When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?

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Question 1 of 5

When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?

Correct Answer: B

Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.

Question 2 of 5

24 hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:

Correct Answer: A

Rationale: Hyperacute rejection occurs immediately after transplantation, within minutes to up to 24 hours. It is a rapid and severe rejection reaction that is usually irreversible. It occurs due to pre-existing antibodies against the donor organ. In hyperacute rejection, the transplanted kidney must be removed to prevent further complications and ensure the safety of the patient. Treatment with immunosuppressive medications like cyclosporine or corticosteroids is not effective in this situation. Bone marrow transplant is not indicated in the treatment of hyperacute rejection.

Question 3 of 5

A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [retrovir]), 200mg PO every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?

Correct Answer: C

Rationale: Zidovudine (AZT) is an antiretroviral drug used to treat HIV infection, including in AIDS patients. It is important to follow the prescribed dosing schedule to maintain consistent drug levels in the body and effectively control the HIV virus. Taking zidovudine every 4 hours around the clock helps ensure the medication's therapeutic effects are maintained throughout the day. It is crucial for the client to adhere to the prescribed dosing regimen to prevent the development of drug resistance and to achieve the best treatment outcomes. Taking zidovudine with meals, on an empty stomach, or taking over-the-counter drugs for minor adverse reactions are not the correct instructions related to the dosing schedule of zidovudine.

Question 4 of 5

Blood cells are formed in the:

Correct Answer: C

Rationale: Blood cells are formed in the bone marrow, which is a soft tissue found in the center of most bones in the body. The process of blood cell formation is known as hematopoiesis. Bone marrow contains stem cells that can develop into different types of blood cells, including red blood cells, white blood cells, and platelets. These blood cells play essential roles in carrying oxygen, fighting infections, and assisting in blood clotting. While the other choices listed (arterioles, lymphoid tissue, and muscle tissue) have important functions in the body, blood cell formation specifically occurs primarily in the bone marrow.

Question 5 of 5

Which of the following elements shows that the client does not understand the cause of exacerbation of system lupus erythematosus (SLE)?

Correct Answer: B

Rationale: Option B, "I don't have to worry if I get a strep throat," shows that the client does not understand the cause of exacerbation of systemic lupus erythematosus (SLE). Strep throat can trigger SLE exacerbations as infections are known to worsen autoimmune diseases like lupus. This statement indicates a lack of awareness regarding the potential impact of infections on SLE symptoms. Option A and C show a better understanding as they address the importance of diet and stress management, which are significant factors that can influence the course of SLE.

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