CHAPTER 42 PREP U
A 5-year-old has allergic rhinitis. It would be most appropriate to collect information regarding the child's exposure to which substances? * metals foods pollens
pollens
Food allergies have become more and more common in the last few decades.Which of the following are common food allergies of childhood? Banana Apples Cheerios Milk
• Eggs • Milk • Peanuts Explanation:Allergies to eggs, peanuts, and milk are common in childhood. Cheerios are made of oats and are not known to be allergenic. Apples also are not allergenic, unlike bananas, which can cause problems for children who have latex allergies.
After teaching a class about humoral and cellular immunity, the nurse recognizes that additional teaching is needed when a client asks which question? "Does cellular immunity recognize antigens?" "Does cellular immunity involve the T lymphocytes?" "Does humoral immunity cross the placenta?" "Does humoral immunity not destroy the foreign cell?"
"Does cellular immunity recognize antigens?"
The nurse is caring for a child who weighs 44 lb (20 kg) experiencing an anaphylactic reaction. The health care provider has prescribed epinephrine 0.01 mg/kg injection. Epinephrine is supplied at 1mg in 10 ml. How many milliliters will the nurse administer? Record your answer using a whole number.
2 Explanation: To determine the rate, use weight in kilograms. Then, multiply 0.01 mg/kg by 20 kg to determine the appropriate milligrams, which is 0.2 mg. Next, multiply 0.2 mg by 10 ml to determine the appropriate milliliters, which is 2 ml.
The health care provider has prescribed diphenhydramine 5 mg/kg/dose for a child with urticaria weighing 33 lb (15 kg). The medication is supplied as 12.5 mg/5 ml. How many milliliters will the nurse administer to the child for one dose? Record your answer using a whole number.
30 Explanation: To determine the amount of milliliters to administer for one dose, use the child's weight in kilograms. Then, multiply 15 kg by 5 mg to equal 75 mg/dose. Next, divide 75 mg by 12.5 mg to equal 6. Then multiply 6 by 5 mg to determine the needed milliliters per dose, which is 30 ml.
Which nursing intervention is priority when caring for a child with HIV? Review laboratory CD4 counts daily. Assess pain after invasive procedures. Administer prescribed medications. Assist the child with daily activities.
Administer prescribed medications.
The nurse is caring for a child with clear nasal drainage, pale nasal mucous membranes, and a horizontal crease on the nose. What does the nurse suspect? * atopic dermatitis sinusitis upper respiratory infection allergic rhinitis
Allergic rhinitis Explanation:Clear nasal drainage, pale mucous membranes, and a horizontal crease on the nose are all symptoms of allergic rhinitis. Atopic dermatitis has dry, itchy patches of skin, whereas upper respiratory infections often involve a cough and a sore throat, and sinusitis usually is marked with a cough and facial pressure or headaches.
A nurse instructor is teaching pregnant women how HIV can spread from mother to fetus without treatment. For the untreated child who contracts HIV through placental transmission, when will the child test positive for HIV? By 6 months of age By 4 years of age In early adult years After 10 years
By 6 months of age
After reviewing information about the different types of immunodeficiency disorders, nursing students demonstrate the need for additional study when they identify which of the following as a B-lymphocyte deficiency? DiGeorge syndrome common variable immunoglobulin deficiency hypogammaglobulinemia IgA deficiency
Correct response: DiGeorge syndrome Explanation: DiGeorge syndrome is a defect of chromosome 22 or 22q11.2 and involves T-lymphocyte function. IgA deficiency, hypogammaglobulinemia, and common variable immunoglobulin deficiency are considered B-lymphocyte deficiencies.
The nurse is educating an immunocompromised child about the organs that assist in the immune process. The nurse recognizes teaching was effective when the child identifies which organs? Select all that apply. liver spleen thymus gall bladder bone marrow
Correct response: liver spleen thymus bone marrow Explanation: The major organs of the immune system are the thymus, liver, bone marrow, spleen, tonsils, lymph nodes, and blood. The gallbladder assists with digestion.
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? * Bananas Potatoes Eggs Carrots
Eggs
The nurse is caring for an infant who exhibits characteristics of allergies. the following suggestions for the parents are helpful in minimizing allergy development EXCEPT * Keep the room dust free. Avoid perfumes and room fresheners. Discontinue cigarette smoking. Put wall-to-wall carpeting in the room.
Put wall-to-wall carpeting in the room
A 7-year-old child is rushed into the emergency room after being stung by a yellow jacket. The child is nauseated and vomiting and is experiencing itching and swelling on the arm where stung. The is having trouble breathing. Which type of hypersensitivity response is the child experiencing? Type I: anaphylaxis Type IV: cell-mediated hypersensitivity Type III: immune complex Type II: cytotoxic response
Type I: anaphylaxis Explanation: Anaphylactic shock is an immediate, life-threatening, type I hypersensitivity reaction that occurs after exposure to an allergen in a previously sensitized child. Anaphylactic shock must be treated immediately as it can be fatal. Initially, a child may become nauseated, with vomiting and diarrhea, because of the sudden increase in gastrointestinal secretions produced by the stimulation of histamine. This is followed by urticaria (itching) and angioedema (swelling). Bronchospasm can become so severe the child becomes dyspneic, hypoxemic, and then hypoxic.
