Chapter 25: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder

The nurse is monitoring the CD4 count of an infant who has contracted HIV from the mother in utero. The nurse is concerned that treatment with antiretroviral therapy is not effective when noting which CD4 level? 1900/mm3 1700/mm3 1500/mm3 1300/mm3

1300/mm3 Explanation: The number of CD4 T lymphocytes in the blood helps to determine the effectiveness of antiretroviral therapy. Normal is 1500/mm3 in the infant, so anything below that number may indicate that the therapy is not effective.

The nurse is caring for an infant exposed to HIV. The polymerase chain reaction (PCR) test was negative at birth. The nurse tells the mother that the child should be tested again at what age? 4 to 7 weeks 8 to 10 weeks 2 to 3 months 12 months

4 to 7 weeks Explanation: Virologic testing for HIV-exposed infants should be done with the polymerase chain reaction test at birth, at 4 to 7 weeks, and again at 8 to 16 weeks. Serologic testing is done at approximately 12 months of age to document disappearance of the HIV-1 antibody.

A pregnant client who is HIV positive asks the nurse if she will be able to breastfeed the newborn. Which response by the nurse is most appropriate? "Breastfeeding passes protective immunity along to your newborn." "Breastfeeding will increase your newborn's risk of contracting HIV." "Since your newborn will have HIV it is okay for you to breastfeed." "You should speak to your primary health care provider about breastfeeding."

"Breastfeeding will increase your newborn's risk of contracting HIV." Explanation: HIV can be transmitted by breastfeeding. A newborn who received the recommended plan of drug treatment has a reduced risk for contracting the infection. Contracting HIV is not an absolute for this newborn. The client should be discouraged from breastfeeding to limit exposure to the newborn. Breastfeeding does provide immunity when the mother is free of infection but not in this scenario. Telling the mother to speak to the health care provider is not the best response as the nurse is able to provide this education to the client.

The parents of an adolescent tell the nurse, "Our child seems to have allergy symptoms every time we visit our favorite cafe. I don't understand since the only allergy indicated in the testing was to eggs?" How should the nurse respond? "Does your child get a whipped cream or foam topping on their favorite drink?" "Maybe coffee drinks just don't agree with your child's system." "That doesn't really make any sense if your child is only allergic to eggs." "Maybe the allergy testing didn't evaluate everything your child is allergic to."

"Does your child get a whipped cream or foam topping on their favorite drink?" Explanation: Albumin, globulin, ovalbumin should be avoided if allergic to eggs. Some foam toppings for drinks contain these substances and would cause an allergic reaction to the person allergic to eggs. This would be important information to ascertain from the family as they would likely not be aware of this.

The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant the child gets a rash. It just does not make sense to me." How should the nurse respond? "Has your child ever been tested for a peanut allergy?" "Is your child allergic to milk?" "That is odd. Does anyone else in your family react that way?" "Maybe it is an allergy to something else and you just notice after eating there by coincidence."

"Has your child ever been tested for a peanut allergy?" Explanation: Enchilada sauce is an unexpected food that may contain a form of peanuts (such as peanut oil) that may be causing an allergic reaction in the child.

The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education? "Phagocytosis is the process in which phagocytes swallow up and break down microorganisms." "Humoral immunity is immunity mediated by antibodies secreted by B cells." "Cellular immunity is cell-mediated immunity controlled by T cells." "Humoral immunity is generally functional at birth."

"Humoral immunity is generally functional at birth." Explanation: Normal immune function is a complex process involving phagocytosis (process by which phagocytes swallow up and break down microorganisms), humoral immunity (immunity mediated by antibodies secreted by B cells), cellular immunity (cell-mediated immunity controlled by T cells), and activation of the complement system. Cellular immunity is generally functional at birth, and as the infant is exposed to various substances over time, humoral immunity develops.

The nurse is speaking with the parent of a child who has experienced an allergic reaction to peanuts. Which statement by the parent would indicate a need for further education? "If my child's tongue or lips start to itch, my child may be having an anaphylactic reaction." "If my child has high blood pressure and low heart rates, my child is not having an anaphylactic reaction." "If my child has gastrointestinal upset, my child is not having anaphylactic shock." "If my child has shortness of breath, my child may be having a symptom of anaphylaxis."

