Test Bank Nursing A Concept Based Approach To Learning Volume 1 2nd Edition

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Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 8 Immunity
The Concept of Immunity
1) 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
Answer: B, C
Explanation: A) Physiological barriers that protect the body against microorganisms include
adequate urinary output and intact skin. The act of voiding flushes organisms that might try to
enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps
defend the body against microorganisms. The consumption of alcoholic beverages has been
known to increase the risk for infection. Occasional smoking does not defend the body from
microorganisms; it destroys the cilia in the nose that helps to filter organisms. A surgical incision
can both allow microorganisms to enter the body.
B) Physiological barriers that protect the body against microorganisms include adequate urinary
output and intact skin. The act of voiding flushes organisms that might try to enter the body
through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body
against microorganisms. The consumption of alcoholic beverages has been known to increase the
risk for infection. Occasional smoking does not defend the body from microorganisms; it
destroys the cilia in the nose that helps to filter organisms. A surgical incision can both allow
microorganisms to enter the body.
C) Physiological barriers that protect the body against microorganisms include adequate urinary
D) Physiological barriers that protect the body against microorganisms include adequate urinary
1
Copyright © 2015 Pearson Education, Inc.
E) Physiological barriers that protect the body against microorganisms include adequate urinary
Page Ref: 444
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Implementation
Learning Outcome: 1. Summarize the physiology of the immune system related to wellness
promotion and disease prevention.
QSEN Competencies: III.A.1 Demonstrate knowledge of basic scientific methods and processes
AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an
understanding of human growth and development, pathophysiology, pharmacology, medical
management and nursing management across the health-illness continuum, across lifespan, and
in all healthcare settings
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and
quality and safe patient care
MNL Learning Outcome: 8.1.1 Understand the physiology of immunity across the life span.
2
2) 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?
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."
Answer: A, B, C, E
Explanation: A) Macrophages ingest antigens and signal helper T cells that antigens are present.
Lymph nodes filter foreign products or antigens from the lymph system and house and support
proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens
either before or after antigens invade body cells. The immune system damaging the myelin is an
autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen
and will reactivate at a future time if the same type of antigen is present.
B) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes
filter foreign products or antigens from the lymph system and house and support proliferation of
lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or
after antigens invade body cells. The immune system damaging the myelin is an autoimmune
response in MS. Memory B cells and T cells remember how to identify the antigen and will
reactivate at a future time if the same type of antigen is present.
C) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes
D) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes
3
E) Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes
Page Ref: 442
Learning Outcome: 2. Examine the relationship between immunity and other concepts/systems.
MNL Learning Outcome: 8.1.2 Compare common alterations across the life span, concepts
related to immunity, and prevention.
3) 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
Answer: A
Explanation: A) The client who has only a slight elevation in temperature in response to
pneumonia is an example of a decline in the expected immune response. The other clients are
demonstrating an expected immune response as evidenced by redness, swelling, and induration.
B) The client who has only a slight elevation in temperature in response to pneumonia is an
example of a decline in the expected immune response. The other clients are demonstrating an
expected immune response as evidenced by redness, swelling, and induration.
C) The client who has only a slight elevation in temperature in response to pneumonia is an
D) The client who has only a slight elevation in temperature in response to pneumonia is an
Page Ref: 445
4
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
Learning Outcome: 3. Identify commonly occurring alterations in immunity and their related
therapies.
5
4) The nurse is conducting a physical assessment for a client with a compromised immune
system. Which actions by the nurse are appropriate?
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
Answer: A, C, D, E
Explanation: A) The techniques of inspection and palpation are especially important in assessing
a client’s immune system: The nurse will assess the client’s general appearance, inspect the
mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph
nodes for swelling or tenderness, and check the client’s ROM, including that of the spine. While
recommending that the client increase fluid intake may be an appropriate intervention, this is not
an action that is conducted during the physical assessment for this client.
B) The techniques of inspection and palpation are especially important in assessing a client’s
immune system: The nurse will assess the client’s general appearance, inspect the mucous
membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for
swelling or tenderness, and check the client’s ROM, including that of the spine. While
C) The techniques of inspection and palpation are especially important in assessing a client’s
D) The techniques of inspection and palpation are especially important in assessing a client’s
E) The techniques of inspection and palpation are especially important in assessing a client’s
Page Ref: 447
Cognitive Level: Applying
Learning Outcome: 4. Differentiate common assessment procedures used to examine immune
health across the life span.
6
QSEN Competencies: 1.A.1 Integrate understanding of multiple dimensions of patient centered
care:
o patient/family/community preferences, values
o coordination and integration of care
o information, communication, and education
o physical comfort and emotional support
o involvement of family and friends
o transition and continuity
MNL Learning Outcome: 8.1.3 Identify procedures used to determine immunity status across the
life span.
7
5) 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.
Answer: D
Explanation: A) Receiving an immunization for rabies is an example of artificially acquired
passive immunity. Receiving tetanus and immunoglobulin are also examples of artificially
acquired passive immunity, but would not be used in the case of an animal bite. Mother's breast
milk is another example of passive immunity, but would not be used in the case of an animal
bite.
B) Receiving an immunization for rabies is an example of artificially acquired passive immunity.
Receiving tetanus and immunoglobulin are also examples but would not be used in the case of an
animal bite. Mother's breast milk is another example of passive immunity, but would not be used
in the case of an animal bite.
C) Receiving an immunization for rabies is an example of artificially acquired passive immunity.
D) Receiving an immunization for rabies is an example of artificially acquired passive immunity.
Page Ref: 450
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing Process: Planning
Learning Outcome: 6. Explain management of immune health and prevention of infection and
disease.

