Nursing Care of Patients With Immune Disorders

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. A patient is diagnosed with urticaria. For which type of hypersensitivity reaction should the nurse plan care for this patient?
a. Type I
b. Type II
c. Type III
d. Type IV
____ 2. A patient is diagnosed with hypogammaglobulinemia. Which of immune cell should the nurse realize is defective in this disorder?
a. T cells
b. B cells
c. Mast cells
d. Plasma cells
____ 3. The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness?
a. A patient who receives intravenous (IV) penicillin for an infection
b. A patient who has a transfusion with packed red blood cells (RBCs)
c. A patient who is given cryoprecipitate and factor IX after an abdominal injury
d. A patient given steroids and immunosuppressant therapy after organ transplantation
____ 4. The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient?
a. Assist with ambulation.
b. Teach good hand hygiene.
c. Avoid intramuscular injections.
d. Obtain manual blood pressures.
____ 5. The nurse is caring for a patient who has had a portion of stomach removed. Which manifestations should the nurse expect to determine if the patient has a vitamin B12 deficiency?
a. Fever, malaise, muscle soreness, and diarrhea
b. Numbness and tingling, weakness, and glossitis
c. Urticaria, angioedema, anorexia, pruritus, and blistered lesions
d. Frequent infections, fever, malaise, vertigo, and lymphadenopathy
____ 6. The nurse is caring for a patient at risk for infection. Which immunoglobulin should the nurse consider as being the cause of this patient’s infection risk?
a. IgA
b. IgE
c. IgG
d. IgM
____ 7. The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops?
a. Hives
b. Retinal hemorrhage
c. Jugular vein distention
d. Pallor around the sting sites
____ 8. The nurse is caring for a patient with a severe allergic reaction. Which medication and route should the nurse anticipate being ordered for this patient?
a. Intramuscular morphine
b. Subcutaneous epinephrine
c. IV diphenhydramine
d. Oral diphenhydramine (Benadryl)
____ 9. The nurse is caring for a patient with a severe allergic reaction. Which medication should the nurse anticipate being administered to control the itching?
a. Morphine
b. Epinephrine
c. Diphenhydramine (Benadryl)
d. Hydrocortisone sodium succinate (Solu-Cortef)
____ 10. A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient?
a. Wear Medic-Alert identification.
b. Stay indoors as much as possible.
c. Wear insect repellent when outdoors.
d. Take corticosteroids before going outdoors.
____ 11. The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease?
a. Gardening outdoors on dry, windy days
b. Wearing a mask when mowing the lawn
c. Driving the car with the windows open during high pollen counts
d. Taking frequent walks outside in spring when the weather is warm
____ 12. The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms?
a. Installing a hot air heater
b. Cover heating ducts with filters
c. Installing wall-to-wall carpeting
d. Using heavy draperies on sunny windows
____ 13. A patient is experiencing an episode of urticaria. Which intervention should the nurse recommend to include in the teaching plan to assist the patient in controlling the symptoms of urticaria?
a. Avoiding tub baths
b. Taking one aspirin daily
c. Using relaxation techniques
d. Drinking decaffeinated coffee
____ 14. A patient who developed hemolytic anemia related to the administration of penicillin asks for an explanation of this condition. What is the most appropriate response by the nurse?
a. “The red blood cells are being produced inappropriately.”
b. “An antigen–antibody reaction is causing destruction of red blood cells.”
c. “An allergy to penicillin is destroying your platelets for unknown reasons.”
d. “Allergens are invading the bone marrow and interfering with red blood cell production.”
____ 15. A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins the patient reports low back pain and a headache. Which action should the nurse take first?
a. Stop the blood infusion.
b. Notify the physician STAT.
c. Start the new 0.9% normal saline infusion.
d. Prepare a new 0.9% normal saline infusion.
____ 16. A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take?
a. Verify the patient’s kidney function.
b. Verify the patient’s hematocrit level.
c. Verify blood type of the patient and donor.
d. Verify the patient’s admitting medical diagnosis.
____ 17. The nurse is reinforcing teaching provided to a patient with Hashimoto’s thyroiditis. What should the nurse explain as occurring initially in this health problem?
a. Thyroid hormone production increases.
b. Thyroid hormone production decreases.
