IMMUNE SYSTEM DISORDERS COMPREHENSIVE EXAMINATION ANSWERS AND RATIONALES

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1 2504_Ch13_ qxd 11/4/10 9:50 PM Page 566 IMMUNE SYSTEM DISORDERS COMPREHENSIVE EXAMINATION ANSWERS AND RATIONALES This is a sign of an anaphylactic reaction to an allergen and will not happen during this test because of the small amount of allergen used. 2. This indicates a negative test and the client is not sensitive to the allergen. 3. The skin reaction, not the blood pricked, indicates a positive or negative test. 4. During this test, a drop of diluted allergenic extract is placed on the skin and then the skin is punctured through the drop. A positive test causes a localized pruritic wheal and erythema, which occurs in five (5) to 20 minutes The presenting symptom of a client with Guillain-Barré syndrome is ascending paralysis starting in the lower extremities. 2. Abdominal symptoms are not found early in the diagnosis. 3. Chest symptoms are not found early in the diagnosis. 4. Head symptoms are not found early in the diagnosis A dietitian could help the client with any necessary dietary changes for food allergies and with ways to continue to meet nutritional needs. 2. An occupational therapist addresses the client s ability to perform activities of daily living. 3. A recreational therapist works in a psychiatric setting or rehabilitation setting and assists with the client s therapeutic recreational activities. 4. A social worker addresses the client s financial needs. Level Application A urinary output of greater than 30 ml/hr is within normal limits and indicates the client is responding to treatment These vital signs indicate shock, which is a medical emergency and requires immediate intervention. 3. Clear breath sounds indicate response to treatment, and although the RR is increased, this could be the result of anxiety or fear. 4. The client s bowel sounds are not significant data to determine the client s response to treatment Sjögren s syndrome is an autoimmune disorder causing inflammation and dysfunction of exocrine glands throughout the body. Dry mouth and eyes are some of the signs/symptoms. 2. Peripheral joint pain may be a symptom of rheumatoid arthritis. 3. Muscle weakness is a symptom of a variety of disease processes and syndromes but not of Sjögren s syndrome. 4. Severe itching is not a symptom of this syndrome Artificial tears are appropriate for a client diagnosed with Sjögren s syndrome. 2. Nursing care addresses measures to maintain skin integrity and moisturizers help prevent dryness and cracking; once skin elasticity is lost, it cannot be regained. 3. Braces are not prescribed for the client with scleroderma. 4. The client should stop smoking, not just decrease smoking, because of the vasoconstrictive effect of nicotine and the respiratory effects of the disease. Level Application The diagnosis of fibromyalgia is based on the history and physical assessment. There is no laboratory or diagnostic test for However, tests may be performed to rule out other diagnoses.

