Med/Surg Chap 36

A nurse is teaching the parents of an infant about primary immunodeficiencies. Which of the following statements verifies that the parents understand the teaching? a) "The primary immunodeficiency will disappear with age." b) "The majority of primary immunodeficiencies are diagnosed in infancy." c) "My baby cannot survive into childhood with a diagnosis of primary immunodeficiency." d) "Girls are diagnosed with primary immunodeficiencies more often than boys."

"The majority of primary immunodeficiencies are diagnosed in infancy." Explanation: The majority of primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 986. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 986

A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder? a) AIDS b) DAF c) SCID d) CVID

AIDS Explanation: AIDS, the most common secondary disorder, is perhaps the best-known secondary immunodeficiency disorder. It results from infection with the human immunodeficiency virus (HIV). DAF refers to lysis of erythrocytes due to lack of decay-accelerating factor (DAF) on erythrocytes. CVID is a disorder that encompasses various defects ranging from IgA deficiency (in which only the plasma cells that produce IgA are absent) to severe panhypoglobulinemia (in which there is a general lack of immunoglobulins in the blood). Severe combined immunodeficiency disease (SCID) is a disorder in which both B and T cells are missing. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 994. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 994

Telangiectasia is the term that refers to a) Uncoordinated muscle movement b) Difficulty swallowing c) Inability to understand the spoken word d) Vascular lesions caused by dilated blood vessels

Vascular lesions caused by dilated blood vessels Explanation: Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia-telangiectasia is an autosomal-recessive disorder affecting both T-cell and B-cell immunity. Receptive aphasia is an inability to understand the spoken word. Dysphagia refers to difficulty swallowing. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

When administering a gamma-globulin infusion, what nursing guideline applies? a) Observe clents with high gamma-globulin rates for severe reactions over clients with low gamma-globulin rates. b) Weigh the client after treatment. c) Do not exceed an infusion rate of 3 mL/min. d) Administer pretreatment prophylactic antihistamine as ordered 8 hours prior to infusion.

Do not exceed an infusion rate of 3 mL/min. Explanation: Nursing guidelines that apply when administering IV gamma globulin include the IV infusion rate should not exceed 3 mL/min, the client should be weighed prior to treatment, clients with low gamma globulin have more severe reactions, and the nurse should administer pretreatment prophylactic antihistamine 30 minutes prior to beginning infusion. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991

Which type of phagocytic disorder (formerly known as Job syndrome) occurs when white blood cells cannot initiate an inflammatory response to infectious organisms? a) Hyperimmunoglobulinemia E b) Telangiectasia c) Panhypoglobulinemia d) Agammaglobulinemia

Hyperimmunoglobulinemia E Explanation: In hyperimmunoglobulinemia E, white blood cells cannot initiate an inflammatory response to an infectious organism. Agammaglobulinemia is a disorder marked by an almost complete lack of immunoglobulins or antibodies. Panhypoglobulinemia is a general lack of immunoglobulins in the blood. Telangiectasias are vascular lesions caused by dilated blood vessels. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 988. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 988

A majority of patients with CVID develop which type of anemia? a) Hemolytic b) Sickle cell c) Macrocytic d) Pernicious

Pernicious Explanation: A majority of patients with CVID develop pernicious anemia. The majority of patients with CVID do not develop the other types of anemia. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 990. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 990

Ataxia is the term that refers to a) difficulty swallowing. b) inability to understand the spoken word. c) uncoordinated muscle movement. d) vascular lesions caused by dilated blood vessels.

uncoordinated muscle movement. Explanation: Ataxia-telangiectasia is an autosomal recessive disorder affecting both T-cell and B-cell immunity. Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Receptive aphasia is an inability to understand the spoken word. Dysphagia refers to difficulty swallowing. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

A client is to receive intravenous immunoglobulin (IVIG). The infusion is started at 10 a.m. The nurse would be alert for signs and symptoms of an anaphylactic reaction during which time frame? a) 10:30 to 11:00 a.m. b) 11:00 to 11:30 a.m. c) 12:30 p.m. to 1:30 p.m. d) 11:30 a.m. to 12:00 p.m.

10:30 to 11:00 a.m. Explanation: When administering IVIG, anaphylactic reactions typically occur 30 to 60 minutes after the start of the infusion. Therefore, the time frame would be 10:30 to 11:00 a.m. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991

A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included? a) If the client experiences nausea, omit the dose. b) The client should be alert for joint aches. c) Be alert for signs and symptoms of infection and report them immediately to the physician. d) This medication is commonly used for many inflammatory reactions and is relatively safe

Be alert for signs and symptoms of infection and report them immediately to the physician. Explanation: Instruct the client about signs and symptoms of and the increased risk for infection. Instruct the client to report signs and symptoms of infection immediately to the physician. Early treatment promotes a shorter duration of illness and reduced complication. Tell the client to avoid high-risk activities, such as being in crowds, during periods of immunosuppression. The client should not omit a dose if nausea is experienced;he may take the medication with food. There are many side effects and required laboratory work to detect the side effects from immunosuppressive therapy. Joint aches are vague symptoms and are not a priority for reporting purposes. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 39: Assessment and Management of Patients With Rheumatic Disorders, p. 1071. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1071

Agammaglobulinemia is also known as which of the following? a) Nezelof syndrome b) Bruton's disease c) Common variable immunodeficiency (CVID) d) Wiskott-Aldrich syndrome

