Ch. 47 Immunity
The nurse is monitoring the CD4 count of an infant who has contracted HIV from the mother in utero. The nurse is concerned that treatment with antiretroviral therapy is not effective when noting which CD4 level? 1900/mm3 1700/mm3 1500/mm3 1300/mm3
1300/mm3 Explanation: The number of CD4 T lymphocytes in the blood helps to determine the effectiveness of antiretroviral therapy. Normal is 1500/mm3 in the infant, so anything below that number may indicate that the therapy is not effective. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, COMMON LABORATORY AND DIAGNOSTIC TESTS 47.1, p. 1747.
Which nursing intervention is priority when caring for a child with HIV? Administer prescribed medications. Assist the child with daily activities. Assess pain after invasive procedures. Review laboratory CD4 counts daily.
Administer prescribed medications. Explanation: Although assisting with activities, assessing pain, and reviewing CD4 counts are all important, the priority when caring for a child with HIV is to administer prescribed medications. Prescribed medications prevent progressive deterioration of the immune system and provide prophylaxis against opportunistic infections. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, SECONDARY IMMUNODEFICIENCIES, p. 1754.
Which nursing problems could be associated with a child with primary immunodeficiency? Select all that apply. Risk for infection Altered skin integrity Delayed growth and development Altered fluid and electrolytes Altered gastrointestinal function
Risk for infection Altered skin integrity Delayed growth and development Explanation: All of these can be problems associated with immune system dysfunction. Fluid and electrolytes and GI function are not commonly associated with primary immunodeficiency. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, COMMON MEDICAL TREATMENTS, p. 1747.
The nurse is caring for a child with an elevated erythrocyte sedimentation rate, a hemoglobin level of 9.3 g/dL (93 g/L), and a positive antinuclear antibody. What would the nurse expect to identify when assessing this child? Select all that apply. The child reports increasing joint pain after exercise. The child reports stiffness in the joints that is worse in the morning. redness and warmth in the affected joint swelling noted in the affected joint increased range of motion in the affected joint
The child reports stiffness in the joints that is worse in the morning. redness and warmth in the affected joint swelling noted in the affected joint Explanation: Juvenile arthritis is characterized by changes in laboratory results, which include anemia and elevations in the erythrocyte sedimentation rate. Children with juvenile arthritis also may have a positive antinuclear antibody test. Stiffness (reduced range of motion), redness, warmth, and pain are noted in the affected joints. Stiffness and pain are worse after periods of inactivity such as sleeping. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, AUTOIMMUNE DISORDERS, pp. 1759-1760.
The parents of a 10-year-old with HIV have never told their child that he has the virus. The child asks the nurse why he is "on so many medications." What action should the nurse take? The nurse should explain the infection to the child. The nurse should tell the parents when they enter the child's room that their child has a question for them. The nurse should encourage the child to talk with his parents about his medications. The nurse should suggest to the child to speak with his doctor.
The nurse should encourage the child to talk with his parents about his medications. Explanation: Generally, children older than 6 years of age will eventually need to have their diagnosis disclosed to them in an age-appropriate manner. They begin to ask questions and often seem to sense that something is going on other than what they've been told so far. Encouraging discussion with the parents is the best first step. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, SECONDARY IMMUNODEFICIENCIES, p. 1757.
A 7-year-old child is rushed into the emergency room after being stung by a yellow jacket. The child is nauseated and vomiting and is experiencing itching and swelling on the arm where stung. The is having trouble breathing. Which type of hypersensitivity response is the child experiencing? Type I: anaphylaxis Type II: cytotoxic response Type III: immune complex Type IV: cell-mediated hypersensitivity
Type I: anaphylaxis Explanation: Anaphylactic shock is an immediate, life-threatening, type I hypersensitivity reaction that occurs after exposure to an allergen in a previously sensitized child. Anaphylactic shock must be treated immediately as it can be fatal. Initially, a child may become nauseated, with vomiting and diarrhea, because of the sudden increase in gastrointestinal secretions produced by the stimulation of histamine. This is followed by urticaria (itching) and angioedema (swelling). Bronchospasm can become so severe the child becomes dyspneic, hypoxemic, and then hypoxic. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, p. 1763.
The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of greatest concern? elevated temperature elevated blood pressure hypotension reduced body temperature
elevated blood pressure Explanation: Renal complications may result from lupus. This may be accompanied by hypertension, making monitoring of blood pressure of the highest importance. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, AUTOIMMUNE DISORDERS, p. 1758.
A child is diagnosed with a latex allergy. When developing the teaching plan for this child, the nurse would include what foods to avoid? Select all that apply. pineapples cherries bananas cheese peanut butter squash
pineapples cherries bananas Explanation: Certain foods have shown a cross-sensitivity to latex and should be avoided. These include pear, peach, passion fruit, plum, pineapple, kiwi, fig, grape, cherry, melon, nectarine, papaya, apple, apricot, banana, chestnut, carrot, celery, avocado, tomato, or potato. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, p. 1767.
