Chapter 19

The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how the disease process occurred. What should the nurse explain to the mother? a. It rarely occurs in males. b. It occurs after exposure to pesticides. c. It is because the infant was premature. d. There are no known causes for this disorder.

(D) Hypogammaglobulinemia is either a hereditary congenital disorder or acquired after childhood from unknown causes. It is characterized by the absence or deficiency of one or more of the five classes of immunoglobulins (IgG, IgM, IgA, IgD, and IgE) from defective B-cell function. The lack of normal function of these antibodies makes the patient prone to infections.

The nurse notes that a patient has an elevated lactate dehydrogenase, fragmented RBCs seen on microscopic examination, and low RBC count, hematocrit (Hct), and hemoglobin (Hgb) levels. For which health problem should the nurse consider planning care for this patient? a. Serum sickness b. Pernicious anemia c. Hemolytic transfusion reaction d. Idiopathic autoimmune hemolytic anemia

(D) In idiopathic autoimmune hemolytic anemia, the RBC count and Hgb and Hct levels are low, with fragmented RBCs and elevated lactate dehydrogenase because of RBC destruction and tissue ischemia.

A patient is diagnosed with urticaria. For which type of hypersensitivity reaction should the nurse plan care for this patient? a. Type I b. Type II c. Type III d. Type IV

(A) Anaphylaxis, urticaria, and angioedema are the most severe forms of type I hypersensitivity reactions.

The nurse is reinforcing teaching provided to a patient with Hashimotos thyroiditis. What should the nurse explain as occurring initially in this health problem? a. Thyroid hormone production increases. b. Thyroid hormone production decreases. c. Thyroid-stimulating hormone production increases. d. Thyroid-stimulating hormone production decreases.

(A) Autoantibodies for thyroid-stimulating hormone form, bind with the hormone receptors on the thyroid gland, and initially stimulate the thyroid gland to secrete thyroid hormones. B. C. D. These statements do not explain the initial action in Hashimotos thyroiditis.

The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops? a. Hives b. Retinal hemorrhage c. Jugular vein distention d. Pallor around the sting sites

(A) Hives is one of several symptoms of an allergic reaction. B. C. D. These manifestations are not associated with an allergic reaction.

The nurse is caring for a patient with angioedema. Which nursing action should have the highest priority? a. Monitor for restlessness. b. Identify cause of the angioedema. c. Identify the presence of skin lesions. d. Teach the patient about immunotherapy.

(A) If the angioedema reaction is severe, maintenance of a patent airway is a priority. Any symptoms of respiratory distress must be reported immediately and remain the highest priority. B. Because the condition is already present, monitoring the patient takes priority, although the cause needs to be identified.

The nurse is caring for a patient at risk for infection. Which immunoglobulin should the nurse consider as being the cause of this patients infection risk? a. IgA b. IgE c. IgG d. IgM

(A) IgA cannot be replaced, increasing the risk for infections. B. C. D. These immunoglobulins can be replaced.

A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take? a. Verify the patients kidney function. b. Verify the patients hematocrit level. c. Verify blood type of the patient and donor. d. Verify the patients admitting medical diagnosis.

(A) Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a reaction are noted, the blood is immediately stopped so that no more blood is infused into the patient. B. The physician should be notified after the transfusion is stopped.

The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness? a. A patient who receives intravenous (IV) penicillin for an infection b. A patient who has a transfusion with packed red blood cells (RBCs) c. A patient who is given cryoprecipitate and factor IX after an abdominal injury d. A patient given steroids and immunosuppressant therapy after organ transplantation

(A) Serum sickness is seen occasionally after administration of penicillin and sulfonamide.

A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient? a. Wear Medic-Alert identification. b. Stay indoors as much as possible. c. Wear insect repellent when outdoors. d. Take corticosteroids before going outdoors.

(A) The nurse should teach the patient to wear medical alert identification for allergies in order for prompt medical attention to be given if the patient is unable to give information.

