Deck 13: Nursing Care of Patients with Altered Immunity

Question 1

A patient develops hemolytic anemia after receiving a dose of penicillin. The nurse realizes that which of the following is indicated for this patient?

A)Administer no further doses of penicillin.
B)Administer a blood transfusion.
C)Provide oxygen.
D)Increase fluids.

Answer 1

Administer no further doses of penicillin.

Question 2

The home health nurse is revising the care plan for a patient who is immunosuppressed and has developed a vaginal yeast infection. Nursing diagnoses related to this infection include which of the following? Select all that apply.

A)Acute/Chronic Pain
B)Impaired Skin Integrity
C)Deficient Knowledge
D)Anxiety
E)Infection Transmission

Answer 2

Acute/Chronic Pain
Impaired Skin Integrity
Deficient Knowledge
Anxiety

Question 3

A patient tells the nurse that he used to get the "common cold" at least three times a year but now he can't remember the last time had "a cold." The nurse realizes that this patient is describing which of the following?

A)healthy B cell functioning
B)healthy T helper cell functioning
C)T cell secretion of antibodies
D)healthy T regulator cell functioning

Answer 3

healthy B cell functioning

Question 4

A patient is diagnosed with a type IV delayed hypersensitivity reaction. Which of the following is an example of this type of reaction?

A)latex allergy
B)reaction to a wasp sting
C)serum sickness
D)autoimmune hemolytic anemia

Question 5

A patient who is immunosuppressed asks the nurse why he is experiencing so many illnesses. With which of the following should the nurse respond to this patient?

A)"You are unable to develop immunity to common bacteria so you will experience more illnesses."
B)"Your body takes longer to develop an immune response."
C)"Your body thinks everything is foreign matter and will respond with an illness."
D)"You are under severe stress, which is causing the illnesses."

Question 6

A patient, in isolation for an incompetent immune system, asks the nurse what "disease he has" since he has been placed in isolation. With which of the following should the nurse respond to this patient?

A)"Since your immune system is weak, you can develop a disease.The isolation is to protect you."
B)"I will have to find out from your doctor."
C)"It's not a bad disease.The isolation is just to make sure it doesn't spread."
D)"I am sure that once your medications start you work, you won't have to remain in isolation."

Question 7

A patient is following an elimination diet to help determine food allergies. After one week, the patient's symptoms resolve. Which of the following should be planned for this patient?

A)Reintroduce the eliminated foods one at a time to determine the food allergy.
B)Resume regular pre-elimination diet.
C)Ingest an antihistamine before eating a food that causes a food allergy.
D)Consume a diet of foods identified as causing allergies for the full week following the elimination diet.

Question 8

Which statement made by a patient prescribed an immunosuppressive agent would require further teaching?

A)"I should drink a lot of fruit juices, such as grapefruit juice."
B)"I know to call the physician if I start experiencing a lot of bruising."
C)"I should drink plenty of water to keep me from getting dehydrated."
D)"If I experience any joint pain, I should take ibuprofen for the pain as needed every four hours."

Question 9

A patient develops a fever, rash, joint and muscle pain, and swollen lymph nodes after receiving a sulfonamide. Which of the following do these symptoms suggest to the nurse?

A)serum sickness
B)exacerbation of a disease process
C)acute influenza
D)subacute rheumatoid arthritis

Question 10

A patient is diagnosed with valvular heart disease after experiencing rheumatic heart fever. The nurse realizes this disorder is caused by which of the following?

A)molecular mimicry
B)release of hidden antigens into the circulation
C)biologic changes that caused self-antigens to produce autoantibodies
D)an autoimmune response by slow growing mycobacteria

Question 11

A patient had skin taken from the upper thigh and placed over a burn area located on the shoulder. The nurse realizes that which of the following is most likely going to occur in this patient?

A)The graft will be successful.
B)The graft will immediately become cyanotic.
C)The graft will become swollen and edematous within three to four months.
D)The graft will lift away from the body over several years.

Question 12

A patient has a history of severe responses to skin testing done for allergies. Which of the following can be used in place of skin testing for this patient?