care:
8
9
6) 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
Answer: B
Explanation: A) An area of erythema after a patch test indicates a positive response to a specific
antigen. Indirect Coombs' test detects the presence of circulating antibodies against RBCs. No
agglutination is considered a normal finding. An eosinophil count of 2% is within the normal
range. An Rh antigen with a negative result indicates that the client does not carry the antigen
and is not an indicator of a reaction to a specific antigen.
B) An area of erythema after a patch test indicates a positive response to a specific antigen.
Indirect Coombs' test detects the presence of circulating antibodies against RBCs. No
C) An area of erythema after a patch test indicates a positive response to a specific antigen.
D) An area of erythema after a patch test indicates a positive response to a specific antigen.
Page Ref: 450, 490
Nursing Process: Evaluation
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's
immune status.
life span.
7) The nurse is teaching a group of parents at the local elementary school health fair about
10
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: B
Explanation: A) When the client has the disease, the body stimulates the process of acquired
active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of
artificially acquired passive immunity.
B) When the client has the disease, the body stimulates the process of acquired active immunity.
Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired
passive immunity.
C) When the client has the disease, the body stimulates the process of acquired active immunity.
passive immunity.
D) When the client has the disease, the body stimulates the process of acquired active immunity.
passive immunity.
Page Ref: 450
disease.

care:
11
8) 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
Answer: A
Explanation: A) While of these may be appropriate treatment for a client who is experiencing a
compromised immune system, the only independent nursing intervention is educating the client
on the importance of a nutritious diet. Administering corticosteroids, per order, is a collaborative
intervention. It is outside the scope of nursing practice to prescribe medication and to
recommend therapies. The nurse can administer antibiotics and educate the client on gene
transfer therapy, if prescribed by the health care provider.
B) While of these may be appropriate treatment for a client who is experiencing a compromised
immune system, the only independent nursing intervention is educating the client on the
importance of a nutritious diet. Administering corticosteroids, per order, is a collaborative
C) While of these may be appropriate treatment for a client who is experiencing a compromised
D) While of these may be appropriate treatment for a client who is experiencing a compromised
Page Ref: 454
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in immune function.

care:
12
MNL Learning Outcome: 8.1.4 Explain independent and collaborative interventions for clients
with alterations in immunity.
13
9) 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?
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
Answer: A, C, D, E
Explanation: A) When providing care to a client who is receiving any medication, it is important
to monitor the client for signs of an allergic reaction. Taking NSAIDs with food may help reduce
irritation of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced
blood flow can permanently damage your kidneys and it can eventually lead to kidney failure
and require dialysis. Abrupt discontinuation can have serious side effects. NSAIDs have been
linked to heart failure; therefore, this action by the nurse is not appropriate when providing care
to this client.
B) When providing care to a client who is receiving any medication, it is important to monitor
the client for signs of an allergic reaction. Taking NSAIDs with food may help reduce irritation
of the stomach and prevent an ulcer. If you take NSAIDs in high doses, the reduced blood flow
can permanently damage your kidneys and it can eventually lead to kidney failure and require
dialysis. Abrupt discontinuation can have serious side effects. NSAIDs have been linked to heart
failure; therefore, this action by the nurse is not appropriate when providing care to this client.
C) When providing care to a client who is receiving any medication, it is important to monitor
D) When providing care to a client who is receiving any medication, it is important to monitor
E) When providing care to a client who is receiving any medication, it is important to monitor
Page Ref: 455
14
disease.

care:
10) 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.
Answer: C
Explanation: A) A client with leukocytosis has a white blood cell (WBC) count that is elevated
above normal (>10,000 mm3) which is an indication of infection. The appropriate action by the
nurse is to assess the client for a source of the infection. Instructing the client on the use of an
electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate
actions for a client with decreased platelet levels, or thrombocytopenia. Placing the client in
reverse isolation precautions would be appropriate for the client with neutropenia, a decrease in
the number of neutrophils.
B) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal
(>10,000 mm3) which is an indication of infection. The appropriate action by the nurse is to
assess the client for a source of the infection. Instructing the client on the use of an electric razor
and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a
client with decreased platelet levels, or thrombocytopenia. Placing the client in reverse isolation
precautions would be appropriate for the client with neutropenia, a decrease in the number of
neutrophils.
C) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal
15
neutrophils.
D) A client with leukocytosis has a white blood cell (WBC) count that is elevated above normal
neutrophils.
Page Ref: 438
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's
immune status.
life span.
11) 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?
A) MMR booster
B) Papillomavirus vaccine
C) TDaP booster
D) Meningococcal vaccine
E) Hepatitis B vaccine
Answer: B, C
Explanation: A) The immunizations that the nurse anticipates administering during this routine
visit for the adolescent client is the papillomavirus and meningococcal vaccines. The MMR and
TDaP boosters would be anticipated for an adult client. A hepatitis B vaccine would be anticipate
for an infant client.
B) The immunizations that the nurse anticipates administering during this routine visit for the
adolescent client is the papillomavirus and meningococcal vaccines. The MMR and TDaP
16
boosters would be anticipated for an adult client. A hepatitis B vaccine would be anticipate for
an infant client.
C) The immunizations that the nurse anticipates administering during this routine visit for the
an infant client.
D) The immunizations that the nurse anticipates administering during this routine visit for the
an infant client.
E) The immunizations that the nurse anticipates administering during this routine visit for the
an infant client.
Page Ref: 451
Client Need: Health Promotion and Maintenance
Client Need Sub:
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in immune
function.