c. Thyroid-stimulating hormone production increases.
d. Thyroid-stimulating hormone production decreases.
____ 18. The nurse is collecting data from a patient with skin eruptions. What should the nurse recall to differentiate urticaria from angioedema?
a. It is less pruritic.
b. It lasts a shorter period of time.
c. It includes mucous membrane edema.
d. It causes more widespread skin lesions.
____ 19. The nurse is c caring for a patient with angioedema. Which nursing action should have the highest priority?
a. Monitor for restlessness.
b. Identify cause of the angioedema.
c. Identify the presence of skin lesions.
d. Teach the patient about immunotherapy.
____ 20. The nurse is assisting in the planning of care for a patient with chronic serum sickness. Which action should be a priority for this patient?
a. Assessing for a decrease in urine output
b. Administration of immunosuppressive medications
c. Closely monitoring the patient during the transfusion of blood products
d. Discussing with the patient and significant other the need for genetic counseling
____ 21. The nurse is caring for a patient who had a kidney transplant 5 days ago. The patient had been very outgoing and jovial, but this morning the patient is very quiet and refusing breakfast, and ambulation. What would be the most appropriate nursing action at this time?
a. Notify the physician for laboratory orders.
b. Notify the social worker for discharge follow-up care.
c. Inform the patient that kidney rejection signs are appearing.
d. Spend extra time with the patient, allowing verbalization of feelings.
____ 22. The nurse is caring for a patient with severe ankylosing spondylitis. What nursing action would be most appropriate?
a. Provide tepid tub soaks.
b. Encourage a high-fiber diet.
c. Provide activity every 2 hours.
d. Administer narcotic analgesics.
____ 23. The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how the disease process occurred. What should the nurse explain to the mother?
a. It rarely occurs in males.
b. It occurs after exposure to pesticides.
c. It is because the infant was premature.
d. There are no known causes for this disorder.
____ 24. The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus. Which adverse effect should the nurse encourage the patient to report when taking this medication?
a. Tarry stools
b. Vision changes
c. Any weight gain
d. Changes in joint movement
____ 25. The nurse has been caring for a patient with pernicious anemia. Which finding should indicate to the nurse that treatment has been successful?
a. Decreased folic acid level and an increase in enlarged RBCs
b. A decrease in intrinsic factor and increased vitamin B12 excreted in the urine
c. An increase in vitamin B12 levels and decrease in number of enlarged RBCs
d. A decrease in hydrochloric acid levels in gastric secretion and decrease in production of RBCs
____ 26. The nurse notes that a patient has an elevated lactate dehydrogenase, fragmented RBCs seen on microscopic examination, and low RBC count, hematocrit (Hct), and hemoglobin (Hgb) levels. For which health problem should the nurse consider planning care for this patient?
a. Serum sickness
b. Pernicious anemia
c. Hemolytic transfusion reaction
d. Idiopathic autoimmune hemolytic anemia
____ 27. The nurse is reviewing data collected on several patients. Which patient should the nurse identify as being most likely to exhibit signs and symptoms of systemic lupus erythematosus?
a. A 16-year-old Caucasian man
b. A 20-year-old Hispanic woman
c. A 45-year-old Caucasian woman
d. A 42-year-old Asian American man
____ 28. The nurse recommends the diagnosis Disturbed Body Image for a patient with systemic lupus erythematosus. What would be an appropriate long-term outcome for this patient?
a. Engages in diversional activities
b. Uses normal coping mechanisms
c. Returns to previous social involvement
d. Verbalizes feelings about body changes
____ 29. A patient is suspected as having a blood transfusion reaction. Which laboratory test should the nurse expect to be done to confirm this diagnosis?
a. Skin testing
b. Direct Coombs’ test
c. White blood cell count
d. C-reactive protein level
____ 30. A patient comes into the emergency department with a fear of developing poison ivy after falling while walking through a wooded area earlier in the day. What should the nurse instruct the patient to do if exposure to poison ivy occurs again?
a. Flood the area with cold water.
b. Wrap the area with a thick towel.
c. Cover the area with cotton gauze.
d. Wash the area with brown soap or any soap.
