Nursing 265 Immunity week 3
Immediately after cataract surgery a client reports feeling nauseated. What should the nurse do?
dminister the prescribed antiemetic Rationale An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Aggressive intervention is required rather than dry crackers. Explaining that this is expected after surgery is incorrect. Deep breathing will not minimize nausea; aggressive intervention is required to prevent vomiting.
An instructor is teaching about wheal-and-flare reactions. Which statement made by the student nurse indicates that further education is required?
A wheal-and-flare reaction is very dangerous."
Which type of hepatitis virus spreads through contaminated food and water?
Hepatitis A virus Rationale Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products.Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action?
Place the patient recumbent and elevate the legs. In this emergency situation, the ABCs (airway, breathing, circulation) are being followed. For hypotension, the patient should be placed in a recumbent position with the legs elevated, epinephrine will continue to be administered every 2 to 5 minutes, and fluids will be administered with vasopressors. Diphenhydramine is an antihistamine used to treat allergy symptoms. Anticipating a tracheostomy may occur with ongoing patient monitoring. Nitroprusside is a vasodilator and would not be used now.
Which age-related effects on the immune system are seen in the older client?
Increased autoantibodies Rationale The effects of aging on the immune system include increased autoantibodies. Expression of IL-2 receptors, delayed hypersensitivity reaction, and primary and secondary antibody responses decrease in older adults because of the effects of aging on the immune system.
Which type of immunity is acquired through the transfer of colostrum from the mother to the child?
Natural passive immunity Rationale Natural passive immunity is acquired through the transfer of colostrum from the mother to the child. Natural active immunity is acquired when there is a natural contact with an antigen through a clinical infection. Artificial active immunity is acquired through immunization with an antigen. Artificial passive immunity is acquired by injecting serum from an immune human.
The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond?
"Maternal antibodies interfere with the development of active antibodies by the infant when immunize Rationale Passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases. The spleen does not produce antibodies. Infants often are exposed to infectious diseases. The viruses in immunizations are inactivated or attenuated; they may cause irritability and fever but will not cause the related disease.
A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure?
All metal, such as jewelry and hair ornaments, has been removed. Rationale All metal must be removed because the MRI emits a strong magnetic field[1][2]. All medications may not be necessary before the test. Prehydration is not necessary and may cause interruptions for client to void. The client should have the opportunity to void before going for the test.STUDY TIP: Try to decrease your workload and maximize your time by handling items only once. Most of us spend a lot of time picking up things we put down rather than putting them away when we have them in hand. Going straight to the closet with your coat when you come in instead of throwing it on a chair saves you the time of hanging it up later. Discarding junk mail immediately and filing the rest of your bills and mail as they come in rather than creating an ever-growing stack saves time when you need to find something quickly. Filing all items requiring further attention in some fashion helps you remember to take care of things on time rather than being so engrossed in your schoolwork that you forget about them. Many nursing students have had their power or telephone service cut off because the bill simply was forgotten or buried in a pile of old mail.
Which hospital department plays a primary role in disaster preparedness?
Emergency department Rationale The emergency department plays a primary role in emergency disaster preparedness. While all departments in the hospital contribute to disaster planning, the only department that plays a primary role is the emergency department.
Which sexually transmitted disease is caused by a virus?
Genital warts Rationale Genital warts are caused by a sexually transmitted virus. Bacteria cause syphilis, gonorrhea, and chlamydial infections.
What teaching must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge?
Medications must be continued even when the child is asymptomatic. Rationale Children with persistent asthma must continue taking medications to keep them asymptomatic. Inhaled corticosteroids, long-acting β 2-agonists, and leukotriene modifiers are used as controller medications. Some environmental moisture is necessary for these children. Consistent limits should be placed on any child's behavior, regardless of the disease; a chronic illness does not remove the need for setting limits. The child's symptoms are being controlled by medications that are necessary to keep the child asymptomatic.
A patient being tested for multiple allergies develops localized redness and swelling in reaction to a patch skin test. Which intervention by the nurse would have the highest priority?