care:
MNL Learning Outcome: 8.1.4 Explain independent and collaborative interventions for clients
with alterations in immunity.
17
Exemplar 8.1 HIV and AIDS
1) 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.
Answer: A, C, D, E, B
Explanation: A) The HIV virus gains entry into helper T cells, uses the cell DNA to replicate,
interferes with normal function of the T cells, and destroys the normal cells.
B) The HIV virus gains entry into helper T cells, uses the cell DNA to replicate, interferes with
normal function of the T cells, and destroys the normal cells.
C) The HIV virus gains entry into helper T cells, uses the cell DNA to replicate, interferes with
D) The HIV virus gains entry into helper T cells, uses the cell DNA to replicate, interferes with
E) The HIV virus gains entry into helper T cells, uses the cell DNA to replicate, interferes with
Page Ref: 457
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of human immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS).
MNL Learning Outcome: 8.2.1 Differentiate the pathophysiology, etiology, risk factors,
prevention, and clinical manifestations.
18
2) The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is
antiretroviral therapy. The client complains of nausea, fever, severe diarrhea, and anorexia.
Which prescribed medications does the nurse anticipate in order to relieve the anorexia and to
stimulate the client’s appetite?
A) Dronabinol (Marinol)
B) Zidovudine (Retrovir, AZT)
C) Abacavir (Ziagen)
D) Ciprofloxacin (Cipro)
E) Megestrol (Megace)
Answer: A, E
Explanation: A) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase
client appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication,
and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent inhibitor
of reverse transcriptase.
B) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase client appetite
and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine
(Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent inhibitor of reverse
transcriptase.
C) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase client appetite
transcriptase.
D) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase client appetite
transcriptase.
E) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase client appetite and
promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine
transcriptase.
Page Ref: 478
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with HIV/AIDS.
QSEN Competencies: I.A.1 Demonstrate knowledge of basic scientific methods and processes
MNL Learning Outcome: 8.2.2 Identify collaborative therapies used by interdisciplinary teams.
19
3) 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?"
Answer: D
Explanation: A) One risk factor for contracting HIV is the use of intravenous recreational drugs.
This question is appropriate to determine the client’s risk for HIV. The client’s first sexual
experience is not applicable to the client’s current risk for HIV. Assessing recent symptoms, and
asking if the client’s partner is experiencing the same symptoms, does not assess the client’s risk
factors for HIV transmission.
B) One risk factor for contracting HIV is the use of intravenous recreational drugs. This question
is appropriate to determine the client’s risk for HIV. The client’s first sexual experience is not
applicable to the client’s current risk for HIV. Assessing recent symptoms, and asking if the
client’s partner is experiencing the same symptoms, does not assess the client’s risk factors for
HIV transmission.
C) One risk factor for contracting HIV is the use of intravenous recreational drugs. This question
HIV transmission.
D) One risk factor for contracting HIV is the use of intravenous recreational drugs. This question
HIV transmission.
Page Ref: 458
Learning Outcome: 2. Identify risk factors and prevention methods associated with HIV/AIDS.
20
4) 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 B)
D) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)
Answer: A
Explanation: A) A child with an immune disorder such as HIV/AIDS should not be immunized
with a live varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and
hepatitis B vaccinations are not live vaccines, and should be given on schedule.
B) A child with an immune disorder such as HIV/AIDS should not be immunized with a live
varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and hepatitis B
vaccinations are not live vaccines, and should be given on schedule.
C) A child with an immune disorder such as HIV/AIDS should not be immunized with a live
D) A child with an immune disorder such as HIV/AIDS should not be immunized with a live
Page Ref: 476
Client Need Sub:
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with HIV/AIDS.
QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

care:
MNL Learning Outcome: 8.2.3 Apply the nursing process to provide culturally competent care
across the life span.
21
5) 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
Answer: C
Explanation: A) While all options are appropriate nursing diagnosis, the priority diagnosis is
Deficient Knowledge due to the client statement, “I don’t plan on giving up sex just because I am
HIV positive.” The client requires education regarding safer sex practices to decrease the risk of
transmission to potential sexual partners.
B) While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient
Knowledge due to the client statement, “I don’t plan on giving up sex just because I am HIV
positive.” The client requires education regarding safer sex practices to decrease the risk of
C) While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient
D) While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient
Page Ref: 474
Client Need Sub: Basic Care and Comfort
Nursing Process: Diagnosis
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
HIV/AIDS.

care:
22
23
6) 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: A
Explanation: A) The nurse should educate the client on methods that will decrease the risk of
transmitting the HIV. The client statement regarding the use of an oil-based lubricant requires
further education. The client should use only water-based lubricants–not oil-based, such as
petroleum jelly, which can result in condom damage. The other statements by the client indicate
appropriate understanding of the information presented by the nurse.
B) The nurse should educate the client on methods that will decrease the risk of transmitting the
HIV. The client statement regarding the use of an oil-based lubricant requires further education.
The client should use only water-based lubricants–not oil-based, such as petroleum jelly, which
can result in condom damage. The other statements by the client indicate appropriate
understanding of the information presented by the nurse.
C) The nurse should educate the client on methods that will decrease the risk of transmitting the
D) The nurse should educate the client on methods that will decrease the risk of transmitting the
Page Ref: 478
Learning Outcome: 6. Plan evidence-based care for an individual with HIV/AIDS and his or her
family in collaboration with other members of the healthcare team.
QSEN Competencies: III.A.2 Describe EBP to include the components of research evidence,
clinical expertise and patient/family values.
24
7) 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?
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
Answer: B, D, E
Explanation: A) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and
opportunistic infections because of the effect of the virus on the immune system. The nurse
teaches the family to keep those who have symptoms of illness away from the child and also
instructs them in proper hand-washing technique and proper food handling to prevent infection.
Tuberculosis skin tests should be administered annually, not every six months. Fresh fruits and
vegetables are not recommended for a client with a depressed immune system.
B) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic
infections because of the effect of the virus on the immune system. The nurse teaches the family
to keep those who have symptoms of illness away from the child and also instructs them in
proper hand-washing technique and proper food handling to prevent infection. Tuberculosis skin
tests should be administered annually, not every six months. Fresh fruits and vegetables are not
recommended for a client with a depressed immune system.
C) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic
D) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic
E) A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic
Page Ref: 475-476
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
25
8) 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?
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
Answer: B, C, D
Explanation: A) The risk of opportunistic infection is the most common manifestation of AIDS.
The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4
cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count
and the WBC, which was within normal range.
B) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of
opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count
is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the
WBC, which was within normal range.
C) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of
D) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of
E) The risk of opportunistic infection is the most common manifestation of AIDS. The risk of
Page Ref: 468
26
care of an individual with HIV/AIDS.
27
9) 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
Answer: B
Explanation: A) The home health nurse should see the client with PCP because of the complaint
of shortness of breath with the new onset of fever. All of the clients need to be seen by the nurse,
but based on the ABCs (airway, breathing, and circulation), the nurse should visit this client first
to obtain vital signs and perform a respiratory assessment.
B) The home health nurse should see the client with PCP because of the complaint of shortness
of breath with the new onset of fever. All of the clients need to be seen by the nurse, but based
on the ABCs (airway, breathing, and circulation), the nurse should visit this client first to obtain
vital signs and perform a respiratory assessment.
C) The home health nurse should see the client with PCP because of the complaint of shortness
D) The home health nurse should see the client with PCP because of the complaint of shortness
Page Ref: 463
Client Need Sub: Management of Care
28
10) 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?
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: A, C, D, E
Explanation: A) Positive outcomes for an HIV client would include remaining free from
secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with
the stress of chronic disease, and attending school.
B) Positive outcomes for an HIV client would include remaining free from secondary infection,
displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic
disease, and attending school.
C) Positive outcomes for an HIV client would include remaining free from secondary infection,
D) Positive outcomes for an HIV client would include remaining free from secondary infection,
E) Positive outcomes for an HIV client would include remaining free from secondary infection,
Page Ref: 479
Client Need Sub:
Learning Outcome: 7. Evaluate expected outcomes for an individual with HIV/AIDS.

