Chapter 34: Caring for Clients with Immune-Mediated Disorders

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 Signs and symptoms of adverse reactions Formulas for calculating daily doses Technique for adding medications to the IVIG

Signs and symptoms of adverse reactions

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? Beta blocker Angiotensin-converting enzyme (ACE) inhibitor Angiotensin receptor blocker Vasodilator

Angiotensin-converting enzyme (ACE) inhibtor

The nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency diseases? They require IVIG as treatment. They are the result of intrauterine infection. They have a genetic origin. They are communicable.

They have a genetic origin

T-cell deficiency occurs when which gland fails to develop normally during embryogenesis? Thyroid Thymus Pituitary Adrenal

Thymus

A client presents with itching, swelling, redness, and wheals of superficial skin layers. What is the most likely type of allergy this client is displaying? urticaria dermatitis medicamentosa contact dermatitis angioedema

urticaria

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% 3% to 4% 5% to 10% 15% to 40%

15% to 40%

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 woman whose diagnosis of sepsis is attributable to her recent chemotherapy 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 man who developed deep vein thrombosis (DVT) after being immobilized during recovery from orthopedic surgery

A woman whose diagnosis of sepsis is attributable to her recent chemotherapy

A nurse is caring for a patient who has an immunodeficiency. What assessment finding should prompt the nurse to consider the possibility that the patient is developing an infection? Uncharacteristic aggression Persistent diarrhea Pruritis (itching) Constipation

persistent diarrhea

Which intervention is the single most important aspect for the client at risk for anaphylaxis? Use of antihistamines Desensitization Wearing a medical alert bracelet Prevention

Prevention

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. Hypotension and tachycardia The presence and location of pruritus The severity of cutaneous warmth and flushing

Dyspnea, bronchospasm, and/or laryngeal edema.

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.

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 Beef Chicken

Milk eggs shrimp

A client is learning about his new diagnosis of asthma with the asthma nurse. What medication will best prevent the onset of acute asthma exacerbations? Diphenhydramine Montelukast Albuterol sulfate Epinephrine

Montelukast

A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is the nurse's priority for health education? The need to begin immunotherapy as soon as possible The need for the parents to carry an epinephrine pen The need to vigilantly maintain the child's immunization status The need for the child to avoid all foods that have a high potential for allergies

The need for the parents to carry an epinephrine pen

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? abdominal pain conjunctivitis laryngeal swelling urticaria

laryngeal swelling

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? Anaphylaxis Hypertension Hypothermia Joint pain

Anaphylaxis

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 Rapid activation of the clotting cascade A massive release of histamine Activation of the sympathetic nervous system (SNS)

A massive release of histamine

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. Give metoprolol. Have respiratory therapy provide an albuterol treatment. Monitor international normalized ratio (INR) level.

Administer Diphenhydramine Insert an intravenous line Have respiratory therapy provide an albuterol treatment

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? Page an anesthesiologist immediately. Administer epinephrine, as ordered. Continue to monitor the client's vital signs. Insert an indwelling urinary catheter.

Administer epinephrine, as ordered.

The nurse is preparing to administer IVIG to a patient who has an immunodeficiency. What nursing guideline should the nurse apply? Do not exceed an infusion rate of 300 mL/hr. Slow the infusion rate if the patient exhibits signs of a transfusion reaction. Weigh the patient immediately after the infusion is complete. Administer pretreatment medications as ordered 30 minutes prior to infusion.

Administer pretreatment medications as ordered 30 minutes prior to infusion

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. diuresis. hypoglycemia. hypotension.

Adrenal supression

A child has been transported to the emergency department (ED) after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply. Facilitate lung function testing. Assess breath sounds. Measure the child's oxygen saturation by oximeter. Monitor the child's respiratory pattern. Assess the child's respiratory rate.

