Chapter 10 IMMUNE
SYSTEM
A Client with Autoimmune Disease
1.The nurse is administering medications to the clients on a medical unit. Which medication should the
nurse question be administering?
1.Atropine, an anti-muscarinic, to a client with myasthenia gravis.
2.Chloroquine, an antimalarial, to a client with a butterfly rash.
3.Prednisone, a corticosteroid, to a client with polymyalgia rheumatica.
4.Mestinon, a cholinesterase inhibitor, to a client in a cholinergic crisis.
Answer: 4
Rationale
:
1. Atropine works in an opposite manner from the cholinesterase inhibitors administered to treat
myasthenia gravis, but atropine in small doses is prescribed to reduce the gastrointestinal side effects of
the cholinesterase inhibitor. The nurse would not question this medication.
2. The antimalarial medications are prescribed to treat cutaneous lupus erythematosus. The nurse would
not question this medication.
3. The client diagnosed with polymyalgia rheumatica must take the prescribed steroid medication or he or
she can become blind. The nurse would not question this medication.
4. Mestinon is prescribed to increase the available amount of acetylcholine for muscle movement.
Aclient in a cholinergic crisis has too much medication on board. The nurse would question
administering this medication until the crisis is resolved.
2.The client diagnosed with systemic lupus erythematosus (SLE) is experiencing an acute exacerbation
and the HCP has ordered high doses of glucocorticoid medications. Which statement supports the goal of
this therapy?
1.To provide a permanent cure for lupus.
2.To allow a peaceful, dignified death.
3.To help enable the client to maintain weight.
4.To prevent permanent damage to the organs.
Answer: 4
Rationale
:
1. There is no cure for SLE. The goal of treatment is to prevent or minimize damage to the internal organs.
2. The goal is not death, but to assist the client to live as full a life as possible.
3. The medication may have a side effect of weight gain, but this is not the desired result.
4. The goal of high-dose steroids during an exacerbation is to decrease the inflammatory response
in the internal organs and prevent permanent damage.
,3.The female client diagnosed with systemic lupus erythematosus (SLE) complains to the nurse that she
has pain; she is stiff when she gets up in the morning; and she takes ibuprofen, an NSAID, to help ease
the pain and stiffness. Which question is most important for the nurse to ask the client?
1.―How often do you have to take the ibuprofen?‖
2.―Do you take the medication on an empty stomach?‖
3.―Does the medication help with menstrual cramping too?‖
4.―Have you noticed an improvement in the pain and stiffness?‖
Answer: 2
Rationale
:
1. This may be asked, but it is not the most important question.
2. This is the most important question. The client reports the pain and stiffness on awakening in
the morning. Taking NSAIDs then places the client at risk for developing peptic ulcer disease.
The client should be taught to take these medications with food.
3. NSAID medications are frequently taken by female clients to relieve menstrual cramps. This is not the
most important question.
4. This is the reason the client is taking the medication. NSAIDs are used to treat the pain and stiffness,
but they are also helpful in decreasing the inflammation associated with SLE and in allowing a reduction
in the dosage of steroids.
4.The client diagnosed with multiple sclerosis (MS) is prescribed the intravenous glucocorticoid
hydrocortisone (Solu- Cortef). The client has a saline lock. Which procedures should the nurse follow
when administering the medication? Rank in order of performance.
1.Administer the diluted medication intravenously over 1–2 minutes.
2.Aspirate the syringe to obtain a blood return.
3.Flush the saline lock with 2 mL of sterile normal saline.
4.Flush the saline lock again with 2 mL of normal saline.
5.Check the client’s identification bands against the
MAR.
Answer: 5, 2, 3, 1, 4
Rationale:
5. The nurse must determine that the ―right‖ medication is being administered to the ―right‖ client. This is
the first step.
2. The nurse should assess the intravenous catheter placement prior to administering the medication. If
there is a blood return, the catheter is in the vein.
3. The nurse should flush the saline lock with 2 mL of sterile saline before ad-ministering the medication
to make sure that any previously administered medication is flushed from the line to avoid inadvertent
mixing of medications.
1.Solu-Cortef can be administered safely over 1–2 minutes.
4. The final step is to flush the saline lock to make sure the client receives all the prescribed medication.
Answer: 5, 2, 3, 1, 4
5.The client diagnosed with multiple sclerosis is prescribed baclofen (Lioresal), an antispasmodic. Which
data should the nurse assess?
Select all that apply.
1. The client’s serum baclofen levels.
, 2. The client’s complaint of urinary urgency.
3. The client’s muscle rigidity and range of
motion. 4.The client’s BUN and creatinine levels.
5.The client’s muscle spasticity and pain.