____ 31. The nurse is reinforcing teaching provided to a patient with pernicious anemia. Which patient statement indicates that teaching has been effective?
a. “I can miss a month or two of injections if I am feeling better.”
b. “I will need to take vitamin B12 injections for the rest of my life.”
c. “I will take the vitamin B12 injections until my strength returns.”
d. “I can take a vitamin B12 injection when I feel tired or fatigued.”
____ 32. A patient is being started on a blood transfusion. For how many minutes should the nurse stay with the patient during this transfusion?
a. 5
b. 10
c. 15
d. 20
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 33. The nurse is reinforcing teaching about potential triggers with a patient experiencing allergic rhinitis. What should the nurse include in the teaching? (Select all that apply.)
a. Dust
b. Penicillin
c. Ragweed
d. Pet dander
e. Topical lotion
f. Oral multivitamin
____ 34. The nurse is assisting in an educational seminar on common allergens. What should the nurse include as the most common irritant causing contact dermatitis? (Select all that apply.)
a. Bleach
b. Rubber
c. Fire ants
d. Poison ivy
e. Poison oak
____ 35. The nurse is participating in a teaching plan to address Risk for Impaired Skin Integrity for a patient with contact dermatitis. Which information should the nurse recommend be included in this plan? (Select all that apply.)
a. Keep fingernails short.
b. Take baths with an oatmeal solution.
c. Use oil-in-water lubricants for skin dryness.
d. Rub affected area roughly, but do not scratch.
e. Avoid washing affected area with brown soap.
f. Use cool washcloths over affected area to ease itching.
____ 36. The nurse is contributing to the teaching plan for a patient diagnosed with Hashimoto’s thyroiditis who has progressed to hypothyroidism with a goiter. Which self-care instructions should the nurse recommend? (Select all that apply.)
a. Eat a soft diet.
b. Increase activity slowly.
c. Eat more foods high in iodine.
d. Keep home at a cool temperature.
e. Eat a high-carbohydrate, high-protein diet.
f. During low-energy periods, use anti-embolism stockings.
____ 37. The nurse is contributing to a staff education program about nursing care for hypersensitivity reactions. Which should the nurse include as examples of type I hypersensitivity reactions? (Select all that apply.)
a. Anaphylaxis
b. Angioedema
c. Serum sickness
d. Allergic rhinitis
e. Contact dermatitis
f. Hypogammaglobulinemia
____ 38. A patient with lupus erythematosis is prescribed a corticosteroid. What side effects of this medication should the nurse review with the patient? (Select all that apply.)
a. Tinnitus
b. Facial hair
c. Moon face
d. Mood changes
e. Increased weight
f. Rash and pruritus
____ 39. The nurse is assisting in the care of a patient with ankylosing spondylitis. What should the nurse expect to find in the patient’s collaborative plan of care? (Select all that apply.)
a. Physical therapy daily
b. Sitz baths three times daily
c. Tylenol #3 every 4 hours prn pain
d. Administer Remicade as prescribed
e. Activity as tolerated; up with assistance
____ 40. The nurse is contributing to the plan of care for a patient with systemic lupus erythematosus (SLE). Which interventions should the nurse recommend for this patient? (Select all that apply.)
a. Eat a balanced diet.
b. Report “foamy urine” to physician.
c. Take cool showers or baths to relieve joint stiffness.
d. Avoid naps and obtain a minimum of 6 hours of sleep.
e. Exercise when pain and inflammation in joints is increased.
f. Use a daily personal schedule to plan activities to reduce fatigue.
____ 41. A patient with an autoimmune disorder asks, “What might cause my body to do this to itself?” What should the nurse state as reasons for the body to have lost the ability to recognize self? (Select all that apply.)
a. Drugs
b. Hormones
c. Vaccinations
d. Viral infections
e. Bacterial infections
____ 42. The nurse is experiencing severe skin blisters after wearing latex gloves at work. Which treatment should the nurse expect to be prescribed by the health care provider for these skin lesions? (Select all that apply.)
a. Oral antibiotics
b. Topic drying agent
c. Oral antihistamines
d. Topical corticosteroid
e. Topical immunomodulators
____ 43. The nurse applies clean white cotton socks over the hands of a patient with contact dermatitis. What should the nurse explain to the patient about the purposes of this intervention? (Select all that apply.)
a. Cotton allows air movement.
b. White cotton has no dye in the material.
c. White cotton prevents the wounds from spreading.
d. The cotton will absorb the drainage from the wounds.
e. Scratching is less during sleep when the area is covered.
Completion
Complete each statement.

