8.B Hypersensitivity
Which nursing interventions address the immediate priority of care for a client experiencing a severe hypersensitivity reaction? (Select all that apply.) A. Assess respiratory status continuously. B. Administer subcutaneous epinephrine as prescribed. C. Administer oxygen via nasal cannula at the prescribed rate. D. Teach the client when and how to use an anaphylactic kit. E. Monitor urine output.
A, B, C Rationale: Administering epinephrine is a component of emergency management and will interrupt the anaphylactic response. Assessing respiratory status and administering oxygen to preserve ventilation and perfusion are acute priorities. Monitoring urine output in the setting of hypotension is important, as is client teaching, but these are not priorities over emergency management, ventilation, and perfusion.
Which nonpharmacologic treatments should the nurse suggest for the client who is experiencing seasonal allergic rhinitis due to the pollen in the air? (Select all that apply.) A. Keep doors and windows closed. B. Use special filters on the air conditioners. C. Maintain a clean, dust-free environment. D. Remain indoors during the day. E. Shower before exiting the house.
A, B, C, D Rationale: The most effective treatment is reducing exposure to the allergen by remaining indoors, showering upon entering the house to remove pollen, keeping doors and windows closed, using special filters on air conditioners, and maintaining a clean, dust-free environment. Showering after being outdoors for extended periods, especially before bed, would help remove pollen from hair.
When planning care for a client admitted with a hypersensitivity reaction, the nurse addresses the potential problem of airway clearance. Which intervention will assist in addressing this potential problem? (Select all that apply.) A. Administering epinephrine B. Assessing level of consciousness C. Administering oxygen D. Auscultating lung sounds E. Placing the client in a supine position
A, B, C, D Rationale: Auscultating lung sounds, administering oxygen, administering subcutaneous epinephrine, and assessing level of consciousness will assist in addressing the potential problem of airway clearance. Placing the client in a supine position will not assist in addressing the potential problem of airway clearance. The nurse needs to place the head of the bed in a Fowler to high Fowler position to assist in addressing this problem.
A client presents to the clinic with erythema and vesicles on the trunk and bilateral upper and lower extremities. Which type of skin testing should the nurse anticipate being prescribed for the client to determine the cause of hypersensitivity reaction? A. Epicutaneous test B. Intradermal test C. Patch test D. Food allergy test
A. Epicutaneous test Rationale: An epicutaneous test will be prescribed. Epicutaneous testing (prick testing) generally is done first to avoid a systemic reaction; it is followed by intradermal testing of allergens with a negative response to prick testing. Performing the large-dose intradermal test first would place individuals who are highly allergic to a substance at increased risk for an anaphylactic reaction. A patch test is used to determine an allergen such as perfume, cosmetics, detergents, or clothing fibers on the skin. A food allergy test is performed when a food allergy is suspected but the source or implicated food item has not been clearly identified.
The nurse is caring for a client with a history of anaphylaxis related to a known latex allergy. Which is a priority goal when planning a nursing intervention for the client? A. The client will avoid the known allergen. B. The client will avoid the foods linked to a latex allergy. C. The client will teach family members about the life-threatening condition. D. The client will verbalize an understanding of the goal.
A. The client will avoid the known allergen. Rationale: A priority goal is for the client with a history of anaphylaxis related to a known latex allergy is to avoid the known allergen. Exposure to the allergen can cause a life-threatening condition. If the client is not allergic to the foods linked to a latex allergy, it is not necessary to avoid them. Verbalizing understanding of the goal is important, but observation of achievement of the goals is a more effective way to ensure the client has met the goals. The nurse can partner with the client in educating family members about the anaphylaxis related to a latex allergy.
A client is noted to have a type I (IgE-mediated) hypersensitivity reaction with a systemic response. Which clinical manifestation should the nurse anticipate? (Select all that apply.) A. Allergic rhinitis B. Urticaria C. Hypotension D. Wheezing E. Stridor
B, C, D, E Rationale: Anaphylaxis is a systemic, type I response. Some signs of anaphylaxis are wheezing, stridor, urticaria, and hypotension. Allergic rhinitis is a sign of a less serious, local type I response.
In performing a physical assessment on a client who is experiencing a hypersensitivity reaction, which findings should the nurse anticipate? (Select all that apply.) A. Cold, moist skin B. Skin lesions or rashes C. Eyes with tearing and redness D. Adventitious breath sounds E. Altered respiratory rate
B, C, D, E Rationale: Increased respiratory rate, wheezing, skin lesions, and red, tearing eyes are expected findings in an allergic reaction. Cold, moist skin is not an expected finding.