Bruton's disease Explanation: Bruton's disease is a sex-linked disease that results in infants born with the disorder suffering severe infections soon after birth. Nezelof syndrome is a disorder involving lack of a thymus gland. Wiskott-Aldrich syndrome involves the absence of T cells and B cells and the presence of thrombocytopenia. CVID is another term for hypogammaglobulinemia. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 988. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 988

The nurse is preparing a teaching plan for a client with an immunodeficiency. Which of the following would the nurse emphasize as most important? a) Adherence to prophylactic medication administration b) Incorporation of treatment regimens into daily patterns c) Identifying the signs and symptoms of infection d) Frequent and thorough handwashing

Frequent and thorough handwashing Explanation: Although identifying the signs and symptoms of infection, adherence to medication prophylaxis, and incorporation of treatment regimens into daily patterns are important, the most important aspect is frequent and thorough handwashing to prevent infection. If infection is prevented, signs and symptoms will not develop and medications would not necessarily be needed. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 993. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 993

Which of the following is a lack of one or more of the five immunoglobulins? a) Agammaglobulinemia b) Telangiectasia c) Hypogammaglobulinemia d) Panhypoglobulinemia

Hypogammaglobulinemia Explanation: Hypogammaglobulinemia is a lack of one or more of the five immunoglobulins. Agammaglobulinemia is a disorder marked by an almost complete lack of immunoglobulins or antibodies. Panhypoglobulinemia is a general lack of immunoglobulins in the blood. Telangiectasia are vascular lesions caused by dilated blood vessels. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 989. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 989

What severe complication does the nurse monitor for in a patient with ataxia-telangiectasia? a) Acute kidney injury b) Neurologic dysfunction c) Overwhelming infection d) Chronic lung disease

Overwhelming infection Explanation: Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination), telangiectasia (vascular lesions caused by dilated blood vessels), and immune deficiency. The immunologic defects reflect abnormalities of the thymus. The disorder is characterized by some degree of T-cell deficiency, which becomes more severe with advancing age. Immunodeficiency is manifested by recurrent and chronic sinus and pulmonary infections, leading to bronchiectasis. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

The nurse is preparing to infuse gamma-globulin intravenously (IV). When administering this drug, the nurse knows the speed of the infusion should not exceed what rate? a) 6 mL/min b) 10 mL/min c) 1.5 mL/min d) 3 mL/min

3 mL/min Explanation: The nurse should administer the IV infusion at a slow rate, not to exceed 3 mL/min, usually at 100-200 mL/h. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991

A male client is prescribed antihistamines. He asks the nurse about antihistamines administration and its adverse effects. What advice should the nurse offer the client? a) Avoid exposure to sunlight. b) Avoid applying skin moisturizers. c) Avoid seafood. d) Avoid alcohol.

Avoid alcohol. Explanation: The nurse should advise a client taking antihistamines to not take it with alcohol or other central nervous system depressants because additive sedative effects can occur. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 38: Assessment and Management of Patients with Allergic Disorders, p. 1041. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1041

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)? a) Bone marrow transplantation b) Radiation therapy c) Removal of the thymus gland d) Antibiotics

Bone marrow transplantation Explanation: Treatment options for SCID include stem cell and bone marrow transplantation. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

A patient with paroxysmal hemoglobinuria, a deficiency of complement proteins, is complaining of headache and weakness of the right arm and leg. Based on these symptoms, for which health complication should the nurse assess with this patient? a) Edema formation in the subcutaneous tissues of the extremities b) Cerebral venous thrombosis c) Rheumatoid arthritis d) Bacterial meningitis

Cerebral venous thrombosis Explanation: Paroxysmal nocturnal hemoglobinuria is an acquired clonal stem cell disorder resulting from a somatic mutation in the hematopoietic stem cell. Clinical manifestations may be indolent or life threatening. The disorder is characterized by hemoglobinuria that increases during sleep, as well as intravascular hemolysis, cytopenia, infections, bone marrow hyperplasia, and a high incidence of life-threatening venous thrombosis, which occurs most commonly in the abdominal and cerebral veins. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 993. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 993

A newborn has been diagnosed with DiGeorge syndrome. Which of the following would the nurse least likely expect to assess? a) Hypoparathyroidism b) Hypercalcemia c) Congenital heart defect d) Cleft palate

Hypercalcemia Explanation: Infants born with DiGeorge syndrome have hypoparathyroidism with resultant hypocalcemia resistant to standard therapy, congenital heart disease, cleft palate and lip, dysmorphic facial features, and possibly renal abnormalities. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 990. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 990

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. Which of the following would the nurse expect to be started? a) Chest physiotherapy b) Immunosuppressive agents c) Anticoagulation d) Antibiotic therapy

Immunosuppressive agents Explanation: For a client undergoing a hematopoietic stem cell transplant, immunosuppression is started to ensure engraftment of depleted bone marrow. Antibiotic therapy may or may not be indicated. Chest physiotherapy would be appropriate for clients with ataxia-telangiectasis who have chronic lung disase. Anticoagulation would not be used. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis? a) Vascular lesions b) Thrombocytopenia c) Eczema d) Thrush

Vascular lesions Explanation: Ataxia-telangiectasis is characterized by loss of muscle coordination and vascular lesions. Thrombocytopenia and eczema are associated wtih Wiskott-Aldrich syndrome. Thrush is a manifestation associated with severe combined immunodeficiency (SCID). (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

The majority of patient with primary immunodeficiency are in which age group? a) 41 to 50 b) 20 to 40 c) Younger than 20 d) 51 to 60

Younger than 20 Explanation: About 80% of the patients with primary immunodeficiency are younger than age 20 years. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 987. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 987

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response? a) "It is a hyperimmune response to something in the environment that is usually harmless." b) "It is a harmless reaction to something in the environment." c) "It is a muted response to something in the environment." d) "It means you are very sensitive to something inside of yourself."