To avoid anaphylactic reactions in children, which question would be most important to ask a parent before administering penicillin to her infant? "Has she ever had penicillin before?" "Is there any family history of allergy to penicillin?" "What do you give her to alleviate itching?" "Do you have a telephone to call us immediately if she develops trouble breathing?"
"Has she ever had penicillin before?" Explanation: Penicillin is a drug frequently involved in allergic reactions. The reaction occurs after the child has first been sensitized to the drug. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, p. 1766.
The mother of a child with a possible food allergy asks the nurse for information about how to test for it. Which response by the nurse would be most appropriate? "Skin testing using a patch is probably the easiest method." "We can check the level of antibodies in the blood to confirm the allergy." "The best way is to eliminate the food from the diet and then look for improvement." "We can inject an extract of the food under the skin and see if there is a reaction."
"The best way is to eliminate the food from the diet and then look for improvement." Explanation: Food allergies are best identified by eliminating a suspected food from the diet and observing whether symptoms improve. After a time of improvement, the food is reintroduced and if the child is allergic to the food, the symptoms will return. Skin testing with either a patch or intracutaneous injection is ineffective for determining food allergies. Serum antibody levels can be measured but are not specific in helping to determine food allergies. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, p. 1763.
A nurse is providing education to pregnant women diagnosed with HIV. Which statement indicates the need for further teaching? Pregnancy will accelerate the progression of the disease. It is not safe to breastfeed my baby, so I will use formula. Antiretroviral treatment is effective in reducing maternal-fetal transmission. My health care provider may want me to have a cesarean birth.
Pregnancy will accelerate the progression of the disease. Explanation: Of the nearly 1,000,000 people in the United States infected with HIV, 25% are female. There isn't any research showing pregnancy accelerates the progression of the disease. Women with HIV should not breastfeed, because they could transmit the virus to the baby via the breastmilk. Early use of antiretroviral medications are effective in reducing transmission, and a cesarean birth may be scheduled to reduce potential transmission to the newborn. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, SECONDARY IMMUNODEFICIENCIES, p. 1756.
The nurse is monitoring the labs of a child admitted for an exacerbation of juvenile pauciarticular arthritis. Which lab result does the nurse expect to be elevated? immunoglobulin electrophoresis lymphocyte immunophenotyping T-cell quantification erythrocyte sedimentation rate (ESR) radioallergosorbent test
erythrocyte sedimentation rate (ESR) Explanation: Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, AUTOIMMUNE DISORDERS, p. 1760.
A nurse is providing care to a child who is HIV positive and prescribed IV zidovudine. Which nursing actions would be appropriate when administering the drug? Select all that apply. Infuse the drug over 60 minutes. Monitor the child for paresthesias. Adhere to droplet precautions. Give the drug in the morning and after lunch. Reinforce use of meticulous handwashing.
Infuse the drug over 60 minutes. Monitor the child for paresthesias. Give the drug in the morning and after lunch. Reinforce use of meticulous handwashing. Explanation: When administering IV zidovudine, the nurse should administer the drug over 60 minutes to prevent too rapid an infusion and give the drug around the clock for maximum effectiveness. The nurse should also monitor the child for paresthesias and institute safety precautions if they occur. The drug does not reduce the risk for HIV transmission, so the nurse should reinforce the need for meticulous handwashing and standard precautions. Droplet precautions are not necessary. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, COMMON MEDICAL TREATMENTS, PRIMARY IMMUNODEFICIENCIES, p. 1748, 1753.
An infant born to a mother who was HIV positive was tested at birth and found to be negative. The infant is scheduled for follow-up testing. Which test would the nurse expect to be performed? Polymerase chain reaction (PCR) test Enzyme-linked immunosorbent assay (ELISA) Platelet count CD4 counts
Polymerase chain reaction (PCR) test Explanation: The PCR is the preferred test to determine HIV infection in infants over 1 month of age. The ELISA is positive in infants of HIV-infected mothers because of transplacentally received antibodies. These antibodies may persist and remain detectable up to 24 months of age, making the ELISA test less accurate at detecting HIV infection in infants and toddlers than the PCR. The platelet count would provide no information about the infant's HIV status. CD4 counts would be used to monitor HIV infection but not to confirm whether the infant is positive or negative for the virus. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, COMMON LABORATORY AND DIAGNOSTIC TESTS 47.1 ,SECONDARY IMMUNODEFICIENCIES, p. 1747, 1755.
The nurse is caring for an infant exposed to HIV. The polymerase chain reaction (PCR) test was negative at birth. The nurse tells the mother that the child should be tested again at what age? 4 to 7 weeks 8 to 10 weeks 2 to 3 months 12 months
4 to 7 weeks Explanation: Virologic testing for HIV-exposed infants should be done with the polymerase chain reaction test at birth, at 4 to 7 weeks, and again at 8 to 16 weeks. Serologic testing is done at approximately 12 months of age to document disappearance of the HIV-1 antibody. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, COMMON LABORATORY AND DIAGNOSTIC TESTS 47.1 ,SECONDARY IMMUNODEFICIENCIES, p. 1747,1755.
