PNE 111/Health & Disease/PrepU 34
A patient is admitted for the treatment of a primary immunodeficiency and intravenous immunoglobulin (IVIG) is ordered. What should the nurse monitor for as a potential adverse effect of IVIG administration? Joint pain Anaphylaxis Hypothermia Hypertension
Anaphylaxis Explanation: Potential adverse effects of an IVIG infusion include hypotension, flank pain, chills, and tightness in chest, terminating with a slightly elevated body temperature and anaphylactic reaction. Hypertension, hypothermia, and joint pain are not usual adverse effects of IVIG.
The nurse knows the best strategy for latex allergy is antihistamines. avoidance of latex-based products. epinephrine from an emergency kit. corticosteroids.
avoidance of latex-based products. Explanation: The best strategy available for latex allergy is to avoid latex-based products, but this is often difficult because of their widespread use. Antihistamines and an emergency kit containing epinephrine should be provided to these clients, along with instructions about emergency management of latex allergy.
The nurse is preparing to administer a medication that has an affinity for H1 receptors. Which medication would the nurse administer? Diphenhydramine Nizatidine Cimetidine Omeprazole
Diphenhydramine Explanation: Certain medications are categorized by their action at these receptors. Diphenhydramine (Benadryl) is an example of an antihistamine, a medication that displays an affinity for H1 receptors. Cimetidine (Tagamet) and nizatidine (Axid) target H2 receptors to inhibit gastric secretions in peptic ulcer disease.
The nurse is educating a client about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms to report. Which COX-2 inhibitor is the nurse educating the client about? Piroxicam Ibuprofen Tolmetin sodium Celecoxib
Celecoxib Explanation: The COX-2 inhibitor celecoxib (Celebrex) is associated with an increased risk of cardiovascular events, including myocardial infarction and stroke.
While monitoring the patient's eosinophil level, the nurse suspects a definite allergic disorder when seeing an eosinophil value of what percentage of the total leukocyte count? 1% to 3% 5% to 10% 3% to 4% 15% to 40%
15% to 40% Explanation: Eosinophils, which are granular leukocytes, normally make up 0% to 3% of the total number of WBCs (Fischbach & Dunning, 2009). A level between 5% and 15% is nonspecific but does suggest allergic reaction. Higher percentages of eosinophils are considered to represent moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and may be found in patients with allergic disorders.
A 10-year-old boy has been brought to the emergency department (ED) by ambulance in apparent anaphylaxis after accidentally eating a snack bar that contained peanuts. The ED nurse should be aware that this patient's signs and symptoms are attributable to: Dissolution of the basement membranes of epithelium A massive release of histamine Activation of the sympathetic nervous system (SNS) Rapid activation of the clotting cascade
A massive release of histamine Explanation: Anaphylaxis occurs when the body's immune system produces specific IgE antibodies toward a substance that is normally nontoxic (e.g., food such as a peanut). If the substance is ingested more than once, the body releases excess amounts of the protein histamine, resulting in anaphylaxis. The pathophysiology of anaphylaxis is not a consequence of the dissolution of the basement membrane, SNS activation, or inappropriate clotting.
The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family? How to choose antibiotics based on the client's symptoms The need to report any slight changes in the client's health status How to promote immune function through nutrition The importance of maintaining the client's vaccination status
The need to report any slight changes in the client's health status Explanation: They must be informed of the need for continuous monitoring for subtle changes in the client's physical health status and of the importance of seeking immediate health care if changes are detected. Nutrition is important, but infection control is the priority. Clients and families do not choose antibiotics independently. Vaccinations are often contraindicated in immunocompromised clients.
The nurse is teaching a client about histamine release during an anaphylactic reaction. What does histamine release in anaphylaxis cause? nasal congestion stomach cramps feeling of impending doom urinary urgency
nasal congestion Explanation: Histamine release causes sweating, sneezing, shortness of breath, and nasal congestion. Feelings of impending doom are related to activation of IgE and subsequent release of chemical mediators. Urinary urgency and stomach cramps occur from smooth muscle contractions of intestines and bladder.
Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle? Histamine Bradykinin Prostaglandin Serotonin
Histamine Explanation: When cells are damaged, histamine is released. Bradykinin is a polypeptide that stimulates nerve fibers and causes pain. Serotonin is a chemical mediator that acts as a potent vasoconstrictor and bronchoconstrictor. Prostaglandins are unsaturated fatty acids that have a wide assortment of biologic activities.