Answer: 2, 3, 5
Rationale:
1. There is no serum baclofen level.
2. Baclofen can cause urinary urgency so this should be assessed.
3. Baclofen is administered to treat the spasticity associated with MS. The nurse should assess
for muscle spasticity, rigidity, movement, and pain to determine the effectiveness of the
medication.
4. The medication can affect the liver, but it does not damage the kidneys.
5. Baclofen is administered to treat the spasticity associated with MS. The nurse should assess
for muscle spasticity, rigidity, movement, and pain to determine the effectiveness of the
medication.
6. The nurse is administering 0800 medications on a medical floor. Which medication should the nurse
administer first?
1.Prostigmin, a cholinesterase inhibitor, to a client diagnosed with myasthenia gravis.
2.Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus. 3.Morphine,
a narcotic analgesic, to a client diagnosed with Guillain-Barré syndrome.
4.Etanercept, a biologic response modifier, to a client with rheumatoid arthritis.
Answer: 1
Rationale:
1. This medication must be administered exactly on time to maintain muscle movement and ability
to swallow in clients diagnosed with MG. This is the priority medication.
2. This medication can be administered within the 30-minute acceptable time frame.
3.A pain medication is a priority but not over prevention of aspiration and maintaining the client’s ability
to use the muscles of respiration.
4.Etanercept (Enbrel) can be administered within the 30-minute acceptable time frame.
7.The nurse administered edrophonium (Tensilon), a cholinesterase inhibitor, to a client diagnosed with
rule-out myasthenia gravis (MG). Which response by the client indicates the client has myasthenia
gravis?
1.The client loses the ability to breathe without mechanical support. 2.The
client’s strength improves briefly without signs of fasciculation. 3.The
client cannot gaze at the ceiling for 2 minutes without fatigue.
4.The client’s paroxysmal atrial tachycardia converts to normal sinus rhythm.
Answer: 2
Rationale
:
1. Tensilon is used to help diagnose MG and to determine if a client diagnosed with MG is in a cholinergic
versus a myasthenic crisis. A client losing the ability to breathe without mechanical support when given
Tensilon is in a cholinergic crisis in which too much medication is in the body.
2. This response is the response that is diagnostic of myasthenia gravis.
3. This is a nonpharmacologic test that can be performed to assess for MG. This is a positive finding, but
it does not apply to edrophonium.
SYSTEM
A Client with Autoimmune Disease
1.The nurse is administering medications to the clients on a medical unit. Which medication should the
nurse question be administering?
1.Atropine, an anti-muscarinic, to a client with myasthenia gravis.
2.Chloroquine, an antimalarial, to a client with a butterfly rash.
3.Prednisone, a corticosteroid, to a client with polymyalgia rheumatica.
4.Mestinon, a cholinesterase inhibitor, to a client in a cholinergic crisis.
Answer: 4
Rationale
:
1. Atropine works in an opposite manner from the cholinesterase inhibitors administered to treat
myasthenia gravis, but atropine in small doses is prescribed to reduce the gastrointestinal side effects of
the cholinesterase inhibitor. The nurse would not question this medication.
2. The antimalarial medications are prescribed to treat cutaneous lupus erythematosus. The nurse would
not question this medication.
3. The client diagnosed with polymyalgia rheumatica must take the prescribed steroid medication or he or
she can become blind. The nurse would not question this medication.
4. Mestinon is prescribed to increase the available amount of acetylcholine for muscle movement.
Aclient in a cholinergic crisis has too much medication on board. The nurse would question
administering this medication until the crisis is resolved.
2.The client diagnosed with systemic lupus erythematosus (SLE) is experiencing an acute exacerbation
and the HCP has ordered high doses of glucocorticoid medications. Which statement supports the goal of
this therapy?
1.To provide a permanent cure for lupus.
2.To allow a peaceful, dignified death.
3.To help enable the client to maintain weight.
4.To prevent permanent damage to the organs.
Answer: 4
Rationale
:
1. There is no cure for SLE. The goal of treatment is to prevent or minimize damage to the internal organs.
2. The goal is not death, but to assist the client to live as full a life as possible.
3. The medication may have a side effect of weight gain, but this is not the desired result.
4. The goal of high-dose steroids during an exacerbation is to decrease the inflammatory response
in the internal organs and prevent permanent damage.
,3.The female client diagnosed with systemic lupus erythematosus (SLE) complains to the nurse that she
has pain; she is stiff when she gets up in the morning; and she takes ibuprofen, an NSAID, to help ease
the pain and stiffness. Which question is most important for the nurse to ask the client?
