Chapter 25: Nursing Care of the Child With an Alteration in Immunity or Immunologic Disorder

19. A child with hypogammaglobulinemia is to receive intravenous immunoglobulin (IVIG). What action would not be correct to take? A) Shake the vial after reconstituting it B) Premedicate the child with acetaminophen C) Obtain preinfusion vital signs D) Check serum blood urea nitrogen and creatinine levels

Ans: A Feedback: Many IVIG products are packed as two vials, one the IVIG powder and one the sterile diluents. Once reconstituted, the IVIG should not be shaken because this leads to foaming and may cause the immunoglobulin protein to degrade. The child can be premedicated with acetaminophen or diphenhydramine. Baseline serum blood urea nitrogen and creatinine should be assessed because acute renal insufficiency may occur as a serious adverse reaction.

2. A nurse is caring for a 12-year-old girl with a severe peanut allergy. The girl's parents are upset because the school does not permit her to carry her EpiPen with her. It must remain in the school's office per school regulations. Which response by the nurse would be most appropriate? A) "She is allowed by law to carry her EpiPen with her; I will talk to school authorities." B) "Let's file an action plan and keep it in the school office in the event of anaphylaxis." C) "Make sure she wears a medical alert bracelet so that school staff know she has allergies." D) "I will be happy to train school authorities and staff to recognize anaphylaxis."

Ans: A Feedback: Public Law No. 108-377, the Asthmatic Schoolchildren's Treatment and Health Management Act of 2004, was passed by the U.S. Congress. This law is intended to ensure that students with severe allergies can carry prescribed medications such as an EpiPen with them at all times. The nurse must contact the school and inform them of this law so that the girl is allowed to carry her EpiPen on her person at all times. The school staff should be trained to recognize anaphylaxis, there should be an action plan on file, and the girl should wear a medical alert bracelet as well. However, the most important action is to notify school authorities of the law.

10. The nurse is administering intravenous immune globulin (IVIG). The nurse assesses vital signs and for adverse reactions every 15 minutes for the first hour of administration. After the first hour, the nurse most likely would continue to assess the child at which frequency? A) Every 30 minutes B) Every 45 minutes C) Every 60 minutes D) Every 2 hours

Ans: A Feedback: The nurse needs to continue assessments according to institutional protocol. Every 15 minutes for the first hour and every 30 minutes through the remainder of the infusion is the standard assessment.

6. The nurse is providing home care instructions for a 13-year-old girl recently diagnosed with systemic lupus erythematosus. Which response by the girl indicates a need for further teaching? A) "I need to wear sunscreen in the summer to prevent rashes." B) "I need to eat a healthy diet, exercise, and get plenty of sleep." C) "I need an eye examination every year." D) "I need to be careful when it is cold; I should always wear gloves."

Ans: A Feedback: The nurse needs to emphasize that the girl should apply sunscreen every day, not just in the summer, to prevent rashes resulting from photosensitivity. A healthy diet, sleep, yearly eye examinations, and protection from cold weather are appropriate measures.

5. The nurse is caring for a child undergoing highly active antiretroviral therapy (HAART) for HIV infection. The nurse is preparing to administer the prescribed medication. In addition to the nucleoside analog reverse transcriptase inhibitors (NRTIs) and the nonnucleoside analog reverse transcriptase inhibitors (NNRTIs), the nurse is cognizant that the child will be taking which additional medication as part of the three-drug regimen? A) Protease inhibitors B) Corticosteroids C) Cytotoxic drugs D) Disease-modifying antirheumatic drugs (DMARDs)

Ans: A Feedback: The nurse understands that the child will be taking protease inhibitors as part of the three-drug regimen for HAART. Corticosteroids, cytotoxic agents, and DMARDs are typically used for the treatment of juvenile idiopathic arthritis (JIA).

12. What would the nurse expect to find in a male infant with Wiskott-Aldrich syndrome? A) Eczema B) Thrombocytosis C) Lymphadenopathy D) Pneumonia

Ans: A Feedback: Wiskott-Aldrich syndrome is manifested by eczema that usually worsens with time, petechiae, bloody diarrhea, or a bleeding episode in the first 6 months of life. Thrombocytopenia is present. Lymphadenopathy is associated with hypogammaglobulinemia. Pneumonia is associated with severe combined immune deficiency.