"It is a hyperimmune response to something in the environment that is usually harmless." Explanation: An allergic disorder is characterized by a hyperimmune response to weak antigens that usually are harmless. The antigens that can cause an allergic response are called allergens. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 38: Assessment and Management of Patients With Allergic Disorders, p. 1030. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1030

The nurse is preparing to administer the recommended dose of intravenous gamma-globulin for a 60-kg male patient. How many grams will the nurse administer? a) 30 g b) 90 g c) 15 g d) 60 g

30 g Explanation: The optimal dose is determined by the patient's response. In most instances, an IV dose of 200-800 mg/kg of body weight is administered every 3-4 weeks to ensure adequate serum levels of immunoglobulin G (IgG). (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991

A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen? a) Thymus grafting b) IV gamma globulin administration c) Factor VIII administration d) Platelet administration

IV gamma globulin administration Explanation: Treatment for ataxia-telangiectasia includes IV gamma globulin, antimicrobial therapy, and bone marrow transplantation. It does not include platelet administration, factor VIII administration, or thymus grafting. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is a) Neutropenia b) Hypocalcemia c) Chronic diarrhea d) Malnutrition

Malnutrition Explanation: The most prevalent cause of immunodeficiency worldwide is severe malnutrition. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 994. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 994

A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which of the following statements? a) "We can ask our family members to donate blood for stem cell harvesting." b) "Hematopoietic stem cell transplantation (HSCT) cannot be performed until the age of 5 years." c) "The only treatment option is thymus gland transplantation." d) "We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen (HLA)-identical sibling.

"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen (HLA)-identical sibling." Explanation: Treatment options for SCID include stem cell and bone marrow transplantation. HSCT is the definitive therapy for SCID; the best outcome is achieved if the disease is recognized and treated early in life.sThe ideal donor is a human leukocyte antigen (HLA)-identical sibling. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

A client has been having joint pain and swelling in the left foot and is diagnosed with rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and the client has significant joint destruction. What type of disease is this considered? a) An alloimmunity disorder b) A cause-and-effect relationship c) An exacerbation of a previous disorder d) Autoimmune

Autoimmune Explanation: Diseases are considered autoimmune disorders when they are characterized by unrelenting, progressive tissue damage without any verifiable etiology. The client did not have a previous disorder that has caused an exacerbation. An alloimmunity describes an immune response that is waged against transplanted organs and tissues that carry non self antigens. Because there is no identifiable cause, there can be no effect. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 39: Assessment and Management of Patients With Rheumatic Disorders, p. 1054. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1054

A patient is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. He asks the nurse about the infusion's administration and its adverse effects. Which of the following choices should the nurse instruct this patient to report immediately? a) Constipation b) Tickle in the throat c) Mouth sores d) Sneezing

Tickle in the throat Explanation: Continually assess the patient for adverse reactions; be especially aware of complaints of a tickle or lump in the throat, which could be the precursor to laryngospasm that precedes bronchoconstriction. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991

A client calls the clinic and asks the nurse if using Afrin nasal spray would be alright to relieve the nasal congestion he is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications? a) Do not operate machinery or drive while using Afrin nasal spray. b) Taper the dose when discontinuing the medication. c) Do not use Afrin for longer than 3 to 5 days in a row or rebound congestion can occur. d) Report white patches in the mouth because Afrin can cause a fungal infection.

Do not use Afrin for longer than 3 to 5 days in a row or rebound congestion can occur. Explanation: Using Afrin nasal spray for more than 3 to 5 days can cause rebound congestion so the client should be sure that he is discontinuing use after that time. Afrin does not cause fungal infection. Corticosteroids should be tapered, but it is not necessary to taper the Afrin. Afrin does not cause sleepiness so the client can operate machinery or drive. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 38: Assessment and Management of Patients With Allergic Disorders, p. 1040. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1040

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements? a) Primary immunodeficiencies occur most commonly in the aged population. b) Primary immunodeficiencies develop as a result of treatment with antineoplastic agents. c) Primary immunodeficiencies develop early in life after protection from maternal antibodies decreases. d) Primary immunodeficiencies disappear with age.

Primary immunodeficiencies develop early in life after protection from maternal antibodies decreases. Explanation: These disorders may involve one or more components of the immune system. Primary immunodeficiencies are seen primarily in infants and young children. Primary immunodeficiencies are rare disorders with genetic origins. Without treatment, infants and children with these disorders seldom survive to adulthood. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, pp. 986-987. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 986

A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which of the following symptoms? Choose all that apply. a) Hunger b) Shaking chills c) Flank pain d) Fatigue e) Tightness in the chest

• Tightness in the chest • Flank pain • Shaking chills Explanation: Adverse reactions can include reports of flank and back pain, shaking chills, dyspnea, and tightness in the chest, as well as headache, fever, and local reaction at the infusion site. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991

Which of the following would a nurse be least likely to identify as a cause of secondary immunodeficiency? a) Diabetes b) Genetics c) Burns d) Chronic stress

Genetics Explanation: Genetics most likely would be a cause of primary immunodeficiency. Burns, chronic stress, and diabetes are associated causes of secondary immunodeficency. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 994. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 994

After teaching a client with immunodeficiency about ways to prevent infection, the nurse determines that teaching was successful when the client states which of the following? a) "I should avoid eating cooked fruits and vegetables." b) "Alcohol is good to clean any skin areas that are dry or chafed." c) "I will clean my kitchen counter with hot water." d) "I should avoid being around other people who have an infection.