An immunocompromised client is being treated in the hospital. The nurse's assessment reveals that the client's submandibular lymph nodes are swollen, a finding that represents a change from the previous day. What is the nurse's most appropriate action? Administer a PRN dose of acetaminophen as ordered. Monitor the client's vital signs q2h for the next 24 hours. Inform the client's primary care provider of this finding. Implement standard precautions in the client's care.
Inform the client's primary care provider of this finding. Explanation: Swollen lymph nodes are suggestive of infection and warrant prompt medical assessment and treatment. Acetaminophen is an ineffective response. The nurse should monitor the client's vital signs closely, but the physician should also be informed. Standard precautions should be in place regardless of the client's status.
A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply. Chicken Milk Beef Shrimp Eggs
Milk Shrimp Eggs Explanation: Common food causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Beef and chicken are not common causes.
The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution? Intramuscular Intravenous Intradermal Subcutaneous
Intradermal Explanation: The intradermal route is the correct route of administration for skin testing and therefore a safe route. Another safe route is epicutaneous. The type of skin testing being performed determines whether the nurse will administer the solution via the epicutaneous or intradermal route
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? 6 mL/min 3 mL/min 10 mL/min 1.5 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.
A nurse has developed a latex allergy and now uses latex-free purple gloves to avoid a hypersensitivity response. What in this nurse's reaction to latex differs from all other types of hypersensitivity responses? no antibody production reaction occurs within 6 hours. reaction occurs within minutes. antibody production
no antibody production Explanation: Antibody production is not a component of a delayed hypersensitivity response. A delayed hypersensitivity response may develop over several hours or days, or it may reach maximum severity after repeated exposure.
A school nurse is caring for a 10-year-old who appears to be having an allergic response. Which intervention should be the initial action of the school nurse? Administer epinephrine. Assess for signs and symptoms of anaphylaxis. Administer an over-the-counter (OTC) antihistamine. Assess for erythema and urticaria.
Assess for signs and symptoms of anaphylaxis. Explanation: If a client is experiencing an allergic response, the nurse's initial action is to assess the client for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction.
A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"? Drink plenty of fluids. Be sure to use the nasal spray for at least 10 days to ensure the stuffiness is gone. Only use the nasal spray for 3 to 4 days once every 12 hours. Use the medication every 4 hours to prevent congestion from recurring.
Only use the nasal spray for 3 to 4 days once every 12 hours. Explanation: Adrenergic agents, which are vasoconstrictors of mucosal vessels, are used topically in nasal (oxymetazoline [Afrin]) and ophthalmic (brimonidine [Alphagan P]) formulations in addition to the oral route (pseudoephedrine [Sudafed]). The topical route (drops and sprays) causes fewer side effects than oral administration; however, the use of drops and sprays should be limited to a few days to avoid rebound congestion.
A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid: seafood. alcohol. exposure to sunlight. applying skin moisturizers.
alcohol. Explanation: The nurse should advise a client taking antihistamines not to take it with alcohol or other central nervous system depressants because additive sedative effects can occur.
The nurse is teaching a client after a medication allergic reaction has occurred. What is the most important action for the nurse to teach the client to take to prevent anaphylaxis? Carry an emergency kit. Wear a medical alert bracelet. Avoid potential allergens. Undergo desensitization treatment.
Avoid potential allergens. Explanation: Strict avoidance of potential allergens is the most important preventive measure for the patient at risk for anaphylaxis. People who have experienced food, medication, idiopathic, or exercise-induced anaphylactic reactions should always carry an emergency kit containing epinephrine for injection to prevent the onset of the reaction upon exposure, but avoiding potential allergens is more important. Desensitization, based on controlled anaphylaxis with a gradual release of mediators, is an effective treatment option, but it is more important to avoid allergic triggers. The medical alert bracelet will assist those rendering aid to the patient who has experienced an anaphylactic reaction, but it's better to avoid the reaction in the first place.
Which type of hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign? Cytotoxic Immune complex Anaphylactic Delayed
Cytotoxic Explanation: Cytotoxic hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Anaphylactic hypersensitivity is the most severe immune-mediated reaction. Delayed hypersensitivity occurs 24 to 72 hours after exposure to an allergen. Immune complex hypersensitivity involves immune complexes that are formed when antigens bind to antibodies.