The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education? "Phagocytosis is the process in which phagocytes swallow up and break down microorganisms." "Humoral immunity is immunity mediated by antibodies secreted by B cells." "Cellular immunity is cell-mediated immunity controlled by T cells." "Humoral immunity is generally functional at birth."
"Humoral immunity is generally functional at birth." Explanation: Normal immune function is a complex process involving phagocytosis (process by which phagocytes swallow up and break down microorganisms), humoral immunity (immunity mediated by antibodies secreted by B cells), cellular immunity (cell-mediated immunity controlled by T cells), and activation of the complement system. Cellular immunity is generally functional at birth, and as the infant is exposed to various substances over time, humoral immunity develops. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY, p. 1744.
The nurse is providing dietary interventions for a 12-year-old child with a shellfish allergy. Which response by the parent most concerns the nurse? "My child will likely outgrow this." "My child must avoid consuming lobster." "We will only eat at home and not dine out." "I am very upset about this diagnosis."
"My child will likely outgrow this." Explanation: Older children and adolescents with allergic reactions to fish, shellfish, and nuts usually continue to have that concern as a life-long problem. The nurse wants to ensure the parent understands the severity of the allergy and does not expose the child as the child ages. Lobster should be avoided because it is a shellfish. The nurse needs to educate the parent that the child can dine in restaurants as long as questions are asked of meal contents and menus are read carefully. The nurse also needs to explore the parent's feelings; however, client safety is priority. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, p. 1763.
A nurse is providing care to a child with HIV who is prescribed therapy with a nucleoside reverse transcriptase inhibitor. What would the nurse expect to administer? Zidovudine Nevirapine Efavirenz Ritonavir
Zidovudine Explanation: Zidovudine is a nucleoside reverse transcriptase inhibitor. Nevirapine and efavirenz are classified as nonnucleoside reverse transcriptase inhibitors. Ritonavir is a protease inhibitor. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, DRUG GUIDE 47.1 Common Drugs for Immunologic Disorders, p. 1750.
A nurse instructor is teaching pregnant women how HIV can spread from mother to fetus without treatment. For the untreated child who contracts HIV through placental transmission, when will the child test positive for HIV? After 10 years In early adult years By 6 months of age By 4 years of age
By 6 months of age Explanation: HIV appears to progress more rapidly in untreated infants and children who contract it through placental transmission. These children usually are HIV positive by 6 months old and develop clinical signs by 1 to 3 years old. If a mother is treated for HIV during pregnancy, the infant will also receive HIV medication for 6 weeks after birth. The infant will need to be tested at 1 month of age and at 4 months of age. This testing will determine the absence of HIV in the infant. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, SECONDARY IMMUNODEFICIENCIES, p. 1755.
The nurse is instructing a group of women of childbearing age about human immunodeficiency virus (HIV) during pregnancy. What would be a priority recommendation in this setting? Screening for sexually transmitted infections (STIs) Screening for HIV Prophylactic treatment for HIV Proper nutrition
Screening for HIV Explanation: No screening mandate has been put forth for HIV, but all pregnant women should be encouraged to undergo this test. Prophylactic treatment would be initiated only once the woman has been screened. Screening for STIs and ensuring proper nutrition are also part of health promotion for women in this age group, but they are of lower priority than identifying HIV-positive individuals. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, SECONDARY IMMUNODEFICIENCIES, p. 1756.
The nurse is caring for a child with juvenile idiopathic arthritis (JIA). There is involvement of five or more small joints and it is affecting the body symmetrically. This tells the nurse that the child: has polyarticular JIA. has systemic JIA. has pauciarticular JIA. is at risk for anaphylaxis.
has polyarticular JIA. Explanation: Polyarticular JIA is defined by the involvement of five or more joints, frequently the small joints, and affects the body symmetrically. Pauciarticular JIA is defined by the involvement of four or fewer joints. Systemic JIA presents with fever and rash in addition to join involvement at the time of diagnosis. The child with JIA is not at greater risk for anaphylaxis. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, TABLE 47.2 Types of Juvenile Idiopathic Arthritis, p. 1759.
The nurse is explaining patterns of incidence and transmission of HIV to a group of adolescent girls. She explains that the risks for this population are much higher because of the possibility of both vertical and horizontal transmission. Horizontal transmission refers to transmission of the disease during: sexual contact. feeding with breast milk. the birthing process. pregnancy.
sexual contact. Explanation: Horizontal transmission refers to person-to-person transfer of the virus. Transmission by feeding with breast milk, birthing, and pregnancy are all examples of vertical transmission. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, SECONDARY IMMUNODEFICIENCIES, p. 1754.
The nurse is caring for a 6-month-old infant with Wiskott-Aldrich syndrome. Which teaching does the nurse provide the parent? "Do not use a tub bath for daily cleansing." "Do not encourage a pacifier due to possible oral malformation." "Do not insert anything in the rectum." "Do not use a sponge bath for light cleaning."
