Chapter 36 Management of Patients with Immunodeficiency Disorders

The nurse is teaching the patient who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed?

"I will be sure to eat lots of fresh fruits and vegetables every day."

When administering intravenous gamma globulin infusion, the nurse recognizes that which of the following complaints, if reported by the client, may indicate an adverse effect of the infusion?

Flank pain

When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?

Risk for infection related to altered immune cell function

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?

"Although AIDS is an immune deficiency, your child's condition is different from AIDS."

A nurse knows that more than 50% of clients with CVID develop the following disorder.

Pernicious anemia

When administering intravenous immunoglobulin (IVIG), which of the following would be most important for the nurse to do?

Premedicate with acetaminophen and diphenhydramine 30 minutes before starting.

The nurse is caring for a young patient who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed?

"I can take my child to the beach, as long as we play in the sand rather than swim in the water."

A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse?

"The doctor could prescribe anti-inflammatory drugs."

A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which of the following statements?

"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen (HLA)-identical sibling."

A majority of patients with CVID develop which type of anemia?

Pernicious

A patient with common variable immunodeficiency (CVID) comes to the ED with complaints of tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this patient developed?

Pernicious anemia

A client is diagnosed with severe combined immunodficiency (SCID). Which of the following would the nurse expect to integrate into the client's plan of care?

Preparation for bone marrow transplantation

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements?

Primary immunodeficiencies develop early in life after protection from maternal antibodies decreases.

A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which of the following symptoms? Choose all that apply.

- Flank pain - Shaking chills - Tightness in the chest

A mother brings her young child to the clinic for an evaluation of an infection. The mother states, "He's been taking antibiotics now for more than 2 months and still doesn't seem any better. It's like he's always sick." During the history and physical examination, which of the following would alert the nurse to suspect a primary immunodeficiency?

Ten ear infections in the past year

A nurse is assessing a patient with a primary immunodeficiency. Afterward she documents that the patient displayed ataxia. Which of the following statements explains the documentation?

The patient has uncoordinated muscle movements.

T-cell deficiency occurs when which of the following glands fails to develop normally during embryogenesis?

Thymus

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?

Vascular lesions

Ataxia is the term that refers to

uncoordinated muscle movement.

A nurse is teaching a client with immunodeficiency about the signs and symptoms of infection to report. The nurse determines that the teaching was successful when the client states which of the following?

"Any change, however subtle, might mean that I have an infection."

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?

"I can eat whatever I want as long as it's low in fat."

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 nurse is teaching the parents of an infant about primary immunodeficiencies. Which of the following statements verifies that the parents understand the teaching?

"The majority of primary immunodeficiencies are diagnosed in infancy."

The nurse is preparing to infuse gamma-globulin intravenously (IV). When administering this drug, the nurse knows the speed of the infusion should not exceed what rate?

3 mL/min

A client is given a dose of ketorolac (Toradol), a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do?

Administer epinephrine.

The nurse practitioner working in a health clinic at an over-55 retirement community would recommend HIV testing based on the following primary rationale:

Age-related immune system changes increase the risks of infections for older adults.

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

Your client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?

Avoid antihistamines and cold preparations for 48 to 72 hours before the test.

A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included?

Be alert for signs and symptoms of infection and report them immediately to the physician.

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?

Bone marrow transplantation

A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring?

Delayed hypersensitivity response

The nurse is preparing a teaching plan for a client with an immunodeficiency. Which of the following would the nurse emphasize as most important?

Frequent and thorough handwashing

Which of the following adverse effects should the nurse closely monitor in a patient who has secondary immunodeficiencies due to immunosuppressive therapy?

Respiratory or urinary system infections

A patient is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. He asks the nurse about the infusion's administration and its adverse effects. Which of the following choices should the nurse instruct this patient to report immediately?

Tickle in the throat

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements? Primary immunodeficiencies

develop early in life after protection from maternal antibodies decreases.

The nurse is working with a mother whose child has just been diagnosed with selective immunoglobulin A deficiency. The mother asks the nurse, "Does this mean that my child is going to die?" How will the nurse respond?

"Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A (IgA), a type of antibody that protects against infections of the lining the mouth and digestive tract."

Which of the following would the nurse expect to assess in a client with ataxia-telangiectasis? Select all that apply.

- Loss of muscle coordination - Vascular lesions - Immune deficiency

A treatment option for SCID includes

a stem cell transplant.

A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid:

alcohol.

Which allergic reaction is potentially life threatening?

angioedema

A man with chronic mucocutaneous candidiasis, an autosomal recessive disorder, asks the nurse, "Will my children have this disease?" Which response by the nurse is appropriate?

"All of your children will be carriers of the recessive gene but may not develop the disease."

Agammaglobulinemia is also known as which of the following?

Bruton's disease

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is

Malnutrition

The majority of patient with primary immunodeficiency are in which age group?

Younger than 20

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. Which of the following would the nurse expect to be started?

Immunosuppressive agents

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?

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