Nursing students demonstrate an understanding of how the body protects itself from invasion of bacteria which of the following is NOT physical protective barriers? * cilia skin blood vessels mucous membranes
blood vessels
Which drug should be available for emergency treatment of a child who goes into anaphylactic shock? * epinephrine insulin ephedra dopamine
epinephrine Epinephrine is the recommended emergency treatment for symptoms of anaphylaxis. Epinephrine helps quickly reverse the life-threatening symptoms of anaphylaxis.
A nursing instructor teaching a class about immunity asks the students to identify the organs of the immune system. Which would the nursing instructor will not Include? * thymus lymph nodes heart bone marrow
heart
What occurs with complement activation? Select all that apply. Decreased vascular permeability Smooth muscle relaxation Phagocytosis Chemotaxis Lysis of the foreign antigen
Correct response: Chemotaxis Phagocytosis Lysis of the foreign antigen
A nursing instructor is preparing a teaching plan for a class about the immune response. When discussing the immune response, which of the following would the instructor describe as being primarily involved in a secondary immune response? IgA IgG IgM IgE
Correct response: IgG
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." "It is to help prevent transmission of the disease to your infant." "This medication will help to restore your coagulation ability before labor." "Zidovudine will help stimulate your fetus's growth during pregnancy."
"It is to help prevent transmission of the disease to your infant."
The nurse is caring for a child who is beginning to show signs and symptoms of anaphylaxis. Which intervention would be the priority? * Assessing patency of the airway Obtaining brief history of allergen exposure Administering IV diphenhydramine Administering corticosteroids
Assessing patency of the airway Explanation:The priority nursing intervention is to assess patency of the airway and breathing. If the child is stable, the next step would be to obtain a brief history of allergen exposure. If epinephrine is required, it would be administered prior to diphenhydramine. Corticosteroids would be used to prevent late-onset reactions.
The nurse is reviewing a child's chart and notes hypersensitivity reactions under the diagnosis section. Which additional diagnosis would confirm a type III hypersensitivity reaction? Select all that apply. rheumatoid arthritis atopic dermatitis asthma systemic lupus erythematosus contact dermatitis
Correct response: rheumatoid arthritis systemic lupus erythematosus Explanation: Examples of type III hypersensitivity include rheumatoid arthritis and systemic lupus erythematosus. Contact dermatitis is an example of a type IV hypersensitivity reaction. Asthma and atopic dermatitis are examples of type I hypersensitivity reactions.
the following are the immune cells are disrupted when a child is infected with human immunodeficiency virus (HIV) EXCEPT * T cells Platelets Phagocytes B cells
Platelets
The nurse is discussing food allergies with parents of a young child, explaining that a very effective way to determine which foods a child may be allergic to is to implement: an elimination diet. a raw food diet. a food diary. allergy skin testing.
an elimination diet.
A child is scheduled to undergo hyposensitization. Which result confirms progress? increased concentration of IgG an increased level of IgE blockage of histamine release reduction in allergen exposure
increased concentration of IgG Explanation: Hyposensitization works by increasing the plasma concentration of IgG antibodies. IgG acts to prevent or block IgE antibodies from coming into contact with the allergen. IgE levels are not increased. Antihistamines block the release of histamine. Environmental control helps to reduce exposure to potential allergens.
It is the group of cells whose job is to ingest, engulf, and neutralize pathogens as: * immunogens. immunoglobins. red blood cells. macrophages.
macrophages.
A nursing instructor is preparing a teaching plan for a class about the immune response. When discussing the immune response, which of the following would the instructor describe as being primarily involved in a secondary immune response? IgG IgM IgE IgA
Correct response: IgG Explanation: Only IgM and IgG are involved in primary and secondary immune responses. The main immunoglobulin produced in a secondary response is IgG. With a primary immune response, IgM antibodies peak at 14 days after an initial exposure to an antigen and then decline. This is followed by the production of IgG, which remains high for several weeks. IgE antibodies are involved in an immediate hypersensitivity reaction.
Which immune cells are disrupted when a child is infected with human immunodeficiency virus (HIV)? Select all that apply. B cells Erythrocytes Phagocytes Platelets T cells
Correct response: T cells B cells Phagocytes Explanation: Platelets and erythrocytes are not affected by the HIV virus because the disease affects primarily the immune system.
A pediatric client is prescribed methotrexate for the treatment of juvenile rheumatoid arthritis. Which statement by the child's parent indicates to the nurse additional teaching is needed? "If my child develops a fever, I will give ibuprofen." "My child will need to have periodic blood work." "I will give my child this medication on an empty stomach." "It will take 3 to 6 weeks for my child to notice benefits."