A patient who has received a heart transplant is taking cyclosporine, an immunosuppressant. What should the nurse emphasize during health education about infection prevention? Take prophylactic antibiotics as ordered. Eat a high-calorie, high-protein diet. Perform frequent handwashing. Limit physical activity in order to conserve energy.
Perform frequent handwashing. Explanation: Hand hygiene is imperative in infection control. A well-balanced diet is important, but for most patients this is secondary to hygiene as an infection-control measure. Prophylactic antibiotics are not normally used. Limiting physical activity will not protect the patient from infection.
The client is scheduled for a tilt-table test to assist in the diagnosis of chronic fatigue syndrome (CFS). What is the nurse's responsibility while the client is having the test? Position the client while monitoring blood pressure and pulse. Perform venipuncture for glucose levels during testing. Position the client while monitoring the oxygen saturation. Diagnose the client's chronic fatigue syndrome.
Position the client while monitoring blood pressure and pulse. Explanation: A tilt-table test, one in which the client lies horizontally on a table whose incline is elevated to approximately 79° for 45 minutes, may be done. During the test, the blood pressure and pulse are monitored. The test tends to provoke hypotension in 97% of those eventually diagnosed with CFS. The diagnosis is made by the physician, not the nurse. It is not necessary to monitor the oxygen saturation or glucose levels for testing purposes.
A client is scheduled for a skin test. The client informs the nurse that the client used a corticosteroid earlier today to alleviate allergy symptoms. Which nursing intervention should the nurse implement? Administer sodium valproate to reverse the effects of corticosteroid usage. Modify the skin test to check for grass, mold, or dust allergies only. Cancel and reschedule the skin test when the client stops taking the corticosteroid. Note the corticosteroid use in the electronic health record and continue with the test.
Cancel and reschedule the skin test when the client stops taking the corticosteroid. Explanation: Corticosteroids and antihistamines, including over-the-counter allergy medications, suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. If the client takes one of these medications within this time frame, the nurse should cancel the skin test and reschedule for a time when the client is not taking it. The nurse should not continue with the test. The nurse should not modify the test. Administration of sodium valproate is used to reverse corticosteroid-induced mania, not to reverse it effects, in general.
A nurse is teaching a client about allergic rhinitis. What client statements indicate teaching has been effective? Select all that apply. "I can only have one alcoholic drink while I am taking my antihistamine." "I am allowed to miss only one desensitization appointment before my treatment is affected." "I should use my medication for allergy exacerbation only when my allergy is apparent." "I will remove as much carpet from my house as I can." "I need to reduce my exposure to people that have upper respiratory infections."
"I should use my medication for allergy exacerbation only when my allergy is apparent." "I will remove as much carpet from my house as I can." "I need to reduce my exposure to people that have upper respiratory infections." Explanation: The client should only use their medication when allergy is apparent so they do not develop a tolerance, which can occur when the medication is used all the time. The client should reduce their exposure to people that have upper respiratory infections because they are more susceptible to getting sick. Removing as much carpet from the house as possible will help reduce allergens. The client cannot miss any desensitization appointments because it will interfere with dosage adjustments. While taking an antihistamine, alcohol cannot be consumed at all, as antihistamines can exaggerate the effects of alcohol.
A clinic nurse has been charged with the responsibility of teaching avoidance strategies to an adult patient who has allergic rhinitis. What measure should the nurse recommend to this patient? "Avoid the use of air conditioning whenever possible." "Make sure that there are never air drafts in your home." "If possible, make sure that no one smokes tobacco in your home." "Keep your windows open to ensure adequate air circulation."
"If possible, make sure that no one smokes tobacco in your home." Explanation: Avoidance strategies for allergic rhinitis include maintaining a smoke-free home, keeping windows closed during peak times, and using air conditioning whenever possible. Air drafts do not necessarily exacerbate allergies.
A home health nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurse's teaching? "I need to know how to treat my infections in a home setting." "My family needs to understand that I'll probably need lifelong treatment." "I need to understand how to give my platelet transfusions." "My family needs to understand when I can go get the seasonal flu shot."
"My family needs to understand that I'll probably need lifelong treatment." Explanation: The patient must be made aware that all health-related instructions are lifelong. Immunizations may be contraindicated and infection usually requires inpatient treatment. Platelet transfusions are not indicated for most patients who have immunodeficiencies.
