from yellow fever-specific T cells is activated. B cells secrete yellow fever antibodies."
D) "The body's immune system eats away at the protective sheath (myelin) that covers the nerves."
E) "The initial weak infection is eliminated and the client is left with a supply of memory T and B cells for future protection against yellow fever."

Question 16

The nurse is discharging a pediatric who recently developed acquired immunodeficiency syndrome (AIDS).When discussing appropriate health promotion activities for this child,which immunization is not appropriate for this client to receive due to AIDS diagnosis?

A) Varicella vaccine
B) Haemophilus influenzae type B (HIB conjugate vaccine)
C) Hepatitis B vaccine (hep
D) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

Question 17

A home health nurse is conducting home visits for several clients who are diagnosed with acquired immunodeficiency syndrome (AIDS).Which client would the nurse see first?

A) A client who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count
B) A client with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath
C) A client with wasting syndrome who needs modifications and education regarding dietary changes
D) A client who is receiving IV antibiotics daily for toxoplasmosis

Question 18

The nurse is reviewing the laboratory values of a client who is newly diagnosed with acquired immunodeficiency syndrome (AIDS).Which values should be reported to the client's healthcare provider? Select all that apply.

A) CD4 cell count 1,100/mm³
B) T4 cell count 150
C) CD4 lymphocytes 12%
D) Viral load 11,500 copies/mL
E) WBC 6,500

Question 19

A nurse is performing an admission assessment on a client with symptoms that indicate the client may have human immunodeficiency virus (HIV).Which question from the nurse addresses a major risk factor for contracting HIV?

A) "Has your partner been experiencing these symptoms?"
B) "When was your first sexual experience?"
C) "Have you had any fever, diarrhea, or chills over the last 48 hours?"
D) "Have you ever experimented with intravenous drugs?"

Question 20

The nurse is caring for a client who is hospitalized on a medical unit for a systemic infection.The client asks the nurse which defenses the body has against infection.Which physiological barriers that protect the body against microorganisms will the nurse include in the response to the client? Select all that apply.

A) Alcoholic beverages
B) Adequate urinary output
C) Intact skin
D) Occasional smoking
E) A surgical incision

Question 21

A nurse is working in a summer camp for children.One of the children comes to the clinic with several bee stings.Which clinical manifestations would necessitate the need to inject the child with epinephrine (EpiPen)? Select all that apply.

A) Skin that is cold and clammy to the touch
B) Skin that is warm and dry to the touch
C) The child is hyperactive and hyperverbal.
D) Complaints of thirst
E) Restlessness and confusion

Question 22

The nurse is caring for a client with a history of latex allergies.The client develops audible wheezing,pruritus,urticaria,and signs of angioedema.Which is the priority intervention for this client?

A) Teach the client regarding using a kit that contains treatment for allergic reactions.
B) Administer diphenhydramine (Benadryl) by mouth every 4 hours per the healthcare provider's orders.
C) Administer epinephrine 1:1,000 by subcutaneous injection per the healthcare provider's orders.
D) Collect a detailed history from the client regarding the history of latex allergies.

Question 23

A nurse is caring for a pediatric client who is receiving an infusion of intravenous antibiotic at the ambulatory clinic.Which clinical manifestation indicates that the client is experiencing a type I hypersensitivity reaction?

A) Erythema
B) Fever
C) Joint pain
D) Hypotension

Question 24

A pediatric client with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen.Which statements are appropriate for the nurse to include in the discharge instructions for this client and family? Select all that apply.

A) "It is recommended that the child wear a medical alert bracelet."
B) "This medication does not come pre-filled and must be measured."
C) "Keep the medication in the car at all times."
D) "Frequently check the expiration date of the medication."
E) "Keep the medication in one location that is easy to remember."

Question 25

A client,recently diagnosed with rheumatoid arthritis (RA),asks the nurse whether RA will affect her in other ways.When responding to the client,which systems will the nurse include as possibly being affected by the diagnosis? Select all that apply.

A) Respiratory
B) Cardiovascular
C) Exocrine
D) Reproductive
E) Hematologic

Question 26

The nurse is caring for a client who was diagnosed with rheumatoid arthritis (RA)last year.The client has recently been placed on prednisone for treatment.The nurse is teaching the client about safe medication administration.Which client statement indicates that the medication teaching was successful?

A) "I will not have to limit my consumption of canned vegetables."
B) "I will take this medication on a full stomach to enhance absorption."
C) "I will not need to monitor my blood sugar more frequently while on this medication."
D) "I will take the ordered dose at the same time every day."

Question 27

The nurse is caring for a client in an allergy clinic.After completing the client history,the nurse selects the nursing diagnosis of Risk for Shock.Which item in the client's history supports the need for this nursing diagnosis? ?

A) Anaphylactic reaction to shellfish
B) A drug reaction to penicillin causing a rash
C) Glomerulonephritis
D) Dermatitis resulting from a response to changing laundry detergent

Question 28

A nurse is caring for a client who was admitted to the hospital with an exacerbation of rheumatoid arthritis (RA).The client reports pain is a 3 on a scale from 1 to 10 today.Which non-pharmacological interventions can the nurse provide to enhance the client's comfort? Select all that apply.