Correct response: "If my child develops a fever, I will give ibuprofen." Explanation: The nurse will intervene and provide additional education if the parent states ibuprofen will be administered to the child receiving methotrexate, because this could lead to potentially fatal gastrointestinal toxicity, bone marrow suppression, or aplastic anemia. Methotrexate is an antineoplastic medication. It is best if taken on an empty stomach to ensure maximum absorption. White and red blood cell counts, platelets, and hemoglobin should be monitored in clients taking methotrexate. It generally takes 3 to 6 weeks for benefits of this treatment to be noticed.
A child is undergoing skin testing for allergies. About 10 minutes after a scratch test with an allergen, the child develops signs and symptoms of anaphylaxis. The nurse prepares to administer epinephrine subcutaneously. The child weighs 88 pounds. The nurse would administer which dosage of epinephrine? 0.4 mg 1 mg 0.8 mg 0.2 mg
Correct response: 0.4 mg Explanation: The child weighs 88 pounds or 40 kg. The dose of epinephrine is 0.01 mg/kg. So for a child weighing 40 kg, the nurse would give 0.4 mg.
Which food component is most likely to cause an immediate allergic reaction? Egg whites Gluten Milk products High-fructose corn syrup
Correct response: Egg whites Explanation: Egg whites are whole proteins and commonly cause immediate reactions in children who are allergic to eggs. Milk proteins and gluten cause delayed allergic reactions.
The nurse is explaining to a parent some of the basic aspects of the immune system and its functions. She informs them that B cells, also known as _________ cells, will attack __________ antigens. killer; bacterial killer; viral humoral; viral humoral; bacterial
Correct response: humoral; bacterial Explanation: B cells are also called humoral cells and typically attack bacterial organisms. Another term for T cells is killer cells, and they most commonly attack viral organisms.
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. Transfusion of contaminated blood Sharing the same bathroom Sharing contaminated needles Exposure to blood and body fluids through sexual contact Through breastfeeding Perinatally from mother to fetus
Correct response: Exposure to blood and body fluids through sexual contact Sharing contaminated needles Transfusion of contaminated blood Perinatally from mother to fetus Through breastfeeding
The nursing instructor is describing the events of anaphylaxis. Place the assessment findings in the order that they would occur from first to last. 1Seizures 2Nausea, vomiting, diarrhea 3Hypoxia 4Bronchospasm 5Urticaria, angioedema
Correct response: Nausea, vomiting, diarrhea Urticaria, angioedema Bronchospasm Hypoxia Seizures Explanation: Initially, a child may be nauseous, with vomiting and diarrhea, because of the sudden increase in gastrointestinal secretions produced by the stimulation of histamine. This is followed by urticaria and angioedema. Bronchospasm can become so severe the child becomes dyspneic and hypoxemic. Continued bronchospasm leads to hypoxia. As blood vessels dilate, the blood pressure and pulse rate fall. Seizures and death may follow as soon as 10 minutes after the allergen is introduced into the child's body.
The parents are concerned their child with atopic dermatitis is having an allergic reaction to diphenhydramine because the child became "sleepy and has a dry throat" after receiving the medication. Which education provided to the parents by the nurse is most important? "Your child is exhibiting signs and symptoms of an allergic reaction." "Side effects, such as drowsiness and dryness, do not indicate an allergy." "Children with eczema are more likely to have a medication allergy." "Toxic amounts of diphenhydramine can cause this response in children."
Correct response: "Side effects, such as drowsiness and dryness, do not indicate an allergy." Explanation: Although children with atopic dermatitis (eczema) are more likely to develop a medication allergy, side effects of diphenhydramine (drowsiness, dry mouth, constipation, etc.) can occur normally alongside the therapeutic effect of the medication. Common side effects do not indicate a toxic amount of the medication was given. Signs of an allergic reaction to a medication include: urticaria, angioedema, allergic contact dermatitis, flushing, pruritus, purpura, wheezing and/or rhinitis.
The nurse is caring for a child and notes periorbital edema on the left eye with urticaria. Which action by the nurse is priority? Administer a corticosteroid. Evaluate fluid volume status. Ask if the child has allergies. Assess lung sounds bilaterally.
Correct response: Assess lung sounds bilaterally. Explanation: When a child has signs of angioedema, the nurse's priority is to ensure the airway is patent, by assessing breathing sounds, because angioedema can cause laryngeal obstruction and asphyxiation. Evaluating fluid volume status, asking about allergies, and administering a corticosteroid are all actions that could be performed after first ensuring the child was breathing.
The nurse is caring for a child with severe allergies to mold, dust, and feathers. Therapeutic management for this child would include which of the following? Select all that apply. IM injection of epinephrine Modifying the child's response to the allergens with cetirizine Reducing the child's exposure to mold, dust, and feathers hyposensitizing the child to mold, dust, and feathers
Correct response: hyposensitizing the child to mold, dust, and feathers Reducing the child's exposure to mold, dust, and feathers Modifying the child's response to the allergens with cetirizine Explanation: Management of a child with allergies includes attempts to hyposensitize the child to the allergens, reduce the child's exposure to the allergens through environmental modification, and modifying the child's immune response to the allergens with the use of medication. IM epinephrine is used for anaphylactic reactions to allergens.
