Chapter 48: The Child With Alterations in Immune Function

The nurse is caring for a child with rheumatoid arthritis. Which nonpharmacologic intervention should the nurse include in the plan of care for joint pain? 1. Elevation of the extremity 2. Immobilization 3. Massage 4. Application of moist heat

4. Moist heat can promote relief of pain and decrease joint stiffness.

The nurse is providing care for the family of a child who is diagnosed with acquired immunodeficiency syndrome (AIDS). Which priority nursing diagnosis should the nurse include in the plan of care? 1. Anticipatory Grieving 2. Risk for Impaired Parenting 3. Compromised Family Coping 4. Parental Role Conflict

1. AIDS is not curable, so the problem nurses can anticipate, for all families, is Anticipatory Grieving.

A child is prescribed oral corticosteroid for a rash caused by graft-versus-host disease. Which should the nurse monitor the child for after administering the drug? 1. Hyperglycemia 2. Hepatic toxicity 3. Seizures 4. Renal toxicity

1. Hyperglycemia is a side effect of steroid therapy.

A parent of a newborn asks the nurse why young children seem to become ill so often when compared with older children and adults. Which is the best response by the nurse? 1. "Newborns have lower numbers of natural killer cells." 2. "Newborns have high levels of IgA in their systems." 3. "Newborns are lacking lymphoid tissue." 4. "Newborns have an immature thymus gland."

1. Newborns have lower numbers of natural killer cells than do older children and adults, decreasing their ability to respond to certain antigens.

Which is the priority nursing action when providing care to a pediatric client who has documented allergies to cow's milk, peanuts, and latex? 1. Evaluating the hospital room for equipment containing latex 2. Ordering an EpiPen for the child 3. Notifying dietary of the milk and peanut allergy 4. Placing a sign on the door which identifies all allergies

1. This is appropriate as latex allergies can be life threatening. Many pieces of medical equipment may contain latex.

After a severe allergic reaction, an EpiPen is prescribed for the school-age child. Which instructions should the nurse provide to this child's parents based on the current data? Select all that apply. 1. "It is important that your child always has access to this medication." 2. "Your child is too young to self-administer this medication." 3. "If you are able to administer the medication, there is no need for follow-up care." 4. "It is important to check the expiration date on the medication and replace if expired." 5. "Your child should wear a Medic Alert bracelet at all times."

1. This is appropriate care. 4. An expired EpiPen may have less than desired effects. 5. If the child is unable to speak due to anaphylaxis, it is important that rescuers have information about the child's allergies.

In which position should the nurse place a child who is experiencing an anaphylactic shock reaction? 1. Trendelenburg position 2. Flat, with legs slightly elevated 3. High Fowler position 4. Reverse Trendelenburg position

2. Flat, with legs slightly elevated, is the position that is used for a client experiencing shock. This allows for the blood pressure to be maintained during this critical time.

A premature neonate is at greater risk for infection than a full-term newborn because of a reduced number of which immunoglobulin? 1. IgE 2. IgG 3. IgA 4. IgM

2. Maternal IgG crosses the placenta. Newborns' levels are similar to their mothers'. Premature infants have lower levels of IgG obtained from their mothers and are at greater risk for infection.

The nurse is providing discharge instructions to the family of a child who experienced an anaphylactic reaction. Which parental statements indicate accurate understanding of the action that histamine plays during this type of reaction? Select all that apply. 1. "Histamine releases IgE antibodies, which help to stop the reaction." 2. "Histamine causes smooth muscle contraction, which causes the wheezing." 3. "Histamine causes increased capillary permeability, which is what causes difficulty breathing." 4. "Histamine causes vasoconstriction leading to respiratory issues." 5. "Histamine causes the destruction of red blood cells, which is why we administer the EpiPen."

2. Smooth muscle contraction causes the constriction of the bronchioles, which causes the wheezing and respiratory distress. 3. Increased capillary permeability causes the plasma to leak into surrounding tissues, including the lungs, leading to pulmonary edema.

A child with human immunodeficiency virus (HIV) is diagnosed with oral candidiasis. Which should the nurse include in the plan of care related to oral care based on this information? 1. Listerine 2. Normal saline 3. Viscous lidocaine 4. Scope

2. The mouth care should be with a nonalcohol base. Normal saline can keep the child's lips and mouth moist.

Which interventions should the nurse include in the plan of care to address nutrition for a child who is diagnosed with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Encourage three large meals each day. 2. Eliminate unpleasant odors from the environment during meals. 3. Weigh the child each day, using the same scale. 4. Assess skin turgor every 4 hours. 5. Include favorite foods in the meal plan.

2. Unpleasant stimuli and odors often decrease the desire for food. 3. Taking daily weights, using the same scale, is an appropriate intervention to monitor the child's nutritional status. 5. Allowing children to eat their favorite foods encourages intake.

