ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 34 : Caring for Clients With Immune-Mediated Disorders Questions
Question 1 of 5
A client has an allergic reaction to seafood with generalized edema and reports being unable to get a wedding ring off as it is too tight. The client was unable to remove it with soap and water. What action by the nurse can facilitate removal of the ring without damaging it?
Correct Answer: C
Rationale: If applying soap or oil to the finger proves unsuccessful, the nurse may wrap the finger with twine. Once the tissue is compressed, the ring can be removed by pulling on the free end of the twine. This technique is preferable to damaging the ring with a metal cutter. If nothing else facilitates ring removal, however, cutting the ring is a better option than allowing damage from ischemia to develop. The nurse cannot administer a diuretic without a physician's prescription, and allowing the swelling to go down may cause tissue ischemia from the constricted ring. There are options other than cutting the ring, but if they fail, there is no other choice. A tongue blade will not remove a ring that is too tight.
Question 2 of 5
A client is scheduled for diagnostic skin testing in 1 week. What should the nurse be sure to instruct the client prior to the scheduled appointment?
Correct Answer: A
Rationale: The nurse instructs clients who are scheduled for diagnostic skin testing to avoid taking prescribed or over-the-counter antihistamines or cold preparations for at least 48 to 72 hours before testing. Doing so reduces the potential for false-negative results. Clients must temporarily discontinue some medications for even longer. Antihypertensive medication should not be omitted the day of the procedure. It is not necessary to omit the use of NSAIDs.
Question 3 of 5
A client has been having joint pain and swelling in the left foot and is diagnosed with rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and the client has significant joint destruction. What type of disease is this considered?
Correct Answer: B
Rationale: Diseases are considered autoimmune disorders when they are characterized by unrelenting, progressive tissue damage without any verifiable etiology. The client did not have a previous disorder that has caused an exacerbation. An alloimmunity describes an immune response that is waged against transplanted organs and tissues that carry non self antigens. Because there is no identifiable cause, there can be no effect.
Question 4 of 5
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?
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.
Question 5 of 5
A client with Crohn's disease, an autoimmune disorder, reports not having had any symptoms of the disease in 8 months. What does the nurse understand this asymptomatic period is referred to?
Correct Answer: B
Rationale: Periods of remission refer to times when the client has no symptoms. The duration of these periods is completely unpredictable. An exacerbation is periods of acute flare-ups when the client often experiences a low-grade fever, malaise, or fatigue. The client may also lose weight. Other symptoms such as pain and diarrhea can be associated with a flare-up of Crohn's disease. The client is not having an acute inflammatory response that would be considered an exacerbation.