Chapter 20: Care of Patients with Hypersensitivity (Allergy) and Autoimmunity

1. The nurse is to give a client 80 mg of diphenhydramine (Benadryl) by IV push. The vial contains a solution with a concentration of 25 mg/mL. How many milliliters of diphenhydramine does the nurse administer? __________ mL

ANS: 3.2 Ratio and proportion: 80 mg is to x mL as 25 mg is to 1 mL. 80/25 = 3.2 mL

6. A client with Sjgrens syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest? a. Frequent eyedrops b. Home humidifier c. Strong moisturizer d. Tear duct plugs

ANS: B A humidifier will help relieve many of the clients Sjgrens syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.

4. A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition? a. Blood urea nitrogen: 12 mg/dL b. Creatinine: 3.2 mg/dL c. Hemoglobin: 8.2 mg/dL d. White blood cell count: 12,000/mm3

ANS: B The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related.

17. An unknown unconscious client with an elevated temperature is ordered intravenous penicillin. What is the best action for the nurse to take? a. Administer the medication. b. Check the chart for allergies. c. Look for medical alert identification. d. Notify the nursing supervisor.

ANS: C Allergies need to be identified before medications are administered. This client cannot talk and is unknown, so a chart cannot be retrieved. Clients with allergies are taught to carry medical alert identification.

1. A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies

ANS: A All actions are appropriate for this nurse; however, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses.

8. A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. I dont need to go to the hospital after using it. b. I must carry two EpiPens with me at all times. c. I will write the expiration date on my calendar. d. This can be injected right through my clothes.

ANS: A Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.

5. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-thecounter antihistamines. What response by the nurse is most appropriate? a. Antihistamines do not help poison ivy. b. There are different antihistamines to try. c. You should be seen in the clinic right away. d. You will need to take some IV steroids.

ANS: A Since histamine is not the mediator of a type IV reaction such as with poison ivy, antihistamines will not provide relief. The nurse should educate the client about this. The client does not need to be seen right away. The client may or may not need steroids; they may be given either IV or orally.

11. A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the clients lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer? (Click the media button to hear the audio clip.) a. Albuterol (Proventil) via nebulizer b. Diphenhydramine (Benadryl) IM c. Epinephrine 1:10,000 5 mg IV push d. Methylprednisolone (Solu-Medrol) IV push

ANS: A The nurse has auscultated wheezing in the clients lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.

2. What intervention does the nurse implement to provide for client safety during intradermal allergy testing? a. Stay with the client and ensure that emergency equipment is in the room b. Pretreat the skin area to be tested with a cortisone-based cream. c. Apply oxygen by mask or nasal cannula before injecting the test agent. d. Cover the examination table and pillow with plastic or an ultrafine mesh.

ANS: A Although it is usually a safe procedure, intradermal testing increases the risk for an adverse reaction, including anaphylaxis. Emergency equipment should be available. Pretreating the skin with cortisone will not decrease the risk of anaphylaxis. Applying oxygen will not help prevent a reaction. Covering the examination table will also not prevent allergic reactions.

9. Which intervention is most important for the nurse to teach the client who is recovering from an allergic reaction to a bee sting? a. How to use an EpiPen b. Wearing a medical alert bracelet c. Avoiding contact with the allergen d. Keeping diphenhydramine (Benadryl) available

ANS: A If an anaphylactic reaction starts, the client will need to self-medicate very rapidly with the EpiPen. He or she should carry it at all times and should be proficient in its assembly and use. This is the highest priority intervention. The client should get a medical alert bracelet and keep away from bees if at all possible. It is also advised that diphenhydramine be kept on hand in case of a less severe reaction.

18. A nurse suspects that a client has serum sickness. For which manifestation does the nurse assess the client? a. Joint pain b. Allergic rhinitis c. Stridor d. Wheezing

ANS: A Serum sickness is a delayed reaction, type III. Signs and symptoms include fever, arthralgia, fever, rash, malaise, and lymphadenopathy. The other signs and symptoms are related to type I allergic reactions.

