303 Hinkle PrepU Chapter 37: Assessment and Management of Patients With Allergic Disorders

Which term refers to an incomplete antigen?

hapten A hapten is an incomplete antigen. An allergen is a substance that causes manifestations of allergy. An antigen is a substance that induces the production of antibodies. An antibody is a protein substance developed by the body in response to and interacting with a specific antigen.

When evaluating a client's knowledge about use of antihistamines, what statement indicates further education is required?

"If I am pregnant, I should take half the dose" Antihistamines are contraindicated during the third trimester of pregnancy, in nursing mothers and newborns, in children and elderly people, and in patients whose conditions may be aggravated by muscarinic blockade (e.g., asthma, urinary retention, open-angle glaucoma, hypertension, prostatic hyperplasia). The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines. Additional side effects include nervousness, tremors, dizziness, dry mouth, palpitations, anorexia, nausea, and vomiting.

The nurse tells the client that if exposure to an allergen occurs around 8:00 AM, then the client should expect a mild or moderate reaction by what time?

10:00am Mild and moderate reactions begin within 2 hours of exposure.

The maximum intensity of histamine occurs within which time frame after contact with an antigen?

5 to 10 minutes Histamine's effects peak 5 to 10 minutes after antigen contact. The other time frames are inaccurate.

The nurse is administering a sympathomimetic drug to a patient. What areas of concern does the nurse have when administering this drug? (Select all that apply.)

Causes bronchodilation Constricts integumentary smooth muscle Dilates the muscular vasculature The patient must be aware of the effects caused by overuse of the sympathomimetic agents in nose drops or sprays, because a condition referred to as rhinitis medicamentosa may result. After topical application of the medication, a rebound period occurs in which the nasal mucous membranes become more edematous and congested than they were before the medication was used.

A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include

adrenal suppression 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.

The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?

intradermal 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 working with a client with allergies. What will the nurse use to confirm allergies and decrease the risk of anaphylaxis?

intradermal testing The diagnosis of anaphylaxis risk is determined by prick and intradermal skin testing. Skin testing of patients who have clinical symptoms consistent with a type I, IgE-mediated reaction has been recommended. A nasal smear, punch biopsy, and peripheral blood smear would not be used for allergy testing.

The nurse is teaching a client about contact dermatitis. What type of contact dermatitis requires light exposure in addition to allergen contact?

photo allergenic Photoallergic contact dermatitis resembles allergic dermatitis, but it requires light exposure in addition to allergen contact to produce immunologic reactivity. Phototoxic contact dermatitis resembles the irritant type, but it requires sunlight in combination with the chemical to damage the epidermis. Allergic contact dermatitis results from contact of skin with a allergenic substance. Irritant contact dermatitis results from contact with a substance that chemically or physically damages the skin on a nonimmunologic basis.

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 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, shape, and itch, which cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema, the result of increased interstitial fluid, is associated with disorders such as congestive heart failure.

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?

avoid potential allergens 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.

A nurse comes to the employee health center for evaluation and is diagnosed with allergic contact dermatitis related to latex. What manifestation would the nurse most likely exhibit?

blistering Manifestations associated with allergic contact dermatitis related to latex include blisters, pruritus, erythema, swelling, and crusting or other skin lesions. Laryngeal edema, rhinitis, and angioedema would be noted with a latex allergy.

While interviewing a client with an allergic disorder, the client tells the nurse about an allergy to animal dander. The nurse knows that animal dander is what type of substance?

complete protein antigen Animal dander is considered a complete protein antigen. Immunoglobulins are antibodies formed by lymphocytes and plasma cells. Chemical mediators are substances released by the mast cells upon stimulation by an antigen. T-lymphocytes assist the B cells in producing antibodies.

A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply.

milk shrimp eggs Common food causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Beef and chicken are not common causes.

T-cell deficiency occurs when which gland fails to develop normally during embryogenesis?

thymus T-cell deficiency occurs when the thymus gland fails to develop normally during embryogenesis.

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?

IgE Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates complement. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.