A)radioallergosorbent test
B)white blood cells count and differential
C)blood type and crossmatch
D)immune complex assay

Question 13

A patient is admitted to receive a kidney transplant from a live sibling. The nurse realizes that which of the following had to have occurred for this surgery to be planned?

A)The human leukocyte antigens between the patient and sibling must be very similar.
B)The human leukocyte antigens between the patient and sibling must be very different.
C)The patient has an overactive immune system.
D)The donor has an overactive immune system.

Question 14

An elderly patient tells the nurse that he develops pneumonia easily; however, his wife of the same age rarely "gets sick." With which of the following should the nurse respond to this patient?

A)"Not everyone's immune system is the same, regardless of the age."
B)"Your wife must be doing something that you are not doing."
C)"Maybe your wife just doesn't tell you when she's sick."
D)"It's just a matter of time and your wife will have the same illnesses and you do."

Question 15

A patient who is a bone marrow transplant recipient develops a maculopapular rash on the palms of both hands and the soles of the feet. The patient complains of severe abdominal pain with bloody diarrhea. The nurse would suspect that the patient is experiencing which of the following?

A)graft-versus-host disease
B)chronic tissue rejection
C)acute tissue rejection
D)hyperacute tissue rejection

Question 16

A patient comes into the emergency department with itching, swelling, and slight shortness of breath after being stung by a bee. The nurse realizes this patient is experiencing which of the following types of hypersensitivity reactions?

A)type I IgE-mediated hypersensitivity
B)type II cytotoxic hypersensitivity
C)type III immune complex-mediated hypersensitivity
D)type IV delayed hypersensitivity

Question 17

A patient is suspected of having a hypersensitivity reaction. Which of the following laboratory values would suggest to the nurse that the patient is experiencing a hypersensitivity reaction?

A)patch test with a one-inch area of erythema
B)eosinophils of 2% of the total WBC
C)indirect Coombs' showing no agglutination
D)elevated hematocrit level

Question 18

A patient with an immunodeficiency has developed oral candidiasis. To best manage this opportunistic infection, the nurse should instruct the patient's family to do which of the following? Select all that apply.

A)Avoid offering the patient salty popcorn.
B)Allow the patient's soup to cool before serving it.
C)Provide the patient with a variety of his favorite beverages.
D)Offer to quit smoking with the patient.
E)Assist the patient with oral care three times a day.

Question 19

The intradermal skin test conducted on a patient has been determined as being positive. Which of the following did the nurse most likely assess in this patient?

A)a wheal greater than 5 cm from the control and erythema
B)localized itchy wheal
C)papules
D)ulceration

Question 20

A patient tells the nurse that she hopes she does not develop rheumatoid arthritis since her mother suffers so much pain with the disorder. Which of the following should the nurse respond to this patient?

A)"Autoimmune disorders are linked genetically and women have a higher incidence than men."
B)"The only way you will develop this disorder is if you become highly stressed."
C)"The amount of estrogen you have in your body will prevent the onset of the disorder."
D)"Limit your physical activity to prevent the onset of the disorder."

Question 21

A patient diagnosed with AIDS complains of nausea, fever, severe diarrhea, and anorexia. Which of the following medications would be the most effective to relieve the anorexia, as well as to stimulate the patient's appetite?

A)megestrol (Megace)
B)ciprofloxacin (Cipro)
C)zidovudine (Retrovir, AZT)
D)abacavir (Ziagen)

Question 22

The nurse is instructing a patient, diagnosed with AIDS, regarding foods to increase caloric intake. Which of the following meal plans would indicate that the patient has an understanding of the types of foods to ingest?

A)spaghetti and meat sauce, raisin salad, whole grain roll with butter, vanilla milkshake (with Ensure), and a piece of pecan pie
B)baked chicken (thigh), cabbage, small green salad, slice of white bread, dried prunes, and a soda
C)red beans and rice, slaw, tomato, crackers, chocolate pudding, and iced tea
D)vegetable soup, small piece of cornbread, banana pudding, and water

Question 23

A patient is demonstrating signs of anaphylactic shock. Which of the following should the nurse do first to assist this patient?