13. A client is hospitalized with Goodpastures syndrome. Which intervention by the nurse takes priority? a. Monitor urine output and renal function tests. b. Teach the client to manage peritoneal dialysis. c. Administer antibiotics strictly on time. d. Have separate IV access for immune globulin (IVIG) administration.

ANS: A The main cause of death in clients with Goodpastures syndrome is renal failure. The nurse must monitor renal function meticulously. Some, but not all, clients need dialysis and IVIG infusions. Antibiotics are not used in the management of this condition.

2. The nurse is preparing to administer a medication when the client states, Im allergic to that. How will the nurse proceed? (Select all that apply.) a. Check the chart for allergies. b. Notify the health care provider. c. Ask what reaction the client gets. d. Continue to give the medication. e. Perform a skin test first. f. Notify the pharmacist. g. Document the allergy on the chart.

ANS: A, B, C, F, G If a client states that he or she has an allergy to a medication, the nurse should not administer the medication. The nurse should find out what reaction the client experiences from the medication and then should notify the health care provider and the pharmacist of the clients response. The nurse should document the allergy on the chart, including the reaction to the medication and notification of the provider and the pharmacist, and should indicate what other drug was ordered in its place. Before administering any drug, the nurse should have already checked the chart for allergies.

1. The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I Examples include hay fever and anaphylaxis b. Type II Mediated by action of immunoglobulin M (IgM) c. Type III Immune complex deposits in blood vessel walls d. Type IV Examples are poison ivy and transplant rejection e. Type V Examples include a positive tuberculosis test and sarcoidosis

ANS: A, C, D Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves disease and B-cell gammopathies.

3. The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client

ANS: B A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.

9. A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the clients bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight.

ANS: B Antihistamines can cause drowsiness, so for the clients safety, he or she should be instructed to call for assistance prior to trying to get up. Hyperglycemia and tachycardia are side effects of sympathomimetics. Fluid and sodium retention are side effects of corticosteroids.

8. What dose of epinephrine does the nurse prepare for a client in anaphylaxis who is 6 feet 3 inches tall and weighs 250 lb? a. 0.2 mL of a 1:1000 solution b. 0.5 mL of a 1:1000 solution c. 0.3 mL of a 1:10,000 solution d. 0.5 mL of a 1:10,000 solution

ANS: B Adult doses of epinephrine for anaphylaxis range between 0.3 and 0.5 mL of a 1:1000 solution. Because this client is large, the nurse should be prepared to give the higher dose initially.

14. A client is in the clinic having had rhinorrhea and headache for the last 2 weeks. Which laboratory value alerts the nurse to the possibility of a type I hypersensitivity reaction? a. White blood cell count, 8900/mm3 b. Eosinophils, 10% c. Neutrophils, 65% d. Hemoglobin, 14 g/dL

ANS: B An increase in eosinophils indicates an allergic reaction (type I) or allergic rhinitis. Normal eosinophil count is 1% to 2%. The other laboratory values are normal.

10. A client has angioedema of the lower face. What will the nurse assess next? a. Pulse oximetry b. Airway patency c. Breath sounds d. Chest wall symmetry

ANS: B Angioedema of the lower face includes the mouth and can rapidly lead to laryngeal edema and obstruction of the airway. Other assessments of the clients respiratory status could be done after the airway is assessed, such as pulse oximetry, breath sounds, and chest symmetry.

3. What is most important for the nurse to teach the client with allergic rhinitis and glaucoma? a. If your heartbeat increases, be sure to contact your health care provider. b. Avoid allergy drugs containing pseudoephedrine or phenylephrine. c. Be sure to drink plenty of water with antihistamines. d. You should use an eye-moistening agent such as Restasis.

ANS: B Ephedrine, phenylephrine, and pseudoephedrine may cause vasoconstriction, increase blood pressure, and increase intraocular pressure. The client should avoid these drugs. An increased heart rate is not a reason to call the health care provider. The client may be thirstier when on allergy medications, or the client may need an eye-moistening agent, but these are not the most important things for the nurse to teach.