A pediatric client is recovering from an anaphylactic reaction to an allergen which brought him to the ED. The client's mother is quite concerned with the potential reoccurrence of her child's reaction. In attempting to narrow down the possible allergen, it is important to consider that clinical manifestations generally correlate with:

route of exposure Clinical manifestations generally correlate with the manner in which the allergen enters the body. For example, inhaled allergens usually cause respiratory symptoms, including nasal congestion, runny nose, sneezing, coughing, dyspnea, and wheezing. Inhaled allergens often trigger asthma.

A patient with a history of allergies comes to the clinic for an evaluation. The following laboratory test findings are recorded in a patient's medical record:Total serum IgE levels: 2.8 mg/mLWhite blood cell count: 5,100/cu mmEosinophil count: 4%Erythrocyte sedimentation rate: 20 mm/hThe nurse identifies which result as suggesting an allergic reaction?

serum IgE level Normally, serum IgE levels are below 1.0 mg/mL. The patient's level is significantly elevated suggesting allergic reaction. The other values are within normal parameters.

The nurse explains to a client that immunotherapy initially starts with injections at which interval?

weekly Typically, immunotherapy begins with very small amounts and gradually increases, usually at weekly intervals until a maximum tolerated dose is attained. Then maintenance booster injections are administered at 2- to 4-week intervals, frequently for a period of several years.

The nurse is teaching a client with allergic rhinitis about medications. What medication is a mast cell stabilizer used in the treatment of allergic rhinitis?

intranasal cromolyn sodium Intranasal cromolyn sodium is a mast cell stabilizer. Tetrahydrozoline hydrochloride, oxymetazoline hydrochloride, and pseudoephedrine hydrochloride are adrenergic agents.

A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply.

Administer Diphenhydramine. Insert an intravenous line. Have respiratory therapy provide an albuterol treatment. Administering diphenhydramine reverses the effect of histamine. Inserting an intravenous line will allow access to administer medications quickly. Metoprolol is a medication used to treat hypertension or chest pain. Administering an albuterol treatment reverses histamine-induced bronchospasm. The international normalized ratio (INR) level is monitored for warfarin treatment.

A client is prescribed montelukast as part of a treatment plan for an allergic disorder. The nurse understands that this drug belongs to which class?

leukotriene receptor antagonist Montelukast is classified as a leukotriene-receptor antagonist. Cromolyn sodium is a mast cell stabilizer. Cetirizine, loratadine, and fexofenadine are nonsedating antihistamines. Beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, and triamcinolone are corticosteroids.

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?

for their immunosuppressant effects 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.

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?

jab the autoinjector into the outer thigh at a 90 degree angle 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.

The nurse teaches the client with allergies about anaphylaxis, including which statement?

the most common cause of anaphylaxis is penicillin The most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the United States, is penicillin. 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 occur within about 30 minutes of exposure involving cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.

The nurse is teaching a group of health care workers about latex allergies. What reaction will the nurse teach the workers to be most concerned about with laryngeal edema?

IgE mediated hypersensitivity A type I, IgE-mediated hypersensitivity can cause severe reaction symptoms such as laryngeal edema and bronchospasm. Irritant and allergic contact dermatitis result in more localized skin reactions. IgG antibodies are important in fighting viral and bacterial infections.

What is the most common cause of anaphylaxis?

penicillan Penicillin is the most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the United States each year. Opioids, NSAIDs, and radiocontrast agents are some of the medications that are frequently reported as causing anaphylaxis.

A health care provider prescribed fluticasone for a client with a severe case of allergic rhinitis. The client took a first dose on February 2. What is the latest date by which the drug will be fully effective?

February 15 The full benefit of fluticasone (Flonase) should occur no later than *14 days* after the first dose. The drug was initiated on February 2. Thirteen days later would be February 15.

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"?

Only use the nasal spray for 3 to 4 days once every 12 hours. 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 patient comes to the clinic with pruritus and nasal congestion after eating shrimp for lunch. The nurse is aware that the patient may be having an anaphylactic reaction to the shrimp. These symptoms typically occur within how many hours after exposure?

