Chapter 19. Nursing Care of Patients With Immune Disorders

The nurse is assisting in an educational seminar on common allergens. What should the nurse include as the most common irritant causing contact dermatitis? (Select all that apply.) a. Bleach b. Rubber c. Fire ants d. Poison ivy e. Poison oak

d. Poison ivy e. Poison oak

A patient with lupus erythematosis is prescribed a corticosteroid. What side effects of this medication should the nurse review with the patient? (Select all that apply.) a. Tinnitus b. Facial hair c. Moon face d. Mood changes e. Increased weight f. Rash and pruritus

a. Tinnitus b. Facial hair d. Mood changes

A patient with systemic lupus erythematosis is prescribed Prednisone, 60 mg PO, in three equal doses. If using 5 mg tablets, how many tables should the nurse provide for each dose?

4

A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Place the actions in order (15) of importance of performance. A. ___ Stop the blood infusion. B. ___ Notify the physician stat. C. ___ Obtain vital signs and assess patient. D. ___ Start the new 0.9% normal saline infusion. E. ___ Prepare a new 0.9% normal saline infusion.

A, C, B, E, D Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a reaction are noted, the blood transfusion is immediately stopped and agency policy for a suspected transfusion reaction is followed. A normal saline infusion with new tubing is started to keep the vein patent. The physician and blood bank are immediately notified. A nurse remains with the patient for reassurance and monitoring of symptoms and vital signs. If a blood incompatibility is suspected, the unused blood and blood tubing are returned to the blood bank for testing. A series of blood and urine specimens are collected and sent to the laboratory for analysis. The physicians orders are followed to treat the patients symptoms

The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness? a. A patient who receives intravenous (IV) penicillin for an infection b. A patient who has a transfusion with packed red blood cells (RBCs) c. A patient who is given cryoprecipitate and factor IX after an abdominal injury d. A patient given steroids and immunosuppressant therapy after organ transplantation

a. A patient who receives intravenous (IV) penicillin for an infection

The nurse is contributing to a staff education program about nursing care for hypersensitivity reactions. Which should the nurse include as examples of type I hypersensitivity reactions? (Select all that apply.) a. Anaphylaxis b. Angioedema c. Serum sickness d. Allergic rhinitis e. Contact dermatitis f. Hypogammaglobulinemia

a. Anaphylaxis b. Angioedema d. Allergic rhinitis

The nurse is assisting in the planning of care for a patient with chronic serum sickness. Which action should be a priority for this patient? a. Assessing for a decrease in urine output b. Administration of immunosuppressive medications c. Closely monitoring the patient during the transfusion of blood products d. Discussing with the patient and significant other the need for genetic counseling

a. Assessing for a decrease in urine output The patient is at risk for low fluid volume which can lead to renal failure. Monitoring urine output can help reduce the risk of renal failure from occurring. B. C. D. These actions are not indicated in the care of this patient.

The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient? a. Assist with ambulation. b. Teach good hand hygiene. c. Avoid intramuscular injections. d. Obtain manual blood pressures.

a. Assist with ambulation. With anemia, the patient will be fatigued and may have activity intolerance and be a fall risk. Assistance with ambulation should be done for safety. C. D. These actions would be appropriate if the patient had thrombocytopenia. B. This action would be appropriate if the patient had neutropenia.

The nurse applies clean white cotton socks over the hands of a patient with contact dermatitis. What should the nurse explain to the patient about the purposes of this intervention? (Select all that apply.) a. Cotton allows air movement. b. White cotton has no dye in the material. c. White cotton prevents the wounds from spreading. d. The cotton will absorb the drainage from the wounds. e. Scratching is less during sleep when the area is covered.

a. Cotton allows air movement. b. White cotton has no dye in the material e. Scratching is less during sleep when the area is covered.

A patient with an autoimmune disorder asks, What might cause my body to do this to itself? What should the nurse state as reasons for the body to have lost the ability to recognize self? (Select all that apply.) a. Drugs b. Hormones c. Vaccinations d. Viral infections e. Bacterial infections

a. Drugs b. Hormones d. Viral infections

The nurse is reinforcing teaching about potential triggers with a patient experiencing allergic rhinitis. What should the nurse include in the teaching? (Select all that apply.) a. Dust b. Penicillin c. Ragweed d. Pet dander e. Topical lotion f. Oral multivitamin

a. Dust c. Ragweed d. Pet dander

. The nurse is contributing to the plan of care for a patient with systemic lupus erythematosus (SLE). Which interventions should the nurse recommend for this patient? (Select all that apply.) a. Eat a balanced diet. b. Report foamy urine to physician. c. Take cool showers or baths to relieve joint stiffness. d. Avoid naps and obtain a minimum of 6 hours of sleep. e. Exercise when pain and inflammation in joints is increased. f. Use a daily personal schedule to plan activities to reduce fatigue

a. Eat a balanced diet. b. Report foamy urine to physician f. Use a daily personal schedule to plan activities to reduce fatigue.