care:
29
30
11) 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
Answer: C
Explanation: A) Healthcare workers can prevent most exposures to HIV by using standard
precautions. With standard precautions, the healthcare professionals treat all clients alike,
eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are
infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous
exposure to these fluids.
B) Healthcare workers can prevent most exposures to HIV by using standard precautions. With
standard precautions, the healthcare professionals treat all clients alike, eliminating the need to
know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier
precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.
C) Healthcare workers can prevent most exposures to HIV by using standard precautions. With
D) Healthcare workers can prevent most exposures to HIV by using standard precautions. With
Page Ref: 461
Learning Outcome: 2. Identify risk factors and prevention methods associated with HIV/AIDS.
31
12) 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
Answer: B
Explanation: A) The 1994 Revised HIV Pediatric Classification System remains the standard for
determining clinical staging and related treatment for children with HIV. The client described is
Category C, a severely symptomatic client with lymphoma and wasting syndrome. The other
choices are incorrect.
B) The 1994 Revised HIV Pediatric Classification System remains the standard for determining
clinical staging and related treatment for children with HIV. The client described is Category C,
a severely symptomatic client with lymphoma and wasting syndrome. The other choices are
incorrect.
C) The 1994 Revised HIV Pediatric Classification System remains the standard for determining
incorrect.
D) The 1994 Revised HIV Pediatric Classification System remains the standard for determining
incorrect.
Page Ref: 469
direct and indirect causes of human immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS).
32
Exemplar 8.2 Hypersensitivity
1) 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
Answer: D
Explanation: A) Clinical manifestations associated with a type I hypersensitivity reaction
include hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria. Erythema
and fever are associated with type IV hypersensitivity reactions. Fever and joint pain are
associated with a type III hypersensitivity reactions.
B) Clinical manifestations associated with a type I hypersensitivity reaction include hypotension,
wheezing, gastrointestinal or uterine spasm, stridor, and urticaria. Erythema and fever are
associated with type IV hypersensitivity reactions. Fever and joint pain are associated with a type
III hypersensitivity reactions.
C) Clinical manifestations associated with a type I hypersensitivity reaction include hypotension,
D) Clinical manifestations associated with a type I hypersensitivity reaction include hypotension,
Page Ref: 481
direct and indirect causes of hypersensitivity.
33
2) The nurse is assessing a client who is receiving IV antibiotics. Which item in the client’s
health history increases the risk for experiencing a hypersensitivity reaction?
A) 26 years of age
B) Caucasian race
C) Previous antibiotic therapy
D) Concurrent chronic illness
Answer: C
Explanation: A) Anyone can have a hypersensitivity reaction. However, risk generally increases
with previous exposure, because antigens must be formed with the first exposure before
hypersensitivity is likely to occur. Age, sex, concurrent illnesses, and previous reactions to
related substances have been identified as having a role in risk for hypersensitivity; however,
previous exposure presents the greatest risk.
B) Anyone can have a hypersensitivity reaction. However, risk generally increases with previous
exposure, because antigens must be formed with the first exposure before hypersensitivity is
likely to occur. Age, sex, concurrent illnesses, and previous reactions to related substances have
been identified as having a role in risk for hypersensitivity; however, previous exposure presents
the greatest risk.
C) Anyone can have a hypersensitivity reaction. However, risk generally increases with previous
the greatest risk.
D) Anyone can have a hypersensitivity reaction. However, risk generally increases with previous
the greatest risk.
Page Ref: 486
Learning Outcome: 2. Identify risk factors and prevention methods associated with
hypersensitivity.
34
3) 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
Answer: D
Explanation: A) Clients with a history of meningocele typically experience severe latex
allergies. It is important for the nurse, and other healthcare providers, to use latex alternative
products on this client. The other options are appropriate for this client.
B) Clients with a history of meningocele typically experience severe latex allergies. It is
important for the nurse, and other healthcare providers, to use latex alternative products on this
client. The other options are appropriate for this client.
C) Clients with a history of meningocele typically experience severe latex allergies. It is
D) Clients with a history of meningocele typically experience severe latex allergies. It is
Page Ref: 486
across the life span for individuals with hypersensitivity.