"I should avoid being around other people who have an infection." Explanation: Strategies to prevent infection include avoiding being around others who have an infection and avoiding crowds. The client should avoid consumption of raw fruits and vegetables and use creams and emollients to prevent or manage dry, chafed, or cracked skin. A disinfectant, not just hot water, should be used to clean kitchen and bathroom surfaces. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 995. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 995

A man with chronic mucocutaneous candidiasis, an autosomal recessive disorder, asks the nurse, "Will my children have this disease?" Which response by the nurse is appropriate? a) "Your female children will be carriers for the disease, but only male children will develop the disease." b) "Only your male children are at risk for developing this disease." c) "All of your children will be carriers of the recessive gene but may not develop the disease." d) "All of your children will develop the disease."

"All of your children will be carriers of the recessive gene but may not develop the disease." Correct Explanation: Chronic mucocutaneous candidiasis is a rare T-cell disorder, which is thought to be an autosomal recessive disorder that affects both males and females. In pedigrees, an autosomal recessive disorder is revealed by the appearance of the phenotype in the male and female progeny of unaffected individuals. Parents must both be heterozygotes, C/c. (Both must have a c allele in order to contribute one to create a homozygote affected child with a cc phenotype displaying the disease.) A child born with Cc will be phenotypically normal, but carry the recessive trait. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 990. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 990

A patient with common variable immunodeficiency (CVID) comes to the ED with complaints of tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this patient developed? a) Pernicious anemia b) Gastric ulcer c) Sickle cell anemia d) Hyperthyroidism

Pernicious anemia Explanation: More than 50% of patients with CVID develop pernicious anemia. Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy, which is detected by biopsy of the stomach, are common findings. Gastrointestinal malabsorption may occur. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 988. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 988

DeShawn, a 17-year-old high school student, has been seeing an allergist for 6 months for treatment of allergies. His allergies have been insufficiently controlled by symptomatic treatments and his health care provider has suggested desensitization. Which of the following is the anticipated outcome of desensitization? a) Repeated exposure to the weak antigen promotes the production of IgG, an antibody that blocks IgE so it cannot stimulate mast cells. b) Repeated exposure to the weak antigen promotes the production of IgE, an antibody that blocks IgG so it cannot stimulate basophils. c) Repeated exposure to the strong antigen promotes the production of IgG, an antibody that blocks IgE so it cannot stimulate basophils. d) Repeated exposure to the strong antigen promotes the production of IgE, an antibody that blocks IgG so it cannot stimulate mast cells.

Repeated exposure to the weak antigen promotes the production of IgG, an antibody that blocks IgE so it cannot stimulate mast cells. Explanation: Desensitization is a form of immunotherapy in which a person receives weekly or twice weekly injections of dilute but increasingly higher concentrations of an allergen without interruption. Repeated exposure to the weak antigen promotes the production of IgG, an antibody that blocks IgE so it cannot stimulate mast cells. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 38: Assessment and Management of Patients with Allergic Disorders, p. 1042. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1042

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate? a) "Your child's condition is extremely serious. Like AIDS, it will most likely be fatal." b) "We need to do some more testing before we will know if your child's condition is AIDS." c) "Your child does not have AIDS but his condition puts him at risk for it later in life." d) "Although AIDS is an immune deficiency, your child's condition is different from AIDS."

"Although AIDS is an immune deficiency, your child's condition is different from AIDS." Explanation: Primary immune deficiencies should be not be confused with AIDS. They are not the same condition. In addition, a primary immune disorder does not increase the child's risk for developing AIDS later in life. Primary immune deficiency diseases are serious, but they are rarely fatal and can be controlled. Testing will reveal the evidence of a primary immune disease, not AIDS. AIDS is classified as a seconary immunodeficiency. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 994. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 994

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? a) "I can eat whatever I want as long as it's low in fat." b) "I won't go to see my nephew right after he gets his vaccines." c) "I stopped smoking last year; this year I'll quit drinking alcohol." d) "I won't go to see my sister while she has a cold.

"I can eat whatever I want as long as it's low in fat." Explanation: The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 995. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 995

The nurse is caring for a young patient who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed? a) "I can take my child to the beach, as long as we play in the sand rather than swim in the water." b) "I will avoid letting my child drink any juice that has been sitting out for more than an hour." c) "I will apply lotion following every bath to prevent dry skin." d) "I will let my neighbor have my pet iguana."

"I can take my child to the beach, as long as we play in the sand rather than swim in the water." Explanation: Parents should verbalize ways to plan for regular exercise and activity that does not pose a risk of infections. Immunocompromised patients should avoid touching sand or soil because of the high level of bacteria and increased risk of diseases such as toxoplasmosis. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 995. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 995

The nurse is teaching the patient who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? a) "I will avoid contact with people who are sick or who have recently been vaccinated." b) "I will be sure to eat lots of fresh fruits and vegetables every day." c) "I will make sure to have my own toothbrush and tube of toothpaste at home." d) "I will wash my hands whenever I get home from work."