A)Administer subcutaneous epinephrine.
B)Maintain an airway.
C)Provide calm reassurance.
D)Place on a cardiac monitor.

Question 24

Which of the following statements made by a patient diagnosed with HIV would indicate the need for additional teaching by the nurse?

A)"I know to use an oil-based lubricant to prevent spread of the disease to my partner."
B)"I know I have to practice safe sex with my partner."
C)"I will not share my toothbrush or razor with my partner."
D)"I know I can't donate blood anymore since I have HIV."

Question 25

A young HIV female patient tells the nurse she does not want to see the gynecologist because, "I'm going to die anyway." Which of the following should the nurse say in response to this patient?

A)"Having a PAP smear will help detect the onset of cervical cancer."
B)"Why do you think that you are going to die?"
C)"The gynecologist will help diagnose any Hodgkin's disease."
D)"But you still should be on birth control."

Question 26

In a Type I hypersensitivity reaction, an antigen-antibody or antigen-lymphocyte interaction is triggered when an allergen interacts with IgE. What chemical mediators cause this patient's symptoms? Select all that apply.

A)histamine
B)compliment
C)autoantibodies
D)erythrocytes
E)kinins

Question 27

A patient receiving cyclosporine after an organ transplant is experiencing an acute onset of hypertension and headaches. Which of the following do these assessment findings suggest to the nurse?

A)These are signs of toxicity.
B)This is a normal reaction to the medication.
C)These are signs of pending transplanted organ failure.
D)This means the transplanted organ is beginning to function.

Question 28

A patient, diagnosed with rheumatoid arthritis, is not responding to NSAID therapy. Which of the following would most likely be prescribed for this patient?

A)gold salt
B)plasmapheresis
C)methotrexate (Rheumatrex)
D)infliximab (Remicade)

Question 29

The nurse is preparing to instruct a class of young adults about ways to achieve safe sex. What should be included in the nurse's presentation? Select all that apply.

A)Avoid spermicidal agents.
B)Be HIV tested if entering into a new monogamous relationship and have the test repeated in six months.
C)Avoid sexual activity until both partners found HIV negative for two tests.
D)Only use water-based lubricants with condoms.

Question 30

Before a bone marrow transplant, a patient is prescribed ganciclovir (Cytovene). Which of the following should be included in the instructions to the patient about this medication?

A)It will prevent the development of herpes pneumonia.
B)It will decrease the onset of bacterial infections.
C)It will maintain cardiac output.
D)It will prevent the development of cytomegaloviral pneumonia.

Question 31

A patient is scheduled for a bone marrow transplant. The nurse realizes that which of the following medications will most likely be prescribed for this patient?

A)acyclovir (Zovirax)
B)azathioprine (Imuran)
C)muromonab-CD3 (Orthoclone)
D)antilymphocyte globulin

Question 32

An adolescent patient asks the nurse about sexual practices and the onset of HIV. Which of the following should the nurse instruct this patient?

A)Always use a condom.
B)Be sure to be tested for HIV every six months.
C)There is no such thing as safe sex.
D)The only safe sex is no sex.

Question 33

An HIV positive patient comes into the clinic complaining of increasing pain in his feet and legs. The nurse realizes that this patient is demonstrating which of the following?

A)a reaction to the medication
B)an opportunistic infection
C)a secondary cancer
D)a nervous system manifestation of the disease

Question 34

Which patient physiologic assessment findings are consistent with those of an adult patient 12 weeks post exposure to HIV? 11ea992e_0a77_7e8b_9f38_9b0bbdd28352

A)Patients A and C
B)Patient A only
C)Patients B and D
D)Patient C only

Question 35

A patient with an autoimmune disorder tells the nurse, "My family keeps telling me that I don't look sick." The nurse should utilize which of the following nursing diagnoses to help this patient?