The nurse is contributing to the teaching plan for a patient diagnosed with Hashimotos thyroiditis who has progressed to hypothyroidism with a goiter. Which self-care instructions should the nurse recommend? (Select all that apply.) a. Eat a soft diet. b. Increase activity slowly. c. Eat more foods high in iodine. d. Keep home at a cool temperature. e. Eat a high-carbohydrate, high-protein diet. f. During low-energy periods, use anti-embolism stockings.

a. Eat a soft diet. b. Increase activity slowly f. During low-energy periods, use anti-embolism stockings.

The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops? a. Hives b. Retinal hemorrhage c. Jugular vein distention d. Pallor around the sting sites

a. Hives Hives is one of several symptoms of an allergic reaction. B. C. D. These manifestations are not associated with an allergic reaction

The nurse is caring for a patient at risk for infection. Which immunoglobulin should the nurse consider as being the cause of this patients infection risk? a. IgA b. IgE c. IgG d. IgM

a. IgA IgA cannot be replaced, increasing the risk for infections. B. C. D. These immunoglobulins can be replaced.

. The nurse is participating in a teaching plan to address Risk for Impaired Skin Integrity for a patient with contact dermatitis. Which information should the nurse recommend be included in this plan? (Select all that apply.) a. Keep fingernails short. b. Take baths with an oatmeal solution. c. Use oil-in-water lubricants for skin dryness. d. Rub affected area roughly, but do not scratch. e. Avoid washing affected area with brown soap. f. Use cool washcloths over affected area to ease itching

a. Keep fingernails short. b. Take baths with an oatmeal solution. c. Use oil-in-water lubricants for skin dryness f. Use cool washcloths over affected area to ease itching.

. The nurse is c caring for a patient with angioedema. Which nursing action should have the highest priority? a. Monitor for restlessness. b. Identify cause of the angioedema. c. Identify the presence of skin lesions. d. Teach the patient about immunotherapy.

a. Monitor for restlessness If the angioedema reaction is severe, maintenance of a patent airway is a priority. Any symptoms of respiratory distress must be reported immediately and remain the highest priority. B. Because the condition is already present, monitoring the patient takes priority, although the cause needs to be identified. C. D. These may be addressed later but are not the priority.

The nurse is assisting in the care of a patient with ankylosing spondylitis. What should the nurse expect to find in the patients collaborative plan of care? (Select all that apply.) a. Physical therapy daily b. Sitz baths three times daily c. Tylenol #3 every 4 hours prn pain d. Administer Remicade as prescribed e. Activity as tolerated; up with assistance

a. Physical therapy daily c. Tylenol #3 every 4 hours prn pain d. Administer Remicade as prescribed e. Activity as tolerated; up with assistance

A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins the patient reports low back pain and a headache. Which action should the nurse take first? a. Stop the blood infusion. b. Notify the physician STAT. c. Start the new 0.9% normal saline infusion. d. Prepare a new 0.9% normal saline infusion.

a. Stop the blood infusion

The nurse is reinforcing teaching provided to a patient with Hashimotos thyroiditis. What should the nurse explain as occurring initially in this health problem? a. Thyroid hormone production increases. b. Thyroid hormone production decreases. c. Thyroid-stimulating hormone production increases. d. Thyroid-stimulating hormone production decreases.

a. Thyroid hormone production increases. Autoantibodies for thyroid-stimulating hormone form, bind with the hormone receptors on the thyroid gland, and initially stimulate the thyroid gland to secrete thyroid hormones. B. C. D. These statements do not explain the initial action in Hashimotos thyroiditis.