A patient has been diagnosed with an allergy to peanuts. What is a priority for this patient to carry at all times? An H1 blocker An oral airway A medical alert bracelet An EpiPen
An EpiPen Explanation: All patients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed.
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)? Radiation therapy Antibiotics Removal of the thymus gland Bone marrow transplantation
Bone marrow transplantation Explanation: Treatment options for SCID include stem cell and bone marrow transplantation.
A client has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on the client's hands. What should the nurse teach the client to do? Wash her hands with antibacterial soap every few hours. Keep the hands well moisturized at all times. Wear powdered latex gloves when in public. Maintain room temperature at 75 to 80°F (24° to 27°C) whenever possible.
Keep the hands well moisturized at all times. Explanation: Powdered latex gloves can cause contact dermatitis. Skin should be kept well hydrated and should be washed with mild soap. Maintaining room temperature at 75 to 80°F (24° to 27°C) is excessively warm.
The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan? Risk for disuse syndrome related to dermatitis Risk for self-care deficit related to skin lesions Risk for disturbed body image related to skin lesions Risk for ineffective role performance related to dermatitis
Risk for disturbed body image related to skin lesions Explanation: The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of clients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit.
What are expected client outcomes the nurse would include in a plan of care for a client with allergic rhinitis? Select all that apply. The client will wear a dampened mask if dust is a problem The client reports no symptoms of peripheral tingling The client develops cachexia The client controls outdoor precipitating factors The client's lungs will have occasional crackles or rhonchi
The client will wear a dampened mask if dust is a problem The client reports no symptoms of peripheral tingling The client controls outdoor precipitating factors Explanation: Wearing a dampened mask if there is a dust problem, reporting no symptoms of peripheral tingling, and controlling outdoor precipitating factors are all expected client outcomes that would be included in a plan of care. Lungs should be absent of crackles or rhonchi. Cachexia is seen in clients with a chronic illness, such as AIDS, chronic obstructive pulmonary disease, or heart failure.
The nurse is conducting a community education program on allergies and anaphylactic reactions. The nurse determines that the participants understand the education when they make which statement about anaphylaxis? The most common cause of anaphylaxis is penicillin. Systemic reactions include urticaria and angioedema. The most common food item that causes anaphylaxis is chocolate. Anaphylactoid (anaphylaxis-like) reactions are commonly fatal.
The most common cause of anaphylaxis is penicillin. Explanation: The most common cause of anaphylaxis is penicillin, accounting for about 75% of fatal anaphylactic reactions in the United States. Although possibly severe, anaphylactoid reactions are rarely fatal. Food items that are common causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Local reactions usually involve urticaria and angioedema at the site of the antigen exposure. Systemic reactions, which occur within about 30 minutes of exposure, involve cardiovascular, respiratory, gastrointestinal, and integumentary organ systems
A nurse is providing health education regarding self-care to a patient with an immunodeficiency. What teaching point should the nurse emphasize? The need for thorough oral hygiene The need to keep fingernails and toenails closely trimmed The importance of aggressive treatment of acne The importance of avoiding alcohol-based cleansers
The need for thorough oral hygiene Explanation: Many patients develop oral manifestations and need education about promoting good dental hygiene to diminish the oral discomfort and complications that frequently result in inadequate nutritional intake. Alcohol cleansers do not necessarily need to be avoided and nail care is not a central concern. Acne care is not a main focus of education, since it is not relevant to many patients.
Atopic allergic disorders are characterized by a hereditary predisposition. an IgA-mediated reaction. production of a systemic reaction. a response to physiologic allergens.
a hereditary predisposition. Explanation: Atopic allergic disorders are characterized by a hereditary predisposition and production of a local reaction to IgE antibodies produced in response to common environmental allergens. Atopic and nonatopic allergic disorders are IgE-mediated allergic reactions.
A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include hypotension. hypoglycemia. diuresis. adrenal suppression.
adrenal suppression. Explanation: The nurse should instruct the client that side effects of oral corticosteroid therapy include adrenal suppression, fluid retention, weight gain, glucose intolerance, hypertension, and gastric irritation.
A client has begun sensitivity testing to determine the allergen which caused an anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more sensitive to allergens? upper arm forearm chest back
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.
A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit? type 1 type 11 type 111 type 1V
type 1 type 11 type 111 type 1V 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.
