Ch 55: Care of the Patient with an Immune Disorder

29. The purpose of immunotherapy is .

ANS: desensitization The theory behind immunotherapy is to assist the individual to build a tolerance to the allergen without developing fever or increased signs and symptoms. Desensitization is another term used for immunotherapy. REF: Page 1960 TOP: Immunotherapy

9. A patient, age 42, develops a severe angioedema involving her face, hands, and feet, with burning and stinging of the lesions. During the assessment, which significant risk factor for allergies does the nurse recognize? a. Family history of allergies b. History of a recent fungal infection c. Use of OTC medications d. Recurrent respiratory infections

ANS: A A thorough history is the most important diagnostic tool. There is a genetic link to both well-developed immune systems and poorly developed or compromised immune systems. REF: Page 1961, Health Promotion box TOP: Allergic reaction

20. The correct nursing intervention for anaphylaxis would be a. assess respiratory status, including dyspnea. b. hypertension and elevated albumin levels. c. assess skin status, including erythema, urticaria, cyanosis, and pallor. d. assess GI status, including nausea, vomiting, diarrhea, incontinence.

ANS: A Anaphylaxis—If moderate to severe signs and symptoms occur, IV therapy may be initiated to prevent vascular collapse and the patient may be intubated to prevent airway obstruction. Nursing interventions and patient teaching—Assess respiratory status, including dyspnea, wheezing, and decreased breath sounds. REF: Page 1963 TOP: Anaphylaxis Step: Assessment

15. The delayed major process that leads to organ transplant rejection is a. hypersensitivity. b. cellular immunity. c. autoimmune factors. d. immunodeficiency.

ANS: A Delayed hypersensitivity reactions occurring 24 to 72 hours after exposure are mediated by T cells accompanied by release of lymphokines. Tissue transplant rejection is another example. REF: Page 1965 TOP: Transplant Step: Planning

14. After a bee sting, a patient's face becomes edematous and she begins to wheeze. Based on this assessment, the nurse would be prepared to administer: a. aminophylline. b. diphenhydramine (Benadryl). c. diazepam (Valium). d. epinephrine.

ANS: D At the first sign of reaction, 0.2 to 0.5 mL of epinephrine 1:1,000 is given subcutaneously. REF: Pages 1960, 1963 TOP: Allergic reaction

25. The LPN/LVN has arrived at the patient's bedside with a unit of packed cells to be connected to an IV that is infusing. When the RN arrives, what is the first thing the nurses must do? a. Do the checks to ensure that the donor and recipient numbers match according to policy. b. Leave the packed cells at the bedside until the saline is infused. c. Immediately hang the packed cells to get the infusion started. d. Check the patients ID bracelet and then hang the packed cells.

ANS: A Donor and recipient numbers are specific and must be thoroughly checked and the patient identified with an armband. REF: Page 1965 TOP: Blood transfusion

28. A patient has experienced an anaphylaxis reaction and is being monitored to ensure she is stable. A nursing diagnosis for her will be a. Decreased cardiac output. b. Impaired skin integrity. c. Imbalanced nutrition: less than required. d. Feeding self-care deficit.

ANS: A In a patient suffering an anaphylaxis reaction, a nursing diagnosis is Decreased cardiac output. REF: Pages 1963-1964, Nursing Diagnoses box TOP: Anaphylactic reaction

17. During a patient history, the nurse notices that the patient has had five upper respiratory infections in the past 18 months. The nurse begins to suspect that the patient may have an immunodeficiency disease because the first evidence of this disease is a. an increased susceptibility to infection. b. an increased coagulation problem. c. a problem with hemostasis. d. localized edema, raised wheals.

ANS: A The first evidence of immunodeficiency disease (an abnormal condition of the immune system in which cellular or humoral immunity is inadequate and resistance to infection is decreased) is an increased susceptibility to infection. REF: Page 1966 TOP: Immunodeficiency

4. A 72-year-old female patient is admitted with a diagnosis of immunodeficiency disease. The primary nursing goal would be to a. reduce the risk of her developing an infection. b. encourage her to provide self-care. c. plan nutritious meals to provide adequate intake. d. encourage her to interact with other patients.

ANS: A Unusually severe infections with complications or incomplete clearing of an infection may also indicate an underlying immunodeficiency. REF: Pages 1966-1967 TOP: Immunodeficiency diseases Step: Planning

32. Which are autoimmune diseases? (Select all that apply.) a. Lupus erythematosus b. Glomerulonephritis c. Polio d. Rheumatoid arthritis e. Thrombocytopenic purpura f. Osteoarthritis

ANS: A, B, D, E Autoimmune diseases such as systemic lupus erythematosus, glomerulonephritis, myasthenia gravis, thrombocytopenic purpura, rheumatoid arthritis, and Guillain-Barré syndrome are treated with plasmapheresis. REF: Pages 1966-1967 TOP: Autoimmune disorders

31. The first line of defense is innate (natural) immunity. Which is part of that protective mechanism against the external environment? (Select all that apply.) a. Skin and mucous membranes b. Lungs c. Heart d. Tears and saliva e. Natural intestinal and vaginal flora f. Stomach acid