"Do not insert anything in the rectum." Explanation: Children with Wiskott-Aldrich syndrome should not be given rectal suppositories or temperatures since these children are at a high risk for bleeding. Tub baths are not contraindicated. Pacifiers are not contraindicated in Wiskott-Aldrich but should be kept as sanitary as possible to avoid oral infections. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, COMMON MEDICAL TREATMENTS 47.1, p. 1749.
The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education? "I will make sure my daughter always has her EpiPen® with her all the time." "If we need to use the EpiPen® we will need to notify her physician's office the next business day." "I have found a website that makes medical alert bracelets in my daughter's favorite color." "The grey part of the EpiPen® should never be removed until right before we use it."
"If we need to use the EpiPen® we will need to notify her physician's office the next business day." Explanation: If an EpiPen® is used, the child still needs immediate medical attention. An EpiPen should be carried with the client at all times. When administering an EpiPen, the grey safety cap should not be removed until immediately prior to use. Medical alert bracelets or necklaces should be worn by all children with severe allergies. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, pp. 1764-1766.
The nurse is caring for a child who has been prescribed cyclophosphamide. What nursing consideration is indicated? Administer the medication at bedtime. Limit the child's fluid intake while taking this medication. Administer medication prior to food intake. Encourage voiding with medication administration.
Encourage voiding with medication administration. Explanation: Cyclophosphamide is a cytotoxic medication. It suppresses bone marrow activity. The child should be encouraged to void during and after administration to prevent hemorrhagic cystitis. The medication should be administered in the morning. Food intake does not have a bearing on the administration of this medication. Adequate hydration should be encouraged to decrease the risk of hemorrhagic cystitis. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, DRUG GUIDE 47.1 Common Drugs for Immunologic Disorders, p. 1750.
The nurse is providing teaching about food substitutions when cooking for the child with an allergy to eggs. Which response indicates a need for further teaching? "I must not feed my child eggs in any form." "I can use the egg white when baking, but not the yolk." "1 tsp yeast and ¼ cup warm water is a substitute in baked goods." "1.5 Tbsp each of water and oil, plus 1 tsp baking powder, equals one egg in a recipe."
"I can use the egg white when baking, but not the yolk." Explanation: The parents must understand that their child cannot consume any part of an egg in any form. The other statements are accurate. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, BOX 47.5 Food Substitutions, p. 1765.
The nurse is reviewing the medical history of a 4-year-old child. What would the nurse identify as potentially indicative of a primary immunodeficiency? Select all that apply. Acute otitis media, one episode every 3 to 4 weeks over the past year. Recurrent deep abscess of the thigh Oral candidiasis (thrush), persistent over the past 6 to 7 months Infected laceration requiring IV antibiotic 2 months ago; healed Pneumonia last spring; resolved with antibiotics
Acute otitis media, one episode every 3 to 4 weeks over the past year. Recurrent deep abscess of the thigh Oral candidiasis (thrush), persistent over the past 6 to 7 months Explanation: Warning signs associated with primary immunodeficiency include four or more new episodes of acute otitis media in 1 year, recurrent deep skin or organ abscesses, persistent oral candidiasis (thrush) or skin candidiasis after 1 year of age. A history of infections requiring IV antibiotics to heal and two or more episodes of pneumonia in 1 year are also warning signs. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, BOX 47.1 10 Warning Signs of Primary Immunodeficiency, p. 1751.
Susie is a 3-year-old with a history of neonatal transmission of HIV and recent diagnosis of AIDS, as manifested by M. tuberculosis infection. To date, Susie has been relatively healthy with few illnesses associated with high fever; she has been developing appropriately and is at the 5th percentile for height and weight. Susie is at risk for all of the following diagnoses. Prioritize the order of urgency of these diagnoses based on the scenario provided.
Altered family coping related to new presentation of significant illness Altered comfort related to severity of new illness Inadequate adherence to medication regimen related to side effects Inadequate nutrition related to side effects of medication Delayed growth and development related to frequent infections Explanation: Because Susie has been relatively healthy since she was diagnosed with HIV, the change in her status is likely to cause changes in family coping mechanisms and dynamics that will have implications for the entire family. Next, the nurse needs to address the specific symptoms of the child. With the increased degree of illness and altered coping strategies, the child may have more difficulty with medication adherence, as well as other complications of AIDS-related illness and treatment, such as poor nutritional intake and delayed growth and development. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, COMMON MEDICAL TREATMENTS, p. 1747.
A nurse is preparing a presentation for a group of new parents and is planning to discuss nutrition during the first year. As part of the presentation, the nurse is planning to address foods that should be avoided to reduce the risk of possible food allergies. Which foods would the nurse most likely include? Select all that apply. Eggs Shrimp Peanuts Carrots Potatoes Bananas
Eggs Shrimp Peanuts Explanation: Foods that should be avoided in children younger than 1 year of age include cow's milk, eggs, peanuts, tree nuts, sesame seeds, and fish and shellfish (i.e., shrimp). Carrots, potatoes, and bananas are not considered problematic. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, TEACHING GUIDELINES 47.1, p. 1764.