7. Which client characteristic places her or him at high risk for latex hypersensitivity? a. Allergy to shellfish b. History of spina bifida c. Total hip replacement d. Taking oral contraceptives

ANS: B People who have spina bifida have lifelong exposure to latex products and frequently develop latex hypersensitivities. An allergy to shellfish does not put a person at increased risk for latex allergies. A total hip replacement will not place a client at risk for latex hypersensitivity, nor does use of oral contraceptives.

4. A client has received diphenhydramine (Benadryl) and is currently oriented but drowsy. What is the best action for the nurse to take? a. Perform a neurologic assessment every 2 hours. b. Document the response and continue to monitor. c. Prepare to administer epinephrine subcutaneously. d. Have the nursing assistant stimulate the client every hour.

ANS: B The client is experiencing normal side effects of the medication. The nurse will continue to monitor for additive effects. Performing a neurologic assessment is not necessary, nor is administration of epinephrine. There is no reason for the client to be stimulated hourly.

1. Which characteristic is common to all types of hypersensitivity reactions? a. Decreased inflammatory responses b. Presence of tissue-damaging reactions c. Enhanced natural killer cell activity d. Inability to recognize extraneous cells

ANS: B The defining difference between a normal immune response and that termed hypersensitivity is that the immune system reacts excessively or inappropriately, with resultant tissue damage and pathology.

6. A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate? a. Elevate the head of the clients bed to 45 degrees. b. Have another nurse call the Rapid Response Team. c. Prepare to administer diphenhydramine (Benadryl). d. Slow the rate of the IV infusion.

ANS: B This client has early signs of anaphylaxis. The nurse must notify the Rapid Response Team but also needs to stay with the client in case of cardiovascular collapse. The nurses best action is to ask another nurse to call the Team while he or she continues to assess the client. The nurse will prepare to administer epinephrine. Slowing the IV rate will not help the situation; if the client is reacting to the antibiotic, the nurse should change the IV tubing and solution. If the client is not hypotensive, the nurse can raise the head of the bed.

2. A client in the family practice clinic reports a 2-week history of an allergy to something. The nurse obtains the following assessment and laboratory data: Physical Assessment Data Laboratory Results Reports sore throat, runny nose, headache Posterior pharynx is reddened Nasal discharge is seen in the back of the throat Nasal discharge is creamy yellow in color Temperature 100.2 F (37.9 C) Red, watery eyes White blood cell count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? (Select all that apply.) a. Elimination of any pets b. Chlorpheniramine (Chlor-Trimaton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics

ANS: B, C, D, E This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature.

1. A client is admitted for a cardiac catheterization. It is essential for the nurse to ask the client about which allergies? (Select all that apply.) a. Penicillin b. Latex c. Iodine d. Shellfish e. Keflex f. Dilantin g. Bananas

ANS: B, C, D, G It is important to check for all allergies, but for a cardiac catheterization, the nurse needs to question about shellfish, iodine, latex, and bananas specifically. The contrast used contains iodine, and the equipment in the laboratory frequently contains latex. Information concerning these allergies needs to be passed on to laboratory personnel before the client goes to the laboratory. This will prevent the client from having an anaphylactic reaction during the procedure.

11. A mother brings her child to the clinic requesting genetic testing to determine whether her child suffers from the same multiple allergies as herself. What action by the nurse is most appropriate? a. Provide a referral to an allergist so the child can be tested. b. Refer the mother to a geneticist for genetic testing on the child. c. Ask the mother about specific symptoms the child may have had. d. Have the mother list her allergies and the symptoms they cause her.

ANS: C Allergic tendencies can be inherited, but no single gene has been identified that causes allergies, and allergies to specific items are not inherited. The nurse should ask the mother about any symptoms the child has that seem related to allergies. The child will not be tested by an allergist simply because the mother has allergies, and a geneticist will not be able to identify an allergy gene in the child. Because specific allergies are not inherited, having the mother list her allergies will not be beneficial.