ANS: A, D, E, F The innate system is composed of the skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissues, and secretions provide biochemical and physical barriers to disease. REF: Page 1956 TOP: Natural immunity

24. Once blood is removed from refrigeration, what is the length of time allotted for the blood to be transfused? a. 2 hours b. 4 hours c. 6 hours d. 3 hours

ANS: B Blood must be administered within 4 hours of refrigeration, and blood components within 6 hours of refrigeration. REF: Page 1965 TOP: Blood products Step: Planning

13. The nurse has held a unit conference on the specific immune response. Which statement by a colleague indicates an understanding of cell-mediated immune response? "Cell-mediated responses are a. directed from humorally mediated B cells." b. the direct attack of activated T-cell lymphocytes." c. from cells matured in the bone marrow." d. characterized by antigen-specific immunoglobulins."

ANS: B Cell-mediated immunity (the mechanism of acquired immunity characterized by the dominant role of small T cells) results when T cells are activated by an antigen. REF: Page 1958 TOP: Immune response

22. When assessing the patient for hypersensitivity, the nurse should a. review the immunization history. b. discuss seasonal occurrence of signs and symptoms. c. evaluate nutritional status. d. observe the range of joint mobility.

ANS: B Common offenders include pollens, spores, dusts, food, drugs, and insect venoms. Many, but not all, offenders are seasonal in nature. REF: Page 1960, Box 55-4 TOP: Hypersensitivity

18. A cancer patient who has been receiving cytotoxic drugs has been having frequent sinus infections. During planning of his care, the nurse must remember that this frequency of infections is an indication of possible a. immunotherapy. b. drug-induced immunosuppression. c. delayed hypersensitivity. d. autoimmune disorder.

ANS: B Drug-induced immunosuppression is the most common type of secondary immunodeficiency disorder. Immunosuppression is a serious side effect of cytotoxic drugs used in cancer chemotherapy. REF: Page 1966 TOP: Immunosuppression Step: Planning

2. A patient comes to the emergency department with dyspnea, wheezing, and urticaria over the arms and face after being stung by a bee. The nurse would begin immediate care for this patient because he or she is having a(n) a. asthma attack. b. anaphylactic reaction. c. pulmonary embolism. d. acute psychotic episode.

ANS: B Fatal reactions are associated with a fall in blood pressure, laryngeal edema, and bronchospasm, leading to cardiovascular collapse, myocardial infarction, and respiratory failure. Early recognition of signs and symptoms and early treatment may prevent severe reactions and even death. REF: Page 1963 TOP: Anaphylactic reaction

7. A liver transplant patient is receiving azathioprine (Imuran). What nursing goal is critical for this patient? a. Maintain bed rest with minimal exertion. b. Minimize his risk for infection. c. Allow several visitors. d. Monitor vital signs every 15 minutes.

ANS: B Graft rejection is slowed through the use of chemical agents that interfere with the immune response process. Included are corticosteroids, cyclosporine (Neoral, Sandimmune), and azathioprine (Imuran). This chemical therapy is referred to as immunosuppressive (the administration of agents that significantly interfere with the ability of the immune system to respond to antigenic stimulation by inhibition of cellular and humoral immunity) therapy. REF: Page 1966 TOP: Transplant Step: Planning

27. Which sign and symptom is a sign of a mild reaction as a result of a blood transfusion? a. Vomiting b. Urticaria c. Diaphoresis d. Sore throat

ANS: B Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. REF: Page 1965 TOP: Blood transfusion

19. A patient with rheumatoid arthritis is scheduled for plasmapheresis. She asks the nurse why they are going to do this procedure. In forming an answer the nurse must remember that the purpose of plasmapheresis is to a. add medication to relieve pain symptoms. b. remove plasma-containing components that may be causing the disease. c. remove waste products such as urea. d. add saline or albumin that lubricates joints.

ANS: B Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease. REF: Page 1967 TOP: Plasmapheresis Step: Planning

11. A patient, age 28, is treated at the clinic with an injection of long-acting penicillin for a streptococcal throat infection. Her history reveals that she has received penicillin before with no allergic responses. When the penicillin injection is administered, which information should be given to the patient by the nurse? a. Because she has taken penicillin before without problems, she can safely take it now. b. She must wait in the clinic area for 20 minutes before she is discharged. c. She would have immediate symptoms if she had developed an allergy to penicillin. d. She should monitor for fever and skin rash typical of serum sickness after taking penicillin.

ANS: B The patient must always be observed for at least 20 minutes after administration, because hypersensitivity reaction or anaphylaxis may occur. REF: Page 1960 TOP: Medication

30. If a nurse is sensitive to latex gloves, what potential food sensitivities might the nurse develop? (Select all that apply.) a. Peanuts b. Avocados c. Milk d. Bananas e. Tomatoes f. Potatoes

ANS: B, D, E, F A person sensitive to latex may also be sensitive to certain foods, including avocados, kiwi, guava, bananas, water chestnuts, hazelnuts, tomatoes, potatoes, peaches, grapes, and apricots. REF: Page 1964 TOP: Latex allergy

23. A 25-year-old male patient with severe rhinitis asks the nurse what is causing his nose to run. The symptoms are caused by a reaction to a substance, usually a protein, that causes the formation of an antibody and reacts specifically with an antibody called a(n) a. proliferation. b. complement. c. antigen. d. lymphokine.

