NCLEX - Immune Questions and Answers

NCLEX - Immune Questions and Answers

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

• A kidney transplant client
• A male with a history of same-sex partners
• A client receiving antineoplastic medications
• An individual working in an environment

where exposure to asbestos exists - answerAnswer: 2

Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It isn't seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant 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.

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 in the plan during the bathing of this client?

• Wearing gloves
• Wearing a gown and gloves
• Wearing a gown, gloves, and a mask
• Wearing a gown and gloves to change the bed linens and gloves only for the bath -

answerAnswer: 2

Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while 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.

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

• Weight gain
• Subnormal temperature
• Elevated red blood cell count
• Rash on the face across the bridge of the nose and on the cheeks - answerAnswer: 4

Rationale: 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.

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?

• The presence of tiny red vesicles
• An autoimmune disease that causes blistering in the epidermis
• The presence of skin vesicles found along the nerve caused by a virus
• The presence of red, raised papules and large plaques covered by silvery scales - answerAnswer:

2 Rationale: 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 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.

The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care?

• Protecting the client from infection
• Providing emotional support to decrease fear
• Encouraging discussion about lifestyle changes

4. Identifying factors that decreased the immune function - answerAnswer: 1

Rationale: The client with immune deficiency has inadequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection.Options 2, 3, and 4 may be components of care but are not the priority.

A client calls the office of his primary care health care provider and tells the nurse that he was just stung by a bumblebee 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:

• Advise the client to soak the site in hydrogen peroxide.

2.Ask the client if he ever sustained a bee sting in the past.

• Tell the client to call an ambulance for transport to the emergency room.
• Tell the client not to worry about the sting unless difficulty with breathing occurs. -

answerAnswer: 2

Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that immunization provides which of the following?

• Protection from all diseases
• Innate immunity from disease
• Natural immunity from disease

4. Acquired immunity from disease - answerAnswer: 4

Rationale: 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.

The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse

plans care knowing that this disorder is:

• A local rash that occurs as a result of allergy
• A disease caused by overexposure to sunlight
• An inflammatory disease of collagen contained in connective tissue
• A disease caused by the continuous release of histamine in the body - answerAnswer: 3

Rationale: SLE is an inflammatory disease of collagen contained in connective tissue. Options 1, 2, and 4 are not associated with this disease.

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?

• Lyme disease is caused by a tick carried by deer.
• Lyme disease is caused by contamination from cat feces.
• Lyme disease can be contagious by skin contact with an infected individual.
• Lyme disease can be caused by the inhalation of spores from bird droppings. - answerAnswer: 1

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

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

• Arthralgias
• Flu-like symptoms
• Enlarged and inflamed joints

4. Signs of neurological disorders - answerAnswer: 2

Rationale: The hallmark of stage I is the development of a skin 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 bullseye 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.

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 appropriate?

• Refer the client for a blood test immediately.