Chapter 33: Assessment and Management of Patients with Allergic Disorders PrepU

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 with a history of anaphylactic reactions to insect stings has just been stung by a wasp. Place the steps in the correct order that the client will follow for self-administration of an EpiPen. Use all options.

1) Remove the gray safety-release cap 2) Inject the black tip into the outer thigh 3) Massage the injection area 4) Call the emergency medical response number (911)

The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?

Apply an allergy bracelet and flag the chart.

The nurse is obtaining a medication history from a patient with allergic rhinitis. The patient states, "I've been on numerous medications over the years and nothing seems to work. Plus I get so tired and sleepy from them." The nurse documents the medications used in the patient's medical record: Diphenhydramine 50 mg orally twice a day Hydroxyzine 25 mg orally three times a day Chlorpheniramine 4 mg orally every 6 hours Fexofenadine 60 mg orally twice a day When reviewing the list, which medication would the nurse identify as causing the least sedation?

Fexofenadine -Fexofenadine is a second-generation antihistamine considered "nonsedating." Diphenhydramine, hydroxyzine, and chlorpheniramine are first-generation antihistamines associated with sedation.

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?

Jabs 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.

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."

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?

"It is a hyperimmune response to something in the environment that is usually harmless."

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?

"The full benefit of the medication may take up to 2 weeks to be achieved."

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."

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 teaching a client after a medication allergic reaction has occurred. What is the mostimportant action for the nurse to teach the client to take to prevent anaphylaxis?

Avoid potential allergens.

A client with a history of allergic rhinitis comes to the clinic for an evaluation. The client is prescribed triamcinolone. What will the nurse include when teaching the client about this drug?

Be aware that some nasal burning and itching may occur.

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

Immunoglobulin E (IgE) is involved with an

allergic reaction.

IgA combines with

antigens and activates complement.

A nurse is working in a dermatology clinic with clients who have allergies. What is the most important chemical mediator involved in the allergic response?

histamine

A client has had several recent clinical visits for allergic contact dermatitis. The nurse explains to the client that allergy testing is indicated. Which test will most likely be performed?

patch test

IgG is

the principal immunoglobulin formed in response to most infectious agents.

In its attempt to suppress allergic responses, the body releases several chemicals which have a role in mediating physical reactions. Epinephrine, which interferes with vasoactive chemical release from mast cells, is instrumental in suppressing which type of hypersensitivity response?

type I

A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?

type I -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.

A client has been seeing an allergist for 6 months for treatment of allergies. The client's allergies have been insufficiently controlled by symptomatic treatments and the physician has suggested desensitization. The anticipated outcome of desensitization is that repeated exposure to the:

weak antigen promotes the production of IgG, an antibody that blocks IgE so it cannot stimulate mast cells.

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."

A client is experiencing severe anaphylactic shock. What actions should the nurse take first? Select all that apply.

- Administer diphenhydramine. - Ask the client if they are lightheaded. - Give intravenous fluids. - Prepare for insertion of an endotracheal tube.

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.

A patient received epinephrine in response to an anaphylactic reaction at 10:00 AM. The nurse knows to observe the patient for a "rebound" reaction that may occur as early as:

2:00 PM. -Rebound reactions can occur from 4 to 10 hours after an initial allergic reaction. Therefore the patient needs to be assessed from 2:00 PM to 8:00 PM.

Which of the following is the most frequent route of exposure to a latex allergy?

Cutaneous

Which type of hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign?

Cytotoxic -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 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

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

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

For their immunosuppressant effects

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.

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

IgE

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

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective?

Reduced sneezing

An infant is born to a mother who had no prenatal care during her pregnancy. What type of hypersensitivity reaction does the nurse understand may have occurred?

Rh-hemolytic disease

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

What education should the nurse provide to the patient taking long-term corticosteroids?

The patient should not stop taking the medication abruptly and should be weaned off of the medication.

After receiving a dose of penicillin, a client develops dyspnea and hypotension and the nurse suspects the client is experiencing anaphylactic shock. What is the nurse's first action?

Administer epinephrine, as ordered.

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.

IgB coats the surface of

B lymphocytes.

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.

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.

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.

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 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

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.

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 antihistamines - Administration of emergency epinephrine

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 - Eggs - Shrimp

The client presents to the health care provider's office with an allergic reaction. The health care provider documents the client's condition as a nonatopic, IgE-mediated response. What allergic reaction is this client experiencing?

A latex allergy

The nurse is evaluating a client's readiness for allergy skin testing. The nurse determines that the testing will need to be postponed when it is revealed that the client took which classification of medication the night before?

Antihistamine -Antihistamines and corticosteroids suppress skin test reactivity and should be stopped at least 48 hours before testing, some experts state 72 hours to 96 hours before testing. It is best to check with the primary care provider regarding the use of antihistamines and corticosteroids and false negatives can occur during the skin testing.