5. Which condition is a type II hypersensitivity reaction? a. Allergic rhinitis b. Positive purified protein derivative (PPD) test for tuberculosis c. Transfusion reaction to improper blood type d. Serum sickness after receiving immune globulin

ANS: C Common clinical situations caused by type II hypersensitivities include hemolytic transfusion reactions. Type II hypersensitivity reactions are caused by antibodies directed against body tissues that have some form of non-self (foreign) protein attached to them. Allergic rhinitis is an example of a type I hypersensitivity. A positive PPD test is an example of a type IV reaction. Serum sickness is a type III reaction.

12. A client states that he is allergic to poison ivy. Which statement by the client indicates a good understanding of this type of sensitivity? a. Drinking 3 liters of water a day will prevent kidney damage. b. I will always wear a medical alert bracelet for this allergy. c. I need to try to avoid coming into contact with poison ivy. d. I should carry diphenhydramine (Benadryl) with me at all times.

ANS: C Reactions to poison ivy are a type IV hypersensitivity reaction. They are cell mediated by T-lymphocytes in the skin. Avoidance of the offending allergen is the most appropriate intervention. The complexes do not form or precipitate in the kidney. This type of hypersensitivity does not represent an immediate life-threatening emergency and does not respond to histamine antagonists (diphenhydramine).

16. A nurse is planning care for a client with Sjgrens syndrome. At what point does the nurse determine that priority outcomes have been met? a. The client states that he or she is not as fatigued as previously. b. The client dresses attractively despite gaining a large amount of weight. c. The oral mucosa is intact and no systemic signs of infection are present. d. The client is able to complete activities of daily living with minimal shortness of breath.

ANS: C The major symptoms associated with Sjgrens syndrome include dry eyes caused by insufficient tear production and dry mucous membranes of the nose, mouth, and vaginal tissues. Increased dryness reduces the tissues natural defenses against infection. If the client shows no signs of infection, priority outcomes have been met. The other observations do not meet a priority outcome.

19. The nurse enters a clients room and observes the manifestations shown below. What action should the nurse take first? a. Prepare to administer diphenhydramine (Benadryl). b. Prepare to administer epinephrine. c. Assess the clients respiratory status. d. Get a full set of vital signs.

ANS: C This client has angioedema, and the priority action is to assess her respiratory status because respiratory collapse may follow. The nurse should have someone else notify the Rapid Response Team and prepare to administer epinephrine.

15. How does the type V hypersensitivity reaction differ from other reactions? a. It is cell mediated rather than antibody mediated. b. It is an immediate response rather than a delayed response. c. It produces a stimulatory response to normal tissues. d. It results in more severe tissue damage than is caused by other types of reactions.

ANS: C Type V hypersensitivity reactions are known as stimulatory responses. The classic example of type V hypersensitivity is Graves disease, in which the person makes a large amount of antibody that binds to the thyroid-stimulating hormone receptor antibody (TSHr-Ab) on thyroid tissue. The binding of this antibody to the TSH receptor activates the receptor, greatly stimulating the thyroid gland and causing severe hyperthyroid symptoms. This type of reaction is not cell mediated. It is not an immediate response, nor does it cause more severe tissue damage.

2. A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the clients chart. d. Ensure the information is relayed to the surgical team.

ANS: D A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment. Ensuring the clients NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority.

7. A client is receiving plasmapheresis as treatment for Goodpastures syndrome. When planning care, the nurse places highest priority on interventions for which client problem? a. Reduced physical activity related to the diseases effects on the lungs b. Inadequate family coping related to the clients hospitalization c. Inadequate knowledge related to the plasmapheresis process d. Potential for infection related to the site for organism invasion

ANS: D Physical diagnoses take priority over psychosocial diagnoses, so inadequate family coping and inadequate knowledge are not the priority. The client has a potential for infection because plasmapheresis is an invasiveprocedure. Reduced activity is manifested by changes in vital signs, oxygenation, or electrocardiogram, and/or reports of chest pain or shortness of breath. There is no information in the question to indicate that the client is experiencing reduced physical activity.