ANS: C An antigen is referred to as an allergen (a substance that can produce hypersensitive reaction in the body but is not necessarily inherently harmful) when symptoms of allergy occur. REF: Page 1958 TOP: Allergic reaction

10. A patient, age 47, is undergoing skin testing with intracutaneous injections on the forearm to identify allergens to which she is sensitive. Immediately after the nurse administers one of the injections, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially? a. Elevate the arm above the shoulder. b. Administer subcutaneous epinephrine. c. Give 0.2 to 0.5 mL of epinephrine 1:1,000 subcutaneously. d. Apply a local anti-inflammatory cream to the site.

ANS: C At the first sign of reaction, 0.2 to 0.5 mL of epinephrine 1:1,000 is given subcutaneously. REF: Page 1963 TOP: Anaphylactic reaction

6. A patient comes to the clinic for his weekly "allergy shot." He missed his appointment the week before because of a family emergency. Which action by the nurse is appropriate in administering his injection? a. Administer the usual dosage of the allergen. b. Double the dosage to account for the missed injection the previous week. c. Consult with the physician about decreasing the dosage for this injection. d. Reevaluate his sensitivity to the allergen with a skin test.

ANS: C Interrupted regimens may place the patient at risk for reaction. REF: Page 1960 TOP: Allergies Step: Planning

16. A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, she receives a. larger doses each week. b. higher concentrations each week. c. increased amounts and concentrations in 6-week cycles. d. the same amount and concentration each visit.

ANS: C Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better effect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period. REF: Pages 1960-1961 TOP: Immunotherapy

1. A patient has a history of allergic reactions to bee stings. Which actions should the nurse teach to avoid an anaphylactic reaction to bee stings? a. Limit intake of sweets to reduce attraction of bees. b. Carry a dose of aminophylline at all times. c. Take extra precautionary actions when outdoors where bees may be present. d. Wear a Medic-Alert tag that states the patient is allergic to bee stings.

ANS: C Teach the patient avoidance of allergens. REF: Page 1962 TOP: Anaphylactic reaction

21. Which is a factor that contributes to the extent of an allergic response to an allergen? a. The integrity of the skin b. The time of year in which one is exposed c. The amount of exposure d. Exposure to one's clothing

ANS: C The five factors influencing hypersensitivity response include host response to allergen, exposure amount, nature of the allergen, route of allergen entry, and repeated exposure. REF: Page 1961, Box 55-3 TOP: Hypersensitivity

5. What precautionary safety measure should the nurse take for a patient who is receiving first-time intradermal injections for allergy testing? a. Take vital signs every 15 minutes for 1 hour after the patient receives the injection. b. Remind the patient to call the physician if a rash develops. c. Have the patient remain for 20 minutes after the injection. d. Instruct the patient to take epinephrine if an allergic reaction occurs.

ANS: C The patient must always be observed for at least 20 minutes after administration, because hypersensitivity reaction or anaphylaxis may occur. REF: Page 1960 TOP: Medication

8. A patient who has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment? a. "I need to think about a change in my occupation." b. "I will learn to administer epinephrine so that I will be prepared if I am stung again." c. "I should wear a Medic-Alert bracelet indicating my allergy to insect stings." d. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."

ANS: D The nurse's responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance dosages of corticosteroids because this was a short, rapid reaction. REF: Pages 1964-1965 TOP: Allergic reaction Step: Evaluation

3. A patient has been admitted with pernicious anemia and has asked the nurse to tell him what type of disorder pernicious anemia is. The nurse tells him that it is an immune disorder that results from failures of the tolerance to one's "self." Responding immunologically to one's own antigens is called a(n) a. immunodeficiency disorder. b. hypersensitivity disorder. c. desensitization disorder. d. autoimmune disorder.

ANS: D Autoimmune disorders are failures of the tolerance to "self." Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish "self" protein from "foreign" protein. REF: Pages 1966-1967 TOP: Autoimmune disorders

26. The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. The next action for the nurse would be to a. leave and get help. b. take the patient's temperature. c. give him his nose spray. d. stop the transfusion and IV administer saline.

ANS: D Mild transfusion reactions signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. Treatment includes stopping the transfusion and administering saline. REF: Page 1965 TOP: Blood transfusion

12. A patient is recovering from a kidney transplant. He is receiving cyclosporine after surgery. The purpose of this drug is to a. promote diuresis. b. prevent infection. c. manage pain. d. suppress the immune response.

ANS: D Tissue reaction does not occur immediately after transplantation. It takes several days for vascularization to occur. Seven to ten days after blood supply is adequately established, sensitized lymphocytes appear in sufficient numbers for sloughing to occur at the site. Graft rejection is slowed through the use of chemical agents that interfere with the immune response process. REF: Pages 1965-1966 TOP: Transplant