A client is diagnosed with atopic dermatitis and asks the nurse why the skin is so dry and itchy. What is the nurse's best response?

Changes in lipid content

The nurse is evaluating the plan of care for a client with an allergic disorder who has a nursing diagnosis of deficient knowledge related to measures for allergy control. What client statement will indicate to the nurse that the outcome has been met?

Client identifies methods for reducing exposure risk to allergens.

A client calls the clinic and asks the nurse if using oxymetazoline nasal spray would be all right to relieve the nasal congestion the client is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications?

Do not overuse the medication as rebound congestion can occur.

A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?

Dyspnea, bronchospasm, and/or laryngeal edema.

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 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

Which chemical mediators initiate and mediate the inflammatory response?

Leukotrienes -Leukotrienes are chemical mediators from constituents of cell membranes. Cytokines are nonantibody proteins that act as intercellular mediators, as in the generation of the immune response. Prostaglandins are lipid-soluble molecules synthesized from constituents of cell membranes. Complement is a plasma protein associated with immunologic reactions

Which cells present the antigen to T cells and initiate the immune response?

Macrophages

A client with Crohn's disease, an autoimmune disorder, informs the nurse about not having any symptoms of the disease in 8 months. What does the nurse understand this asymptomatic period is referred to?

Remission -Periods of remission refer to times when the client has no symptoms. The duration of these periods is completely unpredictable. An exacerbation is periods of acute flare-ups when the client often experiences a low-grade fever, malaise, or fatigue. The client may also lose weight. Other symptoms such as pain and diarrhea can be associated with a flare-up of Crohn's disease. The client is not having an acute inflammatory response that would be considered an exacerbation.

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

A client seeks medical attention for facial swelling that appeared suddenly and did not respond to oral antihistamines. Which health history information will the nurse use to provide care for bradykinin-induced angioedema?

Takes an angiotensin-converting enzyme inhibitor for hypertension

The nurse knows the best strategy for latex allergy is

avoidance of latex-based products.

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?

back -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.

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.

The nurse is reviewing various medications with a client that can be used to treat allergic disorders. What medication will the nurse identify as an intranasal corticosteroid?

fluticasone -Fluticasone is an example of an intranasal corticosteroid. Cromolyn sodium is a mast cell stabilizer. Zileuton is a leukotriene-receptor inhibitor. Fexofenadine is a second-generation antihistamine.

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?

maintaining an open airway

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 contact dermatitis. What type of contact dermatitis requires light exposure in addition to allergen contact?

photoallergic -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.

What type of immunoglobulin is most likely involved with allergic reactions?

IgE -Immunoglobulins of the IgE class are involved in allergic reactions, with two or more IgE molecules binding together to an allergen and triggering mast cells or basophils to release chemical mediators. IgA protects against respiratory, gastrointestinal, and genitourinary infections. IgG activates the complement system. IgM appears as the first immunoglobulin produced in response to bacterial and viral infections and also activates the complement system.

A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment?

The client will remain in the clinic to be monitored for 30 minutes following the injection.

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

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?

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

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

A nurse is caring for a client with atopic dermatitis. Which suggestions for the client by the nurse would be appropriate? Select all that apply.

- Keep the room temperature at approximately 70 degrees Fahrenheit (21 degrees Celsius). - Apply topical moisturizers to the skin. - Humidify the home when the heat is on during the winter.

A college student reports the onset of skin burning and hives when walking outdoors in cold weather. Which suggestions will the nurse make to limit this reaction from occurring? Select all that apply.

- Use a wetsuit when planning to go swimming in cold water. -Avoid ingesting foods and beverages that are cold in temperature. - Take an over-the-counter antihistamine before going outdoors in cold weather.

A nurse is assessing a client who is experiencing an allergic reaction. What will the nurse identify as resulting from the release of histamine?

Pruritus -Histamine causes erythema, localized edema in the form of wheals, pruritus, contraction of bronchial smooth muscle resulting in wheezing and bronchospasm, dilation of small venules and constriction of larger vessels, and increased secretion of gastric and mucosal cells, resulting in diarrhea. Vasodilation and hypotension result from bradykinin release.

The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction?

Symptoms 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. When clinical manifestations occur within minutes after exposure to latex, which is described as a latex allergy, an immediate hypersensitivity (type I) allergic reaction has occurred.

A client visits the employee health department because of mild itching and a rash on both hands. What will the employee health nurse focus on during the assessment interview?

chemical and latex glove use

What is the most common cause of anaphylaxis?

Penicillin -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.

Which intervention is the single most important aspect for the client at risk for anaphylaxis?

Prevention

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan?

Use a topical skin moisturizer daily.

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 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

Atopic allergic disorders are characterized by

a hereditary predisposition.

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.

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 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.

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.

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