Chapter 34: Caring for Clients with Immune-Mediated Disorders , Prep U Med-Surg
A health care provider is taking post-exposure prophylaxis (PEP) medications for exposure to a client with human immunodeficiency virus (HIV). Which topics will the health care provider need to understand regarding PEP administration prior to beginning this regimen? Select all that apply.
Adherence requirements Potential drug interactions Potential drug toxicities
The nurse in an allergy clinic is educating a new client about the pathology of the client's health problem. What response should the nurse describe as a possible consequence of histamine release?
Contraction of bronchial smooth muscle
A client is prescribed montelukast as part of a treatment plan for an allergic disorder. The nurse understands that this drug belongs to which class?
Leukotriene-receptor antagonist
The nurse is teaching a client how to self-administer epinephrine using an EpiPen autoinjector. What information should be included in the teaching? Select all that apply.
Jab the EpiPen autoinjector firmly into the outer thigh. After administering the injection, massage the area for 10 seconds. Hold the EpiPen autoinjector against the thigh for 10 seconds.
After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action?
Jabs the autoinjector into the outer thigh at a 90-degree angle
The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply.
Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Carry EpiPen autoinjector at all times.
Atopic allergic disorders are characterized by
a hereditary predisposition.
A client has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the client will present with what alteration in laboratory values?
Increased eosinophils
Fibromyalgia is a common condition that involves
chronic fatigue, generalized muscle aching, and stiffness.
A client with a diagnosis of primary immunodeficiency disease informs the nurse that the client has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the client's vital signs are within reference ranges, what action should the nurse take?
Assess the client for signs and symptoms of infection.
A nurse at an allergy clinic is providing education for a client starting immunotherapy for the treatment of allergies. Which education should the nurse prioritize?
Keeping appointments for desensitization procedures
The nurse working in the emergency department is asked to explain allergy testing to a client who experienced an allergic reaction to an unknown allergen. Which test indicates the quantity of allergen necessary to evoke an allergic reaction?
Serum-specific IgE test
The nurse knows the best strategy for latex allergy is
avoidance of latex-based products.
A client has begun sensitivity testing to determine the allergen which caused an anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more sensitive to allergens?
back
The nurse is reviewing various medications with a client that can be used to treat allergic disorders. What medication will the nurse identify as an intranasal corticosteroid?
fluticasone
A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?
type I
A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?
"If I notice tingling in my lips or mouth, gargling may help the symptoms."
A clinic nurse has been charged with the responsibility of teaching avoidance strategies to an adult patient who has allergic rhinitis. What measure should the nurse recommend to this patient?
"If possible, make sure that no one smokes tobacco in your home."
A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse?
"The full benefit of the medication may take up to 2 weeks to be achieved."
While monitoring the patient's eosinophil level, the nurse suspects a definite allergic disorder when seeing an eosinophil value of what percentage of the total leukocyte count?
15% to 40%
A 10-year-old boy has been brought to the emergency department (ED) by ambulance in apparent anaphylaxis after accidentally eating a snack bar that contained peanuts. The ED nurse should be aware that this patient's signs and symptoms are attributable to:
A massive release of histamine
An experienced medical nurse has provided care for patients who have immunodeficiencies that are primary, as well as for patients who have secondary immunodeficiencies. Which of the following individuals is most clearly exhibiting secondary immunodeficiency?
A woman whose diagnosis of sepsis is attributable to her recent chemotherapy
A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply.
Administer Diphenhydramine. Insert an intravenous line. Have respiratory therapy provide an albuterol treatment.
A client is distressed and frustrated reporting severe, ongoing fatigue that doesn't subside with rest. The nurse explains that chronic fatigue syndrome results from:
All options are correct.
A client has been transported to the emergency department after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply.
Assess breath sounds. Measure the client's oxygen saturation by oximeter. Monitor the client's respiratory pattern. Assess the client's respiratory rate.
A school nurse is caring for a 10-year-old who appears to be having an allergic response. Which intervention should be the initial action of the school nurse?
Assess for signs and symptoms of anaphylaxis.
