Hypersensitivity

A pregnant woman with a latex allergy is admitted to the hospital for delivery. Which latex precaution should the nurse implement?

Place a latex allergy sign outside the patient's door

A nurse is caring for a pediatric client who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the client is experiencing a type I hypersensitivity​ reaction?

Hypotension

The nurse is teaching a patient with latex allergy the importance of when to seek medical attention after exposure. Which situation should the nurse include?

If the patient develops hives

A patient presents with signs of severe anaphylaxis including difficulty breathing and urticaria. The nurse notes there is no history of asthma, drug use, or any prescribed medications. Based on this data, which diagnosis should the nurse anticipate for this patient?

Type I (IgE-mediated) hypersensitivity

The nurse is caring for a client with a history of latex allergies. The client develops audible​ wheezing, pruritus,​ urticaria, and signs of angioedema. Which of the following is the priority intervention for this​ client?

Administer epinephrine​ 1:1000 by subcutaneous injection per the healthcare​ provider's orders.

The nurse is caring for a child with a severe peanut allergy who is enrolled in a clinical trial for epicutaneous immunotherapy. The parent asks, "How will this be done?" How should the nurse respond?

"A patch with the allergen will be placed on the skin daily."

The nurse is performing an admission assessment on a patient with suspected serum sickness. Which question by the nurse demonstrates an understanding of potential causes for this condition?

"Have you taken an antibiotic recently?"

The nurse is evaluating a patient's ability to manage an allergic anaphylactic reaction. Which patient statement indicates that further teaching is needed?

"I will carry a medical alert card in my wallet."

The nurse is teaching the parent of a young child with a peanut and dairy allergy. The parent says, "He is such a picky eater—what am I supposed to feed him?" Which response by the nurse provides the most beneficial solution?

"I will provide you a list of nutritious foods and have a dietician speak with you."

The nurse is providing allergy treatment to a child who presents with a bee sting. The nurse provides teaching to the parent as to what to do if the child gets another bee sting. Which parent statement alerts the nurse of the need for further teaching? "I will keep in mind the severity and treatment of my child's first bee sting." "I will be sure that my child wears amedical alert bracelet." "I will be attentive to my child's breathing pattern and use the epinephrine pen as directed." "If my child gets stung by a bee again, I will remove the stinger and apply ice to reduce pain."

"If my child gets stung by a bee again, I will remove the stinger and apply ice to reduce pain."

A pediatric client with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen. Which statements are appropriate for the nurse to include in the discharge instructions for this client and​ family? Select all that apply. ​"Keep the medication in one location that is easy to​ remember." ​"It is recommended that the child wear a medical alert​ bracelet." ​"Frequently check the expiration date of the​ medication." ​"This medication does not come prefilled and must be​ measured." ​"Keep the medication in the car at all​ times."

"It is recommended that the child wear a medical alert​ bracelet." ​"Frequently check the expiration date of the​ medication."

The nurse is caring for a child who presented with hives on the anterior and posterior trunk. Which statement by the child may be an indicator of an emergent hypersensitivity reaction?

"My tongue feels funny."

A patient is prescribed plasmapheresis for treatment of glomerulonephritis. The patient asks the nurse, "Why does my blood need to go through a machine?" Which response by the nurse is accurate?

"The machine removes the harmful components in the plasma."

The nurse is teaching a patient prescribed a leukotriene modifier for treatment of asthma. Which information by the nurse describes the effects of leukotriene modifiers?

"The medication will reduce inflammation and nasal congestion."

The nurse is providing teaching to a patient who has experienced an anaphylactic reaction after eating shrimp. Which statement by the nurse provides the patient with the most accurate information?

"You should avoid eating all seafood, until allergy skin testing is done."

Which action by the nurse is the most appropriate for treating a patient experiencing severe anaphylactic reaction while in the acute care setting?

Administer epinephrine intravenously

The nurse is caring for a client in an allergy clinic. After completing the client​ history, the nurse selects the nursing diagnosis of Risk for Shock. Which item in the​ client's history supports the need for this nursing​ diagnosis?

Anaphylactic reaction to shellfish

The nurse is caring for a patient who presents with symptoms of urticaria on both hands. Which disease in the patient's history is considered as a risk factor related to this hypersensitivity reaction?

Asthma

The nurse is teaching a patient with a latex allergy. Which latex-containing product at home should the nurse encourage the patient to avoid?

Chewing gum

Which information is important for the nurse to consider when caring for children with allergic reactions?

Children are at higher risk for respiratory distress.

The nurse is reviewing the chart of a patient diagnosed with poison ivy. Which hypersensitivity reaction should the nurse anticipate finding upon assessment of the exposed area?