When teaching a group of new parents about newborn care and development, which immunoglobulin would the nurse explain as being primarily responsible for the passive immunity exhibited by newborns? IgM IgG IgA IgE
Correct response: IgG Explanation: IgG is acquired transplacentally, providing the newborn with passive immunity to antigens to which the mother had developed antibodies. IgA, IgD, IgE, and IgM do not cross the placenta and require an antigenic challenge for production.
The nurse is caring for a 6-month-old infant whose mother tested positive for HIV during her pregnancy. The infant had a positive polymerase chain reaction (PCR) for HIV at birth. Which medication would be prescribed for the prevention of pneumocystis pneumonia (PCP)? Trimethoprim-sulfamethoxazole Nitrofurantoin Ceftriaxone Amoxicillin and clavulanate
Correct response: Trimethoprim-sulfamethoxazole
A nurse is instructing parents of a child with allergies the events of a type I hypersensitivity reaction. Which would the nurse describe as being responsible for vessel congestion and edema? Select all that apply. histamine slow-reacting substance of anaphylaxis (SRS-A) leukotrienes IgG immunoglobulin chemotactic substances
Correct response: histamine leukotrienes Explanation: Intracellular granules released from the mast cells contain histamine, leukotrienes, a slow-reacting substance of anaphylaxis, and chemotactic substances. Histamine and leukotrienes cause peripheral vasodilation and permeability of blood vessels, which leads to vascular congestion and edema. SRS-A causes extreme bronchial constriction and reduced vasodilation and permeability. Chemotactic substances draw leukocytes to the area. IgE, not IgG, is involved in initiating the response.
The nurse is caring for a child with wheezing, stridor, pallor, vomiting, and a rash. When the nurse asks the child about pain, the child groans in response. An intravenous line is present. Which action by the nurse is priority? Assess oxygen status with pulse oximetry. Administer epinephrine intramuscularly. Inject diphenhydramine intravenously. Apply an albuterol breathing treatment.
Correct response: Administer epinephrine intramuscularly. Explanation: Epinephrine is the standard treatment for anaphylaxis, regardless of the cause. Signs and symptoms of anaphylaxis include wheezing, pallor, vomiting, and a rash. Stridor and decreased consciousness may indicate the child has progressed to airway obstruction and shock. Diphenhydramine and albuterol will not reverse anaphylactic shock. Assessing oxygen saturation is not the first action the nurse should take when anaphylaxis is suspected.
The most accurate screening test for the presence of HIV antigen in young children is: CD4 count. polymerase chain reaction (PCR). Western blot. enzyme-linked immunosorbent assay (ELISA).
Correct response: polymerase chain reaction (PCR). Explanation: PCR tests directly for the HIV antigen. ELISA and the Western blot test detect the presence of HIV antibodies. The CD4 count is used as a measure of disease status and progression.
A mother who is HIV positive is distraught when she learns that her 6-month-old baby is also HIV-positive. The child had undergone open heart surgery as a newborn and had received numerous blood transfusions. The nurse recognizes that the most likely means of transmission of the disease to this child was: placental spread during pregnancy. breastfeeding. the mother kissing the baby on the forehead. blood transfusion products contaminated with the virus.
Correct response: placental spread during pregnancy. Explanation: Although it is decreasing in incidence, transmission of HIV from mother to child by placental spread is still the most common reason for childhood HIV infection in the United States. Children with hemophilia no longer have a high incidence of the disease because blood products are now screened for the virus. HIV is not transmitted by animals or through usual casual contact, such as shaking hands or kissing, or in households, day care centers, or schools. Infection via breast milk is possible but less likely than via placental spread.
A child is brought to the clinic for evaluation. The mother tells the nurse that she thinks her son has a "summer cold." Which symptoms would lead the nurse to suspect that the child has allergic rhinitis (hay fever) and not an upper respiratory infection? Select all that apply. watery eyes reddened nasal membranes blackened areas under the eyes fever thin, watery nasal secretions
Correct response: thin, watery nasal secretions blackened areas under the eyes watery eyes Explanation: With allergic rhinitis (hay fever), the nasal mucous membranes are apt to be pale rather than reddened. Nasal secretions are typically thin and watery instead of the thick white or yellow discharge of an upper respiratory infection. Fever usually is not seen with allergic rhinitis. Allergic shiners or blackened areas under the eyes and watery eyes are commonly noted with allergic rhinitis.
Place in correct order the steps in the anaphylactic response. 1Circulatory collapse 2Vasodilation 3Rapid immune response 4Exposure to allergen 5Bronchoconstriction
Correct response: Exposure to allergen Rapid immune response Vasodilation Bronchoconstriction Circulatory collapse
The nurse is providing education to the parents of a child prescribed oral cyclophosphamide. Which statement by the parent indicates additional teaching is needed? Correct response: "I need to give this medication to my child at bedtime."
Correct response: "I need to give this medication to my child at bedtime."