"I will be sure to eat lots of fresh fruits and vegetables every day." Explanation: The patient should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 995. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 995

A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse? a) "The doctor could prescribe anti-inflammatory drugs." b) "The doctor could prescribe antihypertensive drugs." c) "The doctor could prescribe antipyretic drugs." d) "The doctor could prescribe antineoplastic drugs."

"The doctor could prescribe anti-inflammatory drugs." Explanation: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Antipyretic and antihypertensive drugs are not prescribed for autoimmune diseases. An antineoplastic drug is not ordered for an autoimmune disorder until it is in its late stages and uncontrolled by the first-line drugs. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 39: Assessment and Management of Patients With Rheumatic Disorders, p. 1060. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1060

The nurse is obtaining an assessment and health history from the parents of a 6-month-old infant with an elevated temperature. Which statement by the parents will alert the nurse to a possible immunodeficiency disorder? a) "I had a good prenatal care and vaginal delivery, although they had to use forceps." b) "This is the third infection with a high fever the baby has had in the past month." c) "My husband's family has a history of hemophilia; can this be the problem?" d) "I usually feed the baby a bottle every 4 to 6 hours during the day."

"This is the third infection with a high fever the baby has had in the past month." Explanation: Infants with X-linked agammaglobulinemia usually become symptomatic after the natural loss of maternally transmitted immunoglobulins, which occurs at about 5 to 6 months of age. Symptoms of recurrent pyogenic infections usually occur by that time. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 989. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 989

The nurse is working with a mother whose child has just been diagnosed with selective immunoglobulin A deficiency. The mother asks the nurse, "Does this mean that my child is going to die?" How will the nurse respond? a) "Selective immunoglobulin A deficiency can cause uncontrolled muscle movements with progressive neurologic deterioration if left untreated." b) "Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A (IgA), a type of antibody that protects against infections of the lining the mouth and digestive tract." c) "Selective immunoglobulin A deficiency is the term used to describe the early stages of the AIDS infection." d) "Your child may die without proper medication and treatment."

"Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A (IgA), a type of antibody that protects against infections of the lining the mouth and digestive tract." Explanation: Selective immunoglobulin A deficiency is congenital and characterized by a lack of immunoglobulin A, which predisposes patients to recurrent infections, adverse reactions to blood transfusions or immunoglobulin, autoimmune diseases, and hypothyroidism. There is no current treatment. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 987. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 987

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? a) A disorder where histocompatible cells attack the immunoglobulins. b) A disorder where the body has too many immunoglobulins. c) A disorder where the body does not have enough immunoglobulins. d) A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self."

A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Explanation: Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Autoantibodies,antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 35: Assessment of Immune Function, p. 972. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 972

A client is given a dose of ketorolac (Toradol), a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do? a) Administer epinephrine. b) Intubate the client. c) Perform an electrocardiogram (ECG). d) Assess the client's vital signs.

Administer epinephrine. Explanation: Anaphylaxis is a rapid and profound type I hypersensitivity response. A massive release of histamine causes vasodilation; increased capillary permeability; angioneurotic edema (acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs); hypotension; and bronchoconstriction. A nurse must administer 0.2 mg of epinephrine subcutaneously to a client experiencing a severe allergic reaction. It is outside of the nurse's practice to intubate a patient. Performing an ECG and assessing the vital signs delays the treatment of the client and can have negative outcomes. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 35: Assessment of Immune Function, p. 1037. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1037

Which of the following allergic reaction is potentially life threatening? a) Angioedema b) Contact dermatitis c) None of the listed allergic reactions is potentially life threatening d) Urticaria

Angioedema Explanation: Angioedema is potentially life threatening. Medical management would include intubation, subcutaneous epinephrine, aminophylline in severe reactions. Angioedema is potentially life threatening. Medical management would include intubation, subcutaneous epinephrine, and aminophylline. (less) Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 38: Assessment and Management of Patients with Allergic Disorders, p. 1048. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1048

The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states he is allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies? a) Call the physician. b) Apply an allergy bracelet and flag the chart. c) Inform the client not to take any medications with those substances in them. d) Tape an Epipen to the head of the bed

Apply an allergy bracelet and flag the chart. Explanation: The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 38: Assessment and Management of Patients With Allergic Disorders, p. 1037. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1037

A patient with common variable immunodeficiency (CVID) is extremely fatigued and not feeling well. What lab test does the nurse anticipate the patient will have to detect a common development related to the disease? a) Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) b) B12 level c) Glucose level d) Blood urea nitrogen (BUN) and creatinine

B12 level Explanation: More than 50% of patients with CVID develop pernicious anemia, a condition in which the body cannot make enough red blood cells due to an inability to absorb vitamin B12. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 990. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 990

Tyler Harris, a 5-year-old male, has recovered from an anaphylactic reaction which brought him to the ED 3 weeks ago. Tyler has begun sensitivity testing to determine the allergen which caused his anaphylactic reaction. In scratch testing, which part of the body is more sensitive to allergens? a) Back b) Chest c) Forearm d) Upper arm

Back Explanation: The scratch or prick test involves scratching the skin and applying a small amount of the liquid test antigen to the scratch. The tester applies one allergen per scratch over the client's forearm, upper arm, or back. The back is more sensitive than the arms. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 38: Assessment and Management of Patients with Allergic Disorders, p. 1035. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1035

More than 50% of individuals with this disease develop pernicious anemia: a) Nezelaf syndrome b) DiGeorge syndrome c) Bruton disease d) Common variable immunodeficiency (CVID)