A)Interrupted Family Processes
B)Ineffective Protection
C)Ineffective Coping
D)Activity Intolerance

Question 36

A patient is prescribed a monoclonal antibody after an allograft on his left thigh. Which of the following should be done for this patient?

A)Instruct the patient that side effects will occur after at least six doses of the medication.
B)Encourage the patient to have a chest x-ray one week after the first dose.
C)Premedicate with hydrocortisone.
D)Closely observe the patient for four hours following the original dose.

Question 37

A patient diagnosed with HIV has an HIV viral load test of 9000 copies/mL. Which of the following does this test's result suggest to the nurse?

A)The current prescribed medication therapy is not effective.
B)The current prescribed medication therapy is effective.
C)The dose of prescribed medication can be reduced.
D)A less toxic medication needs to be prescribed.

Question 38

A patient is experiencing symptoms of exposure to environmental ragweed. The nurse should instruct the patient on the use of which of the following medications?

A)antihistamines
B)antibiotics
C)antiviral medications
D)antifungal medications

Question 39

A patient tells the nurse, "I had this arthritis pain under control but then I learned I might lose my job." With which of the following should the nurse say in response to this patient?

A)"Well, we better do everything to help you before you lose your health benefits."
B)"I'm sure you'll find another job."
C)"Stress can cause an exacerbation of the arthritis."
D)"Have you considered going on disability?"

Question 40

An HIV positive patient is not adhering to the prescribed medication therapy. Which of the following actions by the nurse will best improve patient compliance and long-term treatment of the disease process?

A)Confront the patient about the noncompliant behavior.
B)Talk with the patient about not adhering to the medication schedule.
C)Suggest that the patient take the medication at bedtime to prevent nausea.
D)Refer the patient to a social worker so that lower-cost medications can be obtained.

Question 41

Place an "X" over the area of the body best suited for prick or intradermal testing.

Question 42

Which practice or practices should the patient with known hypersensitivity reaction to bee stings be taught? Select all that apply.

A)Wear a Medic-alert bracelet identifying the allergy at all times.
B)Carry an epinephrine pen at all times.
C)Wear long-sleeved clothing while outdoors.
D)Minimize exposure by staying indoors.
E)Take an antihistamine prior to going outdoors.

Question 43

Which patient's findings are consistent with a Type II cytotoxic hypersensitivity reaction? 11ea992e_0a77_a59d_9f38_0d235945da02

A)Patient A
B)Patient B
C)Patient C
D)Patient D

Question 44

In considering guidelines for safer sex teaching how would the nurse rank the risk for HIV transmission from highest risk to lowest risk? Click and drag the options below to move them up or down.

A)heterosexual intercourse between partners using latex condoms
B)abstinence
C)monogamous sex between partners who are both ELISA and Western Blot negative.
D)anal intercourse between partners using latex condoms

Question 45

Which patient/patients' description is consistent with immunodeficiencies? 11ea992e_0a77_ccae_9f38_994246064653

A)Patient A only
B)Patient D only
C)All patients
D)Patient B and C

Question 46

Which patients are at greatest risk for graft versus host disease reaction? 11ea992e_0a77_a59c_9f38_41dae8c52ae1

A)Patient A and C
B)Patient A only
C)Patient B and C
D)Patient D only

Question 47

Which assessments are included in the physical assessment of a patient's immune function? Select all that apply.

A)skin color, temperature and moisture
B)inspection of mucous membranes
C)assessment of peripheral pulses
D)assessment of joint range of motion
E)assessment of cranial nerve function

Question 48

Which group is at greatest risk for developing AIDS associated secondary cancers? Select all that apply.

A)men who have sex with men
B)heterosexual couples who are monogamous
C)women with cervical dysplasia
D)HIV positive patients with Mycobacterium Avium Complex
E)HIV patients who have just recently seroconverted

Question 49

Which changes are consistent with aging and the effect on older adults' immune systems? Select all that apply.

A)external factors such as environmental pollution
B)the presence of chronic illness
C)decreased response to foreign antigens
D)the presence of autoantibodies
E)nutritional status