The mother of a child with myasthenia gravis has called the clinic and reports her child appears very anxious and the child's heart is beating very fast. What action by the nurse is indicated? Instruct the child be brought to the emergency department promptly. Make an appointment for the child to be seen by the physician within 24 hours. Inquire about any changes in the child's normal routine. Inquire about when the child's last dose of medication was taken.
Instruct the child be brought to the emergency department promptly. Explanation: Myasthenia gravis is an autoimmune disorder that is characterized by weakness and fatigue. There is no cure. The disease may be aggravated by stress, exposure to extreme temperatures, and infections, resulting in a myasthenic crisis. Myasthenic crisis is a medical emergency with symptoms including sudden respiratory distress, dysphagia, dysarthria, ptosis, diplopia, tachycardia, anxiety, and rapidly increasing weakness. The symptoms reported are consistent with a crisis and prompt care is indicated. Waiting 24 hours to have the child seen by the physician is not appropriate. Questions about changes in routine and medication compliance may be asked but the first priority is to have the child seen. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, AUTOIMMUNE DISORDERS, p. 1761.
The nurse is reviewing the immunization schedule with the parent of a child who is HIV positive. What information should the nurse provide? Select all that apply. Pneumococcal vaccination can be given. The child should receive live vaccines only. The human papillomavirus vaccine should not be given. The varicella vaccine should not be given if the child is symptomatic. If the CD4 count is low, the measles, mumps, and rubella vaccine should not be given.
Pneumococcal vaccination can be given. The varicella vaccine should not be given if the child is symptomatic. If the CD4 count is low, the measles, mumps, and rubella vaccine should not be given. Explanation: The nurse should emphasize that live vaccines should not be given to those infected with HIV. Children should receive routine immunizations according to the usual schedule with the killed virus vaccines, including pneumococcal and human papillomavirus vaccine. Symptomatic children should not receive the varicella vaccine, and those with low CD4 counts should not receive measles, mumps, and rubella vaccine. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, HIV Infection, p. 1754.
The parents of a 10-year-old with HIV have never told their child that he has the virus. The child asks the nurse why he is "on so many medications." What action should the nurse take? The nurse should explain the infection to the child. The nurse should tell the parents when they enter the child's room that their child has a question for them. The nurse should encourage the child to talk with his parents about his medications. The nurse should suggest to the child to speak with his doctor.
The nurse should encourage the child to talk with his parents about his medications. Explanation: Generally, children older than 6 years of age will eventually need to have their diagnosis disclosed to them in an age-appropriate manner. They begin to ask questions and often seem to sense that something is going on other than what they've been told so far. Encouraging discussion with the parents is the best first step. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, SECONDARY IMMUNODEFICIENCIES, p. 1757.
When providing discharge instructions to a child who was admitted to the hospital following stridor, wheezing, and urticaria after taking penicillin, which nursing action is priority? Question the child about the amount of penicillin that was taken. Encourage the child to wear a medical alert bracelet for penicillin. Advise the parents to have their child evaluated for atopic diseases. Educate the parents about possible side effects of penicillin in children.
Encourage the child to wear a medical alert bracelet for penicillin. Explanation: Oral medications most likely to cause an allergic reaction include antibiotics, acetylsalicylic acid (aspirin), and NSAIDs. Children experiencing stridor, wheezing, and urticaria after taking a medication most likely have an allergy to that medication. The priority nursing action for discharge education is to prevent the child from being exposed to penicillin again, which could be accomplished by encouraging the child to wear a medical alert bracelet. Although children with atopic diseases are more likely to have medication allergies, requesting parents have the child evaluated is not a priority. Questioning the child about the amount of penicillin taken and educating parents about the side effects of penicillin is not a priority. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, pp. 1766-1767.
The nurse is reviewing the immunization schedule with the parent of a child who is HIV positive. What information should the nurse provide? Select all that apply. Pneumococcal vaccination can be given. The child should receive live vaccines only. The human papillomavirus vaccine should not be given. The varicella vaccine should not be given if the child is symptomatic. If the CD4 count is low, the measles, mumps, and rubella vaccine should not be given.
Pneumococcal vaccination can be given. The varicella vaccine should not be given if the child is symptomatic. If the CD4 count is low, the measles, mumps, and rubella vaccine should not be given. Explanation: The nurse should emphasize that live vaccines should not be given to those infected with HIV. Children should receive routine immunizations according to the usual schedule with the killed virus vaccines, including pneumococcal and human papillomavirus vaccine. Symptomatic children should not receive the varicella vaccine, and those with low CD4 counts should not receive measles, mumps, and rubella vaccine. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, HIV Infection, p. 1754.
A 13-year-old female adolescent is being evaluated for lupus. Which statement(s) by the adolescent indicates a need for further education regarding this disease? Select all that apply. "I am at a higher risk than of developing lupus than a man would be." "Since I am 13, it would be unusual for me to be diagnosed. Younger kids usually get it." "I should have not spent so much time in the sun. That may have been what caused me to get lupus." "My grandmother was diagnosed with lupus, so that means I am at a higher risk." "I just got over a sinus infection last week. This may have been what triggered the disease."
