ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 34 Questions
Question 1 of 5
The clinic nurse is caring for a client with an allergic disorder who has received the first sensitizing dose of a new drug. What nursing action is most important at this point?
Correct Answer: B
Rationale: Monitoring the client for 30 minutes after desensitization injection is necessary to assess for allergic symptoms. Although it is important to ensure the client's comfort, it is not essential to assess the client for changes in urine output, appetite, or heart rate.
Question 2 of 5
The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?
Correct Answer: A
Rationale: Diseases are considered autoimmune disorders and are characterized by unrelenting, progressive tissue damage without any verifiable etiology. In many autoimmune disorders, there tends to be a triggering event, such as an infection, trauma, or introduction of a drug that integrates itself into the membranes of the host's cells. Although older adults face a greater risk of developing autoimmune disorders, persons belonging to any age-group can be affected. Chronic fatigue syndrome is primarily characterized by profound fatigue with no identifiable cause, and this is not a characteristic of autoimmune disorders.
Question 3 of 5
The nurse is caring for a client with chronic fatigue syndrome. What is a realistic nursing intervention when taking care of a client with this diagnosis?
Correct Answer: A
Rationale: The nurse should educate the client about the disease process and the limitations that it requires because nothing, as yet, holds promise for a complete cure. The client need not be advised to avoid moderate exertion because the physician may prescribe a modest exercise program to treat chronic fatigue syndrome. A client who experiences hypotension may be advised to increase salt and water intake but need not reduce the intake of potassium-rich foods or avoid being in crowds.
Question 4 of 5
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?
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.
Question 5 of 5
A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?
Correct Answer: D
Rationale: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not prescribed just so the client has strong drug therapy.