29. While performing an assessment of a patient who is immunocompromised, the nurse notes the child to have thrush in the mouth, tenderness over the spleen upon palpation, and a white blood cell count of 3,000. Which nursing diagnoses will the nurse include in the care plan of this child based on these findings? Select all that apply. A) Ineffective protection B) Risk for imbalanced nutrition, less than body requirements C) Pain D) Impaired skin integrity E) Delayed growth and development

Ans: A, B, C Feedback: Based on these symptoms the diagnosis of Ineffective protection is related to the decreased white blood cell count; Risk for imbalanced nutrition, less than body requirements, is related to the thrush; and Pain is related to the tenderness over the spleen and the thrush. There is no evidence to support the diagnoses of Impaired skin integrity or Delayed growth and development.

26. A nurse is assessing a child who may have a latex allergy. The nurse asks the child about allergic reactions to certain foods. Which foods if identified by the child as experiencing an allergic reaction would help support the suspected latex allergy? Select all answers that apply. A) Peaches B) Plums C) Carrots D) Tomatoes E) Apples F) Lettuce

Ans: A, B, C, D Feedback: Foods with a known cross-sensitivity to latex include pear, peach, passion fruit, plum, pineapple, kiwi, fig, grape, cherry, melon, nectarine, papaya, apple, apricot, banana, chestnut, carrot, celery, avocado, tomato, or potato. Apples and lettuce are not associated with a cross-sensitivity.

20. A nursing student is reviewing information about primary immunodeficiencies. The student demonstrates understanding of the material by identifying which immunodeficiencies as affecting only males? Select all that apply. A) X-linked agammaglobulinemia B) Wiskott-Aldrich syndrome C) Selective IgA deficiency D) X-linked hyper-IgM syndrome E) IgG subclass deficiency F) Severe combined immune deficiency

Ans: A, B, D Feedback: X-linked agammaglobulinemia, Wiskott-Aldrich syndrome, and X-linked hyper-IgM syndrome affect males only. Selective IgA deficiency, IgG subclass deficiency, and severe combined immune deficiency affect boys and girls.

21. The nurse is reviewing the laboratory test results of a child who is suspected of having systemic lupus erythematosus (SLE). What would the nurse identify as supporting this diagnosis? Select all that apply. A) Positive antinuclear antibody (ANA) B) Increased C3 levels C) Thrombocytopenia D) Leukopenia E) Increased hematocrit

Ans: A, C, D Feedback: Laboratory findings may include decreased hemoglobin and hematocrit, decreased platelet count, and low white blood cell count. Complement levels, C3 and C4, will also be decreased. Though not specific to SLE, the ANA is usually positive in children with SLE.

28. The nurse is providing a class for a group of childcare providers. When discussing allergic reactions, which statement by a participant indicates the need for further instruction? A) "Most allergic reactions will happen within a few minutes of eating a problematic food." B) "If a child has previously eaten a food and not had a reaction they are not 'truly' allergic to it. C) "Allergic reactions can happen hours after eating something." D) "In addition to hives some children may also have vomiting and diarrhea when having an allergic reaction to a food."

Ans: B Feedback: Previous exposure with no incident does not mean an individual cannot develop a hypersensitivity to a food or other substance. An allergy may develop at any time. The remaining statements are correct.

23. The nurse is talking to the parents of a child who has been diagnosed with severe combined immune deficiency (SCID). Which statement by the parents best indicates that they understand their child's condition? A) "He'll need to receive intravenous immunoglobulin routinely." B) "We'll need to prepare him and ourselves for a bone marrow transplant." C) "He'll need to receive several different types of antiviral medications." D) "We'll make sure that he has his EpiPen with him at all times."

Ans: B Feedback: SCID is a potentially fatal disorder requiring emergency intervention at the time of diagnosis. Gene therapy provides some promise for the future treatment of SCID, but until then bone marrow or stem cell transplantation is necessary. IVIG may be used to help decrease the number of infections until bone marrow or stem cell transplantation can be done. Antiviral medications are used to treat HIV infection. An EpiPen is used for anaphylaxis.

18. A nurse is preparing a plan of care for a child with a primary immunodeficiency. Which nursing diagnosis is the priority? A) Imbalanced nutrition, less than body requirements related to poor appetite B) Ineffective protection related to impaired humoral defenses C) Acute pain related to inflammatory processes D) Risk for delayed growth and development related to chronic illness

Ans: B Feedback: The child with a primary immunodeficiency lacks the necessary immune responses that provide protection from infection. Therefore, the priority nursing diagnosis would be ineffective protection. Imbalanced nutrition and risk for delayed growth and development may be appropriate, but these would not be the priority. Acute pain would be more appropriate for a child with juvenile idiopathic arthritis.

