Immune Problems of the Adult Client
1. The nurse prepares to give a bath and change the
bed linens of a client with cutaneous Kaposi’s
sarcoma lesions. The lesions are open and draining
a scant amount of serous fluid. Which would the
nurse incorporate into the plan during the bathing
of this client?
a. Wearing gloves
b. Wearing a gown and gloves
c. Wearing a gown, gloves, and a mask
d. Wearing a gown and gloves to change the
bed linens, and gloves only for the bath
2. The nurse provides home care instructions to a
client with systemic lupus erythematosus and tells
the client about methods to manage fatigue. Which
statement by the client indicates a need for further
instruction?
a. “I should take hot baths because they are
relaxing.”
b. “I should sit whenever possible to
conserve my energy.”
c. “I should avoid long periods of rest
because it causes joint stiffness.”
d. “I should do some exercises, such as
walking, when I am not fatigued.”
3. A client develops an anaphylactic reaction after
receiving morphine. The nurse should plan to
institute which actions? Select all that apply.
a. Administer oxygen.
b. Quickly assess the client’s respiratory
status.
c. Document the event, interventions, and
client’s response.
d. Leave the client briefly to contact a
primary health care provider (PHCP).
e. Keep the client supine regardless of the
blood pressure readings.
f. Start an intravenous (IV) infusion of D5W
and administer a 500-mL bolus.
4. The nurse is conducting a teaching session with a
client on their diagnosis of pemphigus. Which
statement by the client indicates that the client
understands the diagnosis?
a. “My skin will have tiny red vesicles.”
b. “The presence of the skin vesicles is
caused by a virus.”
c. “I have an autoimmune disease that causes
blistering in the skin.”
d. “Red, raised papules and large plaques
covered by silvery scales will be present
on my skin.”
5. The nurse is assisting in planning care for a client
with a diagnosis of immunodeficiency and should
incorporate which action as a priority in the plan?
a. Protecting the client from infection
b. Providing emotional support to decrease
fear
c. Encouraging discussion about lifestyle
changes
d. Identifying factors that decreased the
immune function
6. A client calls the nurse in the emergency
department and states that he was just stung by a
bumblebee while gardening. The client is afraid of
a severe reaction because the client’s neighbor
experienced such a reaction just 1 week ago.
Which action should the nurse take?
a. Advise the client to soak the site in
hydrogen peroxide.
b. Ask the client if he ever sustained a bee
sting in the past.
c. Tell the client to call an ambulance for
transport to the emergency department.
d. Tell the client not to worry about the sting
unless difficulty with breathing occurs.
7. The community health nurse is conducting a
research study and is identifying clients in the
community at risk for latex allergy. Which client
population is most at risk for developing this type
of allergy?
a. Hairdressers
b. The homeless
c. Children in day care centers
d. Individuals living in a group home
8. Which interventions apply in the care of a client at
high risk for an allergic response to a latex allergy?
Select all that apply.
a. Use nonlatex gloves.
b. Use medications from glass ampules.
c. Place the client in a private room only.
d. Keep a latex-safe supply cart available in
the client’s area.
e. Avoid the use of medication vials that
have rubber stoppers.
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 Immune Problems of the Adult Client
f. Use a blood pressure cuff from an
electronic device only to measure the
blood pressure.
9. A client presents at the primary health care
provider’s office with complaints of a ring-like
rash on his upper leg. Which question should the
nurse ask first?
a. “Do you have any cats in your home?”
b. “Have you been camping in the last
month?”
c. “Have you or close contacts had any flu-
like symptoms within the last few weeks?”
d. “Have you been in physical contact with
anyone who has the same type of rash?”
10. A client is diagnosed with scleroderma. Which
intervention should the nurse anticipate to be
prescribed?
a. Maintain bed rest as much as possible.
b. Administer corticosteroids as prescribed
for inflammation.
c. Advise the client to remain supine for 1 to
2 hours after meals.
d. Keep the room temperature warm during
the day and cool at night.
11. A client arrives at the health care clinic and tells
the nurse that she was just bitten by a tick and
would like to be tested for Lyme disease. The
client tells the nurse that she removed the tick and
flushed it down the toilet. Which actions are most
appropriate? Select all that apply.
a. Tell the client that testing is not necessary
unless arthralgia develops.
b. Tell the client to avoid any woody, grassy
areas that may contain ticks.
c. Instruct the client to immediately start to
take the antibiotics that are prescribed.
d. Inform the client to plan to have a blood
test 4 to 6 weeks after a bite to detect the
presence of the disease.
e. Tell the client that if this happens again, to
never remove the tick but vigorously scrub
the area with an antiseptic.
12. The nurse is preparing a group of Cub Scouts for
an overnight camping trip and instructs the Scouts
about the methods to prevent Lyme disease. Which
statement by one of the Scouts indicates a need for
further instruction?
a. “I need to bring a hat to wear during the
trip.”
b. “I should wear long-sleeved tops and long
pants.”
c. “I should not use insect repellents because
it will attract the ticks.”
d. “I need to wear closed shoes and socks
that can be pulled up over my pants.”
13. The client with acquired immunodeficiency
syndrome is diagnosed with cutaneous Kaposi’s
sarcoma. Based on this diagnosis, the nurse
understands that this has been confirmed by which
finding?
a. Swelling in the genital area
b. Swelling in the lower extremities
c. Positive punch biopsy of the cutaneous
lesions
d. Appearance of reddish-blue lesions noted
on the skin
14. The nurse is conducting allergy skin testing on a
client. Which postprocedure interventions are most
appropriate? Select all that apply.
a. Record site, date, and time of the test.
b. Give the client a list of potential allergens
if identified.
c. Estimate the size of the wheal and
document the finding.
d. Tell the client to return to have the site
inspected only if there is a reaction.
e. Have the client wait in the waiting room
for at least 1 to 2 hours after injection.
15. The nurse is performing an assessment on a client
who has been diagnosed with an allergy to latex. In
determining the client’s risk factors, the nurse
should question the client about an allergy to
which food item?
a. Eggs
b. Milk
c. Yogurt
d. Bananas
16. The client with acquired immunodeficiency
syndrome and Pneumocystis jiroveci infection has
been receiving pentamidine. The client develops a
temperature of 101° F (38.3° C). The nurse
continues to assess the client, knowing that this
sign most likely indicates which condition?
a. That the dose of the medication is too low
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 Immune Problems of the Adult Client

