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Silvestri Chapter 60 Ed#578

Silvestri Chapter 60 Ed#578

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Published by Linda Kuglarz

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Published by: Linda Kuglarz on Oct 14, 2008
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Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 060 (edited file)—"Immune Disorders"10/14/08, Page 1 of 12, 0 Figure(s), 0 Table(s), 2 Box(es)
60: Immune Disorders
PRACTICE QUESTIONS
1. A client is suspected of having systemic lupus erythematous (SLE). The nurse monitors theclient, knowing that which of the following is a characteristic sign of SLE?1. Rash on the face across the bridge of the nose and on the cheeks2. Fatigue3. Fever 4. Elevated red blood cell countAnswer: 1Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is acharacteristic sign of SLE. Fever and fatigue may potentially occur before and duringexacerbation. Anemia is most likely to occur in SLE.Test-Taking Strategy: Note the key words,
characteristic sign
. Remember, a characteristic signof SLE is a butterfly rash across the face. If you are unfamiliar with this disorder, review thiscontent.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Adult Health/ImmuneReference: Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, p. 548.2. The nurse provides information to a client with systemic lupus erythematous (SLE) aboutmeasures to manage fatigue. The nurse determines that the client needs additional information ithe client states that he or she will1. Avoid long periods of rest.2. Sit whenever possible.3. Take a hot bath in the evening.4. Engage in moderate low-impact exercise when not fatigued.Answer: 3Rationale: To help reduce fatigue in the client with SLE, the nurse should instruct the client tosit whenever possible, to avoid hot baths, to schedule moderate low-impact exercises when notfatigued, and to maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness.Test-Taking Strategy: Note the key words,
needs additional information
. These words indicate afalse response question and that you need to select the incorrect client statement. Focusing onthe issue will direct you to option 3 as being the action that would exacerbate fatigue. If you haddifficulty with this question, review measures to prevent fatigue.Level of Cognitive Ability: ComprehensionClient Needs: Health Promotion and MaintenanceIntegrated Process: Teaching/LearningContent Area: Adult Health/Immune
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 060 (edited file)—"Immune Disorders"10/14/08, Page 2 of 12, 0 Figure(s), 0 Table(s), 2 Box(es)
References: Christensen, B., & Kockrow, E. (2003).
 Adult health nursing 
(4th ed.). St. Louis:Mosby, pp. 81-82.Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rd ed.).Philadelphia: W.B. Saunders, pp. 341, 548.3. A client has requested and undergone testing for human immunodeficiency virus (HIV). Theclient now asks what will be done next, because the results of two enzyme-linkedimmunosorbent assay (ELISA) tests have been positive. The nurse’s response is based on theunderstanding that:1. The client will probably have a bone marrow biopsy done.2. A Western blot test will be done to confirm these findings.3. A CD4
+
cell count will be obtained to measure T-helper lymphocytes.4. The client will be definitively diagnosed as HIV-positive at this point.Answer: 2Rationale: If the results of two ELISA tests are positive, the Western blot test is done to confirmthe findings. If the result of the Western blot test is positive, then the client is considered to be positive for HIV and infected with the HIV virus.Test-Taking Strategy: Knowledge of the diagnostic tests and procedural steps in diagnosing HIVis needed to answer this question. Remember, the Western blot test is done to confirm thefindings if the results of two ELISA tests are positive. Review these diagnostic tests if you haddifficulty with this question.Level of cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Adult Health/ImmuneReferences: Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, p. 550.Pagana, K., & Pagana, T. (2003).
Mosby’s diagnostic and laboratory test reference
(6th ed.). St.Louis: Mosby, pp. 23-27.4. A nurse is caring for the client with acquired immunodeficiency syndrome (AIDS). The nursedetects early infection with
 Pneumocystis jiroveci
(formerly called
 
 Pneumocystis carinii
) bymonitoring the client for which clinical manifestation?1. Dyspnea on exertion2. Dyspnea at rest3. Fever 4. CoughAnswer: 4Rationale: The client with
 Pneumocystis jiroveci
(formerly
 P. carinii
) infection usually has acough as the first symptom, which begins as nonproductive and then progresses to productive.Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.Test-Taking Strategy: Note the key word,
early
. Although all these symptoms may appear atsome point in the client with
 Pneumocystis jiroveci
, knowing that the cough appears first helpsyou eliminate each of the other options. Review the early signs of 
 Pneumocystis jiroveci
infection if you had difficulty with this question.
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 060 (edited file)—"Immune Disorders"10/14/08, Page 3 of 12, 0 Figure(s), 0 Table(s), 2 Box(es)
Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Adult Health/ImmuneReference: Christensen, B., & Kockrow, E. (2003).
 Adult health nursing 
(4th ed.). St. Louis:Mosby, p. 685.5. A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. The nurse notes during data collection that the client has enlarged lymph nodes.The nurse interprets that:1. The client has disseminated histoplasmosis infection.2. This is a side effect of the medications given to treat AIDS.3. This indicates that the histoplasmosis is resolving.4. The client probably has yet another infection that is developing.Answer: 1Rationale: Histoplasmosis usually starts as a respiratory infection in the client with AIDS. Itthen becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver.Options 2, 3, and 4 are incorrect.Test-Taking Strategy: Use the process of elimination. Knowing that lymph nodes may enlargewith generalized infection helps you eliminate options 2 and 3. Because the question contains noinformation that indicates that another infection is developing (option 4), option 1 is the correctchoice by elimination. Review disseminated infections in the client with AIDS if you haddifficulty with this question.Level of Cognitive Ability: AnalysisClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Adult Health/ImmuneReference: Christensen, B., & Kockrow, E. (2003).
 Adult health nursing 
(4th ed.). St. Louis:Mosby, p. 685.6. A nurse is caring for the client with acquired immunodeficiency syndrome (AIDS) who isexperiencing night fever and night sweats. Which nursing intervention would be least helpful inmanaging this symptom?1. Keep a change of bed linens nearby in case they are needed.2. Administer an antipyretic after the client spikes the fever.3. Make sure that the pillow has a plastic cover.4. Keep liquids at the bedside.Answer: 2Rationale: For clients with AIDS who experience night fever and night sweats, it is useful tooffer the client an antipyretic of choice before going to sleep. It is also helpful to keep a changeof bed linens and night clothes nearby for use. The pillow should have a plastic cover, and atowel may be placed over the pillowcase if there is profuse diaphoresis. The client should haveliquids at the bedside to drink.Test-Taking Strategy: Note the key words,
least helpful 
. These words indicate a false responsequestion and that you need to select the least helpful intervention. Options 1 and 3 are helpful

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