The nurse is assisting in the planning of care for a patient with chronic serum sickness. Which action should be a priority for this patient? a. Assessing for a decrease in urine output b. Administration of immunosuppressive medications c. Closely monitoring the patient during the transfusion of blood products d. Discussing with the patient and significant other the need for genetic counseling

(A) The patient is at risk for low fluid volume which can lead to renal failure. Monitoring urine output can help reduce the risk of renal failure from occurring

The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient? a. Assist with ambulation. b. Teach good hand hygiene. c. Avoid intramuscular injections. d. Obtain manual blood pressures.

(A) With anemia, the patient will be fatigued and may have activity intolerance and be a fall risk. Assistance with ambulation should be done for safety. C. D. These actions would be appropriate if the patient had thrombocytopenia. B. This action would be appropriate if the patient had neutropenia.

A patient who developed hemolytic anemia related to the administration of penicillin asks for an explanation of this condition. What is the most appropriate response by the nurse? a. The red blood cells are being produced inappropriately. b. An antigenantibody reaction is causing destruction of red blood cells. c. An allergy to penicillin is destroying your platelets for unknown reasons. d. Allergens are invading the bone marrow and interfering with red blood cell production.

(B) For no known reason, autoantibodies are produced that attach to RBCs and cause them to either lyse or agglutinate (clump).

A patient is diagnosed with hypogammaglobulinemia. Which of immune cell should the nurse realize is defective in this disorder? a. T cells b. B cells c. Mast cells d. Plasma cells

(B) Hypogammaglobulinemia is characterized by the absence or deficiency of one or more of the five classes of immunoglobulins from defective B-cell function. A. C. D. Hypogammaglobulinemia is not caused by defective T, mast, or plasma cells

The nurse is reinforcing teaching provided to a patient with pernicious anemia. Which patient statement indicates that teaching has been effective? a. I can miss a month or two of injections if I am feeling better. b. I will need to take vitamin B12 injections for the rest of my life. c. I will take the vitamin B12 injections until my strength returns. d. I can take a vitamin B12 injection when I feel tired or fatigued.

(B) If vitamin B12 injections are prescribed, the patient must understand that this is a lifelong need to prevent the return of symptoms. A. C. Patients should not miss injections. D. Injections are not taken as needed for fatigue.

The nurse is caring for a patient who has had a portion of stomach removed. Which manifestations should the nurse expect to determine if the patient has a vitamin B12 deficiency? a. Fever, malaise, muscle soreness, and diarrhea b. Numbness and tingling, weakness, and glossitis c. Urticaria, angioedema, anorexia, pruritus, and blistered lesions d. Frequent infections, fever, malaise, vertigo, and lymphadenopathy

(B) Non-immune-related causes of pernicious anemia include any type of gastric or small bowel resections coupled with no or inadequate vitamin B12 or intrinsic factor replacement. Vitamin B12 deficiency symptoms include numbness and tingling, weakness, and glossitis.

The nurse is reviewing data collected on several patients. Which patient should the nurse identify as being most likely to exhibit signs and symptoms of systemic lupus erythematosus? a. A 16-year-old Caucasian man b. A 20-year-old Hispanic woman c. A 45-year-old Caucasian woman d. A 42-year-old Asian American man

(B) Systemic lupus erythematosus tends to develop in young women of child-bearing years and occurs in the African American and Hispanic populations more frequently.

A patient is suspected as having a blood transfusion reaction. Which laboratory test should the nurse expect to be done to confirm this diagnosis? a. Skin testing b. Direct Coombs test c. White blood cell count d. C-reactive protein level

(B) The direct Coombs test confirms the diagnosis of transfusion reaction. In the laboratory, a small amount of the patients RBCs is washed to remove any unattached antibodies. Antihuman globulin is added to see if agglutination (clumping) of the RBCs results. If agglutination occurs, an immune reaction such as a hemolytic transfusion reaction is taking place.