The nurse is evaluating a client's complete blood cell count and differential along with the serum immunoglobulin E (IgE) concentration. Which result might indicate that the client has an allergic disorder? Low white blood cell count Low eosinophil count High neutrophil count High IgE concentration
High IgE concentration Explanation: A high total IgE concentration and/or a high percentage of eosinophils may indicate an allergic disorder. However, normal IgE levels do not exclude the diagnosis of an allergic disorder. The amounts of neutrophils and white blood cells are not affected by allergic disorders.
Which of the following disorders is characterized by an increased autoantibody production? Scleroderma Rheumatoid arthritis (RA) Polymyalgia rheumatic Systemic lupus erythematosus (SLE)
Systemic lupus erythematosus (SLE) Explanation: SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.
A nurse is planning the care of a client who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this client? Antibiotic administration Thorough and consistent hand hygiene Administration of IVIG Appropriate use of gloves and goggles
Thorough and consistent hand hygiene Explanation: Hand hygiene is usually considered the most important aspect of infection control. IVIG and antibiotics are not considered infection control measures, though they enhance resistance to infection and treat infection. Gloves and goggles are sometimes indicated but are less effective than hand hygiene.
T-cell deficiency occurs when which gland fails to develop normally during embryogenesis? Adrenal Pituitary Thymus Thyroid
Thymus Explanation: T-cell deficiency occurs when the thymus gland fails to develop normally during embryogenesis.
A patient was seen in the clinic for hypertension and received a prescription for a new antihypertensive medication. The patient arrived in the emergency department a few hours after taking the medication with severe angioedema. What medication prescribed may be responsible for the reaction? Vasodilator Angiotensin-converting enzyme (ACE) inhibitor Angiotensin receptor blocker Beta blocker
Angiotensin-converting enzyme (ACE) inhibitor Explanation: Several frequently prescribed medications, such as angiotensin-converting enzyme inhibitors and penicillin, may cause angioedema. The nurse needs to be aware of all medications the patient is taking and be alert to the potential of angioedema as a side effect.
A patient's primary immunodeficiency disease is characterized by the inability of white blood cells to initiate an inflammatory response to infectious organisms. What is this patient's most likely diagnosis? Hyperimmunoglobulinemia E syndrome Wiskott-Aldrich syndrome Chronic granulomatous disease Common variable immunodeficiency
Hyperimmunoglobulinemia E syndrome Explanation: In one rare type of phagocytic disorder, hyperimmunoglobulinemia E syndrome (formerly known as Job syndrome), white blood cells cannot initiate an inflammatory response to infectious organisms. The other listed health problems do not have this pathology.
A client with a family history of allergies has experienced an allergic response based on a genetic predisposition. This atopic response is usually mediated by which immunoglobulin (Ig)? IgE IgA IgG IgM
IgE Explanation: Atopy refers to allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions. IgE (0.004% of total Ig) appears in serum; takes part in allergic and some hypersensitivity reactions; and combats parasitic infections. IgA (15% of total Ig) appears in body fluids (blood, saliva, tears, and breast milk, as well as pulmonary, gastrointestinal, prostatic, and vaginal secretions); protects against respiratory, gastrointestinal, and genitourinary infections; prevents absorption of antigens from food; and passes to neonate in breast milk for protection. IgM (10% of total Ig) appears mostly in intravascular serum; appears as the first Ig produced in response to bacterial and viral infections; and activates the complement system. IgG (75% of total Ig) appears in serum and tissues (interstitial fluid); assumes a major role in bloodborne and tissue infections; activates the complement system; enhances phagocytosis; and crosses the placenta.
A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed diagnostic workup that reveals a phagocytic disorder. This patient faces an increased risk of what complication? Thrombocytopenia Hemophilia HIV/AIDS Neutropenia
Neutropenia Explanation: Patients with phagocytic cell disorders may develop severe neutropenia. None of the other listed health problems is a common complication of phagocytic disorders.
Which acts as a potent vasoconstrictor and causes bronchial smooth muscle to contract? Platelet-activating factor Serotonin Prostaglandin Bradykinin
Serotonin Explanation: Serotonin acts as a potent vasoconstrictor and causes contraction of bronchial smooth muscle. Bradykinin is a polypeptide with the ability to cause increased vascular permeability, vasodilation, hypotension, and contraction of many types of smooth muscle, such as the bronchi. Prostaglandin is a polypeptide that stimulates nerve fibers and causes pain. Platelet-activating factor is responsible for initiating platelet aggregation and leukocytes, as well as vasodilation and increased capillary permeability.