"If my child has gastrointestinal upset, my child is not having anaphylactic shock." Explanation: Bloating, abdominal pain, diarrhea and vomiting may be symptoms of anaphylaxis. Shortness of breath as well as itching of the lips, tongue and palate may also be symptoms of anaphylaxis. Hypertension and bradycardia are not associated with anaphylactic shock.

The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education? "I will make sure my daughter always has her EpiPen® with her all the time." "If we need to use the EpiPen® we will need to notify her physician's office the next business day." "I have found a website that makes medical alert bracelets in my daughter's favorite color." "The grey part of the EpiPen® should never be removed until right before we use it."

"If we need to use the EpiPen® we will need to notify her physician's office the next business day." Explanation: If an EpiPen® is used, the child still needs immediate medical attention. An EpiPen should be carried with the client at all times. When administering an EpiPen, the grey safety cap should not be removed until immediately prior to use. Medical alert bracelets or necklaces should be worn by all children with severe allergies.

The nurse is working with a pregnant client who is HIV positive and has been prescribed oral zidovudine. Which statement by the nurse explains the primary rationale for taking this medication? "This will help halt the growth of your Kaposi sarcoma." "Zidovudine will help stimulate your fetus's growth during pregnancy." "It is to help prevent transmission of the disease to your infant." "This medication will help to restore your coagulation ability before labor."

"It is to help prevent transmission of the disease to your infant." Explanation: A goal of therapy during pregnancy is to maintain the CD4 cell count at greater than 500 cells/mm3 by administering oral zidovudine, which helps halt maternal/fetal transmission dramatically along with one or more protease inhibitors, such as ritonavir, in conjunction with a nucleoside reverse transcriptase inhibitor (NRTI). Kaposi sarcoma is normally treated with chemotherapy. Women may need a platelet transfusion close to birth to restore coagulation ability. This medication has no affect on the fetus's growth and development.

The nurse is speaking with a teenager who has requested HIV testing. Which is the best statement by the nurse regarding HIV testing? "The ELISA method detects antibodies so a person may have a false negative test for up to six months after exposure. "Autoimmune disorders may cause you to have a false negative result on the ELISA test." "Since you are a minor, this test is confidential." "The ELISA test is a single test. It does not require you to be tested multiple times."

"The ELISA method detects antibodies so a person may have a false negative test for up to six months after exposure. Explanation: ELISA method detects only antibodies, so the test may remain negative for several weeks up to 6 months (false-negative) after exposure. A false-positive may result with autoimmune disease. The ELISA test requires serial testing. HIV test results are confidential.

The nurse is reviewing the medical history of a 4-year-old child. What would the nurse identify as potentially indicative of a primary immunodeficiency? Select all that apply. Acute otitis media, one episode every 3 to 4 weeks over the past year. Recurrent deep abscess of the thigh Oral candidiasis (thrush), persistent over the past 6 to 7 months Infected laceration requiring IV antibiotic 2 months ago; healed Pneumonia last spring; resolved with antibiotics

Acute otitis media, one episode every 3 to 4 weeks over the past year. Recurrent deep abscess of the thigh Oral candidiasis (thrush), persistent over the past 6 to 7 months Explanation: Warning signs associated with primary immunodeficiency include four or more new episodes of acute otitis media in 1 year, recurrent deep skin or organ abscesses, persistent oral candidiasis (thrush) or skin candidiasis after 1 year of age. A history of infections requiring IV antibiotics to heal and two or more episodes of pneumonia in 1 year are also warning signs.

The nurse is caring for a young child with HIV. Which nursing intervention is a priority for this child? Administer prescribed medications. Assist the child with daily activities. Assess pain after invasive procedures. Review laboratory CD4 counts daily.

Administer prescribed medications. Explanation: Although assisting with activities, assessing pain, and reviewing CD4 counts are all important, the priority when caring for a child with HIV is to administer prescribed medications. Prescribed medications prevent progressive deterioration of the immune system and provide prophylaxis against opportunistic infections.