Common variable immunodeficiency (CVID) Explanation: More than 50% of clients with CVID develop pernicious anemia. Pernicious anemia is not associated with the other conditions. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 990. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 990

When administering intravenous gamma globulin infusion, the nurse recognizes that which of the following complaints, if reported by the client, may indicate an adverse effect of the infusion? a) Flank pain b) Burning urination c) Nasal stuffiness d) Increased thirst

Flank pain Explanation: Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma globulin infusion. Nasal stuffiness is not recognized as an adverse effect of gamma globulin infusion. Increased thirst is not recognized as an adverse effect of gamma globulin infusion. Burning urination is a sign of urinary tract infection, not an adverse effect of gamma globulin infusion. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder? a) Because an autoimmune disease is a neoplastic disease b) For their immunosuppressant effects c) So the client has strong drug therapy d) To decrease the body's risk of infection

For their immunosuppressant effects Explanation: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not ordered just so the client has strong drug therapy. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 35: Assessment of Immune Function, p. 982. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 982

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder? a) To decrease the body's risk of infection b) So the client has strong drug therapy c) Because an autoimmune disease is a neoplastic disease d) For their immunosuppressant effects

For their immunosuppressant effects Explanation: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not ordered just so the client has strong drug therapy. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 35: Assessment of Immune Function, p. 982. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 982

An infant that is 10 hours postdelivery is observed to have tetanic contractions. What symptom does the nurse recognize can indicate DiGeorge syndrome? a) Chronic diarrhea b) Hypocalcemia c) Pernicious anemia d) Neutropenia

Hypocalcemia Explanation: Thymic hypoplasia, also known as DiGeorge syndrome, is associated with recurrent infections, hypoparathyroidism, hypocalcemia, tetany, convulsions, congenital heart disease, possible renal abnormalities, and abnormal facies. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 987. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 987

A patient with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this patient? a) Daily weights and strict monitoring of intake and output b) Meticulous infection control precautions c) Continuous monitoring of cardiac status d) Daily oral assessment and oral care every 4 hours

Meticulous infection control precautions Explanation: Nursing care must be meticulous. Appropriate infection control precautions and thorough hand hygiene are essential. Institutional policies and procedures related to protective care must be followed scrupulously until definitive evidence demonstrates that precautions are unnecessary. Continual monitoring of the patient's condition is critical, so early signs of impending infection may be detected and treated before they seriously compromise the patient's status. It also is imperative that nurses appropriately apply standard precautions (previously known as universal precautions), which have become one of the first-line tools for decreasing transmission of disease. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

A patient is suspected to have an immunodeficiency disorder. The physician orders a nitroblue tetrazolium reductase (NTR) test to diagnose this patient. What does the nurse suspect that this disorder is related to? a) Complement b) Phagocytic cells c) T lymphocytes d) B lymphocytes

Phagocytic cells Explanation: Diagnosis of phagocytic cell disorders is based on the history, signs, and symptoms (see Chart 35-3 in Chapter 35), and laboratory analysis by the nitroblue tetrazolium reductase test, which indicates the cytocidal (causing death of cells) activity of the phagocytic cells. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 988. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 988

You are caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders? a) Progressive tissue damage without any verifiable etiology b) Affects only older adults and infants less than 3 months c) Profound fatigue with no identifiable cause d) Absence of a triggering event

Progressive tissue damage without any verifiable etiology Explanation: Diseases are considered autoimmune disorders and are characterized by unrelenting, progressive tissue damage without any verifiable etiology. In many autoimmune disorders, there tends to be a triggering event, such as an infection, trauma, or introduction of a drug that integrates itself into the membranes of the host's cells. Although older adults face a greater risk of developing autoimmune disorders, persons belonging to any age-group can be affected. Chronic fatigue syndrome is primarily characterized by profound fatigue with no identifiable cause, and this is not a characteristic of autoimmune disorders. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 35: Assessment of Immune Function, p. 970. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 970

Which of the following adverse effects should the nurse closely monitor in a patient who has secondary immunodeficiencies due to immunosuppressive therapy? a) Rheumatoid arthritis b) Respiratory or urinary system infections c) Cardiac dysrhythmias and heart failure d) Depression, memory impairment, and coma

Respiratory or urinary system infections Explanation: Secondary immunodeficiencies occur as a result of underlying disease processes or the treatment of these disorders, including administration of immunosuppressive agents. Abnormalities of the immune system affect both natural and acquired immunity. Because immunodeficiencies result in a compromised immune system and pose a high risk for infection, careful assessment of the patient's immune status is essential. The nurse assesses and monitors the patient for signs and symptoms of infection. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 994. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 994

When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority? a) Anxiety related to an inherited disorder b) Risk for infection related to altered immune cell function c) Impaired skin integrity related to persistent deep skin abscesses d) Grieving related to the poor prognosis of the condition

Risk for infection related to altered immune cell function Explanation: Although anxiety and impaired skin integrity may be appropriate, the priority nursing diagnosis for any immunodeficiency is the risk for infection. Although primary immunodeficiencies can be serious, they are rarely fatal. Therefore, the nursing diagnosis of grieving would be inappropriate. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 994. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 994

Thirty minutes after the nurse begins an intravenous immunoglobulin (IVIG) infusion, the patient complains of itching at the site and a lump in the throat. Which is the first action the nurse should take? a) Administer subcutaneous epinephrine. b) Apply a tourniquet above the infusion site. c) Stop the infusion. d) Notify the physician

Stop the infusion. Explanation: Continually assess the patient for adverse reactions; be especially aware of complaints of a tickle or lump in the throat as the precursor to laryngospasm that precedes bronchoconstriction. Stop the infusions at the first sign of reaction and initiate the institutional protocol to be followed in this emergent situation. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991

A nurse is assessing a patient with a primary immunodeficiency. Afterward she documents that the patient displayed ataxia. Which of the following statements explains the documentation? a) The patient has vascular lesions caused by dilated blood vessels. b) The patient has difficulty swallowing. c) The patient has an inability to understand the spoken word. d) The patient has uncoordinated muscle movements.