A patient is diagnosed with urticaria. For which type of hypersensitivity reaction should the nurse plan care for this patient? a. Type I b. Type II c. Type III d. Type IV

a. Type I Anaphylaxis, urticaria, and angioedema are the most severe forms of type I hypersensitivity reactions. B. A type II hypersensitivity reaction involves the destruction of a cell or substance that has an anti-gen attached to its cell membrane. C. A type III hypersensitivity reaction involves immune complexes formed by antigens and antibodies, usually of the IgG type. D. A type IV hypersensitivity reaction, also called a delayed reaction, occurs when a sensitized T lymphocyte comes in contact with the particular antigen to which it is sensitized

A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient? a. Wear Medic-Alert identification. b. Stay indoors as much as possible. c. Wear insect repellent when outdoors. d. Take corticosteroids before going outdoors.

a. Wear Medic-Alert identification.

The nurse is reviewing data collected on several patients. Which patient should the nurse identify as being most likely to exhibit signs and symptoms of systemic lupus erythematosus? a. A 16-year-old Caucasian man b. A 20-year-old Hispanic woman c. A 45-year-old Caucasian woman d. A 42-year-old Asian American man

b. A 20-year-old Hispanic woman Systemic lupus erythematosus tends to develop in young women of child-bearing years and occurs in the African American and Hispanic populations more frequently. A. C. D. These individuals are less likely to develop manifestations of systemic lupus erythematosus.

A patient who developed hemolytic anemia related to the administration of penicillin asks for an explanation of this condition. What is the most appropriate response by the nurse? a. The red blood cells are being produced inappropriately. b. An antigenantibody reaction is causing destruction of red blood cells. c. An allergy to penicillin is destroying your platelets for unknown reasons. d. Allergens are invading the bone marrow and interfering with red blood cell production.

b. An antigenantibody reaction is causing destruction of red blood cells.

. A patient is diagnosed with hypogammaglobulinemia. Which of immune cell should the nurse realize is defective in this disorder? a. T cells b. B cells c. Mast cells d. Plasma cells

b. B cells Hypogammaglobulinemia is characterized by the absence or deficiency of one or more of the five classes of immunoglobulins from defective B-cell function. A. C. D. Hypogammaglobulinemia is not caused by defective T, mast, or plasma cells.

The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms? a. Installing a hot air heater b. Cover heating ducts with filters c. Installing wall-to-wall carpeting d. Using heavy draperies on sunny windows

b. Cover heating ducts with filters

A patient is suspected as having a blood transfusion reaction. Which laboratory test should the nurse expect to be done to confirm this diagnosis? a. Skin testing b. Direct Coombs test c. White blood cell count d. C-reactive protein level

b. Direct Coombs test

The nurse is reinforcing teaching provided to a patient with pernicious anemia. Which patient statement indicates that teaching has been effective? a. I can miss a month or two of injections if I am feeling better. b. I will need to take vitamin B12 injections for the rest of my life. c. I will take the vitamin B12 injections until my strength returns. d. I can take a vitamin B12 injection when I feel tired or fatigued.

b. I will need to take vitamin B12 injections for the rest of my life.

The nurse is collecting data from a patient with skin eruptions. What should the nurse recall to differentiate urticaria from angioedema? a. It is less pruritic. b. It lasts a shorter period of time. c. It includes mucous membrane edema. d. It causes more widespread skin lesions.

b. It lasts a shorter period of time.

The nurse is caring for a patient who has had a portion of stomach removed. Which manifestations should the nurse expect to determine if the patient has a vitamin B12 deficiency? a. Fever, malaise, muscle soreness, and diarrhea b. Numbness and tingling, weakness, and glossitis c. Urticaria, angioedema, anorexia, pruritus, and blistered lesions d. Frequent infections, fever, malaise, vertigo, and lymphadenopathy

b. Numbness and tingling, weakness, and glossiti Non-immune-related causes of pernicious anemia include any type of gastric or small bowel resections coupled with no or inadequate vitamin B12 or intrinsic factor replacement. Vitamin B12 deficiency symptoms include numbness and tingling, weakness, and glossitis. A. C. D. These are not manifestations associated with vitamin B12 deficiency.