b. That the client is experiencing toxic effects c. Serum amylase level

of the medication d. Serum creatinine level
c. That the client has developed inadequacy 21. The nurse is caring for a postrenal transplantation
of thermoregulation client taking cyclosporine. The nurse notes an
d. That the client has developed another increase in one of the client’s vital signs, and the
infection caused by leukopenic effects of client is complaining of a headache. What vital
the medication sign is most likely increased?
17. The nurse caring for a client who is taking an a. Pulse
aminoglycoside should monitor the client for b. Respirations
which adverse effects of the medication? Select all c. Blood pressure
that apply. d. Pulse oximetry
a. Seizures 22. Amikacin is prescribed for a client with a bacterial
b. Ototoxicity infection. The nurse instructs the client to contact
c. Renal toxicity the primary health care provider (PHCP)
d. Dysrhythmias immediately if which occurs?
e. Hepatotoxicity a. Nausea
18. Ketoconazole is prescribed for a client with a b. Lethargy
diagnosis of candidiasis. Which interventions c. Hearing loss
should the nurse include when administering this d. Muscle aches
medication? Select all that apply. 23. The nurse is assigned to care for a client with
a. Restrict fluid intake. cytomegalovirus retinitis and acquired
b. Monitor liver function studies. immunodeficiency syndrome who is receiving
c. Instruct the client to avoid alcohol. foscarnet, an antiviral medication. The nurse
d. Administer the medication with an should monitor the results of which laboratory
antacid. study while the client is taking this medication?
e. Instruct the client to avoid exposure to the a. CD4 + T cell count
sun. b. Lymphocyte count
f. Administer the medication on an empty c. Serum albumin level
stomach. d. Serum creatinine level
19. The nurse is caring for a client who has been 24. A client who is human immunodeficiency virus
taking a sulfonamide and should monitor for signs seropositive has been taking stavudine. The nurse
and symptoms of which adverse effects of the should monitor which most closely while the client
medication? Select all that apply. is taking this medication?
a. Ototoxicity a. Gait
b. Palpitations b. Appetite
c. Nephrotoxicity c. Level of consciousness
d. Bone marrow suppression d. Gastrointestinal function
e. Gastrointestinal (GI) effects
f. Increased white blood cell (WBC) count
20. The nurse is reviewing the results of serum
laboratory studies drawn on a client with acquired
immunodeficiency syndrome who is receiving
didanosine. The nurse interprets that the client may ANSWERS
have the medication discontinued by the health
care provider if which elevated result is noted? 1. Answer: B Rationale: Gowns and gloves are
a. Serum protein level required if the nurse anticipates contact with soiled
b. Blood glucose level items such as those with wound drainage, or is caring