The nurse is interviewing parents of a child who has been diagnosed with severe combined immune deficiency (SCID). Which statement by the parents best indicates an understanding of their child's condition? "We will need to prepare our child and ourselves for a bone marrow transplant." "Our child will receive antibiotic therapy until the stem cell transplant is completed." "Our child will need to receive several different types of antiviral medications." "We will make sure that our child carries the epinephrine autoinjector at all times."
Correct response: "We will need to prepare our child and ourselves for a bone marrow transplant." Explanation: SCID is a potentially fatal disorder requiring emergency intervention at the time of diagnosis. Gene therapy provides some promise for the future treatment of SCID, but until then bone marrow or stem cell transplantation is necessary. Intravenous immunoglobulin (IVIG) may be used to help decrease the number of infections until bone marrow or stem cell transplantation can be done. Antibiotic therapy is not initiated unless there is a bacterial infection present. Antiviral medications are used to treat HIV infection. An epinephrine autoinjector is used for anaphylaxis.
The nurse is caring for an infant who exhibits characteristics of allergies. Which suggestions for the parents are helpful in minimizing allergy development? Select all that apply. Keep the room dust free. Discontinue cigarette smoking. Avoid perfumes and room fresheners. Put wall-to-wall carpeting in the room. Use laundry solutions that have as few chemicals as possible.
Correct response: Discontinue cigarette smoking. Keep the room dust free. Use laundry solutions that have as few chemicals as possible. Avoid perfumes and room fresheners. Explanation: Smoking should be discontinued as smoke lingers and can fill a room; the smoke also clings to clothing. The floors should be bare, with easy-to-clean area rugs if desired. Carpeting allows for an accumulation of dust and other particles.
Which nursing problems could be associated with a child with primary immunodeficiency? Select all that apply. Risk for infection Delayed growth and development Altered gastrointestinal function Altered skin integrity Altered fluid and electrolytes
Correct response: Risk for infection Altered skin integrity Delayed growth and development
A nurse is providing care to a child with HIV who is prescribed therapy with a nucleoside reverse transcriptase inhibitor. What would the nurse expect to administer? Zidovudine Ritonavir Nevirapine Efavirenz
Correct response: Zidovudine Explanation: Zidovudine is a nucleoside reverse transcriptase inhibitor. Nevirapine and efavirenz are classified as nonnucleoside reverse transcriptase inhibitors. Ritonavir is a protease inhibitor.
A 7-year-old girl has been battling leukemia and receiving radiation therapy. She is highly susceptible to infections, and the nurse recognizes that this is because she is experiencing secondary immunodeficiency. What factors cause secondary immunodeficiency? Select all that apply. Cancer Severe stress Genetic deficiency of B-lymphocytes Hypogammaglobulinemia related to an inherited X-linked recessive gene Radiation therapy Malnutrition
Correct response: Cancer Radiation therapy Severe stress Malnutrition
A group of nursing students are reviewing information about humoral and cellular immunity. The students demonstrate understanding of this material when they identify what as being involved in cellular immunity? T cells Antigens Antibodies B cells
Correct response: T cells Explanation: Cellular immunity involves T cells, which do not recognize antigens. B cells, antibodies, and antigens are involved in humoral immunity.
The nurse is caring for a pediatric client who has a compromised immune system. When reviewing laboratory results, which bone marrow component identifies a dysfunction in bone marrow production? Select all that apply. macrophages T lymphocytes antigens haptens B lymphocytes
Correct response: T lymphocytes B lymphocytes Explanation: Bone marrow produces B lymphocytes and T lymphocytes. Macrophages are mature white blood cells involved with phagocytosis of an invading pathogen. Antigens are foreign substances capable of stimulating an immune response. Hapten formation occurs when a substance becomes antigenic when it combines with a higher weight molecule, usually a protein.
The nurse is caring for a child who is having bronchospasm. The nurse would expect to administer what medication? corticosteroid albuterol epinephrine diphenhydramine
Correct response: albuterol Explanation: The nurse would expect to administer bronchodilation inhalation treatment (albuterol) if bronchospasm is present. Epinephrine, diphenhydramine, and/or corticosteroids are administered to reverse the allergic process.
The nurse is instructing parents on how atopic disorders affect the child. For which disorder would the nurse provide information and counseling? Select all that apply. asthma serum sickness hay fever eczema allergic rhinitis
Correct response: allergic rhinitis asthma eczema hay fever Explanation: Hay fever (or allergic rhinitis), asthma, and eczema (or atopic dermatitis) are classified as atopic disorders. Serum sickness is a type III hypersensitivity response of the body to a foreign serum antigen or drug.
A parent tells the school nurse that her daughter has missed several school days this spring from having a cold and runny nose. When the student states her symptoms, which suggest allergic rhinitis (hay fever)? Select all that apply. reddened nasal mucosa blackened areas under the eyes clear, watery nasal discharge lower respiratory infection frontal headache
Correct response: clear, watery nasal discharge frontal headache blackened areas under the eyes Explanation: The nasal mucosa is typically pale in allergic rhinitis (hay fever). Lower respiratory infection is not present in allergic rhinitis but may be seen in an infectious process. The other symptoms are typical signs of allergic rhinitis.