Assess breath sounds Measure the child's oxygen saturation by oximeter Monitor the child's respiratory pattern Assess the child's respiratory rate

A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse? Assess for signs and symptoms of anaphylaxis. Assess for erythema and urticaria. Administer an over-the-counter (OTC) antihistamine. Administer epinephrine. TAKE ANOTHER QUIZ

Assess for signs and symptoms of anaphylaxis

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. Undergo desensitization treatment. Carry an emergency kit. Wear a medical alert bracelet.

Avoid potential allergens

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 forearm upper arm chest

Back

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

Bone marrow transplantation

A nurse educator is explaining that patients with primary immunodeficiencies are living longer than in past decades because of advances in medical treatment. This increased longevity is associated with an increased risk of what? Chronic obstructive pulmonary disease Dementia Pulmonary fibrosis Cancer

Cancer

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? Ibuprofen Celecoxib Piroxicam Tolmetin sodium

Celecoxib

A client is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the client begins to exhibit signs and symptoms of a transfusion reaction. The client is suffering from which type of hypersensitivity? Anaphylactic (type 1) Cytotoxic (type II) Immune complex (type III) Delayed type (type IV)

Cytotoxic (type II)

A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodeficiency disease (SCID). What medication should the nurse administer prior to initiating the infusion? Diphenhydramine Ibuprofen Hydromorphone Fentanyl

Diphenhydramine

What does the nurse understand will result if the patient has a deficiency in the normal level of complement? Increased susceptibility to infection Decrease in vascularity to the extremities Development of congestive heart failure Risk of stroke

Increased susceptibility to infection

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 clinet's primary care provider of this finding.

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? Avoids massaging the injection site after administration Jabs the autoinjector into the outer thigh at a 90-degree angle Pushes down on the grey release cap to administer the medication Maintains pressure on the auto-injector for about 30 seconds after insertion

Jabs the autoinjector into the outer thigh at a 90-degree angle

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 HIV/AIDS Neutropenia Hemophilia

Neutropenia

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"? Be sure to use the nasal spray for at least 10 days to ensure the stuffiness is gone. Use the medication every 4 hours to prevent congestion from recurring. Drink plenty of fluids. Only use the nasal spray for 3 to 4 days once every 12 hours.

Only use the nasal spray 3 to 4 days once every 12 hours

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

Overwhelming infection

A patient who has received a heart transplant is taking cyclosporine, an immunosuppressant. What should the nurse emphasize during health education about infection prevention? Eat a high-calorie, high-protein diet. Limit physical activity in order to conserve energy. Take prophylactic antibiotics as ordered. Perform frequent handwashing.

Perform frequent handwashing.

The parents of a 3-year-old boy have just been informed that allergy testing suggests their son has multiple food allergies. When providing health education for this family, what subject should the nurse prioritize? Alternative nutritional delivery systems Coping strategies for the lifestyle changes that their son's diagnosis necessitates The appropriate use of antihistamines in pediatric patients Possible sources of food allergens and strategies for avoiding offending foods

Possible sources of food allergens and strategies for avoiding offending foods

A client with Wiskott-Aldrich syndrome is admitted to the medical unit. The nurse caring for the client should prioritize which of the following? Protective isolation Fresh-frozen plasma administration Chest physiotherapy Nutritional supplementation

Protective isolation

After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action? Removing the cat from the family's home Administering over-the-counter (OTC) antihistamines to the child regularly Keeping the cat restricted from the child's bedroom Maximizing airflow in the house

Removing the cat from the familys home

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 medications can be given as prescribed and signs of adverse reactions noted So that early signs of impending infection can be detected and treated So that the nurse's documentation can be thorough and accurate

So that early signs of impending infection can be detected and treated

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 be given a low dose of epinephrine before the treatment. The client will remain in the clinic to be monitored for 30 minutes following the injection. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months. The allergen will be given by the peripheral intravenous route.

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

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." "If I experience recurrent diarrhea after eating, I will need to call my doctor." "Sneezing a lot can be a concern if it continues and does not let up." "Peripheral tingling is a symptom of anaphylaxis reaction." "A feeling of fullness in my mouth is okay as long as it does not increase."