How are the systemic type I IgE-mediated responses initiated? A. The allergen makes contact with the IgE in the circulatory system. B. Allergens are absorbed in the GI mucosa. C. With contact of the allergen and IgE in the conjunctival tissues. D. By contact of the allergen with IgE in the bronchial tree.
B. Allergens are absorbed in the GI mucosa. Rationale: Systemic IgE responses can occur when the GI mucosa is altered by a local allergic response, then the allergen may be absorbed, and the resulting reaction may be systemic. IgE is produced by plasma cells located in lymph nodes. IgE attach to mast cells in body tissues. Contact of allergens with IgE in the bronchial and conjunctival tissues results in a localized response.
When planning care for a client admitted with a hypersensitivity reaction, the nurse addresses the potential problem of impaired tissue perfusion. Which intervention will assist in addressing this potential problem? A. Providing calm reassurance B. Monitoring urine output C. Elevating the head of the bed D. Assessing for pain
B. Monitoring urine output Rationale: Monitoring urine output is the intervention that addresses the potential problem of impaired tissue perfusion. Assessing for pain, providing calm reassurance, and elevating the head of the bed are not interventions that address the potential problem of impaired tissue perfusion.
A nurse is reviewing the chart of a newborn treated for hemolytic disease. Which statement shows the nurse's understanding of the cause of the disease? A. "Neutrophils attempt to phagocytize the RBCs." B. "Antibodies bound with an antigen activate a cascade destroying the RBCs." C. "Endogenous antigens stimulate a type II reaction resulting in lysis of the RBC." D. "Complement activation causes the release of inflammatory chemical mediators resulting in RBC destruction."
B. "Antibodies bound with an antigen activate a cascade destroying the RBCs." Rationale: Hemolytic disease occurs due to a maternal fetal Rh incompatibility. Hemolytic anemia occurs when antibodies are bound with an antigen and activate a cascade destroying the RBCs. Neutrophils do not phagocytize the RBCs in hemolytic anemia. Endogenous antigens (which are produced by the body) can stimulate a type II reaction, resulting in an autoimmune disorder. Complement activation that causes the release of inflammatory chemical mediators does not result in RBC destruction. It is part of a type III (immune complexmediated) hypersensitivity response.
To determine the causes of a hypersensitivity reaction, a prick test may be used. Which statement is the most accurate to describe this procedure and results? (Select all that apply.) A. The diluted allergen extract is intradermally injected in the forearm area. B. The client must avoid contact with the allergen for 48 hours after the skin test. C. A positive response may include pruritus, erythema, and development of a wheal. D. The allergen is diluted only if a severe systemic reaction is anticipated. E. A positive response can be determined within 15 to 20 minutes.
C, E Rationale: In the prick test, potential allergens are applied to the skin's surface and it is then pricked. Redness, induration, and itching are among the positive responses. A positive response will be evident in 15 to 20 minutes; avoiding the allergen after the test is unnecessary. Compounds are diluted when used in the intradermal test.
The nurse is providing teaching for a client on dietary intake and anaphylaxis. Which food should the nurse identify that trigger anaphylaxis in a sensitized individual? (Select all that apply.) A. Fish B. Milk C. Chocolate D. Coconut oil E. Grains
C, E Rationale: The foods that are associated with anaphylaxis in a sensitized individual include grains and chocolate. Milk, fish, and coconut oil are not associated with anaphylaxis in a sensitized individual; however, eggs, seafood, and cottonseed oil are.
The nurse is caring for a client newly diagnosed with seasonal allergic rhinitis. The client is experiencing rhinorrhea, watery eyes, and an itchy throat. Which prescribed initial treatment does the nurse anticipate? A. Oral steroids B. Inhaled corticosteroids C. Antihistamine D. Antibiotic
C. Antihistamine Rationale: Initially, the client newly diagnosed with seasonal allergic rhinitis may be prescribed an antihistamine. Antihistamines block H1-histamine receptors, acting as a competitive antagonist to histamine, but they do not affect the production or release of histamine. They are useful in treating some clients with allergic rhinitis. An antibiotic is not necessary unless there is a diagnosed bacterial infection present. Oral steroids may be necessary to resolve an acute exacerbation, but are not the first line of treatment. Inhaled corticosteroids are used for allergic asthma.