44. A patient with systemic lupus erythematosis is prescribed Prednisone, 60 mg PO, in three equal doses. If using 5 mg tablets, how many tables should the nurse provide for each dose?

Other

45. A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Place the actions in order (1–5) of importance of performance.
A. ___ Stop the blood infusion.
B. ___ Notify the physician stat.
C. ___ Obtain vital signs and assess patient.
D. ___ Start the new 0.9% normal saline infusion.
E. ___ Prepare a new 0.9% normal saline infusion.

Chapter 19. Nursing Care of Patients With Immune Disorders
Answer Section

MULTIPLE CHOICE

1. ANS: A
Anaphylaxis, urticaria, and angioedema are the most severe forms of type I hypersensitivity reactions. B. A type II hypersensitivity reaction involves the destruction of a cell or substance that has an anti-gen attached to its cell membrane. C. A type III hypersensitivity reaction involves immune complexes formed by antigens and antibodies, usually of the IgG type. D. A type IV hypersensitivity reaction, also called a delayed reaction, occurs when a sensitized T lymphocyte comes in contact with the particular antigen to which it is sensitized.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

2. ANS: B
Hypogammaglobulinemia is characterized by the absence or deficiency of one or more of the five classes of immunoglobulins from defective B-cell function. A. C. D. Hypogammaglobulinemia is not caused by defective T, mast, or plasma cells.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

3. ANS: A
Serum sickness is seen occasionally after administration of penicillin and sulfonamide. B. C. D. Serum sickness is not associated with blood transfusions, cryoprecipitate, factor IX, steroids, or immunosuppressant therapy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

4. ANS: A
With anemia, the patient will be fatigued and may have activity intolerance and be a fall risk. Assistance with ambulation should be done for safety. C. D. These actions would be appropriate if the patient had thrombocytopenia. B. This action would be appropriate if the patient had neutropenia.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Application

5. ANS: B
Non-immune-related causes of pernicious anemia include any type of gastric or small bowel resections coupled with no or inadequate vitamin B12 or intrinsic factor replacement. Vitamin B12 deficiency symptoms include numbness and tingling, weakness, and glossitis. A. C. D. These are not manifestations associated with vitamin B12 deficiency.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

6. ANS: A
IgA cannot be replaced, increasing the risk for infections. B. C. D. These immunoglobulins can be replaced.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Analysis

7. ANS: A
Hives is one of several symptoms of an allergic reaction. B. C. D. These manifestations are not associated with an allergic reaction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

8. ANS: B
Epinephrine subcutaneous (SQ) or intramuscular (IM) is given for anaphylactic reactions. It causes vasoconstriction, bronchodilation, and cardiac stimulation. A. Morphine is not used for an allergic reaction. C. D. Diphenhydramine is an oral medication however will not work quickly enough for the patient’s severe allergic reaction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

9. ANS: C
Benadryl blocks histamine at histamine1-receptors, therefore preventing or reversing the effects of histamine. A. Morphine does not reduce itching. B. Epinephrine will help the overall allergic response however will not specifically reduce itching. D. This medication might need to be prescribed long-term if the itching continues.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

10. ANS: A
The nurse should teach the patient to wear medical alert identification for allergies in order for prompt medical attention to be given if the patient is unable to give information. B. Out of doors might not be the reason for the patient’s allergic reaction. C. The patient might not be allergic to stinging insects. D. This medication should not be taken prophylactically.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

11. ANS: B
Allergen avoidance might involve wearing a mask when mowing the lawn or working outdoors or having heating ducts cleaned or heating registers covered with filters. A. C. D. These would increase the patient’s risk of having an allergic reaction.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

12. ANS: B
Filtering the air will reduce dust particles which the other items do not do. C. Carpeting traps dust and is harder to clean. A. A hot air heater will not reduce the amount of dust in the patient’s environment. D. Heavy draperies will trap dust.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

13. ANS: C
Stress management and relaxation techniques may be helpful with urticaria symptoms. A. B. D. These actions are not identified to reduce the symptoms of urticaria.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

14. ANS: B
For no known reason, autoantibodies are produced that attach to RBCs and cause them to either lyse or agglutinate (clump). A. C. D. These choices do not correctly explain the development of hemolytic anemia in this patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

15. ANS: A
Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a reaction are noted, the blood is immediately stopped so that no more blood is infused into the patient. B. The physician should be notified after the transfusion is stopped. C. D. A new normal saline infusion with new tubing is prepared and started to keep the vein patent should medications need to be administered as ordered. New tubing must be used so that not one more drop of blood enters the patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

16. ANS: C
Prevention of hemolytic reactions is crucial. At the bedside, double-check the patient’s name and identification number on the chart, unit of blood, and patient’s identification bracelet, as well as check the patient’s blood type in the chart, on the unit of blood, and paperwork with the unit of blood. A. B. D. These actions will not help prevent the development of a transfusion reaction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

