Chapter 12: Care of Patients with Immune and Lymphatic Disorders My Nursing Test Banks

Chapter 12: Care of Patients with Immune and Lymphatic Disorders

MULTIPLE CHOICE

1. When the patient has an immediate allergic reaction to the injection of radiopaque dye, the nurse is aware that this immediate response is a type ___ response, which is _____ generated.

a.

1, antibody

b.

2, mast cell

c.

1, mast cell

d.

2, antibody

ANS: C

An immediate allergic reaction is a type 1 response, which is mast cell generated. Type 2 are delayed reactions.

DIF: Cognitive Level: Application REF: 236 OBJ: 4 (theory)

TOP: Allergies KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. After an influenza immunization, the patient complains of shortness of breath, breaks out in hives, and begins to twitch. What should the nurse initially give?

a.

Epinephrine by injection

b.

O2 by mask at 5 L/min

c.

Corticosteroid by injection

d.

Bronchodilators per nebulization

ANS: A

Epinephrine is the initial line of defense to reverse anaphylaxis, followed by high-flow oxygen, bronchodilators, and corticosteroid injection as necessary.

DIF: Cognitive Level: Application REF: 243 OBJ: 2 (clinical)

TOP: Anaphylaxis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. Education for the patient with systemic lupus erythematosus (SLE) should include what teaching point?

a.

Training with weights to increase strength

b.

Using alcohol-based skin products

c.

Managing pain with opioids

d.

Using potent sunscreen

ANS: D

Protection against UV rays with a potent sunscreen is advised. NSAIDs are used for pain relief. Alcohol-based skin application and joint strain should be avoided.

DIF: Cognitive Level: Application REF: 247-248 | Nursing Care Plan 12-1

OBJ: 8 (theory) TOP: SLE Teaching

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. The patient reports that he has been diagnosed with stage II Hodgkins disease. The nurse interprets this to mean that the infected lymph node involvement could be:

a.

spreading outside of the lymph system.

b.

in a single node.

c.

in both axillae.

d.

in two nodes in the left axilla area.

ANS: D

Stage II indicates that there are two or more involved lymph nodes on the same side of the diaphragm (or body). The lymph nodes affected could be in any part of the lymphatic system. The disease spreading outside of the lymph system indicates stage IV. Single node involvement is stage I, and lymph involvement on both sides of the diaphragm or body is considered stage III.

DIF: Cognitive Level: Application REF: 252 | Figure 12-6

OBJ: 9 (theory) TOP: Hodgkins Disease Node Staging

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. MOPP and ABVD therapy for the treatment of Hodgkins disease are treatment protocols using:

a.

multiple medications given concurrently.

b.

a combination of heat and exercise and chemotherapy.

c.

alternating radiation and chemotherapy every 4 weeks.

d.

chemotherapy and alternative herbal remedies.

ANS: A

MOPP and ABVD are chemotherapy treatment protocols using a combination of four drugs given concurrently. MOPP is the acronym for the drugs mechlorethamine, vincristine (Oncovin), procarbazine, and prednisone. ABVD is the acronym for the drugs doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine. This treatment protocol is usually used for stages III and IV of the disease.

DIF: Cognitive Level: Application REF: 250 OBJ: 1 (theory)

TOP: Treatment: Hodgkins Disease KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

6. The nurse caring for the patient with lymphedema of the left arm will implement what intervention?

a.

Encourage patient to keep the arms as inactive as possible to reduce further injury.

b.

Clean the arm with mild soap and massage gently.

c.

Take blood pressure and give injections in the right arm.

d.

Keep the arm below the level of the heart to minimize edema.

ANS: C

Taking blood pressure and giving injections in the right arm will reduce the probability of further injury to the left arm. The left arm should be placed above the level of the heart for fluid drainage. Muscle activity enhances the reabsorption of the fluid. Massaging the arm will increase circulation.

DIF: Cognitive Level: Application REF: 253 | Patient Teaching

OBJ: 1 (theory) TOP: Lymphedema

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

7. The patient with rheumatoid arthritis is prescribed an immunosuppressant drug. The patient asks the nurse what this drug is for. What is the nurses best response?

a.

The doctor prescribes these drugs to strengthen your immune system.

b.

The drug inhibits your immune systems normal response.

c.

These medications are used to prevent organ rejection.

d.

This medication will strengthen your joints and repair any joint damage.

ANS: B

Rheumatoid arthritis is an autoimmune disease in which the immune system becomes overactive and the body begins destroying its own tissues; in this case, the joints. The immunosuppressant medication helps inhibit this overreaction of the immune system.