The patient has uncoordinated muscle movements. Explanation: Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination). Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

A major manifestation of Wiskott-Aldrich syndrome includes which of the following? a) Ataxia b) Thrombocytopenia c) Episodes of edema d) Bacterial infection

Thrombocytopenia Explanation: Major symptoms of Wiskott-Aldrich syndrome include thrombocytopenia, infections, and malignancies. Ataxia occurs with ataxia-telangiectasia. Episodes of edema in various body parts occur with angioneurotic edema. Bacterial infection occurs with hyperimmunoglobulinemia E syndrome. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 986, 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 986

T-cell deficiency occurs when which of the following glands fails to develop normally during embryogenesis? a) Pituitary b) Adrenal c) Thyroid d) Thymus

Thymus Explanation: T-cell deficiency occurs when the thymus gland fails to develop normally during embryogenesis. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Burning urination b) Increased thirst c) Nasal stuffiness d) Tightness in the chest

Tightness in the chest Explanation: Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion. Nasal stuffiness is not recognized as an adverse effect of gamma-globulin infusion. Increased thirst is not recognized as an adverse effect of gamma-globulin infusion. Burning urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991

Loren Fawcett, an 18-year-old college student, arrived at your ED presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. After stabilizing Loren, you speak with her family and assuring them that she will recover. What type of hypersensitivity did Loren exhibit? a) Type III b) Type II c) Type IV d) Type I

Type I Explanation: There are four types of hypersensitivity responses, three of which are immediate. This is an example of Type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 38: Assessment and Management of Patients with Allergic Disorders, p. 1032. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1032

The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. A clinical manifestation is telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what? a) Peripheral edema b) A condition marked by development of urticaria c) Vascular lesions caused by dilated blood vessels d) Uncoordinated muscle movement

Vascular lesions caused by dilated blood vessels Explanation: Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia refers to uncoordinated muscle movement and is a clinical manifestation of combined B-cell and T-cell deficiencies. Telangiectasia is not peripheral edema, vascular lesions, or urticaria. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements? Primary immunodeficiencies a) develop early in life after protection from maternal antibodies decreases. b) disappear with age. c) develop as a result of treatment with antineoplastic agents. d) occur most commonly in the aged population

develop early in life after protection from maternal antibodies decreases. Explanation: These disorders may involve one or more components of the immune system. Primary immunodeficiencies are seen primarily in infants and young children. Primary immunodeficiencies are rare disorders with genetic origins. Without treatment, infants and children with these disorders seldom survive to adulthood. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, pp. 986-987. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 986

The nursing instructor is discussing allergic reactions with her clinical group. What allergic reactions would the nursing instructor talk about? Select all that apply. a) Immune complex b) Unmediated c) typical d) Cytotoxic e) Atopic

• Atopic • Immune complex • Cytotoxic Correct Explanation: Once sensitization occurs, one of four types of hypersensitivity responses can occur. These may be immediate or delayed depending on the time it takes for the immune system to mount a response. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly. There are three types of immediate hypersensitivity responses: type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies; type II, cytotoxic, which is mediated by immunoglobulin M or G (IgM or IgG) antibodies; and type III, immune complex, which is mediated by IgG antibodies. The first two types of responses occur within minutes; type III responses reach a peak within 6 hours after exposure to an allergen. Atypical and unmediated hypersensitivity responses are distractors for this question. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 38: Assessment and Management of Patients With Allergic Disorders, pp. 1032, 1036. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 1032

The nurse is caring for a patient with an immunodeficiency disorder. What cardinal symptoms of immunodeficiency does the nurse recognize while caring for this patient? (Select all that apply.) a) Chronic diarrhea b) Nonproductive cough c) Poor response to the treatment with antibiotics d) Chronic or recurrent severe infections e) Vomiting

• Chronic diarrhea • Chronic or recurrent severe infections • Poor response to the treatment with antibiotics Explanation: Regardless of the underlying cause, the cardinal symptoms of immunodeficiency include chronic or recurrent and severe infections, infections caused by unusual organisms or by organisms that are normal body flora, poor response to standard treatment for infections, and chronic diarrhea. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 986. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 986

A nursing student is preparing a teaching plan for a client with an immunodeficiency disorder. The student is going to include the cardinal symptoms in teaching. Which of the following would the student include? Choose all that apply. a) Chronic or recurrent severe infections b) Chronic fatigue c) Facial edema d) Poor response to treatment of infections e) Chronic diarrhea

• Chronic diarrhea • Chronic or recurrent severe infections • Poor response to treatment of infections Explanation: Regardless of the underlying cause, the cardinal symptoms of immunodeficiency include chronic or recurrent and severe infections, infections caused by unusual organisms or by organisms that are normal body flora, poor response to standard treatment for infections, and chronic diarrhea. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 986. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 986