Remove the patch and extract from the skin. If a severe reaction to a patch skin test occurs, the nurse should immediately remove the patch and the extract from the skin. Next the nurse should apply a topical antiinflammatory cream to the site. A subcutaneous injection of epinephrine may also be necessary.
Which vaccine is administered orally in children?
Rotavirus vaccine Rationale Rotavirus vaccines are generally administered orally because these live viruses should replicate in the gut of the infant. MMR vaccines are generally administered subcutaneously in the upper region of the arm. Live influenza vaccines are administered nasally. Meningococcal conjugate vaccines (MCV4) are administered intramuscularly in the deltoid region.
While reviewing laboratory reports of a patient, the nurse finds ulcerative colitis. Which surgery does the nurse expect to be beneficial for this patient?
Total proctocolectomy with ileal pouch/anal anastomosis
A patient reports to the nurse experiencing a runny nose, sneezing, and itchy eyes after visiting botanical gardens. Which type of hypersensitivity does the nurse expect to be involved?
Type 1
A client has a kidney transplant. The nurse should monitor for which assessment findings associated with rejection of the transplant? Select all that apply.
Fever Oliguria Weight gain Fever is a characteristic of the systemic inflammatory response to the antigen (transplanted kidney). Oliguria or anuria occurs when the transplanted kidney is rejected and fails to function. Weight gain can occur from fluid retention when the transplanted kidney fails to function or as a result of steroid therapy; this response must be assessed further. Jaundice is unrelated to rejection. Polydipsia is associated with diabetes mellitus; it is not a clinical manifestation of rejection.
Which cytokine increases growth and maturation of myeloid stem cells?
Granulocyte-macrophage colony-stimulating factor Rationale Granulocyte-macrophage colony-stimulating factor is a cytokine that increases growth and maturation of myeloid stem cells. Interleukin-2 is a cytokine that increases growth and differentiation of T-lymphocytes. Thrombopoietin is a cytokine that increases growth and differentiation of platelets. Granulocyte colony-stimulating factor is a cytokine that increases numbers and maturity of neutrophils.
A client who had a transurethral resection of the prostate is transferred to the postanesthesia care unit with an intravenous (IV) line and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period?
Hemorrhage Rationale After transurethral surgery[1][2], hemorrhage is common because of venous oozing and bleeding from many small arteries in the area. Sepsis is unusual, and if it occurs it will manifest later in the postoperative course. Phlebitis is assessed for, but it is not the most important complication. Hemorrhage is more important than phlebitis. Leaking around the IV catheter is not a major complication.Test-Taking Tip: Work with a study group to create and take practice tests. Think of the kinds of questions you would ask if you were composing the test. Consider what would be a good question, what would be the right answer, and what would be other answers that would appear right but would in fact be incorrect.
What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for a colectomy?
How to deep breathe and cough Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe.Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge.
Which is the first antibody formed after exposure to an antigen?
IgM Rationale IgM (immunoglobulin M) is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.
A nurse bases the plan of care for a 15-month-old toddler with celiac disease on the pathophysiology of the disorder, which is characterized by what?
Inability to metabolize gluten Children with celiac disease are unable to digest the gliadin component of gluten, resulting in fatty, foul-smelling diarrheal stools. Phenylketonuria is caused by the absence of phenylalanine; it is not related to celiac disease. Excessive salt in the sweat glands is a manifestation of cystic fibrosis. Increased viscosity of secretions from mucous glands is also related to cystic fibrosis.
A client making her first visit to the prenatal clinic asks which immunization can be administered safely to a pregnant woman. What should the nurse tell her?
Inactive influenza Rationale The inactive influenza and diphtheria, tetanus, pertussis (dTAP) immunizations can be safely administered during the first trimester of pregnancy, although dTAP is recommended at 27 to 36 weeks' gestation to provide immunity to the mother and infant. The inactivated influenza vaccine may be given because it is a killed virus vaccine and will not have a teratogenic effect. Rubella (measles) and rubeola (German measles) vaccines are both live viruses that should never be administered during pregnancy because they can have teratogenic effects. Varicella (chicken pox) immunization is not given because it may cause birth defects in the fetus.