A school-aged child, who is allergic to bee stings, states, "I think I was stung by a bee outside." Which intervention by the school nurse is most appropriate? Assess the client for signs of anaphylactic shock Administer epinephrine Determine if the client was stung Apply an ice compress to the site

Assess the client for signs of anaphylactic shock Explanation: First, the nurse will assess the client for signs of anaphylactic shock and then administer epinephrine if warranted. Epinephrine counteracts histamine release to decrease bronchospasm and difficulty breathing. If there were no signs of anaphylactic shock, the nurse would determine if the child was actually stung. The nurse would apply ice to promote vasoconstriction once the client was stable.

The nurse is caring for a child who is receiving an intravenous immunoglobulin treatment. The client calls the nurse and reports she vomited. What action should be completed first? Discontinue the infusion. Take the client's vital signs. Check the physician's orders for an antiemetic. Contact the physician.

Discontinue the infusion. Explanation: Clients receiving intravenous immunoglobulin are at risk for anaphylaxis. Vomiting can signal an allergic response. The first action would be to stop the infusion. The remaining activities are appropriate for inclusion in the plan of care but are not of the highest priority.

A nurse is preparing a presentation for a group of new parents and is planning to discuss nutrition during the first year. As part of the presentation, the nurse is planning to address foods that should be avoided to reduce the risk of possible food allergies. Which foods would the nurse most likely include? Select all that apply. Eggs Shrimp Peanuts Carrots Potatoes Bananas

Eggs Shrimp Peanuts Explanation: Foods that should be avoided in children younger than 1 year of age include cow's milk, eggs, peanuts, tree nuts, sesame seeds, and fish and shellfish (i.e., shrimp). Carrots, potatoes, and bananas are not considered problematic.

The nurse is helping the parents of a toddler identify foods that are causing allergic symptoms in the child. Which strategy should the nurse encourage the parents to use? Elimination diet Hyposensitivity testing Corticosteroid challenge testing Complete dietary protein restriction

Elimination diet Explanation: An elimination diet is a traditional method to detect food allergens. Parents feed the child only foods that rarely cause allergy, such as rice, lamb, carrots, peas, and sweet potatoes, for about 7 days. Then they add, one by one, at 2- to 3-day intervals, foods that are suspected of causing allergy. When a food is introduced this way, the child must be encouraged to eat a lot of it that day. If symptoms occur, the food is then eliminated from the child's meals on a permanent basis. If no symptoms occur, the child can continue to eat the food. Hyposensitivity testing is unreliable with food allergies. Corticosteroids delay hypersensitivity reactions. It is difficult to totally eliminate protein from the diet, and this is not a method to determine the cause of food allergies in the toddler.

The nurse is assisting with skin testing on a pediatric client with allergies. What will the nurse do first? Read the test within 15 to 20 minutes of when allergen is introduced. Measure and rate the size of wheal and flare reaction from 1+ to 4+. Draw up 0.3 ml epinephrine in a syringe with intramuscular needle. Ensure the child has not taken diphenhydramine in the past week.

Ensure the child has not taken diphenhydramine in the past week. Explanation: When assisting with skin testing for allergies, it is a priority to ensure the child has not taken an antihistamine within the past week to ensure accurate readings. If the child has taken an antihistamine, the test should not be performed. Reading the test within 15 to 20 minutes and measuring the reaction on a scale from 1+ to 4+ are both necessary to ensure accurate findings. Ensuring there is a protective measure (epinephrine) in place to prevent death from anaphylaxis is also important if the testing can be conducted.

A nurse is giving a talk to high school students about preventing the spread of human immunodeficiency virus (HIV). What does the nurse identify as ways in which HIV is spread? Select all that apply. Exposure to blood and body fluids through sexual contact Sharing contaminated needles Sharing the same bathroom Transfusion of contaminated blood Perinatally from mother to fetus Through breastfeeding

Exposure to blood and body fluids through sexual contact Sharing contaminated needles Transfusion of contaminated blood Perinatally from mother to fetus Through breastfeeding Explanation: HIV is spread by exposure to blood and other body fluids through sexual contact, sharing of contaminated needles for injection, transfusion of contaminated blood, perinatally from mother to fetus, and through breastfeeding. It cannot be contracted by using the same bathroom. It must be direct contact.