The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus. Which adverse effect should the nurse encourage the patient to report when taking this medication? a. Tarry stools b. Vision changes c. Any weight gain d. Changes in joint movement

(B) The patient should have an ophthalmologic examination completed before starting this medication because vision changes can occur. A.C. D. These are not identified adverse effects for this medication

A patient with lupus erythematosis is prescribed a corticosteroid. What side effects of this medication should the nurse review with the patient? (Select all that apply.) a. Tinnitus b. Facial hair c. Moon face d. Mood changes e. Increased weight f. Rash and pruritus

(B,C,D,E) Corticosteroids can cause weight gain, increased facial hair, acne, round moon face, mood changes, irritability, depression, increased appetite, increased weight, poor wound healing, headache, peptic ulcers, and osteoporosis.

The nurse is experiencing severe skin blisters after wearing latex gloves at work. Which treatment should the nurse expect to be prescribed by the health care provider for these skin lesions? (Select all that apply.) a. Oral antibiotics b. Topic drying agent c. Oral antihistamines d. Topical corticosteroid e. Topical immunomodulators

(B,C,D,E) Oral or topical antihistamines and topical drying agents may be used. Topical corticosteroids may be used and are most effective if sparingly applied after a bath or shower. Topical immunomodulators also may be prescribed when other treatments fail.

A patient is being started on a blood transfusion. For how many minutes should the nurse stay with the patient during this transfusion? a. 5 b. 10 c. 15 d. 20

(C)

The nurse is caring for a patient with a severe allergic reaction. Which medication should the nurse anticipate being administered to control the itching? a. Morphine b. Epinephrine c. Diphenhydramine (Benadryl) d. Hydrocortisone sodium succinate (Solu-Cortef)

(C) Benadryl blocks histamine at histamine1-receptors, therefore preventing or reversing the effects of histamine. A. Morphine does not reduce itching. B. Epinephrine will help the overall allergic response however will not specifically reduce itching. D. This medication might need to be prescribed long-term if the itching continues.

The nurse has been caring for a patient with pernicious anemia. Which finding should indicate to the nurse that treatment has been successful? a. Decreased folic acid level and an increase in enlarged RBCs b. A decrease in intrinsic factor and increased vitamin B12 excreted in the urine c. An increase in vitamin B12 levels and decrease in number of enlarged RBCs d. A decrease in hydrochloric acid levels in gastric secretion and decrease in production of RBCs

(C) Macrocytic (enlarged RBCs) anemia, and low vitamin B12 levels are indicators of pernicious anemia, so increased vitamin B12 levels and decreased enlarged RBCs would indicate successful treatment. A. B. D. These findings would not support treatment for pernicious anemia as being successful.

. A patient is experiencing an episode of urticaria. Which intervention should the nurse recommend to include in the teaching plan to assist the patient in controlling the symptoms of urticaria? a. Avoiding tub baths b. Taking one aspirin daily c. Using relaxation techniques d. Drinking decaffeinated coffee

(C) Stress management and relaxation techniques may be helpful with urticaria symptoms. A. B. D. These actions are not identified to reduce the symptoms of urticaria

The nurse is caring for a patient with severe ankylosing spondylitis. What nursing action would be most appropriate? a. Provide tepid tub soaks. b. Encourage a high-fiber diet. c. Provide activity every 2 hours. d. Administer narcotic analgesics.

(C) The patient should not stay in any one position for any length of time to reduce stiffness and pain

The nurse recommends the diagnosis Disturbed Body Image for a patient with systemic lupus erythematosus. What would be an appropriate long-term outcome for this patient? a. Engages in diversional activities b. Uses normal coping mechanisms c. Returns to previous social involvement d. Verbalizes feelings about body changes

(C) The ultimate outcome is for the patient to return to previous social involvement in spite of body image issues such as the butterfly rash.

The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms? a. Installing a hot air heater b. Cover heating ducts with filters c. Installing wall-to-wall carpeting d. Using heavy draperies on sunny windows

(B) Filtering the air will reduce dust particles which the other items do not do. C. Carpeting traps dust and is harder to clean. A. A hot air heater will not reduce the amount of dust in the patients environment. D. Heavy draperies will trap dust.