2 hours Mild systemic, anaphylactic reactions consist of peripheral tingling and a sensation of warmth, possibly accompanied by a sensation of fullness in the mouth and throat. Nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes can also be expected. Onset of symptoms begins within the first 2 hours after exposure.

The parents of a child with contact dermatitis are asking questions about the reaction within the immune system. What description regarding contact dermatitis as a type IV hypersensitivity reaction is accurate?

a delayed type hypersensitivity that is mediated by T cells Contact dermatitis is a delayed-type hypersensitivity response that can occur 24 to 72 hours after exposure to an allergen.

A patient has been diagnosed with an allergy to peanuts. What is a priority for this patient to carry at all times?

an EpiPen All patients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed.

Which allergic reaction is potentially life threatening?

angioedema Angioedema is potentially life threatening. Medical management would include intubation, subcutaneous epinephrine, and aminophylline in severe reactions.

The nurse is working in an allergy clinic with a client with tuberculosis. What other reaction is a type IV hypersensitivity disorder?

contact dermatitis Tuberculosis and contact dermatitis are type IV hypersensitivity reactions. Anaphylaxis, allergic rhinitis, and atopic dermatitis are type I hypersensitivity reactions.

A client presents to the clinic with complaints that he began to itch and break out in hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?

diphenhydramine Diphenhydramine is an antihistamine which blocks histamine receptors and is used for allergic reactions. Flunisolide is a nasal decongestant agent and is used locally to the nasal mucosa. Beclomethasone dipropionate is a nasal steroid spray and inhalant. Pseudoephedrine hydrochloride only constricts nasal membranes.

The nurse is preparing to administer a medication that has an affinity for H1 receptors. Which medication would the nurse administer?

diphenhydramine 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.

When assessing the skin of a client with allergic contact dermatitis, the nurse would most likely expect to find irritation at which area?

dorsal aspect of the hand With allergic contact dermatitis, irritation is most common on the dorsal aspects of the hand. Irritant, phototoxic, and photoallergic types of contact dermatitis are commonly seen on the hands and lower arms.

The nurse is talking to a group of community volunteers about food allergies. What are the foods that cause the most severe allergic reactions and result in the highest client death rates?

peanut and tree nuts Peanuts, cashews, and walnuts are responsible for the most severe allergic reactions. Some individuals are so sensitive that they can have a reaction just by being close enough to the food product to smell it or having the nut oil on their hands. While other foods like seafood, milk, chocolate, berries and seeds cause allergic responses, reactions to these foods do not lead to the highest death rates.

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 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.

The nurse is evaluating a client's complete blood cell count and differential along with the serum immunoglobulin E (IgE) concentration. Which result might indicate that the client has an allergic disorder?

high IgE concentration A 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 statement describes the clinical manifestations of a delayed hypersensitivity (type IV) allergic reaction to latex?

they are localized to the area of exposure, usually the back of the hands Clinical manifestations of a delayed hypersensitivity reaction are localized to the area of exposure. Clinical manifestations of an irritant contact dermatitis can be eliminated by changing glove brands or using powder-free gloves. With an irritant contact dermatitis, avoid use of hand lotion before donning gloves; this may worsen symptoms, as lotions may leach latex proteins from the gloves. Described as a latex allergy, when clinical manifestations occur within minutes after exposure to latex, an immediate hypersensitivity (type I) allergic reaction has occurred.

The nurse is caring for a client exposed to peanuts with a known allergy. What assessment is considered the most serious manifestation of angioneurotic edema?

laryngeal swelling Diffuse swelling can affect many regions: lips, eyelids, cheeks, hands, feet, genitalia, tongue, larynx, bronchi, and the gastrointestinal canal. The most serious is the larynx because of the potential for compromised breathing. Abdominal pain, conjunctivitis and urticaria are not the most serious manifestations.