A nursing instructor teaching a class about immunity asks the students to identify the organs of the immune system. Which would the nursing instructor want them to include? Select all that apply. thymus lymph nodes heart spleen bone marrow tonsils
Correct response: lymph nodes bone marrow thymus spleen tonsils Explanation: The organs of the immune system consist of the lymph nodes, bone marrow, thymus, spleen, and tonsils.
When describing the different types of hypersensitivity reactions to a group of nursing students, the instructor identifies IgE as being involved in which type of reaction? Select all that apply. type II type III type I type IV anaphylaxis
Correct response: type I type III anaphylaxis Explanation: IgE is involved in type I hypersensitivity reaction, which is also called anaphylaxis, and type III reaction, also called immune complex disease. IgG is involved in type II or cytotoxic reactions, and type III immune complex reactions. T lymphocytes are involved in type IV or delayed hypersensitivity reactions.
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? Prepare child for stem cell transplant. Review current CD4 counts. Percuss abdomen for hepatomegaly. Obtain a careful health history.
Correct response: • 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.
The nurse is instructing a group of women of childbearing age about human immunodeficiency virus (HIV) during pregnancy. What would be a priority recommendation in this setting? Proper nutrition Prophylactic treatment for HIV Screening for HIV Screening for sexually transmitted infections (STIs)
Correct response: Screening for HIV Explanation: No screening mandate has been put forth for HIV, but all pregnant women should be encouraged to undergo this test. Prophylactic treatment would be initiated only once the woman has been screened. Screening for STIs and ensuring proper nutrition are also part of health promotion for women in this age group, but they are of lower priority than identifying HIV-positive individuals.
The nurse is assessing a 16-year-old client who presents with red, itchy, watering eyes; sneezing; and rhinorrhea. The caregiver states the child's symptoms only occur during the spring. The client's temperature is 98.8°F (37.1°C). Which prescription by the primary health care provider will the nurse question? Avoid the causative allergen as much as possible. Be sure to wash the hair at the end of each day. Preform nasal washing as needed to control symptoms. Take levocetirizine daily in the morning.
Correct response: Take levocetirizine daily in the morning. Explanation: The nurse would question the administration of levocetirizine in the morning. This is an antihistamine, which blocks histamine release and as a result controls seasonal allergy symptoms. However, these medications also cause drowsiness and should be taken at bedtime. The client should be told to avoid the allergen as much as possible. This may even mean wearing a mask when outdoors. Nasal washing can help control symptoms by washing nasal passages, providing moisture, and easing inflammation. Hair should be washed daily when a client has seasonal allergies to limit the transfer of allergens to the client's bedding.
The nurse is caring for a 3-year-old child admitted to the hospital for recurrent pneumonia. The nurse notes fever, enlarged lymph nodes, and painful white patches in the mouth. Which health care provider prescription will the nurse anticipate to be prescribed first? enzyme-linked immunosorbent assay (ELISA) polymerase chain reaction (PCR) test viral load CD4 count
Correct response: enzyme-linked immunosorbent assay (ELISA) Explanation: HIV can be diagnosed by detecting antibodies in children over age 18 months with an ELISA test. In children younger than 18 months, HIV antigens can be detected with a PCR test. CD4 counts and viral loads are laboratory tests used to determine the severity of HIV status and predict progression of HIV. HIV would need to be confirmed with the ELISA prior to using tests to determine severity.
When assessing environmental factors which may cause a pediatric client's contact dermatitis, which would the nurse address? Select all that apply. cotton underwear pine sap frequent wet diapers exposure to poison ivy zippers and jewelry containing nickel
Correct response: frequent wet diapers exposure to poison ivy zippers and jewelry containing nickel Explanation: Sensitivities to cotton and pine sap are not very common. All the other substances are common causes of skin reactions.
A nurse is providing care to a child who is HIV positive and prescribed IV zidovudine. Which nursing actions would be appropriate when administering the drug? Select all that apply. Reinforce use of meticulous handwashing. Give the drug in the morning and after lunch. Monitor the child for paresthesias. Adhere to droplet precautions. Infuse the drug over 60 minutes.
Correct response: Infuse the drug over 60 minutes. Monitor the child for paresthesias. Give the drug in the morning and after lunch. Reinforce use of meticulous handwashing. Explanation: When administering IV zidovudine, the nurse should administer the drug over 60 minutes to prevent too rapid an infusion and give the drug around the clock for maximum effectiveness. The nurse should also monitor the child for paresthesias and institute safety precautions if they occur. The drug does not reduce the risk for HIV transmission, so the nurse should reinforce the need for meticulous handwashing and standard precautions. Droplet precautions are not necessary.
A nurse is preparing a teaching plan about environmental control measures for the parents of a child with an allergy. Which recommendations would the nurse include? Select all that apply. Replacing wooden chairs with stuffed upholstered furniture Having the child sit close to the blackboard in school Vacuuming the home about once every 2 weeks Encasing the mattress and pillow in sturdy plastic Removing any fur or woolen items from the child's wardrobe
Correct response: Removing any fur or woolen items from the child's wardrobe Encasing the mattress and pillow in sturdy plastic Explanation: Measures to control environmental allergens include replacing stuffed furniture with wooden furniture; removing any fur or woolen items from the child's wardrobe; encasing the mattress and pillow in sturdy plastic; having the child sit away from the blackboard in school; and vacuuming the home frequently.