A nurse is preparing to discharge a patient with an immunodeficiency. When preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize? Sterile technique for establishing a new IV site Formulas for calculating daily doses Signs and symptoms of adverse reactions Technique for adding medications to the IVIG
Signs and symptoms of adverse reactions Explanation: The patient who is to receive IVIG at home will need information about adverse reactions and their management. A patient would not start a new IV site independently and the patient does not calculate changes in dose independently. Medications are not added to IVIG.
A nurse caring for a client who has an immunosuppressive disorder knows that continual monitoring of the client is critical. What is the primary rationale behind the need for continual monitoring? So that the client's functional needs can be met immediately So that early signs of impending infection can be detected and treated So that medications can be given as prescribed and signs of adverse reactions noted So that the nurse's documentation can be thorough and accurate
So that early signs of impending infection can be detected and treated Explanation: Continual monitoring of the client's condition is critical, so that early signs of impending infection may be detected and treated before they seriously compromise the client's status. Continual monitoring is not primarily motivated by the client's functional needs or medication schedule. The nurse's documentation is important, but less than infection control.
Which allergic reaction is potentially life threatening? None of the listed allergic reactions is potentially life threatening. angioedema urticaria contact dermatitis
angioedema Explanation: Angioedema is potentially life threatening. Medical management would include intubation, subcutaneous epinephrine, and aminophylline in severe reactions.
The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as angioneurotic edema. urticaria. pitting edema. contact dermatitis.
angioneurotic edema. Explanation: The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit. Urticaria (hives) is characterized as edematous skin elevations that vary in size and shape, itch, and cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema is the result of increased interstitial fluid and associated with disorders such as congestive heart failure.
The nurse is administering intravenous vancomycin. What will the nurse initially assess the client for if an allergic reaction occurs? the severity of cutaneous warmth and flushing dyspnea, bronchospasm, and/or laryngeal edema hypotension and tachycardia the presence and location of pruritus
dyspnea, bronchospasm, and/or laryngeal edema Explanation: Initial nursing assessment and intervention needs to be directed toward evaluating breathing and maintaining an open airway, so the initial assessment will be for dyspnea, bronchospasm, and laryngeal edema. Hypotension, pruritis, and flushing may occur, but the airway is most important
A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action? encouraging activity decreasing anxiety providing pain relief measures maintaining an open airway
maintaining an open airway Explanation: The priority action at this time is maintaining an open airway because the client is experiencing a severe allergic reaction that is compromising the airway and ability to inhale. There is no indication that the client's difficulty breathing is causing pain. Anxiety and activity are important, but the priority is the client's airway.
A client with multiple food and environmental allergies expresses frustration and anger over having to be so watchful all the time and wonders if it is really worth it. Which response by the nurse would be best? "I can only imagine how you feel. Would you like to talk about it?" "Do you think that maybe you could be managing things more efficiently?" "That's the same way that most clients who have a chronic illness feel." "Let's find a quiet spot, and I'll teach you a few coping strategies."
"I can only imagine how you feel. Would you like to talk about it?" Explanation: To assist the client in adjusting to these modifications, the nurse must have an appreciation of the difficulties encountered by the client. The client is encouraged to verbalize feelings and concerns in a supportive environment and to identify strategies to deal with them effectively. The nurse should not suggest that the client has been mismanaging this health problem, and the nurse should not make comparisons with other patients. Further assessment should precede educational interventions.
A junior nursing student is having an observation day in the operating room. Early in the day, the student reports eye swelling and dyspnea to the OR nurse. What should the nurse suspect? Cytotoxic reaction due to contact with the powder in the gloves Immune complex reaction due to contact with anesthetic gases Anaphylaxis due to a latex allergy Delayed reaction due to exposure to cleaning products
Anaphylaxis due to a latex allergy Explanation: Immediate hypersensitivity to latex, a type I allergic reaction, is mediated by the IgE mast cell system. Symptoms can include rhinitis, conjunctivitis, asthma, and anaphylaxis. The term latex allergy is usually used to describe the type I reaction. The rapid onset is not consistent with a cytotoxic reaction, an immune complex reaction, or a delayed reaction.