7. The nurse is caring for a child who is taking corticosteroids for systemic lupus erythematosus. The nurse closely monitors the child based on the understanding that corticosteroids exert which major action? A) They increase liver enzymes. B) They can mask signs of infection. C) They cause bone marrow suppression. D) They decrease renal function.

Ans: B Feedback: The nurse understands that corticosteroids may mask signs of infection. Cytotoxic drugs cause bone marrow suppression. Nonsteroidal anti-inflammatory drugs can increase liver enzymes and decrease renal function.

13. After teaching a class about humoral and cellular immunity, the nurse recognizes that the additional teaching is needed when the class states that: A) humoral immunity crosses the placenta. B) cellular immunity involves the T lymphocytes. C) cellular immunity recognizes antigens. D) humoral immunity does not destroy the foreign cell.

Ans: C Feedback: Humoral immunity recognizes antigens and cellular immunity does not. Humoral immunity crosses the placenta in the form of IgG. Cellular immunity involves the action of T lymphocytes, and humoral immunity does not destroy the foreign cell.

8. The school nurse is walking through the lunchroom when one of the children says she started to feel strange after trading lunches with a friend. Which assessment would be most important? A) Asking if she has a rash anywhere B) Checking if she has any nausea C) Determining if her throat itches D) Asking if she has abdominal pain

Ans: C Feedback: Asking if the child's throat itches is most important because this aids in determining airway patency, which is always the priority. Asking about a rash, nausea, or abdominal pain can be done after the nurse is certain the child's airway is not jeopardized.

25. A child with systemic lupus erythematosus is receiving high-dose corticosteroid therapy over the long term. The nurse would instruct the parents and child to report: A) difficulty urinating. B) visual changes. C) joint pain. D) rash.

Ans: C Feedback: Avascular necrosis (lack of blood supply to a joint, resulting in tissue damage) may occur as an adverse effect of long-term or high-dose corticosteroid use. Teach families to report new onset of joint pain, particularly with weight bearing, or limited range of motion. Complications of systemic lupus erythematosus include nephritis manifested by urinary changes and visual changes. Rash may develop secondary to photosensitivity. These are unrelated to the long-term or high-dose corticosteroid use.

30. A 16-year-old patient has just been diagnosed with HIV. Which statement by the parent indicates understanding of the diagnosis? A) "It is important for our child to get started on drug therapy for a better chance of a cure of the infection." B) "I must be infected with HIV and passed it to our child while in the uterus for the infection to have occurred." C) "We don't want to face the fact that it is likely our child contracted HIV through sexual contact or IV drug use." D) "Infections as a result of being HIV positive are a low risk since the diagnosis came early."

Ans: C Feedback: In teenagers, HIV is primarily contracted through sexual intercourse with an infected person or sharing of needles with an infected person during IV drug use. There is no cure for HIV, infants primarily contract the virus from their mothers, and infections as a result of having HIV are not dependent on when the diagnosis occurred.

15. Which exercise would the nurse suggest as most helpful to maintain mobility in a child with juvenile idiopathic arthritis? A) Jogging every other day B) Using a treadmill C) Swimming D) Playing basketball

Ans: C Feedback: Swimming is a particularly useful exercise to maintain joint mobility without placing pressure on the joints. Jogging, using a treadmill, and playing basketball would place pressure on the joints of the lower extremities.

24. The nurse is assessing a child with pauciarticular-type juvenile idiopathic arthritis. What would the nurse expect to assess? A) Fever B) Rash C) Eye inflammation D) Splenomegaly

Ans: C Feedback: With pauciarticular juvenile idiopathic arthritis, eye inflammation may be noted. Fever, rash, and enlarged spleen would be noted with systemic juvenile idiopathic arthritis.

17. A group of nursing students are reviewing information about humoral and cellular immunity. The students demonstrate understanding of this material when they identify what as being involved in cellular immunity? A) B cells B) Antibodies C) Antigens D) T cells

Ans: D Feedback: Cellular immunity involves T cells, which do not recognize antigens. B cells, antibodies, and antigens are involved in humoral immunity.

3. The nurse is caring for a newborn whose mother is HIV positive. The nurse would expect to administer a 6-week course of which medication? A) Lopinavir B) Ritonavir C) Nevirapine D) Zidovudine

Ans: D Feedback: Children born to HIV-positive mothers should receive a 6-week course of zidovudine therapy. Lopinavir, ritonavir, and nevirapine are medications used for treatment of HIV-1 infections as part of a three-drug regimen.