The nurse is participating in a teaching plan to address Risk for Impaired Skin Integrity for a patient with contact dermatitis. Which information should the nurse recommend be included in this plan? (Select all that apply.) a. Keep fingernails short. b. Take baths with an oatmeal solution. c. Use oil-in-water lubricants for skin dryness. d. Rub affected area roughly, but do not scratch. e. Avoid washing affected area with brown soap. f. Use cool washcloths over affected area to ease itching.

(A,B,C,F) The patient should be instructed to avoid scratching the skin to prevent the spread of dermatitis and infection development. Ease itching with cool washcloths and oatmeal baths, and keep fingernails short to avoid injury to skin if scratching occurs. Oil-in-water lubricants tend to be the most effective for skin dryness. D. E. Rubbing the skin and avoiding brown soap will not help the patient with contact dermatitis.

The nurse is contributing to a staff education program about nursing care for hypersensitivity reactions. Which should the nurse include as examples of type I hypersensitivity reactions? (Select all that apply.) a. Anaphylaxis b. Angioedema c. Serum sickness d. Allergic rhinitis e. Contact dermatitis f. Hypogammaglobulinemia

(A,B,D) Type I hypersensitivity reactions include conditions such as allergic rhinitis and allergic asthma, atopic dermatitis, anaphylaxis, angioedema. hemolytic transfusion reactions, measles, and transplant rejections. C. E. F. These health problems are not considered type I hypersensitivity reactions.

A patient with an autoimmune disorder asks, What might cause my body to do this to itself? What should the nurse state as reasons for the body to have lost the ability to recognize self? (Select all that apply.) a. Drugs b. Hormones c. Vaccinations d. Viral infections e. Bacterial infections

(A,B,D) number of factors either cause or influence this breakdown of self-recognition, including viral infections, drugs, and cross-reactive antibodies. Hormones have also been found to influence this breakdown of self-recognition.

The nurse is contributing to the plan of care for a patient with systemic lupus erythematosus (SLE). Which interventions should the nurse recommend for this patient? (Select all that apply.) a. Eat a balanced diet. b. Report foamy urine to physician. c. Take cool showers or baths to relieve joint stiffness. d. Avoid naps and obtain a minimum of 6 hours of sleep. e. Exercise when pain and inflammation in joints is increased. f. Use a daily personal schedule to plan activities to reduce fatigue.

(A,B,F) Fatigue during activities of daily living is minimized through the use of a daily personal schedule. Additionally, a minimum of 8 hours of sleep per night with naps as necessary are important to combat fatigue. Because the majority of patients with SLE develop transitory arthralgia, maintaining fitness and joint range of motion through a regular fitness program while decreasing activity during flares is vital. Warm baths may help with morning stiffness. Because renal disease is a major complication of SLE, patients must learn the signs of impending problems that need to be relayed to the physician immediately. These are such findings as facial puffiness and foamy urine or coke-colored urine indicative of proteinuria and hematuria, respectively. Eating a well-balanced diet will also influence level of fatigue and weight gain from the corticosteroids. C. Cool showers will not help relieve the pain and stiffness associated with this disorder.

The nurse is contributing to the teaching plan for a patient diagnosed with Hashimotos thyroiditis who has progressed to hypothyroidism with a goiter. Which self-care instructions should the nurse recommend? (Select all that apply.) a. Eat a soft diet. b. Increase activity slowly. c. Eat more foods high in iodine. d. Keep home at a cool temperature. e. Eat a high-carbohydrate, high-protein diet. f. During low-energy periods, use anti-embolism stockings.

(A,B,F) If the patient has a goiter, a soft diet may be necessary for comfort. Frequent rest periods may be necessary as well as slowly increasing patient activity. Anti-embolic stockings may help prevent venous stasis during the low-energy, decreased-activity phase. E. During the hyperthyroidism phase, a diet high in protein and carbohydrates encourages weight gain. D. The patient will be sensitive to cold, so room temperature will need to be increased for comfort. C. Foods high in iodine should be avoided.