2 CHAPTER 13 IMMUNE SYSTEM DISORDERS This test is not used to diagnose 3. An MRI is not used to diagnose 4. An ESR does not support the diagnosis of An apical heart rate of less than 60 warrants intervention if the primary nurse gave the 2. A blood pressure of less than 90/60 warrants intervention if the primary nurse gave the 3. These medications must be administered exactly on time so increased strength can occur during activity such as eating or grooming. There are very few medications administered exactly on time, but this is one of them. 4. The client with AIDS receives prophylactic treatment for Pneumocystis pneumonia (PCP) when the CD4 count is less than 200 to HIV is transmitted via sexual activity. 2. HIV is transmitted via sexual activity, and the client may have been HIV positive for up to a year and not aware of it, so all past sexual partners should be informed of the HIV status. 3. Blood donations are screened and excluded for this virus, as are organs/ tissues from a client with HIV, because the virus can be transmitted to clients receiving the organ or tissue. 4. HIV can be transmitted to the fetus from the pregnant woman with HIV. 5. The client should tell the HCP, especially dentists, about the HIV status, but the client does not have to tell health-care personnel about the HIV status. Health-care personnel should always follow Standard Precautions. Physiological Adaptation: Cognitive This occurs in the acute stage of Guillain-Barré syndrome. 2. This indicates the client diagnosed with myasthenia gravis is getting better. 3. A positive Babinski s reflex in an adult client is abnormal and indicates neurological deficits. 4. The recovery stage may take from several months to two (2) years, and muscle strength and function return in a descending order The client diagnosed with SLE does not have a butterfly rash on the feet. 2. The client does not have a butterfly rash on the upper-thigh area. 3. The client does not have a butterfly rash on the chest area. 4. The client with SLE often has a reddened area over both cheeks known as a butterfly rash; it is diagnostic of a client with SLE The client is at risk for aspiration as a result of muscle weakness, but modifications of dietary needs address this concern. The client does not require a PEG tube. 2. Polymyositis is a systemic connective tissue disorder characterized by inflammation of connective tissues and muscle fibers and is treated with long-term corticosteroid therapy. Adrenal insufficiency may occur if the client quits taking the corticosteroid. 3. Sunlight does not cause an exacerbation or irritation of polymyositis. 4. The client is not at risk for developing an infection, and an infection will not exacerbate the client s medical condition. Physiological Adaptation: Cognitive Aspirin should be taken with food to prevent gastrointestinal upset. 2. Daily aspirin is used as an anticoagulant; therefore, abnormal bleeding should be reported to the HCP. 3. Aspirin is used to reduce the inflammatory process and manage the signs and symptoms, but it does not stop the disease process.

3 568 MED-SURG SUCCESS 4. Tinnitus (ringing in the ears) is a sign of aspirin toxicity, and the client should be instructed to decrease the aspirin dosage or stop taking aspirin altogether. The client should be instructed to contact the health-care provider Ankylosing spondylitis is a chronic inflammatory arthritis primarily affects the spinal cord. The client complains of intermittent bouts of low back pain with the pain worse at night, followed by morning stiffness relieved by activity. 2. Ascending paralysis makes the nurse suspect Guillain-Barré syndrome. 3. A deep ache and stiffness may indicate osteoarthritis, which occurs in weightbearing joints. 4. This is not a symptom of ankylosing spondylitis Walkers or canes may be weighted to provide support and balance for the client; a wheelchair should be used as a last resort. 2. Standing with the feet slightly apart widens the client s base of support and helps decrease balance problems. 3. The client should widen his or her base of support by standing with the feet slightly apart. Narrowing the base of support does not help. 4. This intervention addresses fatigue, which does not cause balance problems. Basic Care and Comfort: Cognitive This action is appropriate and does not require any intervention by the nurse. 2. The UAP should wear nonsterile gloves, not sterile gloves. Wearing sterile gloves is not cost effective. 3. The client has dementia, so helping the client with activities of daily living is appropriate to enable the client to maintain as much independence as possible. 4. This is an excellent intervention to help prevent skin breakdown; it is relaxing for the client and does not require intervention from the nurse This may indicate a hemolytic reaction. 2. Pale, boggy, edematous nasal mucosa indicates chronic allergies. 3. This may indicate hemolysis or immune deficiency. 4. This may indicate Kaposi s sarcoma. Assessment: Client Needs Physiological Integrity, Reduction of Risk Potential: Cognitive Level Corticosteroids may be used in both systemic and topical forms for many types of hypersensitivity responses, but must be ordered by a health-care provider and are not automatically taken after a bee sting. 2. Antihistamines are the major class of drugs used to treat hypersensitivity responses, but they are not taken prophylactically. They are used when a reaction occurs. 3. This drug treats allergic rhinitis and asthma prophylactically. It does not help bee stings or insect bites. 4. The kit usually includes a prefilled syringe of epinephrine and an epinephrine nebulizer, which allows prompt self-treatment for any future exposures to insect venom or other potential allergen exposure. Physiological Adaptation: Cognitive This will help identify people who can help support the client, but it is not the highest priority. 2. This will help the nurse identify methods which worked previously in stressful situations and may help the client deal with this disease. 3. Developing a therapeutic relationship with the client is priority because the client probably has less than six (6) months to live. All the other interventions can be implemented, but establishing a therapeutic relationship will allow the nurse to discuss and implement additional interventions.