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 Immune Problems of the Adult Client
for a client who is incontinent with diarrhea or a client
who has an ileostomy or colostomy. Masks are not
required unless droplet or airborne precautions are
necessary. Regardless of the amount of wound
drainage, a gown and gloves must be worn.
2. Answer: A Rationale: To help reduce fatigue in the
client with systemic lupus erythematosus, the nurse
should instruct the client to sit whenever possible,
avoid hot baths (because they exacerbate fatigue),
schedule moderate low-impact exercises when not
fatigued, and maintain a balanced diet. The client is
instructed to avoid long periods of rest because it
promotes joint stiffness.
3. Answer: A, B, C Rationale: An anaphylactic reaction
requires immediate action, starting with quickly
assessing the client’s respiratory status. Although the
PHCP and the Rapid Response Team must be notified
immediately, the nurse must stay with the client.
Oxygen is administered and an IV of normal saline is
started and infused per PHCP prescription.
Documentation of the event, actions taken, and client
outcomes needs to be performed. The head of the bed
should be elevated if the client’s blood pressure is
normal.
4. Answer: C Rationale: Pemphigus is an autoimmune
disease that causes blistering in the epidermis. The
client has large flaccid blisters (bullae). Because the
blisters are in the epidermis, they have a thin covering
of skin and break easily, leaving large denuded areas of
skin. On initial examination, clients may have crusting
areas instead of intact blisters. Option 1 describes
eczema, option 2 describes herpes zoster, and option 4
describes psoriasis.
5. Answer: A Rationale: The client with
immunodeficiency has inadequate or absence of
immune bodies and is at risk for infection. The priority
nursing intervention would be to protect the client
from infection. Options 2, 3, and 4 may be components
of care but are not the priority.
6. Answer: B Rationale: In some types of allergies, a
reaction occurs only on second and subsequent
contacts with the allergen. The appropriate action,
therefore, would be to ask the client if he ever
experienced a bee sting in the past. Option 1 is not
appropriate advice. Option 3 is unnecessary. The client
should not be told “not to worry.”
7. Answer: A Rationale: Individuals most at risk for
developing a latex allergy include health care workers;
individuals who work in the rubber industry; or those
who have had multiple surgeries, have spina bifida,
wear gloves frequently (such as food handlers,
hairdressers, and auto mechanics), or are allergic to
kiwis, bananas, pineapples, tropical fruits, grapes,
avocados, potatoes, hazelnuts, or water chestnuts.
8. Answer: A, B, D, E Rationale: If a client is allergic
to latex and is at high risk for an allergic response, the
nurse would use nonlatex gloves and latex-safe
supplies, and would keep a latex-safe supply cart
available in the client’s area. Any supplies or materials
that contain latex would be avoided. These include
blood pressure cuffs and medication vials with rubber
stoppers that require puncture with a needle. It is not
necessary to place the client in a private room. Test-
9. Answer: B Rationale: The nurse should ask
questions to assist in identifying a cause of Lyme
disease, which is a multisystem infection that results
from a bite by a tick carried by several species of deer.
The rash from a tick bite can be a ring-like rash
occurring 3 to 4 weeks after a bite and is commonly
seen on the groin, buttocks, axillae, trunk, and upper
arms or legs. Option 1 is referring to toxoplasmosis,
which is caused by the inhalation of cysts from
contaminated cat feces. Lyme disease cannot be
transmitted from one person to another.
10. Answer: B Rationale: Scleroderma is a chronic
connective tissue disease similar to systemic lupus
erythematosus. Corticosteroids may be prescribed to
treat inflammation. Topical agents may provide some
relief from joint pain. Activity is encouraged as
tolerated, and the room temperature needs to be
constant. Clients need to sit up for 1 to 2 hours after
meals if esophageal involvement is present.
11. Answer: B, C, D Rationale: A blood test is
available to detect Lyme disease; however, the test is
not reliable if performed before 4 to 6 weeks following
the tick bite. Antibody formation takes place in the
following manner. Immunoglobulin M is detected 3 to
4 weeks after Lyme disease onset, peaks at 6 to 8
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 Immune Problems of the Adult Client
weeks, and then gradually disappears; immunoglobulin
G is detected 2 to 3 months after infection and may
remain elevated for years. Areas that ticks inhabit need
to be avoided. Ticks should be removed with tweezers
and then the area is washed with an antiseptic. Options
1 and 5 are incorrect.
12. Answer: C Rationale: In the prevention of Lyme
disease, individuals need to be instructed to use an
insect repellent on the skin and clothes when in an area
where ticks are likely to be found. Long-sleeved tops
and long pants, closed shoes, and a hat or cap should
be worn. If possible, heavily wooded areas or areas