"Since I am 13, it would be unusual for me to be diagnosed. Younger kids usually get it." "I should have not spent so much time in the sun. That may have been what caused me to get lupus." Explanation: Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder that affects both humoral and cellular immunity. SLE can affect any organ system, so the onset and course of the disease are quite variable. There are some identified risk factors including female gender. Groups, such as those of African or Asian descent, have a higher incidence of lupus. Family history does have a role in this condition. A recent infection may be reported by some diagnosed with the condition. Lupus is typically diagnosed around the age of puberty. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, AUTOIMMUNE DISORDERS, p. 1758.
The registered nurse (RN) and unlicensed assistive personnel (UAP) are caring for a pediatric client with an immune disorder receiving a stem cell transplant. Which action by the UAP will cause the RN to intervene? The UAP takes a rectal temperature on the client. The UAP assists the client to ambulate in the room. The UAP places a lunch tray in the client's room. The UAP wears a mask when entering the client's room.
The UAP takes a rectal temperature on the client. Explanation: Precautions must be taken to protect the client from infection. The RN would intervene if the UAP takes a rectal temperature because this increases the client's risk for infection. The client should not receive rectal suppositories as well. The RN would ensure meticulous oral care is provided and encourage appropriate and adequate nutrition. Delivering a meal tray, wearing a mask when entering the room, and assisting the client to ambulate in the room are all appropriate actions by the UAP. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, COMMON MEDICAL TREATMENTS 47.1, p. 1749.
The nurse is caring for a child who is receiving an intravenous immunoglobulin treatment. The client calls the nurse and reports she vomited. What action should be completed first? Discontinue the infusion. Take the client's vital signs. Check the physician's orders for an antiemetic. Contact the physician.
Discontinue the infusion. Explanation: Clients receiving intravenous immunoglobulin are at risk for anaphylaxis. Vomiting can signal an allergic response. The first action would be to stop the infusion. The remaining activities are appropriate for inclusion in the plan of care but are not of the highest priority. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, PRIMARY IMMUNODEFICIENCIES, p. 1752.
The nurse is preparing a care plan for a 4-year-old client newly diagnosed with severe combined immune deficiency. What is the priority goal for this client? The client will perform hygiene care with assistance. The client will remain free from infection. The client will demonstrate basic knowledge of the disorder. The client will return to normal activities after discharge.
The client will remain free from infection. Explanation: While all of these are goals for the client, the highest priority for the immunocompromised client is to remain free from infection since the client is at a high risk for development of an infection. In the immunocompromised client any infection can be life threatening. Performing hygiene care helps promote cleanliness and decrease infection rates. This age group can do some tasks, but still need assistance. The client is old enough to have a basic understanding of the disorder. The primary goal is focused on remaining infection free and not on activities after discharge at this time. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, PRIMARY IMMUNODEFICIENCIES, p. 1753.
The nurse is teaching the parents of a child with a suspected diagnosis of juvenile idiopathic arthritis about the disease. Which statement by the parents demonstrates the need for further teaching? "If our child does not have a positive rheumatoid factor, our child does not have the disease." "It is important to control our child's inflammation and pain." "A warm bath at bedtime and warm compresses can increase our child's comfort." "Swimming is a good activity that will help our child maintain joint mobility."
"If our child does not have a positive rheumatoid factor, our child does not have the disease." Explanation: Unlike adult rheumatoid arthritis, few types of juvenile arthritis actually demonstrate a positive rheumatoid factor. Therapeutic management focuses on inflammation control, pain relief, promotion of remission, and maintenance of mobility. The parents can promote sleep and comfort with a warm bath at bedtime and warm compresses to affected joints or massage. Swimming is a particularly useful exercise to maintain joint mobility without placing pressure on the joints. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, Juvenile Idiopathic Arthritis, p. 1759.
The nurse is providing instructions to the parents of a child with a severe peanut allergy. Which statement by the parents indicates a need for further teaching about the use of an epinephrine auto-injector? "We must massage the area for 10 seconds after administration." "We must make sure that the black tip is pointed downward." "The epinephrine auto-injector should be jabbed into the upper arm." "The epinephrine auto-injector must be held firmly for 10 seconds."
"The epinephrine auto-injector should be jabbed into the upper arm." Explanation: An epinephrine auto-injector should be jabbed into the outer thigh, as this is a larger muscle, at a 90 degree angle, not into the upper arm. The other statements are correct. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, NURSING PROCEDURE 47.1, p. 1766.
A 7-year-old client presents to the emergency room (ER) after experiencing an allergic reaction to a bee sting. The client is breathing and able to verbally communicate. The nurse notes the client's pulse 90 beats/minute, respirations are 23 breaths/minute, blood pressure is 100/60 mm Hg, lungs are clear. Which nursing action is priority? Administer epinephrine to the client. Assess the client's oxygen saturation level. Apply ice to the site of the sting. Ask if any medications were given before arriving to the ER.