Which mechanism of action does norepinephrine promote to manage anaphylaxis?
Increases blood pressure and cardiac output Rationale Norepinephrine is a sympathomimetic vasopressor that elevates the blood pressure and cardiac output in clients with hypotension from anaphylaxis by stimulating alpha- and beta-adrenergic receptors. Diphenhydramine blocks the effects of histamine on various organs. Corticosteroids such as dexamethasone prevent mast cell degranulation. Acetylcholinesterase inhibitors such as neostigmine stimulate the muscarinic and nicotinic receptors for the reversal of neuromuscular blockade agents.
Which cytokine stimulates the liver to produce fibrinogen and protein C?
Interleukin-6 Rationale Interleukin-6 stimulates the liver to produce fibrinogen and protein C. Interleukin-1 stimulates the production of prostaglandins. Thrombopoietin increases the growth and differentiation of platelets. Tumor necrosis factor stimulates delayed hypersensitivity reactions and allergies.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
A patient received penicillin V potassium intramuscular (IM) causing a systemic anaphylactic reaction. What manifestations does the nurse observe initially?
Itching and edema A systemic anaphylactic reaction starts with edema and itching at the site of exposure to the antigen. Shock can rapidly develop with rapid, weak pulse; hypotension; dilated pupils; dyspnea; and possible cyanosis. The wheal-and-flare reaction occurs with a localized anaphylactic reaction such as a mosquito bite.
The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should the nurse give about why the MMR vaccine is administered at 12 to 15 months of age?
Maternal antibodies provide immunity for about 1 year. Rationale Maternal antibodies to measles, mumps, and rubella infection persist in the infant until approximately 15 months of age. Side effects are no more common among infants than in toddlers. The measles vaccination does not interfere with the effectiveness of other vaccines. Although the measles, mumps, and rubella do occasionally occur after the administration of the MMR vaccine during the first year of life, the vaccine is not given during this time because of the presence of maternal antibodies.Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except.
What causes medications used to treat AIDS to become ineffective?
Missing doses of the prescribed medications The most important reason for the development of drug resistance in the treatment of AIDS is missing doses of drugs. When doses are missed, the blood drug concentrations become lower than what is needed to inhibit viral replication. The virus replicates and produces new particles that are resistant to the drugs. Taking the medications 90% of the time prevents medications from becoming ineffective. Taking medications from different classes prevents the drugs from becoming ineffective. Immune reconstitution inflammatory syndrome (IRIS) occurs when T-cells rebound with medication therapy and become aware of opportunistic infections. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.
A primigravida has just given birth. The nurse is aware that the client has type AB Rh-negative blood. Her newborn's blood type is B positive. What should the plan of care include?
Obtaining a prescription to administer Rho(D) immune globulin to the mother Rationale Rho(D) immune globulin will prevent sensitization resulting from Rh incompatibility that may arise between an Rh-negative mother and an Rh-positive newborn. Determining the father's blood type is unnecessary because only the mother's and infant's Rh factors are relevant. Preparing for a maternal blood transfusion is unnecessary; if a transfusion were needed, it would be for the newborn, not the mother. There is no ABO incompatibility; incompatibility might occur if the mother were O positive and the newborn had type A, B, or AB blood.STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.
Which preparations use toxoids but not live viruses? Select all that apply.
PEDIARIX DAPTACEL Rationale PEDIARIX consists of diphtheria and tetanus toxoids plus inactivated bacterial components of pertussis, inactive viral antigen of hepatitis B, and inactivated poliovirus vaccine. DAPTACEL is a preparation consisting of toxoids plus inactive bacterial and viral components of diphtheria and tetanus toxoids and acellular pertussis vaccine. Rotarix, Varivax, and M-M-R II are preparations containing live viruses. PEDIARIX consists of diphtheria and tetanus toxoids plus inactivated bacterial components of pertussis, inactive viral antigen of hepatitis B, and inactivated poliovirus vaccine. DAPTACEL is a preparation consisting of toxoids plus inactive bacterial and viral components of diphtheria and tetanus toxoids and acellular pertussis vaccine. Rotarix, Varivax, and M-M-R II are preparations containing live viruses.