Choice Multiple question - Select all answer choices that apply. A nursing student is recalling and discussing a test question with a fellow student. The question asked the students to identify the five disorders of common, primary immunodeficiencies. The student knows that humoral immunity and T-cell defects are two. Choose the other three from the list below. a) Plasma cells b) Phagocytic disorders c) Severe malnutrition d) Complement production e) Combined B- and T-cell defects

• Complement production • Phagocytic disorders • Combined B- and T-cell defects Explanation: Common primary immunodeficiencies include disorders of humoral immunity (affecting B-cell differentiation or antibody production), T-cell defects, combined B- and T-cell defects, phagocytic disorders, and complement deficiencies. Plasma cells and severe malnutrition are not common, primary immunodeficiencies. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, pp. 986-987. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 986

Choice Multiple question - Select all answer choices that apply. A client is diagnosed with common variable immunodeficiency (CVID). Which of the following would the nurse identify as potential infections for this client? Choose all that apply. a) Haemophilus influenzae b) Staphylococcus aureus c) Streptococcus pneumoniae d) Pneumocystis jiroveci pneumonia

• Haemophilus influenzae • Streptococcus pneumoniae • Staphylococcus aureus Explanation: Clients with CVID are susceptible to infections with Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. Opportunistic infections with Pneumocystis jiroveci pneumonia are seen only in clients with a concomitant deficiency in T-lymphoycte immunity. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 990. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 990

Phagocytic dysfunction is characterized by the following. Choose all that apply. a) Rapid heartbeat b) Immunity to infection with herpes simplex c) Increased incidence of bacterial infections d) Manifestation of underlying disease processes e) Chronic eczematoid dermatitis

• Increased incidence of bacterial infections • Chronic eczematoid dermatitis Explanation: In phagocytic cell disorders, incidence of bacterial and fungal infections is increased, resulting from organisms that are normally nonpathogenic. Clients experience recurrent cutaneous abscesses, chronic eczema, bronchitis, pneumonia, chronic otitis media, and sinusitis. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 988. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 988

Which of the following would the nurse expect to assess in a client with ataxia-telangiectasis? Select all that apply. a) Vascular lesions b) Immune deficiency c) Tetany d) Cardiac anomaly e) Loss of muscle coordination

• Loss of muscle coordination • Vascular lesions • Immune deficiency Explanation: Ataxia-telangiectasis is an autosomal-recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination), telangiectasis (vascular lesions cuased by dilated blood vessels), and immune deficiency. Tetany secondary to hypocalcemia and cardiac anomalies are suggestive of DiGeorge syndrome, a primary T-cell immunodeficiency. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 992. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 992

A T-cell deficiency is a disorder characterized by the following manifestations. Choose all that apply. a) Chronic mucocutaneous candidiasis is an associated disorder. b) It is autosomal dominant. c) Adrenal glands fail to develop. d) There is complete lack of antibody production. e) Lymphopenia is usually present

• Lymphopenia is usually present. • Chronic mucocutaneous candidiasis is an associated disorder. Explanation: Defects in T cells lead to opportunistic infections. Most primary T-cell immunodeficiencies are genetic in origin. Partial T-cell immunodeficiencies constitute a heterogenous cluster of disorders characterized by an incomplete reduction in T-cell number or activity. Chronic mucocutaneous candidiasis is a rare T-cell disorder, which is thought to be autosomal recessive and affects both males and females. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 990. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 990

The two types of inherited B-cell deficiencies result from lack of differentiation of B cells. These types result from which two of the following deficiencies? Choose the two that apply. a) Combined B- and T-cells b) Mature B-cells c) Complement production d) Plasma cells

• Mature B-cells • Plasma cells Explanation: Two types of inherited B-cell deficiencies exist. The first type results from lack of differentiation of B-cell precursors into mature B cells. As a result, plasma cells are absent, and the germinal centers from all lymphatic tissues disappear, leading to a complete absence of antibody production against invading bacteria, viruses, and other pathogens. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 988. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 988

Choice Multiple question - Select all answer choices that apply. A nursing instructor is discussing immunodeficiency disorders with students. The instructor tells the class that immunodeficiency disorders are caused by defects or deficiencies in which of the following? Choose all that apply. a) Phagocytic cells b) Immune system c) B and T lymphocytes d) Neurologic system e) The complement system

• The complement system • B and T lymphocytes • Phagocytic cells Explanation: Immunodeficiency disorders may be caused by a defect in or a deficiency of phagocytic cells, B lymphocytes, T lymphocytes, or the complement system. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 986. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 986

Choice Multiple question - Select all answer choices that apply. The nurse is administering an infusion of gamma-globulin to a patient in the hospital. When should the nurse discontinue the infusion? (Select all that apply.) a) When the patient complains of flank pain b) When the patient complains of tightness in the chest c) When the patient complains of nausea d) When the patient voids 30/mL an hour e) When the patient begins to have shaking chills

• When the patient complains of flank pain • When the patient begins to have shaking chills • When the patient complains of tightness in the chest Explanation: Stop the infusions at the first sign of reaction, and initiate the institutional protocol to be followed in this emergent situation. Reactions include complaints of flank and back pain, shaking chills, flushing, dyspnea, and tightness in the chest; headache, fever, muscle cramps, nausea/vomiting, and local reaction at the infusion site. (less) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 36: Management of Patients With Immunodeficiency Disorders, p. 991. Chapter 36: Management of Patients With Immunodeficiency Disorders - Page 991