To avoid anaphylactic reactions in children, which question would be most important to ask a parent before administering penicillin to her infant? "Has she ever had penicillin before?" "Is there any family history of allergy to penicillin?" "What do you give her to alleviate itching?" "Do you have a telephone to call us immediately if she develops trouble breathing?"

Has she ever had penicillin before?" Explanation: Penicillin is a drug frequently involved in allergic reactions. The reaction occurs after the child has first been sensitized to the drug.

When describing anaphylaxis to a group of parents whose children have experienced anaphylaxis from insect stings, the nurse integrates knowledge that this response is related to which immunoglobulin? IgE IgG IgA IgM

IgE Explanation: Anaphylaxis is an acute IgE-mediated response to an allergen that involves many organ systems and may be life-threatening.

Which nursing action is most appropriate when caring for a child with positive serum IgE antibodies, a white blood cell count of 6,000/mm3, and 10% eosinophils? Review current CD4 counts. Obtain a careful health history. Percuss abdomen for hepatomegaly. Prepare child for stem cell transplant.

Obtain a careful health history. Explanation: The child with positive serum IgE antibodies, a white blood cell count of 6,000/mm3, and 10% eosinophils indicates allergies. Thus, taking a careful history to assess for symptoms and familial tendency is the most appropriate action. Reviewing CD4 counts and percussing for hepatomegaly would be more appropriate if HIV was suspected. Preparing for a stem cell transplant would be more appropriate if severe combined immunodeficiency (SCID) was suspected.

While obtaining a health history on a 3-year-old child, the nurse finds what information a concern? Select all that apply. Parents report the child as an infant had failure to thrive. Parents report the child has had chronic constipation. Parents report the child has had recurrent bacterial infections. Parents report the child didn't start walking until 1½ years old. Parents report the child didn't sit up by herself until 9 months old.

Parents report the child as an infant had failure to thrive. Parents report the child has had recurrent bacterial infections. Parents report the child didn't start walking until 1½ years old. Parents report the child didn't sit up by herself until 9 months old. Explanation: When collecting a health history, the nurse must be attuned to reports that may signal underlying conditions. A child who has experienced failure to thrive, repeated bacterial infections, and developmental delays with regard to walking and sitting up presents the need for further investigation. These are consistent with an autoimmune disorder.

An infant born to a mother who was HIV positive was tested at birth and found to be negative. The infant is scheduled for follow-up testing. Which test would the nurse expect to be performed? Polymerase chain reaction (PCR) test Enzyme-linked immunosorbent assay (ELISA) Platelet count CD4 counts

Polymerase chain reaction (PCR) test Explanation: The PCR is the preferred test to determine HIV infection in infants over 1 month of age. The ELISA is positive in infants of HIV-infected mothers because of transplacentally received antibodies. These antibodies may persist and remain detectable up to 24 months of age, making the ELISA test less accurate at detecting HIV infection in infants and toddlers than the PCR. The platelet count would provide no information about the infant's HIV status. CD4 counts would be used to monitor HIV infection but not to confirm whether the infant is positive or negative for the virus.

A child will receive IV immunoglobulin (IVIG). The nurse assesses the child every 15 minutes for the first hour of infusion for symptoms of anaphylaxis. Which symptom(s) would indicate to the nurse that anaphylaxis is occurring? Select all that apply. The child's face is flushed. The child's temperature begins to elevate. The child's blood pressure begins to elevate. The child appears increasingly anxious. Inspiratory wheezes are heard on auscultation.

The child's face is flushed. The child's temperature begins to elevate. The child appears increasingly anxious. Inspiratory wheezes are heard on auscultation. Explanation: IVIG infusion can cause many side effects such as anaphylaxis. Once the infusion is started, the nurse needs to monitor the vital signs and assess for signs of anaphylaxis every 15 minutes for the first hour and then every 30 minutes thereafter. The nurse would assess for facial flushing, urticaria, dyspnea, shortness of breath, wheezing, chest pain, fever, chills, increased anxiety, and hypotension. The blood pressure would decrease, not increase. Decreased blood pressure could be a sign of anaphylactic shock.