care:
35
36
4) 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
Answer: A
Explanation: A) Type I hypersensitivities, such as anaphylactic reactions, occur immediately
and may be life-threatening. Because the client has a history of this type of reaction, Risk for
Shock is an appropriate nursing diagnosis. The other items would not necessitate the need for
this nursing diagnosis.
B) Type I hypersensitivities, such as anaphylactic reactions, occur immediately and may be life-
threatening. Because the client has a history of this type of reaction, Risk for Shock is an
appropriate nursing diagnosis. The other items would not necessitate the need for this nursing
diagnosis.
C) Type I hypersensitivities, such as anaphylactic reactions, occur immediately and may be life-
diagnosis.
D) Type I hypersensitivities, such as anaphylactic reactions, occur immediately and may be life-
diagnosis.
Page Ref: 492
hypersensitivity.

care:
37
5) 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.
Answer: D
Explanation: A) When symptoms of sensitivity to latex occur on exposure, latex-free products
should be supplied. Transferring the client to a department that does not use latex products is not
realistic because the family member might experience exposure on another unit. (No hospital
unit can be latex-free.) Waiting until Monday does not solve the problem. Asking the family
member to leave would be a violation of the client's right's.
B) When symptoms of sensitivity to latex occur on exposure, latex-free products should be
supplied. Transferring the client to a department that does not use latex products is not realistic
because the family member might experience exposure on another unit. (No hospital unit can be
latex-free.) Waiting until Monday does not solve the problem. Asking the family member to
leave would be a violation of the client's right's.
C) When symptoms of sensitivity to latex occur on exposure, latex-free products should be
D) When symptoms of sensitivity to latex occur on exposure, latex-free products should be
Page Ref: 486
Learning Outcome: 6. Plan evidence-based care for an individual with hypersensitivity and his
or her family in collaboration with other members of the healthcare team.
38
39
6) 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
Answer: D
Explanation: A) The Trendelenburg position elevates the foot of the bed and is no longer
recommended for the treatment of shock, as it causes abdominal organs to press against the
diaphragm, which impedes respirations and decreases coronary artery filling. Lying flat is not
recommended. A person in a supine position may not be able to maintain an open airway.
Placing the client in Fowler or high Fowler position allows optimal lung expansion and ease of
breathing.
B) The Trendelenburg position elevates the foot of the bed and is no longer recommended for the
treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes
respirations and decreases coronary artery filling. Lying flat is not recommended. A person in a
supine position may not be able to maintain an open airway. Placing the client in Fowler or high
Fowler position allows optimal lung expansion and ease of breathing.
C) The Trendelenburg position elevates the foot of the bed and is no longer recommended for the
D) The Trendelenburg position elevates the foot of the bed and is no longer recommended for the
Page Ref: 492
care of an individual with hypersensitivity.
40
7) 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.
Answer: C
Explanation: A) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a
subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse
should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well
but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be
used in the client with a more severe anaphylactic reaction. The nurse does not have time to
collect a detailed history, because of the severity of the client's signs and symptoms. Clients who
have experienced an anaphylactic reaction to insect venom or another potentially unavoidable
allergen should carry a bee sting kit.
B) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous
injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the
epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection,
not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client
with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed
history, because of the severity of the client's signs and symptoms. Clients who have experienced
an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry
a bee sting kit.
C) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous
a bee sting kit.
41
D) For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous
a bee sting kit.
Page Ref: 492
care of an individual with hypersensitivity.
42
8) 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)?
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
Answer: A, D, E
Explanation: A) General symptoms of shock that would necessitate an epinephrine injection
include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy.
Thirst is a common complaint in shock. The skin may feel cold and clammy in shock, not warm
and dry. In shock, the client will not be hyperactive or hyperverbal.
B) General symptoms of shock that would necessitate an epinephrine injection include
behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a
common complaint in shock. The skin may feel cold and clammy in shock, not warm and dry. In
shock, the client will not be hyperactive or hyperverbal.
C) General symptoms of shock that would necessitate an epinephrine injection include
D) General symptoms of shock that would necessitate an epinephrine injection include
E) General symptoms of shock that would necessitate an epinephrine injection include
Page Ref: 493
Learning Outcome: 6. Plan evidence-based care for an individual with hypersensitivity and his
or her family in collaboration with other members of the healthcare team.
43
9) 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?
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."
Answer: B, C
Explanation: A) Proper storage of the kit is important, avoiding exposure to sun or high
temperature. The client and family should frequently check the expiration date of the EpiPen. A
kit should be readily available in all settings where the client studies, works, or plays. In addition
to the client, someone else should always know how to use the kit as well. The client should be
encouraged to wear a medical alert bracelet or tag.
B) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The
client and family should frequently check the expiration date of the EpiPen. A kit should be
readily available in all settings where the client studies, works, or plays. In addition to the client,
someone else should always know how to use the kit as well. The client should be encouraged to
wear a medical alert bracelet or tag.
C) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The
D) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The
E) Proper storage of the kit is important, avoiding exposure to sun or high temperature. The
Page Ref: 493
Learning Outcome: 7. Evaluate expected outcomes for an individual with hypersensitivity.