A client is starting treatment for a hypersensitivity reaction. Which pharmacologic therapy should the nurse anticipate will be initiated to develop IgG antibodies to the allergen? A. Corticosteroids B. Nonsteroidal anti-inflammatory medications C. Immunotherapy D. Antihistamines
C. Immunotherapy Rationale: The nurse needs to provide teaching on immunotherapy because this medication causes the development of IgG antibodies to the allergen. The nurse should not provide teaching about antihistamines, corticosteroids, and nonsteroidal anti-inflammatory medications because these medications do not lead to the development of IgG antibodies to the allergen. Antihistamines block H1-histamine receptors. Corticosteroids provide an anti-inflammatory effect needed in a hypersensitivity reaction. Nonsteroidal anti-inflammatory medications reduce inflammation and pain and are not routinely used for a hypersensitivity reaction.
The nurse is teaching a group of clients with allergies to foods and a history of asthma about the risk factors for the development of anaphylaxis. The nurse identifies which age group as having the highest risk for the development and severity of anaphylaxis? A. Adolescent B. Child C. Older adult D. Adult
C. Older adult Rationale: All Individuals with allergies to food and asthma may have an increased risk for the development of an anaphylactic reaction, with older adults having a greater risk. In the United States, food allergies are estimated to affect approximately 48.5% of children age 0-18 years and are the most common trigger of anaphylaxis in this age group. Teenagers with food allergies have the highest risk for an allergic reaction because they have a greater tendency to eat meals outside the home and are less likely to carry their medication.
Which is the nurse's priority action when managing a client experiencing a type I hypersensitivity? A. Stopping the blood transfusion B. Decreasing a fever C. Management of arthralgia D. Airway management
D. Airway management Rationale: Airway management is a priority with a client experiencing a type I hypersensitivity. A fever is a symptom of a type II, III, and IV hypersensitivity. Arthralgia is a symptom associated with serum sickness, a type III hypersensitivity. A blood transfusion is the result of a type II hypersensitivity
The nurse is caring for a client who requires a course of oral steroids more than once a year for the treatment of asthma related to allergens. Which alternative therapy should the nurse anticipate being prescribed for the client to avoid the frequent use of steroids? A. Omalizumab B. Plasmapheresis C. Antihistamines D. Immunotherapy
D. Immunotherapy Rationale: Immunotherapy is used primarily for allergic asthma related to inhaled allergens that have required oral steroids more than once a year. Omalizumab is approved for use by clients with steroid-dependent asthma and high IgE values who have not achieved adequate results with immunotherapy. Plasmapheresis is the removal of harmful components in the plasma and may be used to treat immune complex responses. Antihistamines are not effective in relieving asthmatic responses to allergens and may actually worsen symptoms by their drying effect on respiratory secretions.
For which allergy will the nurse teach the parents that a child with spinal bifida is at increased risk? A. Drug allergy B. Food allergy C. Contact dermatitis D. Latex allergy
D. Latex allergy Rationale: Latex allergies are common among clients with certain health conditions. Children most at risk for a latex allergy include those with spina bifida. Certain food allergies are associated with latex allergies. Contact dermatitis occurs when an area of skin is exposed to the antigen. Drug allergies occur as a result of adverse reactions to a drug and can produce a localized or systemic response.
Which hypersensitivity reaction releases enzymes that increase tissue damage? A. Type II B. Type I C. Type IV D. Type III
D. Type III Rationale: A type III reaction occurs when neutrophils attempt to phagocytize the immune complexes, and enzymes are released that increase tissue damage. A type I response is triggered when an allergen interacts with IgE, which is bound to mast cells and basophils. A type II reaction is a hemolytic transfusion reaction caused by blood incapability. A type IV reaction is an exaggerated interaction between an antigen and the normal cell-mediated mechanism.
The nurse is providing discharge teaching for a teenager who has experienced anaphylaxis related to a food allergy. Which statement by the nurse addresses the most common risk factor for an allergic reaction in a teenager? A. "Eat nutritional meals and drink plenty of fluids." B. "Limit your exposure to the food that caused the reaction." C. "Seek emergency medical help if you feel you are experiencing anaphylaxis." D. "Monitor what you are eating outside the home."
D. "Monitor what you are eating outside the home." Rationale: One of the most common risk factors for a teenager with a food allergy that contributes to an allergic reaction is the tendency to eat meals outside the home. The client should avoid foods that are associated with allergic reactions. The client should be instructed on how to use an EpiPen as well as the importance of follow-up care after a reaction has occurred.