The nurse is planning care for a child with acquired immune deficiency syndrome (AIDS). Which vaccines should be avoided in the child with AIDS? 1. Inactivated polio vaccine 2. Tetanus toxoid vaccination 3. Varicella vaccine 4. Acellular pertussis vaccine

3. A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease.

An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which should the nurse include in the teaching session regarding an activity that should be avoided? 1. Receiving a manicure and a pedicure 2. Washing the hair with shampoo daily 3. Using a tanning bed 4. Attending late night parties and dances

3. Individuals with SLE have photosensitivity, and tanning beds can lead to exacerbations as well as skin damage from sun burns.

Which is the rationale for ensuring the irrigation of blood products and ensuring that they are cytomegalovirus (CMV)-negative prior to administering a blood transfusion for a pediatric client diagnosed with severe combined immune deficiency (SCID)? 1. Transfusion reaction from lymphocytes and platelets in the donor blood. 2. Transfusion reaction and infection from lymphocytes in the donor blood. 3. Infection and graft-versus-host disease from lymphocytes in the donor blood. 4. Infection and graft-versus-host disease from erythrocytes in the donor blood.

3. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease.

An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of the body changes that occur because of SLE? 1. Attends school but does not stay for after-school activities 2. Discusses the body changes with healthcare providers only 3. Discusses the body changes with her best friend 4. Only attends small parties at friends' homes

3. Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the changes in her body image.

A nurse is planning care for a child with human immunodeficiency virus (HIV). Which is the priority nursing diagnosis for this child? 1. Ineffective Peripheral Tissue Perfusion 2. Ineffective Thermoregulation 3. Risk for Fluid Volume Deficit 4. Risk for Infection

4. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Infection is the priority nursing diagnosis.

A child is receiving a nucleoside reverse transcriptase inhibitor for human immunodeficiency virus (HIV). Which laboratory value should the nurse include in the plan of care as needing to monitor? 1. Glucose 2. Sodium 3. Potassium 4. Red blood cell count

4. A nucleoside transcriptase inhibitor causes bone marrow suppression with resulting anemia. Red blood cell counts are monitored at least monthly for changes.

When teaching a pregnant client about antibodies that are passed from mother to newborn, which antibody should the nurse include? 1. IgM 2. IgA 3. IgD 4. IgG

4. IgG crosses the placenta and provides the newborn with passive immunity.

A school-age client diagnosed with rheumatoid arthritis (RA) wants to participate in the school sports programs. The client asks the nurse to recommend a sporting activity that is appropriate. Which activity would be the most appropriate for the nurse to recommend? 1. Baseball 2. Basketball 3. Football 4. Swimming

4. Swimming helps to exercise all the extremities without putting undue stress on joints.

The nurse is providing care to a child who experienced an anaphylactic reaction to an unknown allergen. Which high-risk foods should the nurse question the family about regarding recent consumption? 1. Peanut butter 2. Shrimp 3. Eggs 4. Milk 5. Soda

Answer: 1, 2, 3 Explanation: 1. Peanut products, such as peanut butter, are considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 2. Shellfish, such as shrimp, is considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 3. Egg whites are considered a high-risk food allergen. The nurse should question the family about the consumption of this product.

Which interventions should the nurse include in the plan of care for a hospitalized child who is diagnosed with rheumatoid arthritis (RA)? Select all that apply. 1. Performing passive range-of-motion (ROM) exercises with the child 2. Discouraging the child from completing activities of daily living (ADLs) 3. Encouraging periods of rest for the child 4. Placing cool compresses on the child's joints 5. Performing daily weights

Answer: 1, 3, 5 Explanation: 1. Active and passive ROM is encouraged as this decreases joint stiffness and inflammation. 3. Exacerbations of RA often cause fatigue; therefore, it is appropriate for the nurse to encourage rest periods. 5. Daily weights are needed, as it is not uncommon for the child with RA to experience reduced activity and metabolic needs yet maintain the same diet, which places the child at risk for overweight and obesity.

The nurse is providing education to a family whose child experiences anaphylaxis when exposed to any amount of latex. Which items, often found in the home or school environment, should the nurse include in the teaching session? Select all that apply. 1. Art supplies 2. Toothpaste 3. Balloons 4. Perfumes 5. Chewing gum

Answer: 1, 3, 5 Explanation: 1. Art supplies often contain latex; therefore, the nurse should include this item in the teaching session. 3. Balloons often contain latex; therefore, the nurse should include this item in the teaching session. 5. Chewing gum often contains latex; therefore, the nurse should include this item in the teaching session.

Which infection control measures should the nurse include in the discharge instructions for the family of a child who is immunodeficient? Select all that apply. 1. "It is important that your child does not share cups with other members of the family." 2. "You should avoid washing your child's utensils in the dishwasher." 3. "You should allow your child to eat fresh fruit with the skin intact." 4. "It is important that everyone practices hand hygiene before touching your child." 5. "You should use alcohol wipes to cleanse your child's diaper area."

Answer: 1, 4 Explanation: 1. Children who are immunodeficient should not share cups with other members of the family, as this increases the child's risk for developing an infection. 4. Hand hygiene before handling the child, after changing diapers, and prior to feeding the child is essential to decrease the risk for infection.