A) Discourage any position changes.
B) Encourage relaxation techniques
C) Immobilize the extremity.
D) Offer a massage
E) Provide diversion activities.

Question 29

A client has just recently been diagnosed with rheumatoid arthritis (RA).The client asks the nurse if RA always causes crippling deformities.Which teaching topics will the nurse include as ways to decrease the likelihood of crippling deformities? Select all that apply.

A) Ignore pain as a warning signal.
B) Type instead of hand-writing items if possible.
C) Use stronger joints for most activity.
D) Avoid stress to any current area of deformity.
E) Stop an activity if it is beyond your ability to perform.

Question 30

The nurse is preparing to assess a client when one of the client's family members begins showing symptoms of a latex sensitivity.Which action by the nurse is the most appropriate?

A) Ask the family member to leave the unit.
B) Transfer the client to a department that does not use latex products.
C) Wait until Monday to report the problem to the supervisor of the unit.
D) Obtain latex-free products for the client's room.

Question 31

The nurse is caring for a client who is experiencing anaphylactic shock following the administration of a medication.Which position is the most appropriate for the nurse to place the client based on this data?

A) Trendelenburg position
B) Flat, with legs slightly elevated
C) Supine position
D) High Fowler position

Question 32

The nurse is collecting a health history for a client being seen in an outpatient clinic who complains of joint pain and swelling that have lasted for about 2 months.The client is diagnosed with rheumatoid arthritis (RA).When planning care for this client,which statement supports the nursing diagnosis of Activity Intolerance?

A) "I seem to get tired early in the day and require a nap."
B) "My joints are stiffest at night before I go to sleep."
C) "I find it difficult to move when I first get up in the morning."
D) "I take ibuprofen for the pain as needed."

Question 33

A nurse working in the pediatric intensive care unit (PICU)is caring for a pediatric client with human immunodeficiency virus (HIV).The client is severely symptomatic with the additional diagnoses of lymphoma and wasting syndrome.Based on this data,which clinical stage of HIV does the nurse anticipate for this client?

A) Category N
B) Category C
C) Category A
D) Category B

Question 34

The nurse is admitting a pediatric client to the hospital with a VP shunt malfunction.The client's family speaks very little English.The interpreter has arrived and the nurse is obtaining a health history from the parents and learns that the client received the shunt at birth after a menigocele repair.Based on this data,which product should be avoided when providing care to this client?

A) Synthetic rubber gloves
B) Polyethylene gloves
C) Non-powdered nitrile gloves
D) Latex gloves

Question 35

A nurse working in an intensive care unit (ICU)is assigned a client diagnosed with acquired immunodeficiency syndrome (AIDS).Based on this data,which type of precaution does the nurse implement when providing direct care?

A) Droplet
B) Reverse
C) Standard
D) Contact

Question 36

A nurse has been providing a young adult client with a history of hypersensitivity reactions.The nurse is preparing instructions on the correct w methods for using an EpiPen.Which client statement indicate understanding of the proper technique? Select all that apply.

A) "It's fine to leave the EpiPen out in the sun"
B) "I frequently check the expiration date"
C) "I make sure the EpiPen is always available."
D) "No one else in my family knows how to use the EpiPen."
E) "I don't need a medical alert tag."

Question 37

A client recently diagnosed with rheumatoid arthritis (RA)asks the nurse if the disease is caused by ethnicity.Which response by the nurse is the most appropriate?

A) "RA affects those of German descent most often."
B) "RA is most prevalent in Caucasian females."
C) "RA is most prevalent in men under the age of 20 years."
D) "RA affects all races at the same rate."

Question 38

The nurse is completing a health screening for a school-age child with rheumatoid arthritis (RA).The parents ask the nurse to recommend activities that will promote exercise for their child.Which recommendation by the nurse is the most appropriate?

A) Swimming
B) Football
C) Softball
D) Basketball

Question 39

A nurse is caring for a client with seasonal hypersensitivity reactions.What teaching would the nurse provide to improve this client's comfort? Select all that apply.

A) Keep doors and windows open on high-allergen days to circulate air.
B) Remain indoors if possible on high-allergen days.
C) Maintain a clean, dust-free environment.
D) Take antihistamine and leukotriene medication as ordered.
E) Stop taking oral corticosteroids immediately once symptoms disappear.

Question 40

A client with rheumatoid arthritis (RA)is being seen in the outpatient clinic for a progress check-up.The nurse is reviewing the client's plan of care and determines that the client has met a goal of treatment when the client makes which statement?

A) "I sleep for 10 hours at night."
B) "I have increased pain in my joints all the time now."
C) "I have delegated many household chores to my children and spouse."
D) "I do not perform household chores at all anymore."

Question 41

A nurse caring for a client with systemic lupus erythematous (SLE)who is prescribed immunosuppressive therapy.When providing teaching for this client,which topics are appropriate for the nurse to include? Select all that apply.