A child is brought to the clinic for evaluation. The mother tells the nurse that she thinks her son has a "summer cold." Which symptoms would lead the nurse to suspect that the child has allergic rhinitis (hay fever) and not an upper respiratory infection? Select all that apply. blackened areas under the eyes fever thin, watery nasal secretions reddened nasal membranes watery eyes
Correct response: Thin, watery nasal secretions Blackened areas under the eyes Watery eyes Explanation: With allergic rhinitis (hay fever), the nasal mucous membranes are apt to be pale rather than reddened. Nasal secretions are typically thin and watery instead of the thick white or yellow discharge of an upper respiratory infection. Fever usually is not seen with allergic rhinitis. Allergic shiners or blackened areas under the eyes and watery eyes are commonly noted with allergic rhinitis.
The nurse is instructing a parent who is questioning when treatment for pediatric allergic rhinitis (hay fever) begins. Which nursing statement is most accurate? "It is important to determine how disruptive the symptoms are to the child." "Side effects of antihistamines determine if treatment is beneficial." The health care provider will assess the child's pain tolerance." "The health care provider will determine the severity of the child's symptoms."
Correct response: "It is important to determine how disruptive the symptoms are to the child." Explanation: Management of allergic rhinitis can be challenging, and the side effects of testing and treatment can be costly and painful. The decision on initiation and type of treatment is geared to the individual child and family—in particular, how much the disease interferes with the child's activities and self-esteem.
The parents of a 5-month-old infant diagnosed with humoral IgA deficiency question the nurse about why the infant was not diagnosed sooner. Which response by the nurse most appropriate? "This is associated with allergies, which may not be noted prior to 5 months." "IgA deficiency is usually found when evaluating for another illness." "Maternal antibodies crossed the placenta and that prevented infections until now." "There is no treatment or cure specific for IgA deficiency in children."
Correct response: "Maternal antibodies crossed the placenta and that prevented infections until now." Explanation: IgA deficiency does not have a specific treatment, is usually found when evaluating other illnesses, and is associated with allergies. However, the nurse's most appropriate response to the parents' question about why the infant was not diagnosed sooner is to explain how maternal antibodies prevent manifestation of the deficiency until the infant is approximately 4 months old.
The nurse is caring for a child diagnosed with juvenile idiopathic arthritis. Which statement(s) by the parents demonstrates an understanding of how to care for their child with this disease? Select all that apply. "Our child may report photosensitivity, so we should always carry sunglasses for our child." "We may notice our child has alopecia and should prepare our child for this." "We may note our child has a fever above 103°F (39.5°C) for a couple weeks and should monitor our child's temperature." "We need to administer medication to decrease inflammation and pain in our child." "We should encourage swimming as an activity for our child."
Correct response: "We may note our child has a fever above 103°F (39.5°C) for a couple weeks and should monitor our child's temperature." "We need to administer medication to decrease inflammation and pain in our child." "We should encourage swimming as an activity for our child." Explanation: Juvenile idiopathic arthritis is an autoimmune disorder in which the autoantibodies mainly target the joints. Inflammatory changes in the joints cause pain, redness, warmth, stiffness, and swelling. Administering medications as prescribed helps control inflammation, pain and disease progression. History of fever higher than 103°F (39.5°C) for 2 weeks or more is seen in systemic disease, and the child's temperature should be monitored. It is important to maintain joint range of motion and muscle strength through exercise, and swimming is a particularly useful exercise to maintain joint mobility without placing pressure on the joints. Common clinical manifestations of systemic lupus erythematosus, not juvenile idiopathic arthritis, include alopecia and photosensitivity.
The school nurse is walking through the lunchroom when one of the children says she started to feel strange after trading lunches with a friend. Which assessment would be most important? Asking if she has abdominal pain Checking if she has any nausea Determining if her throat itches Asking if she has a rash anywhere
Correct response: Determining if her throat itches Explanation: Asking if the child's throat itches is most important because this aids in determining airway patency, which is always the priority. Asking about a rash, nausea, or abdominal pain can be done after the nurse is certain the child's airway is not jeopardized.
The nurse is assisting with skin testing on a pediatric client with allergies. What will the nurse do first? Measure and rate the size of wheal and flare reaction from 1+ to 4+. Ensure the child has not taken diphenhydramine in the past week. Draw up 0.3 ml epinephrine in a syringe with intramuscular needle. Read the test within 15 to 20 minutes of when allergen is introduced.
Correct response: 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.