17. ANS: A
Autoantibodies for thyroid-stimulating hormone form, bind with the hormone receptors on the thyroid gland, and initially stimulate the thyroid gland to secrete thyroid hormones. B. C. D. These statements do not explain the initial action in Hashimoto’s thyroiditis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

18. ANS: B
Angioedema subcutaneous eruptions last longer than with urticaria. A. C. D. These statements describe angioedema.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

19. ANS: A
If the angioedema reaction is severe, maintenance of a patent airway is a priority. Any symptoms of respiratory distress must be reported immediately and remain the highest priority. B. Because the condition is already present, monitoring the patient takes priority, although the cause needs to be identified. C. D. These may be addressed later but are not the priority.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

20. ANS: A
The patient is at risk for low fluid volume which can lead to renal failure. Monitoring urine output can help reduce the risk of renal failure from occurring. B. C. D. These actions are not indicated in the care of this patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

21. ANS: D
Psychological support is important for transplant patients. Patients need time to verbalize feelings and understand that feelings of guilt are normal and diminish with time. A. B. C. These actions are not appropriate for the patient at this time.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

22. ANS: C
The patient should not stay in any one position for any length of time to reduce stiffness and pain. A. B. D. These actions are not specifically identified to help the patient with severe ankylosing spondylitis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

23. ANS: D
Hypogammaglobulinemia is either a hereditary congenital disorder or acquired after childhood from unknown causes. It is characterized by the absence or deficiency of one or more of the five classes of immunoglobulins (IgG, IgM, IgA, IgD, and IgE) from defective B-cell function. The lack of normal function of these antibodies makes the patient prone to infections. A. The congenital form of this disorder affects males. B. It is not linked to pesticide exposure. C. It did not develop because the infant was premature.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

24. ANS: B
The patient should have an ophthalmologic examination completed before starting this medication because vision changes can occur. A.C. D. These are not identified adverse effects for this medication.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

25. ANS: C
Macrocytic (enlarged RBCs) anemia, and low vitamin B12 levels are indicators of pernicious anemia, so increased vitamin B12 levels and decreased enlarged RBCs would indicate successful treatment. A. B. D. These findings would not support treatment for pernicious anemia as being successful.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

26. ANS: D
In idiopathic autoimmune hemolytic anemia, the RBC count and Hgb and Hct levels are low, with fragmented RBCs and elevated lactate dehydrogenase because of RBC destruction and tissue ischemia. A. B. C. These manifestations are not seen in serum sickness, pernicious anemia, or hemolytic transfusion reactions.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

27. ANS: B
Systemic lupus erythematosus tends to develop in young women of child-bearing years and occurs in the African American and Hispanic populations more frequently. A. C. D. These individuals are less likely to develop manifestations of systemic lupus erythematosus.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

28. ANS: C
The ultimate outcome is for the patient to return to previous social involvement in spite of body image issues such as the butterfly rash. A. B. D. These outcomes would be short-term for the patient with systemic lupus erythematosus.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

29. ANS: B
The direct Coombs’ test confirms the diagnosis of transfusion reaction. In the laboratory, a small amount of the patient’s RBCs is washed to remove any unattached antibodies. Antihuman globulin is added to see if agglutination (clumping) of the RBCs results. If agglutination occurs, an immune reaction such as a hemolytic transfusion reaction is taking place. A. Skin testing is used to determine the presence of a type I hypersensitivity reaction. C. D. These tests might be done to determine the presence of serum sickness.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

30. ANS: D
The patient should be instructed to wash the area with a brown soap (e.g., Fels-Naptha) or, if unavailable, any soap when contact with the offending agent is suspected. This removes the offending agent from the skin. A. Cold water is not going to remove the agent from the skin. B. C. Wrapping the area with a towel or gauze is going to trap the offending agent on the skin and make the skin reaction worse.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

31. ANS: B
If vitamin B12 injections are prescribed, the patient must understand that this is a lifelong need to prevent the return of symptoms. A. C. Patients should not miss injections. D. Injections are not taken as needed for fatigue.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

32. ANS: C
The nurse should stay at the bedside with a patient for the first 15 minutes of any blood transfusion to detect signs of a reaction. A. B. The nurse needs to stay longer than 5 or 10 minutes. D. The nurse does not need to stay beyond 15 minutes.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

MULTIPLE RESPONSE

33. ANS: A, C, D
Allergic rhinitis causative antigens are environmental and airborne. Frequent home vacuuming and dusting are recommended. B. E. F. Penicillin, topical lotion, and oral multivitamins are not identified as being triggers for allergic rhinitis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