"If I start having difficulty breathing, I need to get help right away." "Peripheral tingling is a symptom of anaphylaxis reaction."

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? "Make sure that there are never air drafts in your home." "Avoid the use of air conditioning whenever possible." "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."

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? "My family needs to understand when I can go get the seasonal flu shot." "I need to know how to treat my infections in a home setting." "I need to understand how to give my platelet transfusions." "My family needs to understand that I'll probably need lifelong treatment."

"My family need to understand that I'll probably need lifelong treatment."

A nurse practitioner who works in an inner-city health clinic would recommend HIV testing to the patient who is most likely to have a diagnosis of HIV. Which of the following is most likely to have this diagnosis? African American gay man African American woman who is recently divorced Caucasian woman with multiple heterogeneous sex partners Hispanic woman who is bisexual

African American gay man

The nurse in an allergy clinic is educating a new client about the pathology of the client's health problem. What response should the nurse describe as a possible consequence of histamine release? Constriction of small venules Contraction of bronchial smooth muscle Dilation of large blood vessels Decreased secretions from gastric and mucosal cells

Contraction of bronchial smooth muscle

A home health nurse will soon begin administering IVIG to a new client on a regular basis. What teaching should the nurse provide to the client? The need for a sterile home environment Complementary alternatives to IVIG Expected benefits and outcomes of the treatment Technique for managing and monitoring daily fluid intake

Expected benefits and outcomes of the treatment

The nurse is caring for a teenage girl who has had an anaphylactic reaction after being stung by a wasp. The nurse is providing patient teaching prior to the patient's discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site? Forearm Thigh Deltoid muscle Abdomen

Thigh

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 type II type III type IV

Type I

The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. Using appropriate personal protective equipment Placing clients in negative pressure isolation rooms Placing clients in positive pressure isolation rooms Using safe injection practices Performing hand hygiene

Using appropriate personal protective equipment Using safe injection practices Performing hand hygiene

The nurse explains to a client that immunotherapy initially starts with injections at which interval? Daily Weekly Bi-monthly Monthly

Weekly

A young couple visits the nurse practitioner stating that they want to start a family. The husband states that his brother died of a severe infection at age 6 months. He says he never knew what was wrong but his mother had him undergo "blood testing" as a child. Based on these statements, what health problem should the nurse practitioner suspect? Severe neutropenia X-linked agammaglobulinemia Drug-induced thrombocytopenia Aplastic anemia

X-linked agammaglobulnemia

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? cromolyn sodium fluticasone zileuton fexofenadine

fluticasone

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

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 promote immune function through nutrition The importance of maintaining the client's vaccination status How to choose antibiotics based on the client's symptoms The need to report any slight changes in the client's health status

The need t report any slight changes in the client's health status

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. The nurse should administer albuterol 30 to 45 minutes prior to the test. Prophylactic epinephrine should be given before the test. Emergency equipment should be readily available.

Emergency equipment should be readily available.

The nurse is working with the interdisciplinary team to care for a client who has recently been diagnosed with severe combined immune deficiency (SCID). What treatment is likely of most benefit to this client? Combined radiotherapy and chemotherapy Antibiotic therapy Hematopoietic stem cell transplantation (HSCT) Treatment with colony-stimulating factors (CSFs)

Hematopoietic stem cell transplantation (HSCT)

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 High neutrophil count Low eosinophil count Low white blood cell count

High IgE concentration

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." "Drinking two or three alcoholic drinks a week is okay." "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."

"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."

A nurse has asked the nurse educator if there is any way to predict the severity of a client's anaphylactic reaction. What would be the nurse's best response? "The faster the onset of symptoms, the more severe the reaction." "The reaction will be about one-third more severe than the client's last reaction to the same antigen." "There is no way to gauge the severity of a client's anaphylaxis, even if it has occurred repeatedly in the past." "The reaction will generally be slightly less severe than the last reaction to the same antigen."

