Page 2201 - Saunders Comprehensive Review For NCLEX-RN

775. Answer: 3

Rationale: Kaposi’s sarcoma lesions begin as red, dark blue, or purple macules on
the lower legs that change into plaques. These large plaques ulcerate or open and
drain. The lesions spread by metastasis through the upper body and then to the face
and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal
tract. Late disease results in swelling and pain in the lower extremities, penis,
scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy
of pulmonary and gastrointestinal lesions.
Test-Taking Strategy: Focus on the subject, diagnosing Kaposi’s sarcoma.
Eliminate options 1 and 2 first, because these symptoms occur late in the
development of Kaposi’s sarcoma. Then, note the word confirmed in the question.
This word will assist in directing you to the option that will confirm the diagnosis,
the biopsy of the lesions.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Immunodeficiency Syndrome
Priority Concepts: Evidence; Immunity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 354-355.

776. Answer: 1, 2

Rationale: Skin testing involves administration of an allergen to the surface of the
skin or into the dermis. Site, date, and time of the test must be recorded, and the
client must return at a specific date and time for a follow-up site evaluation, even if
no reaction is suspected. A list of potential allergens is identified and reviewed and
given to the client. For the follow-up evaluation, the size of the site has to be
measured and not estimated. After injection, clients only need to be monitored for
about 30 minutes to assess for any adverse effects.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate option
3, because any results must be accurately measured and not estimated. Eliminate
option 4 because of the closed-ended word “only.” Eliminate option 5, because it is
unreasonable to have the client wait 1 to 2 hours.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Hypersensitivity Reactions and Allergies
Priority Concepts: Client Education; Immunity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 444-445.

777. Answer: 4

Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical
fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for

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