The nurse is reinforcing teaching about potential triggers with a patient experiencing allergic rhinitis. What should the nurse include in the teaching? (Select all that apply.) a. Dust b. Penicillin c. Ragweed d. Pet dander e. Topical lotion f. Oral multivitamin

(A,C,D) Allergic rhinitis causative antigens are environmental and airborne. Frequent home vacuuming and dusting are recommended. B. E. F. Penicillin, topical lotion, and oral multivitamins are not identified as being triggers for allergic rhinitis.

The nurse is assisting in the care of a patient with ankylosing spondylitis. What should the nurse expect to find in the patients collaborative plan of care? (Select all that apply.) a. Physical therapy daily b. Sitz baths three times daily c. Tylenol #3 every 4 hours prn pain d. Administer Remicade as prescribed e. Activity as tolerated; up with assistance

(A,C,D,E) Nursing care focuses on patient education and administration and evaluation of prescribed medications. Pain management, rest periods, and assistance with activities of daily living (ADLs) are provided.

The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease? a. Gardening outdoors on dry, windy days b. Wearing a mask when mowing the lawn c. Driving the car with the windows open during high pollen counts d. Taking frequent walks outside in spring when the weather is warm

(B) Allergen avoidance might involve wearing a mask when mowing the lawn or working outdoors or having heating ducts cleaned or heating registers covered with filters. A. C. D. These would increase the patients risk of having an allergic reaction.

The nurse is collecting data from a patient with skin eruptions. What should the nurse recall to differentiate urticaria from angioedema? a. It is less pruritic. b. It lasts a shorter period of time. c. It includes mucous membrane edema. d. It causes more widespread skin lesions.

(B) Angioedema subcutaneous eruptions last longer than with urticaria. A. C. D. These statements describe angioedema.

The nurse is caring for a patient with a severe allergic reaction. Which medication and route should the nurse anticipate being ordered for this patient? a. Intramuscular morphine b. Subcutaneous epinephrine c. IV diphenhydramine d. Oral diphenhydramine (Benadryl)

(B) Epinephrine subcutaneous (SQ) or intramuscular (IM) is given for anaphylactic reactions. It causes vasoconstriction, bronchodilation, and cardiac stimulation

The nurse is caring for a patient who had a kidney transplant 5 days ago. The patient had been very outgoing and jovial, but this morning the patient is very quiet and refusing breakfast, and ambulation. What would be the most appropriate nursing action at this time? a. Notify the physician for laboratory orders. b. Notify the social worker for discharge follow-up care. c. Inform the patient that kidney rejection signs are appearing. d. Spend extra time with the patient, allowing verbalization of feelings.

(D) Psychological support is important for transplant patients. Patients need time to verbalize feelings and understand that feelings of guilt are normal and diminish with time. A. B. C. These actions are not appropriate for the patient at this time.

A patient comes into the emergency department with a fear of developing poison ivy after falling while walking through a wooded area earlier in the day. What should the nurse instruct the patient to do if exposure to poison ivy occurs again? a. Flood the area with cold water. b. Wrap the area with a thick towel. c. Cover the area with cotton gauze. d. Wash the area with brown soap or any soap.

(D) The patient should be instructed to wash the area with a brown soap (e.g., Fels-Naptha) or, if unavailable, any soap when contact with the offending agent is suspected. This removes the offending agent from the skin. A. Cold water is not going to remove the agent from the skin.

The nurse is assisting in an educational seminar on common allergens. What should the nurse include as the most common irritant causing contact dermatitis? (Select all that apply.) a. Bleach b. Rubber c. Fire ants d. Poison ivy e. Poison oak

(D,E) Poison ivy and poison oak are the most common irritants causing contact dermatitis. A. B. C. These items are not known to cause contact dermatitis.