DIF: Cognitive Level: Application REF: 234 | Box 12-1

OBJ: 1 (theory) TOP: Therapeutic Immunosuppressive Drugs

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

8. The patient scheduled for a CT scan with contrast medium questions the nurse why the technologist asked her if she had any food allergies. Which response by the nurse is correct?

a.

The dye used for a CT scan is egg based, so egg allergies would prevent you from having the test.

b.

People who are allergic to dairy products are likely to be allergic to CT scan dye.

c.

Allergies to shellfish can be a problem because shellfish and CT scan dye are iodine based.

d.

Wheat is the preservative used in CT scan dye, so allergies to wheat may cause allergies to the dye.

ANS: C

Allergies to seafood indicate intolerance to iodine. This means there is potential for an allergic reaction to iodine-based contrast agents used in radiologic imaging studies such as CT scans with contrast medium.

DIF: Cognitive Level: Application REF: 241 | Clinical Cues

OBJ: 8 (theory) TOP: Allergies KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

9. The nurse is performing an assessment on a patient admitted for diagnostic testing to rule out fibromyalgia. Which assessment finding would indicate that the patient actually may have the disorder?

a.

A decreased response to painful stimuli

b.

A pain response to nonpainful stimuli

c.

No response to painful stimuli

d.

Numbness and tingling in response to painful stimuli

ANS: B

Allodynia, pain response to nonpainful stimuli, is one of the signs typically seen in the patient with fibromyalgia. Patients with fibromyalgia often experience hyperalgesia, which is a heightened response to painful stimuli.

DIF: Cognitive Level: Comprehension REF: 253-254 OBJ: 15 (theory)

TOP: Fibromyalgia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

10. The patient with cancer has experienced sensitivity to past chemotherapy infusions. The best action to prevent a hypersensitivity reaction is the administration of _____ prior to the chemotherapy infusion.

a.

a corticosteroid

b.

daclizumab

c.

antithymocyte globulin

d.

epinephrine

ANS: A

Steroids or corticosteroids, such as dexamethasone, and antihistamines are given prior to administration of substances that are known to cause hypersensitivity reactions in order to prevent such reactions or anaphylaxis. Daclizumab and antithymocyte globulin are antirejection medications used with transplants, and epinephrine is given to treat an anaphylactic reaction.

DIF: Cognitive Level: Analysis REF: 242 OBJ: 8 (theory)

TOP: Hypersensitivity KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

11. The nurse has just administered a new antibiotic to a patient. What sign or symptom should the nurse be alert to that would be an early indication of an anaphylactic reaction?

a.

Wheezing

b.

Shortness of breath

c.

Difficulty swallowing

d.

Angioedema

ANS: D

The appearance of hives (urticaria) or swelling beneath the skin (angioedema) may signal the onset of an anaphylactic episode. Wheezing, shortness of breath, and difficulty swallowing are later signs of anaphylaxis.

DIF: Cognitive Level: Application REF: 241 OBJ: 8 (theory)

TOP: Anaphylaxis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

12. A patient with an immune deficiency disorder has been admitted to the medical unit due to a current infection and weight loss of 12% of his body weight. The most appropriate nutritional intervention for this patient would be to encourage foods high in:

a.

fat.

b.

vitamin C.

c.

vitamin B12.

d.

protein.

ANS: D

Foods high in protein will not only help with increasing weight but will aid in synthesizing needed antibodies for this condition. Fats, vitamin C, and B12 will not address either the need for weight gain or antibody synthesis.

DIF: Cognitive Level: Application REF: 235 OBJ: 4 (theory)

TOP: Immune Deficiency KEY: Nursing Process Step: Intervention

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

13. The patient voices feeling very stressed regarding her immune deficiency diagnosis and the care regimen. Which response by the nurse is most beneficial in addressing the patients stress?

a.

I cant imagine how it must feel to have this disorder and all of the treatment regimen that goes along with it.

b.

What worries you the most about your immune disorder?

c.

Light exercise and relaxation techniques may really help alleviate your stress.

d.

Maybe you should talk to your doctor about your stress so he can prescribe some antianxiety medication.

ANS: B

Although light exercise and relaxation techniques may be helpful in reducing stress, the nurse should first address concerns and provide information about the disorder. Providing necessary information is a major stress reducer. Stating only that the nurse cant imagine how you feel provides no therapeutic value, and medications are not a first-line treatment for stress.

DIF: Cognitive Level: Analysis REF: 235 OBJ: 8 (theory)

TOP: Immune Deficiency KEY: Nursing Process Step: Intervention

MSC: NCLEX: Psychosocial Integrity

14. The home care nurse is caring for a patient with a severe immune deficiency disorder. What patient teaching point should be stressed in regard to the prevention of infection?

a.

