SAUNDERS NCLEX IMMUNE
DISORDERS QUESTIONS WITH
COMPLETE ANSWERS
The ssnurse ssprovides sshome sscare ssinstructions ssto ssa ssclient sswith sssystemic sslupus
sserythematosus ssand sstells ssthe ssclient ssabout ssmethods ssto ssmanage ssfatigue.
ssWhich ssstatement ssby ssthe ssclient ssindicates ssa ssneed ssfor ssfurther ssinstruction?
ss1.
"I ssshould sstake sshot ssbaths ssbecause ssthey ssare ssrelaxing."
ss2.
"I ssshould sssit sswhenever sspossible ssto ssconserve ssmy ssenergy."
ss3.
"I ssshould ssavoid sslong ssperiods ssof ssrest ssbecause ssit sscauses ssjoint ssstiffness."
ss4.
"I ssshould ssdo sssome ssexercises, sssuch ssas sswalking, sswhen ssI ssam ssnot ssfatigued."
ss- ssAnswer ss1.
"I ssshould sstake sshot ssbaths ssbecause ssthey ssare ssrelaxing."
The ssnurse ssis ssconducting ssa ssteaching sssession sswith ssa ssclient sson sstheir
ssdiagnosis ssof sspemphigus. ssWhich ssstatement ssby ssthe ssclient ssindicates ssthat ssthe
ssclient ssunderstands ssthe ssdiagnosis?
ss1.
"My ssskin sswill sshave sstiny ssred ssvesicles."
ss2.
"The sspresence ssof ssthe ssskin ssvesicles ssis sscaused ssby ssa ssvirus."
ss3.
"I sshave ssan ssautoimmune ssdisease ssthat sscauses ssblistering ssin ssthe ssepidermis."
ss4.
"The sspresence ssof ssred, ssraised sspapules ssand sslarge ssplaques sscovered ssby
sssilvery ssscales sswill ssbe sspresent sson ssmy ssskin." ss- ssAnswer ss3.
,"I sshave ssan ssautoimmune ssdisease ssthat sscauses ssblistering ssin ssthe ssepidermis."
The ssnurse ssis ssassisting ssin ssplanning sscare ssfor ssa ssclient sswith ssa ssdiagnosis ssof
ssimmunodeficiency ssand ssshould ssincorporate sswhich ssaction ssas ssa sspriority ssin ssthe
ssplan?
ss1.
Protecting ssthe ssclient ssfrom ssinfection
ss2.
Providing ssemotional sssupport ssto ssdecrease ssfear
ss3.
Encouraging ssdiscussion ssabout sslifestyle sschanges
ss4.
Identifying ssfactors ssthat ssdecreased ssthe ssimmune ssfunction ss- ssAnswer ss1.
Protecting ssthe ssclient ssfrom ssinfection
A ssclient sscalls ssthe ssnurse ssin ssthe ssemergency ssdepartment ssand ssstates ssthat sshe
sswas ssjust ssstung ssby ssa ssbumblebee sswhile ssgardening. ssThe ssclient ssis ssafraid ssof
ssa sssevere ssreaction ssbecause ssthe ssclient's ssneighbor ssexperienced sssuch ssa
ssreaction ssjust ss1 ssweek ssago. ssWhich ssaction ssshould ssthe ssnurse sstake?
ss1.
Advise ssthe ssclient ssto sssoak ssthe sssite ssin sshydrogen ssperoxide.
ss2.
Ask ssthe ssclient ssif sshe ssever sssustained ssa ssbee sssting ssin ssthe sspast.
ss3.
Tell ssthe ssclient ssto sscall ssan ssambulance ssfor sstransport ssto ssthe ssemergency
ssdepartment.
ss4.
Tell ssthe ssclient ssnot ssto ssworry ssabout ssthe sssting ssunless ssdifficulty sswith ssbreathing
ssoccurs. ss- ssAnswer ss2.
Ask ssthe ssclient ssif sshe ssever sssustained ssa ssbee sssting ssin ssthe sspast.