Ask if any medications were given before arriving to the ER. Explanation: The nurse would first determine if any medications have already been administered to this client. The client does not appear to be in distress based on the assessment in the scenario as the vitals are within normal range and lungs are clear. The nurse would expect stridor, wheezing, hypotension, tachycardia, and shortness of breath—among other symptoms—in the client having an anaphylactic reaction. Since the client is stable, epinephrine is not indicated at this time. The nurse would assess an oxygen level; however, this is not priority over determining how severe the client's reaction was. Ice could be applied to the site. This would be most beneficial if done immediately following the sting. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, p. 1763.
The parents of a 5-month-old infant diagnosed with humoral IgA deficiency question the nurse about why the infant was not diagnosed sooner. Which response by the nurse most appropriate? "There is no treatment or cure specific for IgA deficiency in children." "IgA deficiency is usually found when evaluating for another illness." "Maternal antibodies crossed the placenta and that prevented infections until now." "This is associated with allergies, which may not be noted prior to 5 months."
"Maternal antibodies crossed the placenta and that prevented infections until now." Explanation: IgA deficiency does not have a specific treatment, is usually found when evaluating other illnesses, and is associated with allergies. However, the nurse's most appropriate response to the parents' question about why the infant was not diagnosed sooner is to explain how maternal antibodies prevent manifestation of the deficiency until the infant is approximately 4 months old. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY, p. 1745.
The nurse is helping the parents of a toddler identify foods that are causing allergic symptoms in the child. Which strategy should the nurse encourage the parents to use? Elimination diet Hyposensitivity testing Corticosteroid challenge testing Complete dietary protein restriction
Elimination diet Explanation: An elimination diet is a traditional method to detect food allergens. Parents feed the child only foods that rarely cause allergy, such as rice, lamb, carrots, peas, and sweet potatoes, for about 7 days. Then they add, one by one, at 2- to 3-day intervals, foods that are suspected of causing allergy. When a food is introduced this way, the child must be encouraged to eat a lot of it that day. If symptoms occur, the food is then eliminated from the child's meals on a permanent basis. If no symptoms occur, the child can continue to eat the food. Hyposensitivity testing is unreliable with food allergies. Corticosteroids delay hypersensitivity reactions. It is difficult to totally eliminate protein from the diet, and this is not a method to determine the cause of food allergies in the toddler. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, p. 1763.
The nurse is helping the parents of a toddler identify foods that are causing allergic symptoms in the child. Which strategy should the nurse encourage the parents to use? Elimination diet Hyposensitivity testing Corticosteroid challenge testing Complete dietary protein restriction
Elimination diet Explanation: An elimination diet is a traditional method to detect food allergens. Parents feed the child only foods that rarely cause allergy, such as rice, lamb, carrots, peas, and sweet potatoes, for about 7 days. Then they add, one by one, at 2- to 3-day intervals, foods that are suspected of causing allergy. When a food is introduced this way, the child must be encouraged to eat a lot of it that day. If symptoms occur, the food is then eliminated from the child's meals on a permanent basis. If no symptoms occur, the child can continue to eat the food. Hyposensitivity testing is unreliable with food allergies. Corticosteroids delay hypersensitivity reactions. It is difficult to totally eliminate protein from the diet, and this is not a method to determine the cause of food allergies in the toddler. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, p. 1763.
A 6-month-old boy has been admitted to the hospital with severe bloody diarrhea. The nurse notes petechiae and eczema with signs of secondary infection. As the nurse documents the boy's history, the parents report easy bruising and prolonged bleeding after circumcision. Based on these findings, the nurse suspects a diagnosis of: Wiskott-Aldrich syndrome. beta-thalassemia major. von Willebrand disease. severe combined immunodeficiency.
Wiskott-Aldrich syndrome. Explanation: Severe bloody diarrhea, petechiae, bruising, eczema with secondary infection, and prolonged bleeding episodes are signs and symptoms of Wiskott-Aldrich syndrome. Beta-thalassemia major would be manifested by signs of bleeding. von Willebrand disease would be manifested by signs of bleeding. Severe combined immunodeficiency would be manifested by chronic diarrhea and failure to thrive, persistent oral candidiasis (thrush), and a history of severe infections beginning in infancy. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, PRIMARY IMMUNODEFICIENCIES, pp. 1752-1753.
The nurse is assessing children in a physician's office. Which children may have a primary immunodeficiency? Select all that apply. a child diagnosed with six episodes of acute otitis media during the previous year a child with oral candidiasis (thrush) that is unresolved with treatment a child admitted to the hospital three times within the last year with pneumonia a child diagnosed with a severe case of acute sinusitis during the last year a child who has taken antibiotics for the last 3 months without evidence of the infection clearing
a child diagnosed with six episodes of acute otitis media during the previous year a child with oral candidiasis (thrush) that is unresolved with treatment a child admitted to the hospital three times within the last year with pneumonia a child who has taken antibiotics for the last 3 months without evidence of the infection clearing Explanation: The following children may have a primary immunodeficiency: a child with a persistent case of oral candidiasis (thrush), a child who has been diagnosed with pneumonia at least twice during the previous year, and a child who has taken antibiotics for 2 months or longer with little effect. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, BOX 47.1 10 Warning Signs of Primary Immunodeficiency, p. 1751.
