ATI LPN
Immune System Questions Questions
Question 1 of 5
Systemic lupus erythematosus is:
Correct Answer: D
Rationale: The correct answer is D: An autoimmune condition. Systemic lupus erythematosus is an autoimmune disease where the immune system mistakenly attacks healthy tissues in the body. This condition is not infectious (choice A), not harmless (choice B), and not always associated with HIV (choice C). Lupus is characterized by inflammation and damage to various organs, joints, and skin. It is important to differentiate autoimmune diseases like lupus from infectious diseases and understand their underlying mechanisms for proper diagnosis and treatment.
Question 2 of 5
When completing the child’s admission assessment, which of the following components of the abdominal assessment should the nurse avoid?
Correct Answer: B
Rationale: The correct answer is B: Palpation. During a child's admission assessment, the nurse should avoid palpation of the abdomen because it can potentially cause discomfort or pain to the child, especially if there is an underlying abdominal issue. Instead, the nurse should prioritize other components such as inspection, auscultation, and percussion. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation helps in listening for bowel sounds, which can provide valuable information about gastrointestinal function. Percussion can assist in identifying areas of tenderness or abnormal fluid accumulation. Palpation should be performed cautiously and only if necessary, after obtaining consent and ensuring the child is comfortable.
Question 3 of 5
The nurse is administering packed red blood cells to a child with sickle cell disease (SCD). The nurse is monitoring for a transfusion reaction and knows it is most likely to occur during which time frame?
Correct Answer: B
Rationale: The correct answer is B: Within the first 20 minutes of administration of the transfusion. During the initial stage of transfusion, reactions are most likely to occur due to rapid infusion of blood. This is when the nurse should closely monitor the child for signs of transfusion reactions such as fever, chills, rash, or shortness of breath. Reactions can be severe and life-threatening, so early detection is crucial. Choices A, C, and D are incorrect because reactions are most likely to occur at the beginning of the transfusion due to immediate immune responses, rather than hours later, at the end of the transfusion, or not at all.
Question 4 of 5
A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client?
Correct Answer: A
Rationale: The correct answer is A: Splints. Splints help immobilize joints, reducing pain and preventing further damage in clients with joint pain due to DIC. Cool compresses (B) may provide temporary relief but won't address the underlying issue. Heat (C) can worsen inflammation in joints. Ice (D) is contraindicated in DIC as it can exacerbate clotting issues.
Question 5 of 5
A child is diagnosed with thrombocytopenia secondary to chemotherapy treatments. Which action by the nurse is not appropriate?
Correct Answer: A
Rationale: The correct answer is A: Administer intramuscular injections (IM). In a child with thrombocytopenia, the platelet count is low, leading to an increased risk of bleeding. Administering IM injections can cause bleeding at the injection site due to the potential trauma to blood vessels. Performing oral hygiene (B), monitoring intake and output (C), and using palpation as a component of assessment (D) are appropriate actions that do not pose a significant risk of bleeding in a child with thrombocytopenia. It is crucial to prioritize interventions that minimize the risk of bleeding complications in this scenario.