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
Bone marrow transplantation
A client is scheduled for a skin test. The client informs the nurse that the client used a corticosteroid earlier today to alleviate allergy symptoms. Which nursing intervention should the nurse implement?
Cancel and reschedule the skin test when the client stops taking the corticosteroid.
The nurse is admitting a patient to the unit with a diagnosis of ataxia-telangiectasia. The nurse's assessment should reflect the patient's increased risk for what complication?
Cancer
A 5-year-old has been diagnosed with a severe walnut allergy after experiencing an anaphylactic reaction. Which topic is the nurse's priority when providing health education to the family?
Carrying an epinephrine pen
A patient has been admitted with a phagocytic cell disorder and the nurse is reviewing the most common health problems that accompany these disorders. The nurse should identify which of the following? Select all that apply.
Chronic otitis media Cutaneous abscesses Pneumonia
Which of the following is the most frequent route of exposure to a latex allergy?
Cutaneous
The nurse is preparing to administer a medication that has an affinity for H1 receptors. Which medication would the nurse administer?
Diphenhydramine
A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?
Dyspnea, bronchospasm, and/or laryngeal edema.
A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow?
Emergency equipment should be readily available.
For a client with chronic fatigue syndrome (CFS), what should the nurse emphasize during client teaching?
Ensure a balance of activity and rest.
A home health nurse will soon begin administering IVIG to a new client on a regular basis. What teaching should the nurse provide to the client?
Expected benefits and outcomes of the treatment
Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?
Histamine
The nurse is conducting an initial assessment of a hospitalized client who states that he has a latex allergy. The nurse notes that the skin of the client's hands is dry, thick, and cracked. The nurse documents the client's reaction to latex as which condition?
Irritant contact dermatitis
A client has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on the client's hands. What should the nurse teach the client to do?
Keep the hands well moisturized at all times.
A 6-month-old infant has been diagnosed with X-linked agammaglobulinemia and the parents do not understand why their baby did not develop an infection during the first months of life. The nurse should describe what phenomenon?
Passive acquired immunity
A patient who has received a heart transplant is taking cyclosporine, an immunosuppressant. What should the nurse emphasize during health education about infection prevention?
Perform frequent handwashing.
A nurse is caring for a patient who has an immunodeficiency. What assessment finding should prompt the nurse to consider the possibility that the patient is developing an infection?
Persistent diarrhea
The client is scheduled for a tilt-table test to assist in the diagnosis of chronic fatigue syndrome (CFS). What is the nurse's responsibility while the client is having the test?
Position the client while monitoring blood pressure and pulse.
Which intervention is the single most important aspect for the client at risk for anaphylaxis?
Prevention
A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment?
The client will remain in the clinic to be monitored for 30 minutes following the injection.
Which statement describes the clinical manifestations of a delayed hypersensitivity (type IV) allergic reaction to latex?
They are localized to the area of exposure, usually the back of the hands.
The nurse explains to a client that immunotherapy initially starts with injections at which interval?
Weekly
A young couple visits the nurse practitioner stating that they want to start a family. The husband states that his brother died of a severe infection at age 6 months. He says he never knew what was wrong but his mother had him undergo "blood testing" as a child. Based on these statements, what health problem should the nurse practitioner suspect?
X-linked agammaglobulinemia
A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include
adrenal suppression.
Which allergic reaction is potentially life threatening?
angioedema
The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as
angioneurotic edema.
A home health nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurse's teaching?
"My family needs to understand that I'll probably need lifelong treatment."
The nurse is preparing to administer IVIG to a patient who has an immunodeficiency. What nursing guideline should the nurse apply?
Administer pretreatment medications as ordered 30 minutes prior to infusion.
A mother has come to the emergency department (ED) with her 2-year-old who appears to be having a hypersensitivity reaction. The ED nurse knows that a hypersensitivity reaction may be characterized by an immediate reaction beginning within minutes of exposure to an antigen. What condition is an example of such a reaction?
Anaphylactic reaction immediately following a bee sting
A patient is admitted for the treatment of a primary immunodeficiency and intravenous immunoglobulin (IVIG) is ordered. What should the nurse monitor for as a potential adverse effect of IVIG administration?