A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours?
Prevent pressure ulcers Rationale Pressure ulcers[1][2] easily develop when a particular position is maintained; the body weight, directed continuously in one region, restricts circulation and results in tissue necrosis. Denervated tissue has less perfusion and is more prone to pressure ulcers. Clients often state that they are comfortable and wish to remain in one position. Proper positioning with supportive devices and range of motion are more effective measures to prevent contractures. Because turning usually is done laterally, the circulation to the lower extremities is not dramatically affected. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way.
A young adult with a history of cognitive impairment and tonic-clonic seizures is admitted to a group home. Among the client's medications is a prescription for 125 mg of phenytoin by mouth three times a day. Phenytoin is supplied as an oral suspension of 25 mg/5 mL. How many milliliters of solution will the nurse administer for each dose? Record your answer as a whole number. mL
Rationale The correct amount of solution to administer at each dose is 25 mL. Solve the problem with the use of ratio and proportion.
The nurse is caring for a client who is receiving azathioprine, cyclosporine, and prednisone before receiving a kidney transplant. What does the nurse identify as the purpose of these drugs?
Reduce antibody production Rationale These drugs suppress the immune system, decreasing the body's production of antibodies in response to the new organ, which acts as an antigen. These drugs decrease the risk of rejection. These drugs inhibit leukocytosis. These drugs do not provide immunity; they interfere with natural immune responses. Because these drugs suppress the immune system, they increase the risk of infection.Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority?
Respiratory system Rationale The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.
Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action?
Returning the aspirate and subtracting the amount of the aspirate from the feeding Rationale The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance. STUDY TIP: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment.
A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply.
Rye Oats Wheat Rationale Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.
Which statement is true regarding Sjögren's syndrome?
Sjögren's syndrome decreases the digestion of carbohydrates. Rationale Sjögren's syndrome decreases the digestion of carbohydrates because of insufficient secretion of saliva. Sjögren's syndrome decreases lacrimation. Sjögren's syndrome also decreases body secretions and saliva, therefore increasing the risk of infection.
Which disorder does the image illustrate?
Systemic lupus erythematosus Rationale Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that causes major body organs and systems to fail. The image illustrates a "butterfly" rash, which is a major skin manifestation of systemic lupus erythematosus. Angioedema is the diffuse swelling of the eyes and lips. In oral candidiasis, white plaque-like lesions appear on the tongue, palate, pharynx, and buccal mucosa. In systemic sclerosis, skin thickening on the trunk, face, and extremities is observed.
How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit?
Toilet the client more frequently with supervision. RationaleThe client is voiding on the floor not to express hostility but because of confusion. Taking the client to the toilet frequently reduces the risk of voiding in inappropriate places. Making the client mop the floor is a form of punishment for something the client cannot control. Restricting the client's fluids for the rest of the day is not realistic; it will have no effect on the problem and may lead to physiologic problems. If the client were doing this to express hostility, withholding privileges might be effective, but not when the client is unable to control the behavior.
What type of hypersensitivity reaction is the cause of systemic lupus erythematosus?
Type III Rationale Systemic lupus erythematosus is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I or immediate hypersensitive reaction. Cytotoxic or type II hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions that are caused by delayed or type IV hypersensitivity reactions.Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care.
An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse bestassess the client's pain level?
using wong's "pain faces"-an adult client w/ limited mental capacity may not understand the concepts of numbers as an indicator of levels of pain; wong's "pain faces" uses pictures to which the individual can relate Rationale An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.
The nurse is teaching a patient with a latex allergy about preventing and treating allergic reactions. Which statement, if made by the patient, indicates a need for further teaching?