. The nurse is caring for a patient with a severe allergic reaction. Which medication and route should the nurse anticipate being ordered for this patient? a. Intramuscular morphine b. Subcutaneous epinephrine c. IV diphenhydramine d. Oral diphenhydramine (Benadryl)

b. Subcutaneous epinephrine

The nurse is experiencing severe skin blisters after wearing latex gloves at work. Which treatment should the nurse expect to be prescribed by the health care provider for these skin lesions? (Select all that apply.) a. Oral antibiotics b. Topic drying agent c. Oral antihistamines d. Topical corticosteroid e. Topical immunomodulators

b. Topic drying agent c. Oral antihistamines d. Topical corticosteroid e. Topical immunomodulators

The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus. Which adverse effect should the nurse encourage the patient to report when taking this medication? a. Tarry stools b. Vision changes c. Any weight gain d. Changes in joint movement

b. Vision changes

The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease? a. Gardening outdoors on dry, windy days b. Wearing a mask when mowing the lawn c. Driving the car with the windows open during high pollen counts d. Taking frequent walks outside in spring when the weather is warm

b. Wearing a mask when mowing the lawn

A patient is being started on a blood transfusion. For how many minutes should the nurse stay with the patient during this transfusion? a. 5 b. 10 c. 15 d. 20

c. 15

The nurse has been caring for a patient with pernicious anemia. Which finding should indicate to the nurse that treatment has been successful? a. Decreased folic acid level and an increase in enlarged RBCs b. A decrease in intrinsic factor and increased vitamin B12 excreted in the urine c. An increase in vitamin B12 levels and decrease in number of enlarged RBCs d. A decrease in hydrochloric acid levels in gastric secretion and decrease in production of RBCs

c. An increase in vitamin B12 levels and decrease in number of enlarged RBCs

The nurse is caring for a patient with a severe allergic reaction. Which medication should the nurse anticipate being administered to control the itching? a. Morphine b. Epinephrine c. Diphenhydramine (Benadryl) d. Hydrocortisone sodium succinate (Solu-Cortef

c. Diphenhydramine (Benadryl)

The nurse is caring for a patient with severe ankylosing spondylitis. What nursing action would be most appropriate? a. Provide tepid tub soaks. b. Encourage a high-fiber diet. c. Provide activity every 2 hours. d. Administer narcotic analgesics.

c. Provide activity every 2 hours

The nurse recommends the diagnosis Disturbed Body Image for a patient with systemic lupus erythematosus. What would be an appropriate long-term outcome for this patient? a. Engages in diversional activities b. Uses normal coping mechanisms c. Returns to previous social involvement d. Verbalizes feelings about body changes

c. Returns to previous social involvement

. A patient is experiencing an episode of urticaria. Which intervention should the nurse recommend to include in the teaching plan to assist the patient in controlling the symptoms of urticaria? a. Avoiding tub baths b. Taking one aspirin daily c. Using relaxation techniques d. Drinking decaffeinated coffee

c. Using relaxation techniques

. A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take? a. Verify the patients kidney function. b. Verify the patients hematocrit level. c. Verify blood type of the patient and donor. d. Verify the patients admitting medical diagnosis.

c. Verify blood type of the patient and donor.

The nurse notes that a patient has an elevated lactate dehydrogenase, fragmented RBCs seen on microscopic examination, and low RBC count, hematocrit (Hct), and hemoglobin (Hgb) levels. For which health problem should the nurse consider planning care for this patient? a. Serum sickness b. Pernicious anemia c. Hemolytic transfusion reaction d. Idiopathic autoimmune hemolytic anemia

d. Idiopathic autoimmune hemolytic anemia

The nurse is caring for a patient who had a kidney transplant 5 days ago. The patient had been very outgoing and jovial, but this morning the patient is very quiet and refusing breakfast, and ambulation. What would be the most appropriate nursing action at this time? a. Notify the physician for laboratory orders. b. Notify the social worker for discharge follow-up care. c. Inform the patient that kidney rejection signs are appearing. d. Spend extra time with the patient, allowing verbalization of feelings.

d. Spend extra time with the patient, allowing verbalization of feelings.

The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how the disease process occurred. What should the nurse explain to the mother? a. It rarely occurs in males. b. It occurs after exposure to pesticides. c. It is because the infant was premature. d. There are no known causes for this disorder.

d. There are no known causes for this disorder.

A patient comes into the emergency department with a fear of developing poison ivy after falling while walking through a wooded area earlier in the day. What should the nurse instruct the patient to do if exposure to poison ivy occurs again? a. Flood the area with cold water. b. Wrap the area with a thick towel. c. Cover the area with cotton gauze. d. Wash the area with brown soap or any soap.

d. Wash the area with brown soap or any soap. The patient should be instructed to wash the area with a brown soap (e.g., Fels-Naptha) or, if unavailable, any soap when contact with the offending agent is suspected. This removes the offending agent from the skin. A. Cold water is not going to remove the agent from the skin. B. C. Wrapping the area with a towel or gauze is going to trap the offending agent on the skin and make the skin reaction worse