Anaphylaxis
A junior nursing student is having an observation day in the operating room. Early in the day, the student reports eye swelling and dyspnea to the OR nurse. What should the nurse suspect?
Anaphylaxis due to a latex allergy
The nurse is educating a client about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms to report. Which COX-2 inhibitor is the nurse educating the client about?
Celecoxib
A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodeficiency disease (SCID). What medication should the nurse administer prior to initiating the infusion?
Diphenhydramine
A home health nurse is caring for a client who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis?
Encourage the client and family to be active partners in the management of the immunodeficiency.
The nurse is creating a care plan for a client suffering from allergic rhinitis. What outcome should the nurse identify?
Improved coping with lifestyle modifications
The nurse is evaluating a client's complete blood cell count and differential along with the serum immunoglobulin E (IgE) concentration. Which result might indicate that the client has an allergic disorder?
High IgE concentration
A client with a family history of allergies has experienced an allergic response based on a genetic predisposition. This atopic response is usually mediated by which immunoglobulin (Ig)?
IgE
A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply.
Milk Eggs Shrimp
A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed diagnostic workup that reveals a phagocytic disorder. This patient faces an increased risk of what complication?
Neutropenia
A nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care?
Risk for Falls Due to Loss of Muscle Coordination
The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan?
Risk for disturbed body image related to skin lesions
The nurse is providing care for a client who has a diagnosis of hereditary angioedema. When planning this client's care, what nursing diagnosis should be prioritized?
Risk for impaired gas exchange related to airway obstruction
A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines?
Sedation
A nurse is preparing to discharge a patient with an immunodeficiency. When preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize?
Signs and symptoms of adverse reactions
The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family?
The need to report any slight changes in the client's health status
A patient with severe environmental allergies is scheduled for the first in a planned series of immunotherapy injections. What should be included in teaching the patient about the injection?
The patient will remain in the clinic to be monitored for 30 minutes following the injection.
The nurse is administering intravenous vancomycin. What will the nurse initially assess the client for if an allergic reaction occurs?
dyspnea, bronchospasm, and/or laryngeal edema
In its attempt to suppress allergic responses, the body releases several chemicals which have a role in mediating physical reactions. Epinephrine, which interferes with vasoactive chemical release from mast cells, is instrumental in suppressing which type of hypersensitivity response?
type I
A client with multiple food and environmental allergies expresses frustration and anger over having to be so watchful all the time and wonders if it is really worth it. Which response by the nurse would be best?
"I can only imagine how you feel. Would you like to talk about it?"
During a code blue, a nurse sustained a needlestick injury from a client whose human immunodeficiency virus (HIV) status was unknown. The nursing supervisor is notified, an incident report is generated, and a post-HIV exposure prophylaxis checklist is started for this nurse. Which of the following steps would then occur?
Administer post-exposure prophylaxis (PEP) medication. Advise exposed health care providers to use precautions. Get counseling at the time of exposure. Undergo early reevaluation after exposure. Determine the HIV status of the client.
Which of the following disorders is characterized by an increased autoantibody production?
Systemic lupus erythematosus (SLE)
The nurse is conducting a community education program on allergies and anaphylactic reactions. The nurse determines that the participants understand the education when they make which statement about anaphylaxis?
The most common cause of anaphylaxis is penicillin.
The nurse teaches the client with allergies about anaphylaxis, including which statement?
The most common cause of anaphylaxis is penicillin.
A nurse knows of several clients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which client?
A client who is at 30 weeks' gestation
The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. Which client would have this type of reaction?
A client with an anaphylactic reaction after a bee sting
The nurse is caring for a client with an immunodeficiency who has experienced sudden malaise. The nurse's colleague states, "I'm pretty sure that it's not an infection, because the most recent blood work looks fine." What principle should guide the nurse's response to the colleague?
Immunodeficient clients will usually exhibit subtle and atypical signs of infection.
A client is undergoing sensitivity testing to define the allergen which is causing the client difficulty. Before the procedure begins, the nurse indicates the various routes in which an allergen can be introduced. What is an allergen introduction route?
All options are correct.
The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?
Intradermal