A client with an allergic disorder calls the nurse and asks what treatment is available for allergic disorders. The nurse explains to the client that there is more than one treatment available. What treatments would the nurse tell the client about?

desensitization Desensitization is another option. 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. SLIT is a form of desensitization therapy. Options C and D are distractors for this question.

The nurse is administering intravenous vancomycin. What will the nurse initially assess the client for if an allergic reaction occurs?

dyspnea, bronchospasm, and/or laryngeal edema 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 is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?

type 1 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 teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply.

Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Carry EpiPen autoinjector at all times. Wearing a medic alert bracelet allows others to be alerted of the allergy. Listing symptoms of the allergy makes the client aware of the allergic reaction if symptoms are being experienced. Identifying ways to manage allergies while dining out allows the client to be safe from a potential reaction. All food labels should be read not only baked items. The EpiPen autoinjector should be carried at all times in case it needs to be administered because of an allergic reaction.

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?

autoimmune 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.

Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?

histamine 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.

The nurse is teaching a client about the symptoms of anaphylaxis. Which client statements indicate no further teaching is needed? Select all that apply.

"If I start having difficulty breathing, I need to get help right away." "Peripheral tingling is a symptom of anaphylaxis reaction." Difficulty breathing is a life-threatening symptom of anaphylaxis and requires help right away. Peripheral tingling is a symptom of anaphylaxis reaction. Recurrent diarrhea is not a symptom of anaphylaxis. Sneezing is not a symptom of anaphylaxis reaction. A feeling of fullness in the mouth is a symptom of anaphylaxis reaction.

The nurse is conducting discharge teaching for a client who is being discharged from the emergency department after an anaphylactic reaction to peanuts. Which education should the nurse include in the teaching? Select all that apply.

Wearing a medical alert bracelet Avoiding allergens People who have experienced food, medication, idiopathic, or exercise-induced anaphylactic reactions should make every attempt to strictly avoid the allergen. Additionally, they should wear a medical alert bracelet and carry an emergency kit containing epinephrine for injection to prevent the onset of the reaction on exposure. Sedatives are not used to treat anaphylactic reactions, and desensitization is not used for peanut allergies.

A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

"If I notice tingling in my lips or mouth, gargling may help the symptoms." 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.

The nurse is teaching a client about a recent order for loratadine to help with seasonal allergies. What client statements indicate no further teaching is required? Select all that apply.

"Taking my medication on an empty stomach is a must." "Sucking on ice chips will help if my mouth is dry." "Being careful driving is important after taking the medication." "It is recommended that I buy a humidifier for my bedroom." Client education includes instructing the client to take the medication on an empty stomach to prevent food from interfering with absorption. Avoid alcohol because the medication can cause increased drowsiness. A side effect is dry mouth, and sucking on ice chips will help. Being careful when driving is important because the medication can cause drowsiness. Using a humidifier will help decrease the negative symptoms associated with humidity.

The nurse is teaching a client about histamine release during an anaphylactic reaction. What does histamine release in anaphylaxis cause?

nasal congestion 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.

The nurse is teaching a client about allergic rhinitis and its triggers. What is the most common trigger for the respiratory allergic response?

plant pollen Plant pollen (from trees, grass, and other plants) causes the most common form of allergic rhinitis, which is known as hay fever. Animal dander, dust mites, and mold spores can be triggers, but are not the most common causes.

The nurse is completing the intake assessment of a client new to the allergy clinic. The client states that he was taking nose drops six times a day to relieve his nasal congestion. The nasal congestion increased, causing him to increase his usage of the nasal spray to eight times a day. But again the congestion worsened. The nurse communicates to the health care provider that the client experienced

rhinitis medicamentosa Rhinitis medicamentosa is a rebound reaction from overuse of sympathomimetic nose drops or sprays that worsen the congestion, causing the client to use more of the medication, thereby leading to more nasal congestion. This differs from tolerance, when more medication is needed to achieve the desired effect. Leukotriene modifiers are a category of medications used to treat allergies. Atopic dermatitis is a type I hypersensitivity involving inflammation of the skin evidenced by itching, erythema, and skin lesions.