1.―How often do you have to take the ibuprofen?‖
2.―Do you take the medication on an empty stomach?‖
3.―Does the medication help with menstrual cramping too?‖
4.―Have you noticed an improvement in the pain and stiffness?‖
Answer: 2
Rationale
:
1. This may be asked, but it is not the most important question.
2. This is the most important question. The client reports the pain and stiffness on awakening in
the morning. Taking NSAIDs then places the client at risk for developing peptic ulcer disease.
The client should be taught to take these medications with food.
3. NSAID medications are frequently taken by female clients to relieve menstrual cramps. This is not the
most important question.
4. This is the reason the client is taking the medication. NSAIDs are used to treat the pain and stiffness,
but they are also helpful in decreasing the inflammation associated with SLE and in allowing a reduction
in the dosage of steroids.
4.The client diagnosed with multiple sclerosis (MS) is prescribed the intravenous glucocorticoid
hydrocortisone (Solu- Cortef). The client has a saline lock. Which procedures should the nurse follow
when administering the medication? Rank in order of performance.
1.Administer the diluted medication intravenously over 1–2 minutes.
2.Aspirate the syringe to obtain a blood return.
3.Flush the saline lock with 2 mL of sterile normal saline.
4.Flush the saline lock again with 2 mL of normal saline.
5.Check the client’s identification bands against the
MAR.
Answer: 5, 2, 3, 1, 4
Rationale:
5. The nurse must determine that the ―right‖ medication is being administered to the ―right‖ client. This is
the first step.
2. The nurse should assess the intravenous catheter placement prior to administering the medication. If
there is a blood return, the catheter is in the vein.
3. The nurse should flush the saline lock with 2 mL of sterile saline before ad-ministering the medication
to make sure that any previously administered medication is flushed from the line to avoid inadvertent
mixing of medications.
1.Solu-Cortef can be administered safely over 1–2 minutes.
4. The final step is to flush the saline lock to make sure the client receives all the prescribed medication.
Answer: 5, 2, 3, 1, 4
5.The client diagnosed with multiple sclerosis is prescribed baclofen (Lioresal), an antispasmodic. Which
data should the nurse assess?
Select all that apply.
1. The client’s serum baclofen levels.
, 2. The client’s complaint of urinary urgency.
3. The client’s muscle rigidity and range of
motion. 4.The client’s BUN and creatinine levels.
5.The client’s muscle spasticity and pain.
Answer: 2, 3, 5
Rationale:
1. There is no serum baclofen level.
2. Baclofen can cause urinary urgency so this should be assessed.
3. Baclofen is administered to treat the spasticity associated with MS. The nurse should assess
for muscle spasticity, rigidity, movement, and pain to determine the effectiveness of the
medication.
4. The medication can affect the liver, but it does not damage the kidneys.
5. Baclofen is administered to treat the spasticity associated with MS. The nurse should assess
for muscle spasticity, rigidity, movement, and pain to determine the effectiveness of the
medication.
6. The nurse is administering 0800 medications on a medical floor. Which medication should the nurse
administer first?
1.Prostigmin, a cholinesterase inhibitor, to a client diagnosed with myasthenia gravis.
2.Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus. 3.Morphine,
a narcotic analgesic, to a client diagnosed with Guillain-Barré syndrome.
4.Etanercept, a biologic response modifier, to a client with rheumatoid arthritis.
Answer: 1
Rationale:
1. This medication must be administered exactly on time to maintain muscle movement and ability
to swallow in clients diagnosed with MG. This is the priority medication.
2. This medication can be administered within the 30-minute acceptable time frame.
3.A pain medication is a priority but not over prevention of aspiration and maintaining the client’s ability
to use the muscles of respiration.
4.Etanercept (Enbrel) can be administered within the 30-minute acceptable time frame.
7.The nurse administered edrophonium (Tensilon), a cholinesterase inhibitor, to a client diagnosed with
rule-out myasthenia gravis (MG). Which response by the client indicates the client has myasthenia
gravis?
1.The client loses the ability to breathe without mechanical support. 2.The
client’s strength improves briefly without signs of fasciculation. 3.The
client cannot gaze at the ceiling for 2 minutes without fatigue.
4.The client’s paroxysmal atrial tachycardia converts to normal sinus rhythm.
Answer: 2
Rationale
:
1. Tensilon is used to help diagnose MG and to determine if a client diagnosed with MG is in a cholinergic
versus a myasthenic crisis. A client losing the ability to breathe without mechanical support when given
Tensilon is in a cholinergic crisis in which too much medication is in the body.
2. This response is the response that is diagnostic of myasthenia gravis.
3. This is a nonpharmacologic test that can be performed to assess for MG. This is a positive finding, but
it does not apply to edrophonium.
