Nokea
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
- A. A disorder where the body has too many immunoglobulins.
- B. A disorder where histocompatible cells attack the immunoglobulins.
- C. A disorder where killer T cells and autoantibodies attack or destroy natural cells - those cells that are 'self.'
- D. A disorder where the body does not have enough immunoglobulins.
Correct Answer: C
Rationale: Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells-those cells that are 'self.' Autoantibodies, antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder.
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The nurse is collecting data from a client with the autoimmune disorder endocarditis. What does the nurse recognize as symptom of an acute exacerbation?
- A. Temperature of 100.9?°F
- B. Respiratory rate of 20 breaths/minute
- C. Constipation
- D. Nausea
Correct Answer: A
Rationale: Periods of acute flare-ups (known as exacerbations) are completely unpredictable. During acute exacerbations, clients often experience a low-grade fever, malaise, or fatigue. They also may lose weight. A respiratory rate of 20 breaths/minute is within normal range. Constipation and nausea are not characteristic of a flare-up of endocarditis.
A client sustained an injury in one eye during a basketball game after being hit with another player's elbow. The client reports now having difficulty with vision in the other eye too, although that eye was not hit by the elbow. What does the nurse understand this phenomenon to be known as?
- A. Cataracts
- B. Psychosomatic blindness
- C. Glaucoma
- D. Sympathetic uveitis
Correct Answer: D
Rationale: When a person experiences trauma followed by inflammation to the iris, ciliary body, and choroid layer of one eye, the vision in the untraumatized eye also becomes affected. The term for this phenomenon is sympathetic uveitis. Cataracts do not occur from trauma, they develop over time. Psychosomatic blindness does not relate to the client's visual disturbance because the client is not blind at this time. Glaucoma is an eye disorder that occurs over time and is not related to trauma to the eye.
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client reports being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
- A. Apply an allergy bracelet and flag the chart.
- B. Tape an EpiPen to the head of the bed.
- C. Inform the client not to take any medications with those substances in them.
- D. Call the physician.
Correct Answer: A
Rationale: The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged.
A client comes to the clinic to see the physician, reporting, 'I think I ate something that I am allergic to.' What symptoms would be appropriate for the nurse to ask questions about?
- A. Nasal congestion and coughing
- B. Hives and itching
- C. Sneezing and runny nose
- D. Diarrhea and abdominal cramping
Correct Answer: D
Rationale: Clinical manifestations generally correlate with the manner in which the allergen enters the body. Inhaled allergens usually cause respiratory symptoms, including nasal congestion, runny nose, sneezing, coughing, dyspnea, and wheezing. Contactants cause skin reactions such as hives, which appear as vesicles filled with clear fluid surrounded by a margin of redness, rash, and localized itching. Cramping, vomiting, and diarrhea are associated with ingested food allergens. Allergic skin responses may also occur with allergies to foods.
The nurse has four clients who are scheduled to see the physician for 'fatigue' and other general symptom complaints. Which client does the nurse determine is at most risk for having chronic fatigue syndrome?
- A. Male of Hispanic descent, age 28 years
- B. Female of Caucasian descent, age 47 years
- C. Female of African descent, age 42 years
- D. Female of Chinese descent, age 18 years
Correct Answer: B
Rationale: Estimates are that as many as 4 million people in the United States have symptoms corresponding with chronic fatigue syndrome, but fewer than 80% have been diagnosed by a medical provider. Most clients who seek treatment for their symptoms are Caucasian women 40 to 59 years of age. CFS also occurs at lower rates among children, adolescents, and men.