care:
44
45
10) 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?
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."
Answer: A, D
Explanation: A) An EpiPen is a syringe-and-needle medication system used to treat an
anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential
that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should
recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a
quick delivery when necessary. The medication should not be kept in the car at all times, as the
EpiPen needs to be stored away from high heat and direct sunlight. The client should have
multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date
should be checked frequently to ensure accurate strength.
B) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction.
Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides
thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear
a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary.
The medication should not be kept in the car at all times, as the EpiPen needs to be stored away
from high heat and direct sunlight. The client should have multiple EpiPens and they should be
kept in multiple areas, not one location. The expiration date should be checked frequently to
ensure accurate strength.
C) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction.
D) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction.
46
E) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction.
Page Ref: 493

care:
47
11) A nurse is caring for a client with seasonal hypersensitivity reactions. What teaching would
the nurse provide to improve this client's comfort?
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.
Answer: B, C
Explanation: A) A client with seasonal hypersensitivity should be educated regarding prevention
and comfort measures. The nurse should instruct the client to keep doors and windows closed on
high-allergen days and to remain indoors if possible. The nurse should also include teaching on
maintaining a clean, dust-free environment. Medication instruction should include instruction on
taking antihistamine and anti-leukotriene medication, not leukotriene. The client should also be
instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.
B) A client with seasonal hypersensitivity should be educated regarding prevention and comfort
measures. The nurse should instruct the client to keep doors and windows closed on high-
allergen days and to remain indoors if possible. The nurse should also include teaching on
C) A client with seasonal hypersensitivity should be educated regarding prevention and comfort
D) A client with seasonal hypersensitivity should be educated regarding prevention and comfort
E) A client with seasonal hypersensitivity should be educated regarding prevention and comfort
Page Ref: 488
48
care:
49
Exemplar 8.3 Rheumatoid Arthritis
1) 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?
A) Respiratory
B) Cardiovascular
C) Exocrine
D) Reproductive
E) Hematologic
Answer: A, B, C, E
Explanation: A) RA can affect the respiratory system with pleural effusion (collection of fluid in
the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands,
resulting in dry eyes and mouth; and the hematologic system with a variety of disorders,
particularly anemia. If properly managed, RA is not considered to be a danger for pregnant
women or their babies.
B) RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural
space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in
dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia.
If properly managed, RA is not considered to be a danger for pregnant women or their babies.
C) RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural
D) RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural
E) RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural
Page Ref: 495
direct and indirect causes of rheumatoid arthritis (RA).
50
2) 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.
Answer: B, C, D, E
Explanation: A) The client with RA should never attempt to push a joint beyond its ability.
Writing requires using a strong grip, so typing is preferable. Using a stronger joint or part of the
body, such as the palm, to carry items is preferable to grasping. Pain is a warning signal, and the
client with RA should stop any activity that causes pain. When performing a task, the client
should avoid stress in the area of the deformity to help prevent further deformities.
B) The client with RA should never attempt to push a joint beyond its ability. Writing requires
using a strong grip, so typing is preferable. Using a stronger joint or part of the body, such as the
palm, to carry items is preferable to grasping. Pain is a warning signal, and the client with RA
should stop any activity that causes pain. When performing a task, the client should avoid stress
in the area of the deformity to help prevent further deformities.
C) The client with RA should never attempt to push a joint beyond its ability. Writing requires
D) The client with RA should never attempt to push a joint beyond its ability. Writing requires
E) The client with RA should never attempt to push a joint beyond its ability. Writing requires
Page Ref: 505
Learning Outcome: 2. Identify risk factors and prevention methods associated with RA.
51
52
3) 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."
Answer: D
Explanation: A) RA affects 12% of the total population across all races. It affects women 3
times more than men, and the onset is usually between the ages of 20 and 40 years.
B) RA affects 12% of the total population across all races. It affects women 3 times more than
men, and the onset is usually between the ages of 20 and 40 years.
C) RA affects 12% of the total population across all races. It affects women 3 times more than
D) RA affects 12% of the total population across all races. It affects women 3 times more than
Page Ref: 496
Client Need: Psychosocial Integrity
Client Need Sub:
across the life span for individuals with rheumatoid arthritis.

care:
53
4) 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."
Answer: A
Explanation: A) One hallmark symptom of RA is extreme fatigue. The client’s statement
regarding the need for a nap supports the inclusion of Activity Intolerance in the plan of care. ,
The nurse would teach the client about frequent rest periods during the day to conserve energy.
The client with RA will be stiff early in the morning, but that would not interfere with activities
later in the day. Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does
not affect the ability for activity.
B) One hallmark symptom of RA is extreme fatigue. The client’s statement regarding the need
for a nap supports the inclusion of Activity Intolerance in the plan of care. , The nurse would
teach the client about frequent rest periods during the day to conserve energy. The client with
RA will be stiff early in the morning, but that would not interfere with activities later in the day.
Joints of the RA client are stiffest in the morning. Taking ibuprofen for pain does not affect the
ability for activity.
C) One hallmark symptom of RA is extreme fatigue. The client’s statement regarding the need
D) One hallmark symptom of RA is extreme fatigue. The client’s statement regarding the need
Page Ref: 505
rheumatoid arthritis.

care:
54
55
5) 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
Answer: A
Explanation: A) Swimming exercises all the extremities without putting undue stress on joints.
Softball, football, or basketball could exacerbate joint discomfort.
B) Swimming exercises all the extremities without putting undue stress on joints. Softball,
football, or basketball could exacerbate joint discomfort.
C) Swimming exercises all the extremities without putting undue stress on joints. Softball,
D) Swimming exercises all the extremities without putting undue stress on joints. Softball,
Page Ref: 504
Client Need Sub:
across the life span for individuals with RA.

care:
56
6) 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."
Answer: C
Explanation: A) One technique for reducing stress on the joints is to delegate household tasks to
family members. The client does not need to refrain from all household chores. Sleeping for 10
hours at night will not alleviate the need for frequent rest periods during the day. Increased joint
pain would indicate that goals have not been met.
B) One technique for reducing stress on the joints is to delegate household tasks to family
members. The client does not need to refrain from all household chores. Sleeping for 10 hours at
night will not alleviate the need for frequent rest periods during the day. Increased joint pain
would indicate that goals have not been met.
C) One technique for reducing stress on the joints is to delegate household tasks to family
D) One technique for reducing stress on the joints is to delegate household tasks to family
Page Ref: 507
Learning Outcome: 7. Evaluate expected outcomes for an individual with RA.