"Because my reactions are not severe, I will not need an EpiPen." An individual with latex allergies should carry an injectable epinephrine pen. The proteins in latex are similar to the proteins in certain foods and may cause an allergic reaction in people who are allergic to latex. Foods to avoid include banana, avocado, chestnut, kiwi, tomato, water chestnuts, guava, hazelnuts, potatoes, peaches, grapes, and apricots. Vinyl gloves are not latex and are safe to use. Individuals with latex allergies need to share this information with all health care providers and wear a medical alert bracelet.
A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be prevented. What is the nurse's response?
"Scratching results in skin breaks that can lead to infection." Rationale Scratching can break the integrity of the skin, leaving it vulnerable to infection. Dermatitis is a response to an allergen; it is not contagious. Scratching will not cause the dermatitis to spread. There are no data to indicate that scratching or dermatitis is a precursor to skin cancer.
What is the concentration of estradiol in the blood during the follicular phase of the menstrual cycle?
130 pg/mL Rationale In the follicular phase of the menstrual cycle, 20-150 pg/mL of estradiol is released. Therefore 130 pg/mL of estradiol would be its concentration during the follicular phase of the menstrual cycle. Concentrations of 159, 165, and 171 pg/mL are greater than the reference range.
Which cytokine is used to treat multiple sclerosis?
β-Interferon Rationale β-Interferon is a cytokine used to treat multiple sclerosis. Interleukin-2 is used to treat metastatic melanoma. Erythropoietin is a cytokine used to treat anemia related to chemotherapy. Colony-stimulating factor is a cytokine used to treat chemotherapy-induced neutropenia.
How many hours of sleep should the nurse recommend for the 11-year-old client?
9 Rationale A school-age client who is 11 years of age would require 9 hours of sleep each night. Ten hours of sleep is not recommended for the school-age client. A 5-year-old school-age client requires 11.5 hours of sleep per night; however, 11 and 12 hours of sleep is not recommended for an 11-year-old school-age client.
The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). What does the nurse expect to find?
A decrease in CD4 T-cells .Rationale The human immunodeficiency virus (HIV) infects helper T-cell lymphocytes; therefore 300 or fewer CD4 T cells per cubic millimeter of blood or CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS. The thymic hormones necessary for T-cell growth are decreased. An increase in immunoglobulin E is associated with allergies and parasitic infections. A decrease in the serum level of glucose-6-phosphate dehydrogenase is associated with drug-induced hemolytic anemia and hemolytic disease of the newborn. Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.
A colectomy is scheduled for a patient with ulcerative colitis. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient? Group of answer choices
Administration of a cleansing enema
A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The nurse should plan to include what prescribed measure in the preoperative preparation of this patient?
Administration of a cleansing enema RationalePreoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin, and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. A clear liquid diet will be used the day before surgery with the bowel cleansing. Oral antibiotics are given preoperatively and an IV antibiotic may be used in the operating room.
What is an example of a type I hypersensitivity reaction?
Anaphylaxis Rationale An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A blood transfusion reaction is a type II cytotoxic reaction.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.
What is the priority nursing intervention for a patient who is developing severe symptoms of anaphylactic reaction during intradermal skin testing?
Applying a tourniquet above the site of the test
A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the most appropriate nursing action?
Applying cold compresses to the affected area Rationale A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse should apply cold compresses to the affected area to reduce the pain in the client. A client with Candida albicans infection should keep his or her skin clean and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may suffer from cardiac, arthritic, and neurologic manifestations. Therefore the nurse has to monitor for these symptoms. Direct contact may transmit a Sarcoptes scabiei infection; the nurse should make sure that the client's clothes are bleached to prevent the transmission of the infection. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.
Which type of allergic skin condition in a client is associated with immunological irregularity, asthma, and allergic rhinitis?
Atopic dermatitis Rationale Atopic dermatitis is an allergic skin condition that is a genetically influenced, chronic, relapsing disease. It is associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma. Urticaria is an allergic skin condition that results in a local increase in permeability of capillaries, causing erythema and edema in the upper dermis. Psoriasis is an autoimmune chronic dermatitis but not an allergic skin condition. Acne vulgaris is an inflammatory disorder of sebaceous glands.