with thick underbrush should be avoided. Socks can be
pulled up and over the pant legs to prevent ticks from
entering under clothing.
13. Answer: C Rationale: Kaposi’s sarcoma lesions
begin as red, dark blue, or purple macules on the lower
legs that change into plaques. These large plaques
ulcerate or open and drain. The lesions spread by
metastasis through the upper body and then to the face
and oral mucosa. They can move to the lymphatic
system, lungs, and gastrointestinal tract. Late disease
results in swelling and pain in the lower extremities,
penis, scrotum, or face. Diagnosis is made by punch
biopsy of cutaneous lesions and biopsy of pulmonary
and gastrointestinal lesions.
14. Answer: A, B Rationale: Skin testing involves
administration of an allergen to the surface of the skin
or into the dermis. Site, date, and time of the test must
be recorded, and the client must return at a specific
date and time for a follow-up site evaluation, even if
no reaction is suspected. A list of potential allergens is
identified and reviewed and given to the client. For the
follow-up evaluation, the size of the site has to be
measured and not estimated. After injection, clients
only need to be monitored for about 30 minutes to
assess for any adverse effects.
15. Answer: D Rationale: Individuals who are allergic
to kiwis, bananas, pineapples, tropical fruits, grapes,
avocados, potatoes, hazelnuts, or water chestnuts are at
risk for developing a latex allergy. This is thought to be
the result of a possible cross-reaction between the food
and the latex allergen. Options 1, 2, and 3 are unrelated
to latex allergy.
16. Answer: D Rationale: Frequent adverse effects of
this medication include leukopenia, thrombocytopenia,
and anemia. The client should be monitored routinely
for signs and symptoms of infection. Options 1, 2, and
3 are inaccurate interpretations.
17. Answer: B, C, D Rationale: Aminoglycosides are
administered to inhibit the growth of bacteria. Adverse
effects of this medication include confusion,
ototoxicity, renal toxicity, gastrointestinal irritation,
palpitations or dysrhythmias, blood pressure changes,
and hypersensitivity reactions. Therefore, the
remaining options are incorrect.
18. Answer: B, C, E Rationale: Ketoconazole is an
antifungal medication. There is no reason for the client
to restrict fluid intake; in fact, this could be harmful to
the client. The medication is hepatotoxic, and the nurse
monitors liver function. It is administered with food
(not on an empty stomach), and antacids are avoided
for 2 hours after taking the medication to ensure
absorption. The client is also instructed to avoid
alcohol. In addition, the client is instructed to avoid
exposure to the sun, because the medication increases
photosensitivity.
19. Answer: C, D, E Rationale: Adverse effects of
sulfonamides include nephrotoxicity, bone marrow
suppression, GI effects, hepatotoxicity, dermatological
effects, and some neurological symptoms including
headache, dizziness, vertigo, ataxia, depression, and
seizures. Options 1, 2, and 6 are unrelated to these
medications.
20. Answer: C Rationale: Didanosine can cause
pancreatitis. A serum amylase level that is increased to
1.5 to 2 times normal may signify pancreatitis in the
client with acquired immunodeficiency syndrome and
is potentially fatal. The medication may have to be
discontinued. The medication is also hepatotoxic and
can result in liver failure.
21. Answer: C Rationale: Hypertension can occur in a
client taking cyclosporine, and because this client is
also complaining of a headache, the blood pressure is
the vital sign to be monitored most closely. Other
adverse effects include infection, nephrotoxicity, and
hirsutism. Options 1, 2, and 4 are unrelated to the use
of this medication.
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 Immune Problems of the Adult Client

22. Answer: C Rationale: Amikacin is an

aminoglycoside. Adverse effects of aminoglycosides
include ototoxicity (hearing problems), confusion,
disorientation, gastrointestinal irritation, palpitations,
blood pressure changes, nephrotoxicity, and
hypersensitivity. The nurse instructs the client to report
hearing loss to the PHCP immediately. Lethargy and
muscle aches are not associated with the use of this
medication. It is not necessary to contact the PHCP
immediately if nausea occurs. If nausea persists or
results in vomiting, the PHCP should be notified.

23. Answer: D Rationale: Foscarnet is toxic to the

kidneys. The serum creatinine level is monitored
before therapy, two or three times per week during
induction therapy, and at least weekly during
maintenance therapy. Foscarnet also may cause
decreased levels of calcium, magnesium, phosphorus,
and potassium. Thus, these levels also are measured
with the same frequency.

24. Answer: A Rationale: Stavudine is an antiretroviral

used to manage human immunodeficiency virus
infection in clients who do not respond to or who
cannot tolerate conventional therapy. The medication
can cause peripheral neuropathy, and the nurse should
monitor the client’s gait closely and ask the client
about paresthesia. Options 2, 3, and 4 are unrelated to
this medication.