care:
57
58
7) 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."
Answer: D
Explanation: A) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is
important to take the medication at the same time each day. Steroids are taken with food to
minimize GI distress, not to enhance absorption. Steroids can cause fluid retention, so sodium
intake should be limited. A hidden source of sodium is canned vegetables. Steroids also increase
blood sugar, so blood sugar may need to be monitored more frequently while on the medication
regimen.
B) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take
the medication at the same time each day. Steroids are taken with food to minimize GI distress,
not to enhance absorption. Steroids can cause fluid retention, so sodium intake should be limited.
A hidden source of sodium is canned vegetables. Steroids also increase blood sugar, so blood
sugar may need to be monitored more frequently while on the medication regimen.
C) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take
D) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take
Page Ref: 502
care of an individual with RA.
59
8) 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?
A) Discourage any position changes.
B) Encourage relaxation techniques
C) Immobilize the extremity.
D) Offer a massage
E) Provide diversion activities.
Answer: B, D, E
Explanation: A) Non-pharmacological activities for pain relief include massage, relaxation, and
diversion. Position changes are encouraged along with supportive equipment. Immobilization
would likely cause contractures in the joints.
B) Non-pharmacological activities for pain relief include massage, relaxation, and diversion.
Position changes are encouraged along with supportive equipment. Immobilization would likely
cause contractures in the joints.
C) Non-pharmacological activities for pain relief include massage, relaxation, and diversion.
D) Non-pharmacological activities for pain relief include massage, relaxation, and diversion.
E) Non-pharmacological activities for pain relief include massage, relaxation, and diversion.
Page Ref: 504
Learning Outcome: 6. Plan evidence-based care for an individual with RA and his or her family
in collaboration with other members of the healthcare team.
60
9) 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.
Answer: D
Explanation: A) The pregnant client with RA is at a continued risk for anemia. Many pregnant
clients with RA may have prolonged gestations and often experience a remission during
pregnancy and relapse after delivery. Due to remission, a decrease in medication is often
necessitated.
B) The pregnant client with RA is at a continued risk for anemia. Many pregnant clients with RA
may have prolonged gestations and often experience a remission during pregnancy and relapse
after delivery. Due to remission, a decrease in medication is often necessitated.
C) The pregnant client with RA is at a continued risk for anemia. Many pregnant clients with RA
D) The pregnant client with RA is at a continued risk for anemia. Many pregnant clients with RA
Page Ref: 497
across the life span for individuals with RA.

care:
61
10) 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?
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."
Answer: A, D
Explanation: A) The onset of OA is gradual while the onset of RA may be rapid. RA affects
multiple joints symmetrically while OA affects one joint at a time. The affected joints in OA feel
cold to the touch while the joints affected by RA are warm or hot to the touch. OA is slowly
progressive while RA has exacerbations and remissions. Pain associated with RA is predominant
upon arising versus the pain in OA, which is with activity.
B) The onset of OA is gradual while the onset of RA may be rapid. RA affects multiple joints
symmetrically while OA affects one joint at a time. The affected joints in OA feel cold to the
touch while the joints affected by RA are warm or hot to the touch. OA is slowly progressive
while RA has exacerbations and remissions. Pain associated with RA is predominant upon
arising versus the pain in OA, which is with activity.
C) The onset of OA is gradual while the onset of RA may be rapid. RA affects multiple joints
D) The onset of OA is gradual while the onset of RA may be rapid. RA affects multiple joints
E) The onset of OA is gradual while the onset of RA may be rapid. RA affects multiple joints
Page Ref: 495
Cognitive Level: Understanding
direct and indirect causes of rheumatoid arthritis (RA).
62
63
Exemplar 8.4 Systemic Lupus Erythematosus
1) 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
Answer: A
Explanation: A) The rash over the nose and cheeks is sometimes called a butterfly rash and is
classic for the diagnosis of systemic lupus erythematosus (SLE). While fibromyalgia, Lyme's
disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and
cheeks.
B) The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the
diagnosis of systemic lupus erythematosus (SLE). While fibromyalgia, Lyme's disease, and gout
share some symptoms of SLE, they do not cause a rash over the nose and cheeks.
C) The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the
D) The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the
Page Ref: 510
direct and indirect causes of systemic lupus erythematosus.
64
2) 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."
Answer: C
Explanation: A) Pregnancy can be associated with an exacerbation of SLE due to the rise of
estrogen levels. Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.
B) Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels.
Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.
C) Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels.
D) Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels.
Page Ref: 510
Learning Outcome: 2. Identify risk factors and prevention methods associated with systemic
lupus erythematosus.
65
3) 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.
Answer: D
Explanation: A) Among women who are of child-bearing age, SLE is seen in more African-
Americans, Hispanics, and Asian-Americans than Caucasians. There is no evidence that the
audience asked for the information.
B) Among women who are of child-bearing age, SLE is seen in more African-Americans,
Hispanics, and Asian-Americans than Caucasians. There is no evidence that the audience asked
for the information.
C) Among women who are of child-bearing age, SLE is seen in more African-Americans,
D) Among women who are of child-bearing age, SLE is seen in more African-Americans,
Page Ref: 510
across the life span for individuals with systemic lupus erythematosus.

care:
66
4) 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
Answer: A
Explanation: A) All identified diagnoses are appropriate for a client with SLE. However, the
shift to the left in the WBC count indicates an increased risk for infection. A shift to the left in a
WBC differential is indicative of a large number of immature cells, suggesting infection.
Therefore, the priority diagnosis is Risk for Infection.
B) All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in
the WBC count indicates an increased risk for infection. A shift to the left in a WBC differential
is indicative of a large number of immature cells, suggesting infection. Therefore, the priority
diagnosis is Risk for Infection.
C) All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in
D) All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in
Page Ref: 516
systemic lupus erythematosus.