A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education? "I may experience itching and irritation at the site of the testing." "The test may be mildly uncomfortable." "I'll go directly to the pharmacy with my EpiPen prescription." "If I notice tingling in my lips or mouth, gargling may help the symptoms."
"If I notice tingling in my lips or mouth, gargling may help the symptoms." Explanation: The client requires further teaching if the client states, "I will gargle to help alleviate tingling in the lips or mouth." Allergy testing introduces potentially irritating substances to the client. Tingling in the mouth, lips, or throat indicates the onset of a severe reaction and the need for immediate medical intervention. The testing may cause irritation and itching at the test site. The health care provider may order an epinephrine pen (EpiPen) for the client to self-administer epinephrine if the client experiences an allergic reaction away from the office setting.
A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse? "I am sorry that you are feeling poorly but this is the only medication that will work for your problem." "The full benefit of the medication may take up to 2 weeks to be achieved." "You may be immune to the effects of this medication and will need something else in its place." "You need to come back to the clinic to get a different medication since this one is not working for you."
"The full benefit of the medication may take up to 2 weeks to be achieved." Explanation: Patients must be aware that full benefit of corticosteroid nasal sprays may not be achieved for several days to 2 weeks.
An experienced medical nurse has provided care for patients who have immunodeficiencies that are primary, as well as for patients who have secondary immunodeficiencies. Which of the following individuals is most clearly exhibiting secondary immunodeficiency? A man who developed deep vein thrombosis (DVT) after being immobilized during recovery from orthopedic surgery An elderly resident of a long-term care facility who has been diagnosed with the Norwalk virus A child who had an allergic reaction to a scheduled immunization A woman whose diagnosis of sepsis is attributable to her recent chemotherapy
A woman whose diagnosis of sepsis is attributable to her recent chemotherapy Explanation: Secondary immunodeficiencies affect the normal immune system of the patient, resulting in increased susceptibility to infection and certain types of cancer. Chemotherapy is an example of a factor that can precipitate this susceptibility. Development of postoperative DVT and allergic reactions are not example of secondary immunodeficiency. Infection often results from a secondary immunodeficiency, but not every infection is attributable to this factor.
The nurse is preparing to administer IVIG to a patient who has an immunodeficiency. What nursing guideline should the nurse apply? Slow the infusion rate if the patient exhibits signs of a transfusion reaction. Administer pretreatment medications as ordered 30 minutes prior to infusion. Do not exceed an infusion rate of 300 mL/hr. Weigh the patient immediately after the infusion is complete.
Administer pretreatment medications as ordered 30 minutes prior to infusion. Explanation: The nurse should administer pretreatment acetaminophen and diphenhydramine as prescribed 30 minutes before the start of the infusion. The patient should be weighed prior to the treatment and the IV infusion rate should not exceed 200 mL/hour. The nurse should stop the transfusion in the event of any signs of a reaction.
A client is distressed and frustrated reporting severe, ongoing fatigue that doesn't subside with rest. The nurse explains that chronic fatigue syndrome results from: immune system dysregulation. a combination of immune defects and viral assaults. All options are correct. impaired activation of three neuroendocrine structures: the hypothalamus, pituitary gland, and adrenal glands.
All options are correct. Explanation: No cause for CFS has yet been established. Many theories exist to explain the symptoms. Some believe that the disorder results from immune system dysregulation, in which the immune system remains activated for an extended period after an infectious triggering event. The fact that serum cortisol levels are low among those with CSF symptoms has led to the hypothesis that CSF is a consequence of impaired activation of the hypothalamus, pituitary gland, and adrenal glands. Evidence is mounting that CFS is caused by a combination of immune defects and viral assaults
A mother has come to the emergency department (ED) with her 2-year-old who appears to be having a hypersensitivity reaction. The ED nurse knows that a hypersensitivity reaction may be characterized by an immediate reaction beginning within minutes of exposure to an antigen. What condition is an example of such a reaction? Hay fever Rheumatoid arthritis Skin reaction from tape adhesive Anaphylactic reaction immediately following a bee sting
Anaphylactic reaction immediately following a bee sting Explanation: Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by IgE antibodies and requires previous exposure to the specific antigen. Type II reactions, or cytotoxic hypersensitivity, occur when the system mistakenly identifies a normal constituent of the body as foreign. Type III, or immune complex hypersensitivity, occurs as the result of two factors, the increased amount of circulating complexes and the presence of vasoactive amines. Type IV, or delayed-type hypersensitivity, occurs 24 to 72 hours after exposure to an allergen and is mediated by sensitized T-cells and macrophages.