Which drug used to promote fertility may cause esophageal burns?
Clomiphene Rationale Clomiphene is a serum selective receptor modulator that may cause esophageal burns. Estrogen may cause a thromboembolism. Nifedipine may cause maternal fetal problems. Indomethacin may cause birth defects.
Which autoantigens are responsible for the development of Crohn's disease?
Crypt epithelial cells Rationale Crypt epithelial cells are considered to be the autoantigens responsible for Crohn's disease. Thyroid cell surfaces are autoantigens responsible for Hashimoto's thyroiditis. The pulmonary and glomerular basement membranes act as autoantigens responsible for Goodpasture syndrome.
Which vaccination is given to young children to provide protection against tetanus and diphtheria but not pertussis?
DTaP Rationale DT is given to children to provide protection from both tetanus and diphtheria. Td is used as a booster dose to protect adolescents and adults from tetanus and diphtheria. DTaP is given to children to provide protection from tetanus, diphtheria, and acellular pertussis. Tdap is used as a booster dose to protect adolescents and adults from tetanus, diphtheria, and acellular pertussis.
A child is found to be allergic to dust. The nurse is preparing a teaching plan for the parents. What should the nurse include in the plan?
Damp-dusting the house will help limit dust particles in the air. Rationale Although dust cannot be avoided completely, use of a damp cloth helps eliminate the quantity of airborne particles that might be inhaled. Hiring professional housecleaners is unnecessary and unrealistic. There are ways to limit the quantity of airborne particles. Redecorating will not eliminate dust; it is part of our environment.
Which process does the IgD immunoglobulin support?
Differentiation of the B-lymphocytes Rationale IgD is present on the lymphocyte surface; this immunoglobulin differentiates B-lymphocytes. IgE causes symptoms of allergic reactions by adhering to mast cells and basophils. IgE also helps to defend the body against parasitic infections. IgA lines the mucous membranes and protects the body surfaces. IgM provides the primary immune response.
An adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, what nursing action is mosttherapeutic?
Encouraging her peers to visit Rationale Peer acceptance is crucial during this period; friends must have the opportunity to accept the client with one leg. Concealment does not help the adolescent or others accept the loss. Isolating the adolescent will increase feelings of alienation and being different. An adolescent needs to relate to and be accepted by peers as well as family.
Which type of cytokine is used to treat anemia related to chronic kidney disease?
Erythropoietin Rationale Erythropoietin is used to treat anemia related to chronic kidney disease. α-Interferon is used to treat hairy cell leukemia or malignant melanoma. Interleukin-2 is used to treat metastatic renal carcinoma. Interleukin-11 is used to prevent thrombocytopenia after chemotherapy.
A mother with the diagnosis of acquired immunodeficiency syndrome (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine?
If the baby is breastfeeding Rationale Epidemiologic evidence has identified breast milk as a source of human immunodeficiency virus (HIV) transmission. Kissing is not believed to transmit HIV. When the baby last received antibiotics is unrelated to transmission of HIV. HIV transmission does not occur from contact associated with caring for a newborn.
Which type of immunoglobulin is present in tears, saliva, and breast milk?
IgA Rationale IgA immunoglobulin is present in tears, saliva, and breast milk. IgE and IgG immunoglobulins are present in plasma and interstitial fluids. IgM immunoglobulin is present in plasma.
Which immunoglobulin crosses the placenta?
IgG Rationale IgG is the only immunoglobulin that crosses the placenta. IgE is found in the plasma and interstitial fluids. IgA lines the mucous membranes and protects body surfaces. IgM is found in plasma; this immunoglobulin activates due to the invasion of ABO blood antigens.
A school nurse is teaching a group of parents about pediculosis capitis (head lice). What common secondary infection does the nurse teach the parents to identify?