care:
67
68
5) 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?
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.
Answer: A, C, D, E
Explanation: A) Crowds may increase exposure to infection. Annual influenza vaccination is
recommended but clients with significant immunosuppression should not receive live vaccines.
Immunosuppressive drugs may increase the risk of birth defects. Aspirin products may increase
the risk of bleeding. Chills, fever, sore throat, fatigue, or malaise should be reported.
B) Crowds may increase exposure to infection. Annual influenza vaccination is recommended
but clients with significant immunosuppression should not receive live vaccines.
C) Crowds may increase exposure to infection. Annual influenza vaccination is recommended
D) Crowds may increase exposure to infection. Annual influenza vaccination is recommended
E) Crowds may increase exposure to infection. Annual influenza vaccination is recommended
Page Ref: 516
care of an individual with systemic lupus erythematosus.
69
6) 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?
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.
Answer: A, D
Explanation: A) The nurse teaches the client to live a normal life with a few extra precautions.
There is a relationship between sun exposure and infection, so the client is taught to use
sunscreen with an SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The
client may swim but should reapply sunscreen after swimming. The client does not need to stay
indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m.
B) The nurse teaches the client to live a normal life with a few extra precautions. There is a
relationship between sun exposure and infection, so the client is taught to use sunscreen with an
SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The client may swim
but should reapply sunscreen after swimming. The client does not need to stay indoors on sunny
days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m.
C) The nurse teaches the client to live a normal life with a few extra precautions. There is a
D) The nurse teaches the client to live a normal life with a few extra precautions. There is a
E) The nurse teaches the client to live a normal life with a few extra precautions. There is a
Page Ref: 513
Learning Outcome: 6. Plan evidence-based care for an individual with systemic lupus
erythematosus and his or her family in collaboration with other members of the healthcare team.
70
71
7) 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.
Answer: B
Explanation: A) Discoid lupus erythematosus is an autoimmune disorder of the skin, so the
client must protect against the sun to avoid skin cancers and other complications. It is not fatal, is
not related to weight, and is rarely painful unless complications arise.
B) Discoid lupus erythematosus is an autoimmune disorder of the skin, so the client must protect
against the sun to avoid skin cancers and other complications. It is not fatal, is not related to
weight, and is rarely painful unless complications arise.
C) Discoid lupus erythematosus is an autoimmune disorder of the skin, so the client must protect
D) Discoid lupus erythematosus is an autoimmune disorder of the skin, so the client must protect
Page Ref: 515
Client Need Sub:
Learning Outcome: 7. Evaluate expected outcomes for an individual with systemic lupus
erythematosus.

care:
72
8) 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
Answer: D
Explanation: A) Peer interaction is important to teens. Being able to discuss the physical
changes related to SLE with a friend indicates acceptance of the change in body image. Refusing
to go to school or attend social functions indicates nonacceptance of the changes to body image.
Discussing changes only with healthcare personnel does not indicate the teen has adjusted to the
body image changes.
B) Peer interaction is important to teens. Being able to discuss the physical changes related to
SLE with a friend indicates acceptance of the change in body image. Refusing to go to school or
attend social functions indicates nonacceptance of the changes to body image. Discussing
changes only with healthcare personnel does not indicate the teen has adjusted to the body image
changes.
C) Peer interaction is important to teens. Being able to discuss the physical changes related to
changes.
D) Peer interaction is important to teens. Being able to discuss the physical changes related to
changes.
Page Ref: 515
Client Need: Psychosocial Integrity
Client Need Sub:
erythematosus.

care:
73
74
9) 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."
Answer: A
Explanation: A) Treatment for SLE can include cytotoxic drugs. The client is taught to avoid
pregnancy by using contraceptives, as these drugs can cause birth defects. The client is taught to
avoid crowds, as they are potential sources of infection. Client with SLE should contact their
primary care providers should signs of infection occur, as the immune system is compromised.
Aspirin can cause bleeding and should be taken with extreme care.
B) Treatment for SLE can include cytotoxic drugs. The client is taught to avoid pregnancy by
using contraceptives, as these drugs can cause birth defects. The client is taught to avoid crowds,
as they are potential sources of infection. Client with SLE should contact their primary care
providers should signs of infection occur, as the immune system is compromised. Aspirin can
cause bleeding and should be taken with extreme care.
C) Treatment for SLE can include cytotoxic drugs. The client is taught to avoid pregnancy by
D) Treatment for SLE can include cytotoxic drugs. The client is taught to avoid pregnancy by
Page Ref: 514
Client Need Sub:
erythematosus.

care:
75
76
10) 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
Answer: C
Explanation: A) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce
the frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity
and possible irreversible blindness. Cushingoid effects are a concern with corticosteroid therapy.
Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil. Renal
toxicity is not the primary concern with Plaquenil.
B) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency
of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity and possible
irreversible blindness. Cushingoid effects are a concern with corticosteroid therapy. Pulmonary
fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil. Renal toxicity is not the
primary concern with Plaquenil.
C) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency
D) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency
Page Ref: 514

care:
77
78
11) 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?
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.
Answer: A, B, E
Explanation: A) When teaching a client with SLE who is receiving immunosuppressant therapy,
the nurse will tell the client to avoiding large crowds and situations that increase exposure to
infection; to report difficulty breathing or a cough; and to maintain adequate oral hydration. The
client should report a fever if it develops, and aspirin should not be used, as this may increase the
risk for bleeding. Women may have an absence of menstruation, not heavy bleeding, during
therapy.
B) When teaching a client with SLE who is receiving immunosuppressant therapy, the nurse will
tell the client to avoiding large crowds and situations that increase exposure to infection; to
report difficulty breathing or a cough; and to maintain adequate oral hydration. The client should
report a fever if it develops, and aspirin should not be used, as this may increase the risk for
bleeding. Women may have an absence of menstruation, not heavy bleeding, during therapy.
C) When teaching a client with SLE who is receiving immunosuppressant therapy, the nurse will
D) When teaching a client with SLE who is receiving immunosuppressant therapy, the nurse will
Page Ref: 514

care:
79
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The Concept of Immunity

QSEN Competencies: 1.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: 1.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: 1.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: 1.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: 1.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

o involvement of family and friends

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