The patient should monitor his or her temperature daily.

b.

The patient should perform meticulous hand hygiene.

c.

The patient should monitor for signs of infection daily.

d.

The patient should seek medical advice at the first sign of infection.

ANS: B

In order to prevent infection, meticulous hand hygiene must be practiced. Monitoring the temperature, monitoring for signs of infection, and reporting signs of infection to the physician are not preventative measures but early intervention if infection occurs.

DIF: Cognitive Level: Analysis REF: 235 | Safety Alert

OBJ: 1 (clinical) TOP: Immune Deficiency

KEY: Nursing Process Step: Intervention

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

15. The primary care provider suspects the patient has lymphoma. The patient asks the nurse how the physician will know which type of lymphoma he has. Which response by the nurse is correct?

a.

We will be testing the lymphocytes in your blood for certain types of cells.

b.

We will be performing a bone marrow biopsy to look at your red blood cells.

c.

We will be looking at the number and configuration of the neutrophils in your blood.

d.

We will look closely at your hemoglobin and hematocrit levels for any significant variations in the levels.

ANS: A

Lymphomas are diagnosed by looking at the types of lymphocytes present. Red blood cells, neutrophils, and hemoglobin and hematocrit are not used in the diagnosis of lymphoma.

DIF: Cognitive Level: Application REF: 250 OBJ: 13 (theory)

TOP: Lymphoma: Diagnosis KEY: Nursing Process Step: Intervention

MSC: NCLEX: Physiological Integrity

16. The patient has been diagnosed with Hodgkins lymphoma. The nurse is aware that this patient has which type of cells present in the blood?

a.

Abnormal B cells

b.

Abnormal T cells

c.

Cytotoxic T cells

d.

Reed-Sternberg (R-S) cells

ANS: D

If Reed-Sternberg (R-S) cells are present, the patient has Hodgkins lymphoma. If the R-S cells are not present, the patient is diagnosed as having non-Hodgkins lymphoma. Non-Hodgkins lymphoma is then identified as either B-cell or T-cell lymphoma.

DIF: Cognitive Level: Comprehension REF: 250 OBJ: 13 (theory)

TOP: Lymphoma: Diagnosis KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The nurse is assessing a patients lymph nodes. Which finding would alert the nurse to the possibility of the patient having non-Hodgkins lymphoma (NHL)?

a.

Enlarged lymph nodes that form an adjacent line of enlargement

b.

Painful widespread enlarged lymph nodes

c.

Noncontiguous enlarged lymph nodes

d.

Enlarged lymph nodes primarily in the neck and axillary region

ANS: C

NHL typically manifests as enlargement in one node, then one or more nodes are skipped, and then another node is affected (noncontiguous). These enlarged nodes are usually painless with NHL.

DIF: Cognitive Level: Application REF: 251 OBJ: 13 (theory)

TOP: Lymphoma: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. The nurse is preparing to write a care plan for the patient with fibromyalgia. Which nursing diagnosis best addresses this disorder?

a.

Fatigue

b.

Pain, chronic

c.

Impaired physical mobility

d.

Activity intolerance

ANS: B

Pain is the predominant symptom with fibromyalgia. The pain can lead to other problems, such as fatigue, impaired mobility, and activity intolerance; however, if the pain can be controlled, other health problems may be reduced.

DIF: Cognitive Level: Application REF: 254 OBJ: 15 (theory)

TOP: SLE KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

19. The nurse is providing teaching to a patient who has undergone a liver transplant. Which statement by the patient demonstrates the need for further patient teaching?

a.

I will need to take medications to boost my immune system for the next year.

b.

I will need to be sure to avoid people that have infections.

c.

I will need to take immune suppression medications the rest of my life.

d.

I will need to be monitored to determine if my medications need adjusted.

ANS: A

Immune suppression medications will need to be taken for the rest of the patients life in order to increase the chances of avoiding organ rejection. Boosting the patients immune system would lead to organ rejection. Individuals with infections should be avoided since the immune system is depressed. Doses of medications must be evaluated for necessary adjustments throughout the patients lifetime.

DIF: Cognitive Level: Application REF: 233-234 OBJ: 10 (theory)

TOP: Preventing Transplant Rejection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

20. The nurse is assessing a 75-year-old patient who has presented to the ambulatory care clinic for an annual physical. The patient tells the nurse she seems to get sick more the older she gets. She questions the nurse about the reason. What response by the nurse is most appropriate?

a.

Your bone marrow does not function as precise as you age.

b.

You are likely coming into contact with more illness, so it isnt just age.

c.

Aging does impact the capabilities of the immune system.

d.

You need to take a flu vaccine to offer more protection against illness.