4 CHAPTER 13 IMMUNE SYSTEM DISORDERS An advance directive is important, and unless the client is declared legally incompetent in a court of law, the client can complete an advance directive, but establishing a therapeutic relationship with the client is priority. Implementation: Client Needs Psychosocial Integrity: Cognitive Level Muscle relaxants have sedative effects, so appropriate safety measures should be taken. 2. The client should avoid central nervous system depressants because they can increase the sedative effects of the 3. This will help prevent constipation, which is a side effect of this 4. This medication must be tapered over one (1) to two (2) weeks when discontinuing because sudden withdrawal may cause seizures and paranoid ideation. Drug Administration: Integrated Nursing Process Evaluation: Client Needs Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Rheumatoid arthritis is a chronic illness, and verbalization of feelings is helpful in dealing with disease processes, but it is not the highest priority intervention. 2. This helps the client accept the disease process and body changes and helps the client to begin to identify strategies for coping with them, but it is not the highest priority intervention. 3. Helping the client prioritize activities helps the client maintain independence as long as possible. 4. Pain is priority over psychological problems and activity; remember Maslow s hierarchy of needs. Level A sunscreen with an SPF of at least 15 should be used by the client with SLE. 2. The client with SLE is at risk for infections and should avoid large crowds. 3. Pregnancy is not contraindicated in most women diagnosed with SLE. 4. The client with SLE should use hypoallergenic products and should not use irritating soaps, shampoos, or chemicals Epinephrine is the drug of choice for an anaphylactic reaction. It is a potent vasoconstrictor and bronchodilator counteracting the effects of histamine, but this is not the priority intervention. 2. This is an important intervention, but it is not the priority intervention. 3. Decreasing the client s anxiety is important, but it is not the priority intervention. 4. Establishing a patent airway is priority because facial angioedema, bronchospasm, and laryngeal edema occur with an anaphylactic reaction. Inserting a nasopharyngeal or oropharyngeal airway maintains a patent airway The client must use measures to help prevent fatigue, which increases the depletion of acetylcholine and causes muscle weakness. 2. The client with MG is not on strict bedrest, and impaired skin integrity is not an expected complication of this disease process, especially in the early stages. 3. Pain is not an expected complaint of clients diagnosed with MG. 4. A thymectomy, not a splenectomy, may be recommended. Approximately 75% of clients with MG have dysplasia of the thymus gland. Physiological Adaptation: Cognitive Pneumocystis pneumonia (PCP) occurs in approximately 75% to 80% of clients diagnosed with AIDS. Signs/symptoms of it include fever, cough, and shortness of breath. 2. This is an opportunistic infection, but it is not the most common infection. 3. These are signs/symptoms of Mycobacterium avium complex (MAC), which affects up to 25% of client s with AIDS, but it is not the most common opportunistic infection.

5 570 MED-SURG SUCCESS 4. These are signs/symptoms of Kaposi s sarcoma, which is the most common cancer associated with AIDS; it is not an infectious disease. 26. In order of priority: 1, 3, 2, 5, Airway is always the first priority for any process in which the airway might be compromised. 3. The nurse should start an IV so medications can be administered to treat the anaphylactic reaction. 2. Epinephrine is the drug of choice for the treatment of anaphylaxis. The medication is administered every 10 to 15 minutes until the reaction has subsided. Epinephrine is given for its vasoconstrictive action. 5. Benadryl, an antihistamine, is given to block histamine release, reducing capillary permeability. 4. Teaching is important to prevent or treat further reactions, but this will be done after the crisis is over. Level