34. ANS: D, E
Poison ivy and poison oak are the most common irritants causing contact dermatitis. A. B. C. These items are not known to cause contact dermatitis.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Application

35. ANS: A, B, C, F
The patient should be instructed to avoid scratching the skin to prevent the spread of dermatitis and infection development. Ease itching with cool washcloths and oatmeal baths, and keep fingernails short to avoid injury to skin if scratching occurs. Oil-in-water lubricants tend to be the most effective for skin dryness. D. E. Rubbing the skin and avoiding brown soap will not help the patient with contact dermatitis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

36. ANS: A, B, F
If the patient has a goiter, a soft diet may be necessary for comfort. Frequent rest periods may be necessary as well as slowly increasing patient activity. Anti-embolic stockings may help prevent venous stasis during the low-energy, decreased-activity phase. E. During the hyperthyroidism phase, a diet high in protein and carbohydrates encourages weight gain. D. The patient will be sensitive to cold, so room temperature will need to be increased for comfort. C. Foods high in iodine should be avoided.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

37. ANS: A, B, D
Type I hypersensitivity reactions include conditions such as allergic rhinitis and allergic asthma, atopic dermatitis, anaphylaxis, angioedema. hemolytic transfusion reactions, measles, and transplant rejections. C. E. F. These health problems are not considered type I hypersensitivity reactions.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

38. ANS: B, C, D, E
Corticosteroids can cause weight gain, increased facial hair, acne, round “moon” face, mood changes, irritability, depression, increased appetite, increased weight, poor wound healing, headache, peptic ulcers, and osteoporosis. A. F. Tinnitus, rash, and pruritus are not adverse effects of corticosteroid therapy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

39. ANS: A, C, D, E
Nursing care focuses on patient education and administration and evaluation of prescribed medications. Pain management, rest periods, and assistance with activities of daily living (ADLs) are provided. B. Sitz baths are not indicated for this health problem.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis |

40. ANS: A, B, F
Fatigue during activities of daily living is minimized through the use of a daily personal schedule. Additionally, a minimum of 8 hours of sleep per night with naps as necessary are important to combat fatigue. Because the majority of patients with SLE develop transitory arthralgia, maintaining fitness and joint range of motion through a regular fitness program while decreasing activity during flares is vital. Warm baths may help with morning stiffness. Because renal disease is a major complication of SLE, patients must learn the signs of impending problems that need to be relayed to the physician immediately. These are such findings as facial puffiness and “foamy” urine or “coke-colored” urine indicative of proteinuria and hematuria, respectively. Eating a well-balanced diet will also influence level of fatigue and weight gain from the corticosteroids. C. Cool showers will not help relieve the pain and stiffness associated with this disorder. D. Rest is beneficial for this disorder. E. Exercise should be reduced during flare-ups.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

41. ANS: A, B, D
A number of factors either cause or influence this breakdown of self-recognition, including viral infections, drugs, and cross-reactive antibodies. Hormones have also been found to influence this breakdown of self-recognition. C. E. Vaccinations and bacterial infections have not been identified as contributing to the development of an autoimmune disorder.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

42. ANS: B, C, D, E
Oral or topical antihistamines and topical drying agents may be used. Topical corticosteroids may be used and are most effective if sparingly applied after a bath or shower. Topical immunomodulators also may be prescribed when other treatments fail. A. Oral antibiotics are not indicated in the treatment of a latex allergy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

43. ANS: A, B, E
Cotton allows air movement. White cloth is less irritating than those with dyes. Scratching is decreased during sleep with the use of gloves/mittens or by covering affected area. C. D. The use of white cotton socks over the hands of a patient with contact dermatitis is not done to prevent the wounds from spreading or to absorb the drainage from the wounds.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

COMPLETION

44. ANS:
4
The nurse should use the equation Dosage Required/Dosage Available x 1 tablet or 20 mg/5 mg x 1 = 4 tablets.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

OTHER

45. ANS:
A, C, B, E, D
Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a reaction are noted, the blood transfusion is immediately stopped and agency policy for a suspected transfusion reaction is followed. A normal saline infusion with new tubing is started to keep the vein patent. The physician and blood bank are immediately notified. A nurse remains with the patient for reassurance and monitoring of symptoms and vital signs. If a blood incompatibility is suspected, the unused blood and blood tubing are returned to the blood bank for testing. A series of blood and urine specimens are collected and sent to the laboratory for analysis. The physician’s orders are followed to treat the patient’s symptoms.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application