A child comes to the emergency department with difficulty breathing from severe bronchoconstriction. The parent informs the nurse that the child ate a peanut, to which the child is allergic. Which type of reaction is this client having? Type I: anaphylaxis Type II: cytotoxic response Type III: immune complex Type IV: cell-mediated hypersensitivity

Type I: anaphylaxis Explanation: Anaphylaxis is an acute reaction characterized by extreme vasodilatation that leads to circulatory shock and extreme bronchoconstriction, which in turn decreases the airway.

A school nurse is called to the school cafeteria after a 13-year-old child is reported to have sudden difficulty breathing. The child has a history of asthma and allergies to peanuts. The focused nursing assessment reveals difficulty breathing, inspiratory and expiratory wheezing, swelling of lips, and a rash on the face. The child reports feeling nauseated, having chest tightness, and feeling faint. Complete the following sentence(s) by choosing from the lists of options. The nurse should first address the child's - nausea - rash - wheezing then - chest tightness - feeling faint - swelling of lips

Wheezing Swelling of lips Explanation: The nurse addresses the airway first; wheezing indicates constriction of the airways. The nurse next addresses the child's swollen lips (angioedema) to ensure there is no additional swelling in the mouth that may occlude the airway. Once the nurse addresses the child's airway, breathing, and circulation, the nurse can address the child's nausea. Because the rash does not interfere with the child's airway, breathing, or circulation, and it will resolve once the allergic episode resolves; this can be addressed later. The child's chest tightness is most likely due to the bronchial constriction. Once the airway constriction resolves, the chest tightness should resolve. The child feeling faint is most likely due to the bronchial constriction reducing airflow. Once the airway constriction resolves, the child should not feel faint.

The nurse is providing teaching for the parents of a child with a latex allergy. The nurse tells the client to avoid which food? blueberries pumpkins bananas pomegranates

bananas Explanation: The nurse should instruct children and their families to avoid foods with a known cross-reactivity to latex, such as bananas.

The nurse is educating a child with a peanut allergy about the signs and symptoms of an anaphylactic reaction. The nurse realizes additional teaching is needed when the child identifies which sign/symptom? nausea anxiety itchy mouth constipation

constipation Explanation: Signs and symptoms of an anaphylactic allergic reaction include nausea, anxiety, and itchy mouth. Diarrhea, rather than constipation, is a sign of an allergic reaction.

The nurse is caring for a child with HIV. The doctor will most likely order which test to monitor the child's progress? lymphocyte immunophenotyping T-cell quantification complement assay (C3 and C4) IgG subclasses immunoglobulin electrophoresis

lymphocyte immunophenotyping T-cell quantification Explanation: Lymphocyte immunophenotyping T-cell quantification is for ongoing monitoring of progressive depletion of CD4 T lymphocytes in HIV disease. The nurse would expect the physician to order a complement assay (C3 and C4) for ongoing monitoring of systemic lupus erythematosus. IgG subclasses measure the levels of the four subclasses of IgG and are used to determine immunodeficiencies. Immunoglobulin electrophoresis is ordered for immunodeficiency and autoimmune disorders, not to monitor systemic lupus erythematosus.

The nurse is preparing to administer intravenous immunoglobulin (IVIG) for a child who has not had an IVIG infusion in over 10 weeks. The nurse knows to first: begin infusion slowly, increasing to the prescribed rate. assess for adverse reaction. obtain baseline physical assessment. premedicate with acetaminophen or diphenhydramine.

premedicate with acetaminophen or diphenhydramine. Explanation: Premedication with diphenhydramine or acetaminophen may be indicted in children who have never received intravenous immunoglobulin (IVIG), have not had an infusion in over 8 weeks, have had a recent bacterial infection, or have history of serious infusion-related adverse reactions. The nurse should first premedicate, and then obtain a baseline physical assessment. Once the infusion begins, the nurse should continually assess for adverse reaction.