A) Avoid large crowds and situations that increase exposure to infection.
B) Report difficulty breathing or cough to the physician if taking cyclophosphamide.
C) Use aspirin instead of acetaminophen if fever develops.
D) Heavy menstrual bleeding may occur during therapy.
E) Maintain appropriate oral hydration.

Question 42

A nurse is caring for a client who is newly diagnosed with rheumatoid arthritis (RA).The client asks the nurse what the difference is between RA and osteoarthritis (OA).Which responses by the nurse are the most appropriate? Select all that apply.

A) "The onset of OA is gradual while the onset of RA may be rapid."
B) "With OA, multiple joints are symmetrically affected; RA affects one joint at a time."
C) "The affected joints in RA feel cold to the touch while the joints affected by OA are warm or hot to the touch."
D) "OA is slowly progressive while RA is characterized by exacerbations and remissions."
E) "The pain and stiffness with RA is with activity; OA pain and stiffness is predominant upon arising."

Question 43

A nurse is caring for a pregnant client who has rheumatoid arthritis (RA).Based on this data,which does the nurse anticipate when providing care to this client?

A) A higher risk for preterm delivery.
B) An increased need for medication.
C) An acute exacerbation of symptoms.
D) A continued risk for anemia.

Question 44

A nurse is caring for a client with systemic lupus erythematosus (SLE).The client begins to cry stating,"I am afraid I will be disfigured because of all of these lesions." Which interventions does the nurse plan to teach this client to minimize skin infections associated with SLE? Select all that apply.

A) Use sunscreen with an SPF of 15 or greater.
B) Remain indoors on sunny days.
C) Avoid swimming in a pool or the ocean.
D) Avoid sun exposure between 10:00 a.m. and 3:00 p.m.
E) Decrease sun exposure between 3:00 p.m. and 5:00 p.m.

Question 45

The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE).Which client statement indicates an appropriate understanding of the plan of care?

A) "I will take birth control pills while I am taking cytotoxic medications."
B) "I do not need to contact the doctor if I develop a fever or rash."
C) "I plan to go to the movies this weekend so that I get out of the house."
D) "I can take aspirin as indicated for pain."

Question 46

The nurse is caring for a client who is hospitalized due to an exacerbation of systemic lupus erythematosus (SLE).The nurse is reviewing the client's lab work and finds the white blood cell count (WBC)is shifted to the left.Based on this information,which is a priority nursing diagnosis for this client?

A) Risk for Infection
B) Ineffective Health Maintenance
C) Ineffective Individual Coping
D) Risk for Impaired Skin Integrity

Question 47

A client asks the nurse if there are any conditions that can exacerbate systemic lupus erythematosus (SLE).Which response by the nurse is the most appropriate?

A) "Conditions that cause hypotension can often exacerbate SLE."
B) "GI upset is often associated with SLE exacerbation."
C) "Pregnancy is often associated with an SLE exacerbation."
D) "Fever is a known trigger for an SLE exacerbation."

Question 48

The client enters the outpatient clinic and states to the triage nurse,"I think I have the flu.I'm so tired,I have no appetite,and everything hurts." The triage nurse assesses the client and finds a butterfly rash over the bridge of nose and on the cheeks.Based on this data,which diagnosis does the nurse anticipate?

A) Systemic lupus erythematosus
B) Fibromyalgia
C) Lyme disease
D) Gout

Question 49

The nurse is providing health education to a diverse group at a neighborhood community center.Why does the nurse plan to include signs and symptoms of systemic lupus erythematosus (SLE)?

A) The neighborhood is composed of many young female children.
B) The audience has asked the nurse to include the information.
C) The audience is mainly composed of Caucasian women.
D) The audience is mainly females of Asian-American descent.

Question 50

A client with systemic lupus erythematosus (SLE)is being treated with immunosuppressant drugs and corticosteroids.When providing teaching for this client,which topics are appropriate for the nurse to include? Select all that apply.

A) Avoid large crowds.
B) Don't get a flu shot.
C) Use contraception to prevent pregnancy
D) Refrain from taking aspirin products.
E) Report signs of infection to the healthcare provider.

Question 51

The nurse is planning care for an adolescent client who has systemic lupus erythematosus (SLE).Which action by the client indicates the implemented plan of care is appropriate?

A) Refusing to attend school
B) Refraining from attending any social functions
C) Discussing skin changes with the healthcare provider
D) Discussing skin changes with a good friend

Question 52

A nurse is caring for a client with systemic lupus erythematous (SLE)who is taking hydroxychloroquine (Plaquenil).When providing care for this client,the nurse monitors for which adverse effects associated with the prescribed medication?

A) Pulmonary fibrosis
B) Cushingoid effects
C) Retinal toxicity
D) Renal toxicity

Question 53

The nurse is caring for a client diagnosed with discoid lupus erythematosus.The nurse is collaborating with the client to set goals for the nursing plan of care.Which is an appropriate goal for this client?

A) Work through the stages of death and dying.
B) Compliance with a sun protection plan.
C) Gain weight to within 10 pounds of normal for height.
D) Report pain no higher than 4 on a scale of 1-10.