The sscommunity sshealth ssnurse ssis ssconducting ssa ssresearch ssstudy ssand ssis
ssidentifying ssclients ssin ssthe sscommunity ssat ssrisk ssfor sslatex ssallergy. ssWhich ssclient
sspopulation ssis ssmost ssat ssrisk ssfor ssdeveloping ssthis sstype ssof ssallergy?
ss1.
Hairdressers
,ss2.
The sshomeless
ss3.
Children ssin ssday sscare sscenters
ss4.
Individuals ssliving ssin ssa ssgroup sshome ss- ssAnswer ss1.
Hairdressers
Which ssinterventions ssapply ssin ssthe sscare ssof ssa ssclient ssat sshigh ssrisk ssfor ssan
ssallergic ssresponse ssto ssa sslatex ssallergy? ssSelect ssall ssthat ssapply.
ss1.
Use ssnonlatex ssgloves.
ss2.
Use ssmedications ssfrom ssglass ssampules.
ss3.
Place ssthe ssclient ssin ssa ssprivate ssroom ssonly.
ss4.
Keep ssa sslatex-safe sssupply sscart ssavailable ssin ssthe ssclient's ssarea.
ss5.
Avoid ssthe ssuse ssof ssmedication ssvials ssthat sshave ssrubber ssstoppers.
ss6.
Use ssa ssblood sspressure sscuff ssfrom ssan sselectronic ssdevice ssonly ssto ssmeasure ssthe
ssblood sspressure. ss- ssAnswer ss1.
Use ssnonlatex ssgloves.
ss2.
Use ssmedications ssfrom ssglass ssampules.
ss4.
Keep ssa sslatex-safe sssupply sscart ssavailable ssin ssthe ssclient's ssarea.
ss5.
Avoid ssthe ssuse ssof ssmedication ssvials ssthat sshave ssrubber ssstoppers.
A ssclient sspresents ssat ssthe sshealth sscare ssprovider's ssoffice sswith sscomplaints ssof ssa
ssbulls-eye ssrash sson sshis ssupper ssleg. ssWhich ssquestion ssshould ssthe ssnurse ssask
ssfirst?
, ss1.
"Do ssyou sshave ssany sscats ssin ssyour sshome?"
ss2.
"Have ssyou ssbeen sscamping ssin ssthe sslast ssmonth?"
ss3.
"Have ssyou ssor ssclose sscontacts sshad ssany ssflu-like sssymptoms sswithin ssthe sslast
ssfew ssweeks?"
ss4.
"Have ssyou ssbeen ssin ssphysical sscontact sswith ssanyone sswho sshas ssthe sssame sstype
ssof ssrash?" ss- ssAnswer ss2.
"Have ssyou ssbeen sscamping ssin ssthe sslast ssmonth?"
A ssclient ssis ssdiagnosed sswith ssscleroderma. ssWhich ssintervention ssshould ssthe
ssnurse ssanticipate ssto ssbe ssprescribed?
ss1.
Maintain ssbed ssrest ssas ssmuch ssas sspossible.
ss2.
Administer sscorticosteroids ssas ssprescribed ssfor ssinflammation.
ss3.
Advise ssthe ssclient ssto ssremain sssupine ssfor ss1 ssto ss2 sshours ssafter ssmeals.
ss4.
Keep ssthe ssroom sstemperature sswarm ssduring ssthe ssday ssand sscool ssat ssnight. ss-
ssAnswer ss2.
Administer sscorticosteroids ssas ssprescribed ssfor ssinflammation.
A ssclient ssarrives ssat ssthe sshealth sscare ssclinic ssand sstells ssthe ssnurse ssthat ssshe
sswas ssjust ssbitten ssby ssa sstick ssand sswould sslike ssto ssbe sstested ssfor ssLyme
ssdisease. ssThe ssclient sstells ssthe ssnurse ssthat ssshe ssremoved ssthe sstick ssand
ssflushed ssit ssdown ssthe sstoilet. ssWhich ssactions ssare ssmost ssappropriate? ssSelect ssall
ssthat ssapply.
ss1.
Tell ssthe ssclient ssthat sstesting ssis ssnot ssnecessary ssunless ssarthralgia ssdevelops.
ss2.
Tell ssthe ssclient ssto ssavoid ssany sswoody, ssgrassy ssareas ssthat ssmay sscontain ssticks.
ss3.