Impetigo Rationale Impetigo may develop as a secondary bacterial infection because of breaks in the skin caused by scratching. Eczema is an allergic response, not an infection. Cellulitis is an extended inflammation that is not commonly found in children with pediculosis. Folliculitis is a pimple or an infection of the hair follicle; it does not occur as a result of pediculosis.
A 7-year-old child is admitted for surgery. What is the priority nursing action?
Inspecting the child's mouth for loose teeth and reporting the findings Rationale School-aged children lose their primary teeth, which may be aspirated during surgery. Special precautions must be taken to maintain safety. Allowing a favorite toy to remain with the child is a comforting gesture, but it is not essential. There is no reason to obtain an antistreptolysin O (ASO) titer or a C-reactive protein level. Encouraging a parent to stay until the child leaves for the operating room is important but not always possible.
A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation?
Physical therapy Rationale Rehabilitation needs for a client with Guillain-Barré syndrome focus on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain-Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome.Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason.
A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing?
Rationale The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words ( Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.
A nurse is teaching parents of toddlers about why children receiving specific medications should not receive varicella vaccines. Which medication will be included in the discussion?
Steroids Rationale Steroids have an immunosuppressive effect. It is thought that resistance to certain viral diseases, including varicella, is greatly decreased when a child takes steroids regularly. There is no known correlation between varicella and insulin. Because varicella is a viral disease, antibiotics will have no effect. There is no known correlation between varicella and anticonvulsants.
The primary healthcare provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client reports itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next?
Stop the transfusion immediately. Rationale The client is experiencing an allergic reaction to the transfusion. The nurse should stop the transfusion immediately. The health care provider then should be notified. Flushing red blood cells with dextrose and normal saline will cause hemolysis and will not be effective in stopping the reaction. Slowing down the rate will make the situation worse.
A mother brings her 6-year-old child to the pediatric clinic, stating that the child has not been feeling well, is weak and lethargic, and has a poor appetite, headaches, and smoky-colored urine. What additional information should the nurse obtain that will aid diagnosis?
Strep throat in the past two weeks Rationale The smoky urine and the stated symptoms should lead the nurse to suspect glomerulonephritis, which usually occurs after a recent streptococcal infection. A rash on the hands and feet is associated with scarlet fever, not glomerulonephritis. Shoulder and knee pain is associated with rheumatic fever, not glomerulonephritis. Weight loss generally occurs in children who have type 1 diabetes, not in those with glomerulonephritis.
A nurse is counseling the family of a child with AIDS. What is the most important concern that the nurse should discuss with the parents?
Susceptibility to infection Rationale Children with AIDS have a dysfunction of the immune system (depressed or ineffective T lymphocytes, B lymphocytes, and immunoglobulins) and are susceptible to opportunistic infections. All children are subject to injury because of their curiosity, inexperience, and lack of judgment. Although inadequate nutrition can be a problem for children with AIDS, the prevention of infection is the priority. Although children with AIDS are usually small for age, altered growth and development is not as life threatening as an infection.
The nurse creates a plan of care for a patient who has had an allergic reaction to a bee sting. What is the priority expected outcome for this patient?
This patient is at risk for development of an anaphylactic reaction. Maintaining a clear and patent airway is a priority outcome with a patient who has sustained a bee sting and has a known allergy to bees. Comfort and being free of signs and symptoms of infection are important after ensuring airway patency and breathing. Although the demonstration of self-administered epinephrine is likely valuable for the allergic patient, immediately after the bee sting is not the best time to engage in education because a delay in the administration of epinephrine could result.Text Reference - p. 214
The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for?
Weight gain Rationale The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.
Which is a leukotriene modifier used to manage and prevent allergic rhinitis?
Zileuton Rationale Zileuton is a leukotriene modifier used to manage and prevent allergic rhinitis. Ephedrine is an ingredient in decongestants used to treat allergic rhinitis. Scopolamine is an anticholinergic used to reduce secretions. Cromolyn sodium is a mast cell stabilizing drug used to prevent mast cell membranes from opening when an allergen binds to IgE.Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