"The faster the onset of symptoms, the more severe the reaction."

A client with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurse's best response? "I can only imagine how you feel. Would you like to talk about it?" "Let's find a quiet spot and I'll teach you a few coping strategies." "That's the same way that most clients who have a chronic illness feel." "Do you think that maybe you could be managing things more efficiently?"

"I can only imagine how you feel. Would you like to talk about it?"

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? Anaphylactic reaction immediately following a bee sting Skin reaction from tape adhesive Hay fever Rheumatoid arthritis

Anaphylactic reaction immediately following a bee sting

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 urticaria. contact dermatitis. pitting edema. angioneurotic edema.

Angioneurotic edema

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 states the need for coughing and deep breathing. Client demonstrates appropriate coping strategies for dealing with a chronic disorder. Client identifies methods for reducing exposure risk to allergens. Client reports an absence of symptoms associated with the allergy.

Client identifies methods for reducing exposure risk to allergens

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

Histamine

A client is suspected of having a food allergy. The client's rheumatologist recommends an elimination diet to assist in identifying food allergens. What would not be included in the nurse's description of the process involved? If symptoms return after reintroducing foods, this confirms the food is an allergen that should be avoided. Eliminate suspected foods for a period of 2 weeks. After the elimination period, reintroduce foods one at a time. After introducing each new food, observe for the return of symptoms associated with food allergy.

If symptoms return after reintroducing foods, this confirms the food is an allergen that should be avoided.

What is the most common cause of anaphylaxis? Opioids NSAIDs Penicillin Radiocontrast agent

Penecillin

A client was prescribed an oral antibiotic for the treatment of sinusitis. The client has now stopped, stating she developed a rash shortly after taking the first dose of the drug. What is the nurse's most appropriate response? Encourage the woman to continue with the medication while monitoring her skin condition closely. Refer the woman to her primary provider to have the medication changed. Arrange for the woman to go to the nearest emergency department. Encourage the woman to take an over-the-counter (OTC) antihistamine with each dose of the antibiotic.

Refer the woman to her primary provider to have the medication changed.

The nurse is providing care for a client who has a diagnosis of hereditary angioedema. When planning this client's care, what nursing diagnosis should be prioritized? Risk for Infection Related to Skin Sloughing Risk for Acute Pain Related to Loss of Skin Integrity Risk for Impaired Skin Integrity Related to Cutaneous Lesions Risk for Impaired Gas Exchange Related to Airway Obstruction

Risk for impaired gas exchange related to airway obstruction

A client who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should the nurse implement? The client should take his corticosteroids regularly prior to testing. The client should only be tested for grass, mold, and dust initially. The nurse should have an emergency cart available in case of anaphylaxis during the test. The client's test should be cancelled until he is off his corticosteroids.

The client's test should be cancelled until he is off his corticosteriods

A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid: alcohol. applying skin moisturizers. seafood. exposure to sunlight.

alcohol.

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: All options are correct. immune system dysregulation. a combination of immune defects and viral assaults. impaired activation of three neuroendocrine structures: the hypothalamus, pituitary gland, and adrenal glands.

All options are correct

An office worker takes a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? Anaphylactic (type 1) Cytotoxic (type II) Immune complex (type III) Delayed-type (type IV)

Anaphylactic (type 1)

A home health nurse is caring for a client who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis? Encourage the client and family to be active partners in the management of the immunodeficiency. Encourage the client and family to manage the client's activity level and activities of daily living effectively. Make sure that the client and family understand the importance of monitoring fluid balance. Make sure that the client and family know how to adjust dosages of the medications used in treatment.

Encourage the client and family to be active partners in the management of the immunodeficiency.

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 Disturbed Body Image Related to Skin Lesions Risk for Disuse Syndrome Related to Dermatitis Risk for Ineffective Role Performance Related to Dermatitis Risk for Self-Care Deficit Related to Skin Lesions

Risk for disturbed body image related to skin lesions