A pediatric client is newly diagnosed with a stinging-insect allergy. Which advice is most appropriate for the nurse to provide this client's parent? "Your child should join a peer support group to help relieve anxiety about this problem." "I recommend you consult a genetic counselor to reveal other susceptible family members." "Obtain your child a medical alert ID bracelet so the presence of the allergy can be identified easily." "Arrange for your child to receive allergy testing for foods with ingredients similar to those in insect venom."
"Obtain your child a medical alert ID bracelet so the presence of the allergy can be identified easily." Explanation: Stinging-insect allergy can lead to anaphylactic shock. Alerting others to the possibility of an insect sting and allergy is important. To alert others of the allergy, the client should wear a medical alert ID bracelet at all times. A support group may be joined if needed, but is not priority over the client's safety. Genetic testing is not appropriate for allergies. These are tested through allergy testing. It is also not appropriate to recommend testing for foods similar to insect venom. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, ALLERGY AND ANAPHYLAXIS, p. 1766.
The nurse is administering the prescribed intravenous immunoglobulin to a 10-year-old boy. What step would be most important for the nurse to do? Have epinephrine available. Monitor urine for glucose. Administer with food. Monitor for signs of Cushing syndrome.
Have epinephrine available. Explanation: The nurse should have epinephrine available during the infusion in case of an adverse reaction. Monitoring urine for glucose would be appropriate when corticosteroids are being given. Intravenous immunoglobulin does not need to be administered with food because it is being given as an intravenous infusion. Monitoring for signs of Cushing syndrome would be appropriate when corticosteroids are given. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, DRUG GUIDE 47.1, p. 1749.
The mother of a child with myasthenia gravis has called the clinic and reports her child appears very anxious and the child's heart is beating very fast. What action by the nurse is indicated? Instruct the child be brought to the emergency department promptly. Make an appointment for the child to be seen by the physician within 24 hours. Inquire about any changes in the child's normal routine. Inquire about when the child's last dose of medication was taken.
Instruct the child be brought to the emergency department promptly. Explanation: Myasthenia gravis is an autoimmune disorder that is characterized by weakness and fatigue. There is no cure. The disease may be aggravated by stress, exposure to extreme temperatures, and infections, resulting in a myasthenic crisis. Myasthenic crisis is a medical emergency with symptoms including sudden respiratory distress, dysphagia, dysarthria, ptosis, diplopia, tachycardia, anxiety, and rapidly increasing weakness. The symptoms reported are consistent with a crisis and prompt care is indicated. Waiting 24 hours to have the child seen by the physician is not appropriate. Questions about changes in routine and medication compliance may be asked but the first priority is to have the child seen. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, AUTOIMMUNE DISORDERS, p. 1761.
The nurse is providing education regarding 2030 Health Goals to reduce the incidence of acquired immunodeficiency syndrome (AIDS) within the community. Which goal will the nurse choose as a primary prevention strategy? Refer at-risk community members to the clinic for HIV/AIDS screening. Increase the number of schools with an indoor air management system. Provide education to sexually active females about proper condom usage. Reduce the baseline level of allergens in dust within homes and buildings.
Provide education to sexually active females about proper condom usage. Explanation: Primary prevention strategies focus on preventing a disease before it occurs, which includes condom usage to prevent being exposed to AIDS. Screening for the presence of AIDS is a secondary prevention strategy because it does not prevent an individual from contracting AIDS, but would allow for early identification. Improving air quality and reducing allergens are goals to prevent allergies. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, SECONDARY IMMUNODEFICIENCIES, p. 1756.
The nurse is preparing a care plan for a 4-year-old client newly diagnosed with severe combined immune deficiency. What is the priority goal for this client? The client will perform hygiene care with assistance. The client will remain free from infection. The client will demonstrate basic knowledge of the disorder. The client will return to normal activities after discharge.
The client will remain free from infection. Explanation: While all of these are goals for the client, the highest priority for the immunocompromised client is to remain free from infection since the client is at a high risk for development of an infection. In the immunocompromised client any infection can be life threatening. Performing hygiene care helps promote cleanliness and decrease infection rates. This age group can do some tasks, but still need assistance. The client is old enough to have a basic understanding of the disorder. The primary goal is focused on remaining infection free and not on activities after discharge at this time. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, PRIMARY IMMUNODEFICIENCIES, p. 1753.
The adoptive parents of a child who is 7 years old and HIV positive are concerned about telling their child about his condition. What information can be provided by the nurse? The child should not have information about his health provided at this age. Children at this age should have full disclosure of their condition. When providing health information to a child of this age it should be simplistic and at the child's level of understanding. Once a child is apprised of their health concerns they do not normally experience any after-effects.
When providing health information to a child of this age it should be simplistic and at the child's level of understanding. Explanation: When children have a chronic condition they often realize that they have special concerns even before they are fully able to understand them. Information should be provided that is developmentally appropriate. Excessive information and details should be limited. Children who have this type of information may experience anger, depression, and difficulty in school. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder, SECONDARY IMMUNODEFICIENCIES, p. 1757.