DISORDERS QUESTIONS WITH
COMPLETE ANSWERS
The ssnurse ssprovides sshome sscare ssinstructions ssto ssa ssclient sswith sssystemic sslupus
sserythematosus ssand sstells ssthe ssclient ssabout ssmethods ssto ssmanage ssfatigue.
ssWhich ssstatement ssby ssthe ssclient ssindicates ssa ssneed ssfor ssfurther ssinstruction?
ss1.
"I ssshould sstake sshot ssbaths ssbecause ssthey ssare ssrelaxing."
ss2.
"I ssshould sssit sswhenever sspossible ssto ssconserve ssmy ssenergy."
ss3.
"I ssshould ssavoid sslong ssperiods ssof ssrest ssbecause ssit sscauses ssjoint ssstiffness."
ss4.
"I ssshould ssdo sssome ssexercises, sssuch ssas sswalking, sswhen ssI ssam ssnot ssfatigued."
ss- ssAnswer ss1.
"I ssshould sstake sshot ssbaths ssbecause ssthey ssare ssrelaxing."
The ssnurse ssis ssconducting ssa ssteaching sssession sswith ssa ssclient sson sstheir
ssdiagnosis ssof sspemphigus. ssWhich ssstatement ssby ssthe ssclient ssindicates ssthat ssthe
ssclient ssunderstands ssthe ssdiagnosis?
ss1.
"My ssskin sswill sshave sstiny ssred ssvesicles."
ss2.
"The sspresence ssof ssthe ssskin ssvesicles ssis sscaused ssby ssa ssvirus."
ss3.
"I sshave ssan ssautoimmune ssdisease ssthat sscauses ssblistering ssin ssthe ssepidermis."
ss4.
"The sspresence ssof ssred, ssraised sspapules ssand sslarge ssplaques sscovered ssby
sssilvery ssscales sswill ssbe sspresent sson ssmy ssskin." ss- ssAnswer ss3.
,"I sshave ssan ssautoimmune ssdisease ssthat sscauses ssblistering ssin ssthe ssepidermis."
The ssnurse ssis ssassisting ssin ssplanning sscare ssfor ssa ssclient sswith ssa ssdiagnosis ssof
ssimmunodeficiency ssand ssshould ssincorporate sswhich ssaction ssas ssa sspriority ssin ssthe
ssplan?
ss1.
Protecting ssthe ssclient ssfrom ssinfection
ss2.
Providing ssemotional sssupport ssto ssdecrease ssfear
ss3.
Encouraging ssdiscussion ssabout sslifestyle sschanges
ss4.
Identifying ssfactors ssthat ssdecreased ssthe ssimmune ssfunction ss- ssAnswer ss1.
Protecting ssthe ssclient ssfrom ssinfection
A ssclient sscalls ssthe ssnurse ssin ssthe ssemergency ssdepartment ssand ssstates ssthat sshe
sswas ssjust ssstung ssby ssa ssbumblebee sswhile ssgardening. ssThe ssclient ssis ssafraid ssof
ssa sssevere ssreaction ssbecause ssthe ssclient's ssneighbor ssexperienced sssuch ssa
ssreaction ssjust ss1 ssweek ssago. ssWhich ssaction ssshould ssthe ssnurse sstake?
ss1.
Advise ssthe ssclient ssto sssoak ssthe sssite ssin sshydrogen ssperoxide.
ss2.
Ask ssthe ssclient ssif sshe ssever sssustained ssa ssbee sssting ssin ssthe sspast.
ss3.
Tell ssthe ssclient ssto sscall ssan ssambulance ssfor sstransport ssto ssthe ssemergency
ssdepartment.
ss4.
Tell ssthe ssclient ssnot ssto ssworry ssabout ssthe sssting ssunless ssdifficulty sswith ssbreathing
ssoccurs. ss- ssAnswer ss2.
Ask ssthe ssclient ssif sshe ssever sssustained ssa ssbee sssting ssin ssthe sspast.
The sscommunity sshealth ssnurse ssis ssconducting ssa ssresearch ssstudy ssand ssis
ssidentifying ssclients ssin ssthe sscommunity ssat ssrisk ssfor sslatex ssallergy. ssWhich ssclient
sspopulation ssis ssmost ssat ssrisk ssfor ssdeveloping ssthis sstype ssof ssallergy?
ss1.