16. A child is diagnosed with juvenile idiopathic arthritis and is receiving several different medications listed in the medication administration record. Which agent would the nurse identify as being used to prevent disease progression? A) Aspirin B) Prednisone C) Ibuprofen D) Methotrexate

Ans: D Feedback: Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, are necessary to prevent disease progression. Other agents, such as aspirin and ibuprofen, are helpful with pain relief. Prednisone helps for relief of inflammation.

27. The mother of a 5-year-old child with allergies to a variety of foods including eggs, milk, peanuts and shellfish, asks if her child will "always have these problems". What response by the nurse is most accurate? A) "Sadly, allergies to foods will persist." B) "Most children with allergies will outgrow them." C) "We cannot be sure at this point but most children who are allergic to peanuts will not have this allergy in adulthood." D) "In most cases allergies to peanuts and shellfish persist into adulthood but the others may diminish and disappear."

Ans: D Feedback: Foods such as peanuts, milk, soy, shellfish, tree nuts are common allergens. By adulthood many allergies will diminish or disappear. Allergies to shellfish, peanuts and tree nuts often persist into adulthood.

1. While providing care to a 5-month-old girl whose family has a history of food allergies, the nurse instructs the parents about foods to be avoided in the first year of life. Which response by the parents indicates a need for further teaching? A) "She cannot have any cow's milk." B) "I should continue breastfeeding until at least 6 months." C) "Peanuts in any form should be avoided." D) "Any kind of fruit is acceptable."

Ans: D Feedback: The nurse should caution the parents that kiwifruit should be avoided. Other foods to avoid include cow's milk, eggs, peanuts, tree nuts, sesame seeds, fish, and shellfish. Breastfeeding also is recommended for at least the first 6 months.

Ans: C Feedback: The nurse should monitor the stem cell transplant child closely for a maculopapular rash that usually starts on the palms and soles for indication that graft-versus-host disease is developing. Wheezing and recurrent diarrhea are not typical clinical manifestations of graft-versus-host disease. Splenomegaly is associated with hypogammaglobulinemia.

9. The nurse is caring for a child who has undergone stem cell transplantation for severe combined immune deficiency. What finding would the nurse interpret as indicative of graft-versus-host disease? A) Presence of wheezing B) Splenomegaly C) Maculopapular rash D) Chronic or recurrent diarrhea

14. When teaching a group of new parents about newborn care and development, which immunoglobulin would the nurse explain as being primarily responsible for the passive immunity exhibited by newborns? A) IgA B) IgG C) IgM D) IgE

Ans: B Feedback: IgG is acquired transplacentally, providing the newborn with passive immunity to antigens to which the mother had developed antibodies. IgA, IgD, IgE, and IgM do not cross the placenta and require an antigenic challenge for production.

22. A child is diagnosed with a food allergy to milk. When teaching the parents about this allergy, what would the nurse suggest as possible substitutions for milk? Select all that apply. A) Fruit juice B) Rice milk C) Yogurt D) Nondairy creamers E) Soy milk

Ans: A, B, E Feedback: Milk can be replaced with water, fruit juice, rice milk, or soy milk. Yogurt contains milk and some nondairy products such as creamers may contain milk and should be avoided.

9. The nurse is caring for a child who has undergone stem cell transplantation for severe combined immune deficiency. What finding would the nurse interpret as indicative of graft-versus-host disease? A) Presence of wheezing B) Splenomegaly C) Maculopapular rash D) Chronic or recurrent diarrhea

Ans: C Feedback: The nurse should monitor the stem cell transplant child closely for a maculopapular rash that usually starts on the palms and soles for indication that graft-versus-host disease is developing. Wheezing and recurrent diarrhea are not typical clinical manifestations of graft-versus-host disease. Splenomegaly is associated with hypogammaglobulinemia.

4. The nurse is caring for a child who is having an anaphylactic reaction with bronchospasm. The nurse would expect to administer what medication for bronchospasm as ordered? A) Epinephrine B) Corticosteroid C) Albuterol D) Diphenhydramine

Ans: C Feedback: The nurse would expect to administer bronchodilation inhalation treatment (albuterol) if bronchospasm is present. Epinephrine, diphenhydramine, and/or corticosteroids are administered to reverse the allergic process.