ANS: C

Aging does not affect the bone marrow to a significant degree. It does cause the thymus gland to become smaller, and T cells apparently diminish in the circulation; B-cell numbers usually remain the same. All the mechanisms involved in decreased immune function are not yet clear, but it is apparent that after age 70 there is a definite decline in the function of the immune system. The patient may indeed need a flu vaccine, but this does not answer the inquiry posed by the patient.

DIF: Cognitive Level: Analysis REF: 235 | Elder Care Points

OBJ: 3 (theory) TOP: Elder Care Points

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21. A patient has been exposed to an allergen resulting in a hypersensitivity reaction. The nurse correctly recognizes that which immunoglobulin has been triggered?

a.

IgA

b.

IgB

c.

IgD

d.

IgE

ANS: D

On first contact with the allergen, the bodys immune system is triggered to produce immunoglobulin E (IgE) antibody to recognize the specific antigen.

DIF: Cognitive Level: Comprehension REF: 236 OBJ: 7 (theory)

TOP: Allergy and Hypersensitivity KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

22. The nurse makes a list of conditions that can cause acquired immune deficiency, which includes: (Select all that apply.)

a.

chemotherapy.

b.

viral infections.

c.

smoking.

d.

malnutrition.

e.

bacterial infections.

ANS: A, B, C, D

Bacterial infections do not cause immune deficiency.

DIF: Cognitive Level: Comprehension REF: 233 OBJ: 7 (theory)

TOP: Conditions Causing Immune Deficiency

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

23. During assessment of the patient diagnosed with systemic lupus erythematosus (SLE), which signs and symptoms would the nurse expect to find? (Select all that apply.)

a.

Hair loss

b.

Enlarged cervical lymph nodes

c.

Mouth sores

d.

Fatigue

e.

Rashes

ANS: A, C, D, E

The patient with SLE does not typically have enlarged lymph nodes. Hair loss, mouth sores, fatigue, and rashes are just a few of the symptoms present in a patient with SLE.

DIF: Cognitive Level: Comprehension REF: 246-247 OBJ: 12 (theory)

TOP: SLE KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

24. The nurse is caring for a patient with systemic lupus erythematosus (SLE). The patient complains of severe fatigue, a butterfly rash, and joint pain. Which nursing interventions are most appropriate for this patient? (Select all that apply.)

a.

Encourage the use of a sun lamp to help with the rash.

b.

Assess pain control measures that have helped the patient in the past.

c.

Assist the patient with planning rest periods throughout the day.

d.

Remind the patient to avoid contact with people who have an infection.

e.

Ensure the patient understands the importance of her medication regimen.

ANS: B, C, D, E

Any type of sunlight tends to worsen the rash of patient with SLE and can cause a generalized flare-up of the disease. Pain control measures that have previously been effective should be continued; intense fatigue is a common problem with SLE, so planned rest periods are necessary; infections often exacerbate the disease, so it is important to decrease the chance of the patient with SLE from being exposed to others with infections; and the medication regimen for the SLE patient should be maintained in order to prevent flare-ups of the disease or other body systems from being affected by SLE.

DIF: Cognitive Level: Application REF: 247 | 248-249 | Nursing Care Plan 12-1

OBJ: 3 (clinical) TOP: SLE KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

25. The patient diagnosed with non-Hodgkins lymphoma (NHL) asks the nurse about treatment options. The nurse is aware that various treatment options exist, including: (Select all that apply.)

a.

bone marrow transplantation.

b.

peripheral stem cell transplantation.

c.

injection of monoclonal antibodies.

d.

radiation therapy.

e.

high-dose continuous antibiotic therapy.

ANS: A, B, C, D

High-dose continuous antibiotic therapy is not currently a treatment option for NHL. All other options listed are possible treatment options, as well as chemotherapy and surgery.

DIF: Cognitive Level: Comprehension REF: 252-253 OBJ: 10 (theory)

TOP: Preventing Transplant Rejection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

26. When collecting data from a patient suspected of having an immune deficiency, which factor(s) should be included? (Select all that apply.)

a.

Family history of immune disorders

b.

Age

c.

Weight gain

d.

Alcohol use

e.

Exposure to HIV

ANS: A, B, D, E

When an immune deficiency is suspected, information is gathered about the current physical status of the patient, such as her general state of health, infections she may have had recently, how the infections affected her, and how frequently they occur. It is also important to assess for risk behaviors such as intravenous drug use, multiple sexual partners, exposure to HIV, immunosuppressive drug therapy, alcohol consumption, and family history of genetic immune disorders.

DIF: Cognitive Level: Comprehension REF: 253 OBJ: 4 (theory)

TOP: Nursing Management Immune Deficiency

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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