Contact dermatitis

A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee stings. Which clinical manifestations would necessitate injecting the child with epinephrine​ (EpiPen)? Select all that apply. Skin that is warm and dry to the touch Hyperverbal behavior Extreme anxiety and agitation Skin that is cold and clammy to the touch Facial swelling

Extreme anxiety and agitation Skin that is cold and clammy to the touch Facial swelling

Which potential problem is the priority for the nurse to address while charting a plan of care for a patient with a hypersensitivity reaction?

Ineffective airway clearance

The nurse is caring for a patient who has recently received a stem cell transplant. The patient presents to the clinic with clinical symptoms of graft-versus-host disease. Which finding should the nurse anticipate during the assessment of the patient?

Jaundice

The nurse is admitting a pediatric client to the hospital with a ventriculoperitoneal​ (VP) shunt malfunction. When gathering the​ history, the nurse learns that the client received the shunt at birth after a meningocele repair. Based on this​ data, which product should be avoided when providing care to this​ client?

Latex gloves

Which of the following statements is true with regard to food allergies and​ children?

Many children eventually outgrow​ egg, milk, and soy allergies.

The nurse is preparing to assess a client when one of the​ client's family members begins showing symptoms of latex sensitivity. Which action by the nurse is the most​ appropriate?

Obtain​ latex-free products for the​ client's room.

The nurse suspects that the client is experiencing a reaction to a specific antigen. Which laboratory result supports the conclusion made by the​ nurse?

Patch test with a​ 1-inch area of erythema

The nurse is assessing a client who is receiving IV antibiotics. Which item in the​ client's health history increases the risk for experiencing a hypersensitivity​ reaction?

Previous antibiotic therapy

A patient is undergoing a skin test to assist with diagnosis of a hypersensitivity reaction. Which action should the nurse take when the healthcare provider orders a prick test?

Puncture the skin through the diluted allergenic extract

Which collaborative laboratory test should the nurse anticipate the for a patient to determine food allergies?

Radioallergosorbent test (RAST)

A nurse is caring for a client with seasonal hypersensitivity reactions. What teachings should the nurse provide to improve this​ client's comfort? Select all that apply. Remain indoors if possible on​ high-allergen days. Stop taking oral corticosteroids immediately once symptoms disappear. Take antihistamine and leukotriene medications as ordered. Maintain a​ clean, dust-free environment. Keep doors and windows open on​ high-allergen days to circulate air.

Remain indoors if possible on​ high-allergen days. Maintain a​ clean, dust-free environment. (antileukotriene and antihistamine)

The nurse is caring for an older patient who reports joint pain. Assessment reveals a diffuse rash, arthralgia, and lymphadenopathy. The patient is receiving penicillin for acute glomerulonephritis. Based on the nurse's assessment findings, which hypersensitivity should the nurse suspect?

Serum sickness

Prior to receiving a blood transfusion, the patient's vital signs are T 97.6°F, R 18 breaths/min, P 72 beats/min, BP 124/70 mmHg. The nurse rechecks the patient's vital signs 15 minutes after initiation of the blood transfusion. The vital signs obtained are as follows: T 99.5°F, R 20 breaths/min, P 84 beats/min, BP 128/74 mmHg. Which nursing action should be implemented immediately?

Stop the blood transfusion

Which clinical manifestation of a hypersensitivity reaction should the nurse monitor for in a patient receiving a blood transfusion?

Temperature 101.6ºF

The nurse is preparing discharge instructions for a patient who experienced an unknown anaphylactic reaction. Which is the priority outcome for the patient?

The patient will describe proper self-administration of medications.

A patient presents to the clinic and states, "I think I have poison ivy because my skin is very red and itchy. I was out hiking the other day and came in contact with it." Which further assessment finding should the nurse anticipate at the site of the exposure?

Thickening effect on the skin

A patient is experiencing a hypersensitivity response triggered by hayfever. Which type of hypersensitivity response should the nurse anticipate?

Type I response

A patient is admitted to the emergency department with red, itchy patches on both legs that appeared 24 hours after returning from an overnight camping trip. Which type of hypersensitivity response does the nurse expect the patient to be experiencing?

Type IV

In what ways do type IV hypersensitivity reactions differ from other types of hypersensitivity​ reactions?

Unlike other types of hypersensitivity​ reactions, type IV reactions are​ cell-mediated responses and take 24 hours or more to develop.

The nurse is caring for a client who is experiencing anaphylactic shock following the administration of a medication. Based on this​ data, which position is the most appropriate for the nurse to place the​ client?

​High-Fowler position

Why are​ second-generation antihistamines often preferred to​ first-generation histamines in the treatment of hypersensitivity​ reactions?

​Second-generation antihistamines are less likely than​ first-generation antihistamines to cause drowsiness.