Hairdressers
,ss2.
The sshomeless
ss3.
Children ssin ssday sscare sscenters
ss4.
Individuals ssliving ssin ssa ssgroup sshome ss- ssAnswer ss1.
Hairdressers
Which ssinterventions ssapply ssin ssthe sscare ssof ssa ssclient ssat sshigh ssrisk ssfor ssan
ssallergic ssresponse ssto ssa sslatex ssallergy? ssSelect ssall ssthat ssapply.
ss1.
Use ssnonlatex ssgloves.
ss2.
Use ssmedications ssfrom ssglass ssampules.
ss3.
Place ssthe ssclient ssin ssa ssprivate ssroom ssonly.
ss4.
Keep ssa sslatex-safe sssupply sscart ssavailable ssin ssthe ssclient's ssarea.
ss5.
Avoid ssthe ssuse ssof ssmedication ssvials ssthat sshave ssrubber ssstoppers.
ss6.
Use ssa ssblood sspressure sscuff ssfrom ssan sselectronic ssdevice ssonly ssto ssmeasure ssthe
ssblood sspressure. ss- ssAnswer ss1.
Use ssnonlatex ssgloves.
ss2.
Use ssmedications ssfrom ssglass ssampules.
ss4.
Keep ssa sslatex-safe sssupply sscart ssavailable ssin ssthe ssclient's ssarea.
ss5.
Avoid ssthe ssuse ssof ssmedication ssvials ssthat sshave ssrubber ssstoppers.
A ssclient sspresents ssat ssthe sshealth sscare ssprovider's ssoffice sswith sscomplaints ssof ssa
ssbulls-eye ssrash sson sshis ssupper ssleg. ssWhich ssquestion ssshould ssthe ssnurse ssask
ssfirst?
, ss1.
"Do ssyou sshave ssany sscats ssin ssyour sshome?"
ss2.
"Have ssyou ssbeen sscamping ssin ssthe sslast ssmonth?"
ss3.
"Have ssyou ssor ssclose sscontacts sshad ssany ssflu-like sssymptoms sswithin ssthe sslast
ssfew ssweeks?"
ss4.
"Have ssyou ssbeen ssin ssphysical sscontact sswith ssanyone sswho sshas ssthe sssame sstype
ssof ssrash?" ss- ssAnswer ss2.
"Have ssyou ssbeen sscamping ssin ssthe sslast ssmonth?"
A ssclient ssis ssdiagnosed sswith ssscleroderma. ssWhich ssintervention ssshould ssthe
ssnurse ssanticipate ssto ssbe ssprescribed?
ss1.
Maintain ssbed ssrest ssas ssmuch ssas sspossible.
ss2.
Administer sscorticosteroids ssas ssprescribed ssfor ssinflammation.
ss3.
Advise ssthe ssclient ssto ssremain sssupine ssfor ss1 ssto ss2 sshours ssafter ssmeals.
ss4.
Keep ssthe ssroom sstemperature sswarm ssduring ssthe ssday ssand sscool ssat ssnight. ss-
ssAnswer ss2.
Administer sscorticosteroids ssas ssprescribed ssfor ssinflammation.
A ssclient ssarrives ssat ssthe sshealth sscare ssclinic ssand sstells ssthe ssnurse ssthat ssshe
sswas ssjust ssbitten ssby ssa sstick ssand sswould sslike ssto ssbe sstested ssfor ssLyme
ssdisease. ssThe ssclient sstells ssthe ssnurse ssthat ssshe ssremoved ssthe sstick ssand
ssflushed ssit ssdown ssthe sstoilet. ssWhich ssactions ssare ssmost ssappropriate? ssSelect ssall
ssthat ssapply.
ss1.
Tell ssthe ssclient ssthat sstesting ssis ssnot ssnecessary ssunless ssarthralgia ssdevelops.
ss2.
Tell ssthe ssclient ssto ssavoid ssany sswoody, ssgrassy ssareas ssthat ssmay sscontain ssticks.
ss3.