The nurse is creating a discharge teaching plan for a client with a latex allergy. Which information should be included? Select all that apply. Avoidance of latex-based products Administration of emergency epinephrine Administration of antihistamines Radioallergosorbent testing (RAST)
Avoidance of latex-based products Administration of emergency epinephrine Administration of antihistamines Explanation: The nurse should include in the discharge teaching plan avoidance of latex-based products. Additionally, the nurse should include administration of antihistamines and an emergency epinephrine. RAST testing would not be indicated; it is a diagnostic test for allergies, and the client's latex allergy is already diagnosed.
A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? The client must not have received an immunization within 7 days. Prophylactic epinephrine should be given before the test. The nurse should administer albuterol 30 to 45 minutes prior to the test. Emergency equipment should be readily available.
Emergency equipment should be readily available. Explanation: Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing.
For a client with chronic fatigue syndrome (CFS), what should the nurse emphasize during client teaching? Ensure a balance of activity and rest. Avoid psychotherapy. Experiment with herbal products. Alter diet to exclude red meat and alcohol.
Ensure a balance of activity and rest. Explanation: Without any definitive drug treatment, the client is advised to balance activity with rest. Some clients benefit from cognitive therapy, a form of psychotherapy in which people learn skills to change distorted thoughts about themselves. Herbal products also have potential side effects and toxic effects; therefore, consult with the physician and keep him or her informed of any alternative therapeutic approaches being used. No scientific evidence has shown that excluding red meat will alter the course of CFS.
After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action? Maintains pressure on the auto-injector for about 30 seconds after insertion Avoids massaging the injection site after administration Pushes down on the grey release cap to administer the medication Jabs the autoinjector into the outer thigh at a 90-degree angle
Jabs the autoinjector into the outer thigh at a 90-degree angle Explanation: To self-administer epinephrine, the client should remove the autoinjector from its carrying tube, grasp the unit with the black tip (injecting end) pointed downward, form a fist around the device, and remove the gray safety release cap. Then the client should hold the black tip near the outer thigh and swing and jab firmly into the outer thigh at a 90-degree angle until a click is heard. Next, the client should hold the device firmly in place for about 10 seconds, remove the device, and massage the site for about 10 seconds.
Grace Walters, a 73-year-old female, is a client on the surgical floor where you practice nursing. She is returning from surgical hip repair and has an adhesive patch covering her incision. She has a history of an allergic disorder. Which of the following nursing actions is most important when assessing the dressing site of Mrs. Walters? Apply moisturizer to the site before sticking the patch. Ensure that Mrs. Walters is lying down in a comfortable position. Apply pressure to ensure that the patch is firmly in place. Observe Mrs. Walters for signs of allergic reaction.
Observe Mrs. Walters for signs of allergic reaction. Explanation: Though it is important to ensure that the client is comfortable and the patch is firmly in place, it is not as essential as observing for an allergic reaction. Applying moisturizer to the site may interfere with the results of the patch test.
Which intervention is the single most important aspect for the client at risk for anaphylaxis? Use of antihistamines Wearing a medical alert bracelet Desensitization Prevention
Prevention Explanation: Prevention involves strict avoidance of potential allergens for the individual at risk for anaphylaxis. If avoidance of or exposure to allergens is impossible then the individual should be prepared with an emergency kit containing epinephrine for injection to prevent the onset of the reaction upon exposure. While helpful, there must be no lapses in desensitization therapy because this may lead to the reappearance of an allergic reaction when the medication is reinstituted. A medical alert bracelet will assist those rendering aid to a client who has experienced an anaphylactic reaction. antihistamines may not be effective in preventing anaphylaxis.
A nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care? Risk for Constipation Related to Decreased Gastric Motility Fatigue Related to Pernicious Anemia Risk for Falls Due to Loss of Muscle Coordination Disturbed Kinesthetic Sensory Perception Related to Vascular Changes
Risk for Falls Due to Loss of Muscle Coordination 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. Decreased coordination is likely to constitute a risk for falls. The patient does not characteristically lose tactile sensation or experience pernicious anemia or constipation.
A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines? Sedation Diarrhea Palpitations Anorexia
Sedation Explanation: Antihistamines are the major class of medications prescribed for the symptomatic relief of allergic rhinitis. The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines.