When teaching about primary and secondary humoral responses, what should the nurse identify as the immunoglobin that is first to appear in the serum? IgE IgM IgD IgG
Correct response: IgM Explanation: The fetus lives in an antigen-free environment so it produces only trace amounts of immunoglobulins, specifically IgM. IgA, IgD, IgE, and IgM do not cross the placenta. This means they require an antigenic challenge after birth for them to start producing. IgM reaches the adult level when the infant is 1 year of age. IgD and IgE make up only a small percentage of all immunoglobulins. IgG comes from the mother through the placenta. Because of this, the newborn has passive immunity to antigens in which the mother has developed antibodies.
Which nursing diagnosis will the nurse select as appropriate for the child with atopic dermatitis? Select all that apply. Anxiety related to continuing or uncontrolled allergic response Impaired skin integrity related to skin barrier function Ineffective breathing pattern related to allergic bronchospasm Powerlessness related to difficulty determining a cause of allergy Delayed growth related to chronicity of immune disorder
Correct response: Impaired skin integrity related to skin barrier function Anxiety related to continuing or uncontrolled allergic response Powerlessness related to difficulty determining a cause of allergy Explanation: Atopic dermatitis (eczema) is a highly pruritic, chronic inflammatory skin disease. Nursing diagnoses should focus on impaired skin integrity, anxiety related to the allergic response, and powerlessness related to knowing cause of allergy. A nursing diagnosis of delayed growth is more appropriate for a child with HIV. A nursing diagnosis of ineffective breathing pattern is more appropriate for a child with asthma.
Which nursing diagnosis will the nurse select as appropriate for the child with atopic dermatitis? Select all that apply. Impaired skin integrity related to skin barrier function Delayed growth related to chronicity of immune disorder Anxiety related to continuing or uncontrolled allergic response Ineffective breathing pattern related to allergic bronchospasm Powerlessness related to difficulty determining a cause of allergy
Correct response: Impaired skin integrity related to skin barrier function Anxiety related to continuing or uncontrolled allergic response Powerlessness related to difficulty determining a cause of allergy Explanation: Atopic dermatitis (eczema) is a highly pruritic, chronic inflammatory skin disease. Nursing diagnoses should focus on impaired skin integrity, anxiety related to the allergic response, and powerlessness related to knowing cause of allergy. A nursing diagnosis of delayed growth is more appropriate for a child with HIV. A nursing diagnosis of ineffective breathing pattern is more appropriate for a child with asthma.
A nurse is preparing a teaching plan for the parents of an infant with atopic dermatitis. Which topics are essential to ensure appropriate care? Select all that apply. Soap has a tendency to increase the pruritus. Skin testing is the primary means for diagnosing the condition. It tends to occur more frequently in formula-fed infants. The scalp and forehead are commonly affected. The condition is more problematic during the summer months.
Correct response: It tends to occur more frequently in formula-fed infants. Soap has a tendency to increase the pruritus. The scalp and forehead are commonly affected. Explanation: Atopic dermatitis is more problematic in the winter months when additional irritating clothing is present. Dermatitis tends to improve in the summer months. Atopic dermatitis is found more frequently in formula-fed infants. Sweating, heat, tight clothing, and contact irritants such as soap increase the pruritus. The common sites for lesions include the scalp, forehead, cheeks, neck, behind the ears, and extensor surfaces of the extremities. Skin testing is ineffective because the allergen causing the condition is often a food allergen.
The nurse is preparing an informational brochure about risk factors for immune disorders. Which disease process can indicate a potential underlying immunologic disorder? Select all that apply. Extensive eczema Occasional rhinorrhea Chronic cough Persistent oral thrush Illness with a high-grade fever
Correct response: Persistent oral thrush Chronic cough Extensive eczema Explanation: Occasional rhinorrhea is common and does not indicate an immune disorder. Illness with high fever is a sign of acute illness, rather than a chronic underlying disorder such as immune dysfunction.
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? A. Enzyme-linked immunosorbent assay (ELISA) B. Polymerase chain reaction (PCR) test C.Platelet count D. CD4 counts
Correct response: Polymerase chain reaction (PCR) test explanation: 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.
An infant presents with a rash and signs of secondary infection on the face. The nurse suspects infantile eczema based on which assessment findings? Select all that apply. The lesions are salmon colored and erythematous. The child is 9 months old. The lesions are found on the extensor surfaces. The child is irritable. The child is happy.
Correct response: The child is irritable. The lesions are found on the extensor surfaces. The child is 9 months old. Explanation: Infants with eczema are generally irritable because of discomfort and itching. Because of the infant's age, the infant is more apt to scratch the face opening the lesions and causing a secondary infection. Salmon-colored, erythematous lesions are typical of seborrhea.
The nurse receives a call from a parent whose toddler received a prescription for amoxicillin one teaspoon every 8 hours. The child has received 2 doses and the parent is noticing unusual symptoms. Which symptoms may indicate a severe penicillin allergy? Select all that apply. Seizures Urticaria Wheezing Serum sickness Incontinence
Correct response: • Wheezing • Urticaria • Serum sickness Explanation: A child with a severe penicillin allergy might very likely show symptoms such as wheezing, urticaria, and serum sickness. True drug allergies most commonly affect the dermatologic, immunologic, hemolytic, and respiratory systems.
