Chapter 34: Caring for Clients with Immune-Mediated Disorders

A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse? a. Assess for signs and symptoms of anaphylaxis. b. Assess for erythema and urticaria. c. Administer an over-the-counter (OTC) antihistamine. d. Administer epinephrine.

a If a client is experiencing an allergic response, the nurse's initial action is to assess the client for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction.

T-cell deficiency occurs when which gland fails to develop normally during embryogenesis? a. Thyroid b. Thymus c. Pituitary d. Adrenal

b T-cell deficiency occurs when the thymus gland fails to develop normally during embryogenesis.

A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse informs the client that she should self-administer epinephrine in what site? a. Forearm b. Thigh c. Deltoid muscle d. Abdomen

b The client is taught to position the device at the middle portion of the thigh and push the device into the thigh as far as possible. The device will automatically inject a premeasured dose of epinephrine into the subcutaneous tissue.

The nurse explains to a client that immunotherapy initially starts with injections at which interval? a. Daily b. Weekly c. Bi-monthly d. Monthly

b Typically, immunotherapy begins with very small amounts and gradually increases, usually at weekly intervals until a maximum tolerated dose is attained. Then maintenance booster injections are administered at 2- to 4-week intervals, frequently for a period of several years.

A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply. a. Milk b. Eggs c. Shrimp d. Beef e. Chicken

a, b, c Common food causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Beef and chicken are not common causes.

A pediatric client is recovering from an anaphylactic reaction to an allergen which brought him to the ED. The client's mother is quite concerned with the potential reoccurrence of her child's reaction. In attempting to narrow down the possible allergen, it is important to consider that clinical manifestations generally correlate with: a. route of exposure. b. skin reactions. c. respiratory symptoms. d. systemic effects.

a Clinical manifestations generally correlate with the manner in which the allergen enters the body. For example, inhaled allergens usually cause respiratory symptoms, including nasal congestion, runny nose, sneezing, coughing, dyspnea, and wheezing. Inhaled allergens often trigger asthma.

A nurse educator is explaining that patients with primary immunodeficiencies are living longer than in past decades because of advances in medical treatment. This increased longevity is associated with an increased risk of what? a. Chronic obstructive pulmonary disease b. Dementia c. Pulmonary fibrosis d. Cancer

d Advances in medical treatment have meant that patients with primary immunodeficiencies live longer, thus increasing their overall risk of developing cancer. It does not mean that they are at increased risk of COPD, dementia, or pulmonary fibrosis.

A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid: a. alcohol. b. applying skin moisturizers. c. seafood. d. exposure to sunlight.

a The nurse should advise a client taking antihistamines not to take it with alcohol or other central nervous system depressants because additive sedative effects can occur.

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective? a. Increased salivation b. Increased tearing c. Reduced sneezing d. Headache

c Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, the client shouldn't experience increased salivation or tearing. Because decongestants alleviate congestion, they also relieve headaches, which may be caused by congestion.

The nurse is educating a client about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms to report. Which COX-2 inhibitor is the nurse educating the client about? a. Ibuprofen b. Celecoxib c. Piroxicam d. Tolmetin sodium

b The COX-2 inhibitor celecoxib (Celebrex) is associated with an increased risk of cardiovascular events, including myocardial infarction and stroke.

While monitoring the patient's eosinophil level, the nurse suspects a definite allergic disorder when seeing an eosinophil value of what percentage of the total leukocyte count? a. 1% to 3% b. 3% to 4% c. 5% to 10% d. 15% to 40%

d Eosinophils, which are granular leukocytes, normally make up 0% to 3% of the total number of WBCs (Fischbach & Dunning, 2009). A level between 5% and 15% is nonspecific but does suggest allergic reaction. Higher percentages of eosinophils are considered to represent moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and may be found in patients with allergic disorders.

A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodeficiency disease (SCID). What medication should the nurse administer prior to initiating the infusion? a. Diphenhydramine b. Ibuprofen c. Hydromorphone d. Fentanyl

a Diphenhydramine and acetaminophen are administered 30 minutes prior to an IVIG infusion.

A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit? a. type I b. type II c. type III d. type IV

a There are four types of hypersensitivity responses, three of which are immediate. This is an example of Type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies.

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)? a. Bone marrow transplantation b. Antibiotics c. Radiation therapy d. Removal of the thymus gland

a Treatment options for SCID include stem cell and bone marrow transplantation.

A nurse at an allergy clinic is providing education for a client starting immunotherapy for the treatment of allergies. What education should the nurse prioritize? a. The importance of scheduling appointments for the same time each month b. The importance of keeping appointments for desensitization procedures c. The importance of avoiding antihistamines for the duration of treatment d. The importance of keeping a diary of reactions to the immunotherapy

b The nurse informs and reminds the client of the importance of keeping appointments for desensitization procedures, because dosages are usually adjusted on a weekly basis, and missed appointments may interfere with the dosage adjustment. Appointments are more frequent than monthly and antihistamines are not contraindicated. There is no need to keep a diary of reactions.

An infant is born to a mother who had no prenatal care during her pregnancy. What type of hypersensitivity reaction does the nurse understand may have occurred? a. Bacterial endocarditis b. Rh-hemolytic disease c. Lupus erythematosus d. Rheumatoid arthritis

b A type II hypersensitivity, or cytotoxic, reaction, which involves binding either the IgG or IgM antibody to a cell-bound antigen, may lead to eventual cell and tissue damage. The reaction is the result of mistaken identity when the system identifies a normal constituent of the body as foreign and activates the complement cascade. Examples of type II reactions are myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction, and thrombocytopenia.

The nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency diseases? a. They require IVIG as treatment. b. They are the result of intrauterine infection. c. They have a genetic origin. d. They are communicable.

c Primary immunodeficiency diseases are genetic in origin and result from intrinsic defects in the cells of the immune system. Primary immunodeficiency diseases do not always need IVIG as treatment, and they are not communicable. Primary immunodeficiencies do not result from intrauterine infection.

Which statement describes the clinical manifestations of a delayed hypersensitivity (type IV) allergic reaction to latex? a. They are localized to the area of exposure, usually the back of the hands. b. They can be eliminated by changing glove brands or using powder-free gloves. c. They may worsen when hand lotion is applied before donning latex gloves. d. They occur within minutes after exposure to latex.

a Clinical manifestations of a delayed hypersensitivity reaction are localized to the area of exposure. Clinical manifestations of an irritant contact dermatitis can be eliminated by changing glove brands or using powder-free gloves. With an irritant contact dermatitis, avoid use of hand lotion before donning gloves; this may worsen symptoms, as lotions may leach latex proteins from the gloves. Described as a latex allergy, when clinical manifestations occur within minutes after exposure to latex, an immediate hypersensitivity (type I) allergic reaction has occurred.

A client was prescribed an oral antibiotic for the treatment of sinusitis. The client has now stopped, stating she developed a rash shortly after taking the first dose of the drug. What is the nurse's most appropriate response? a. Encourage the woman to continue with the medication while monitoring her skin condition closely. b. Refer the woman to her primary provider to have the medication changed. c. Arrange for the woman to go to the nearest emergency department. d. Encourage the woman to take an over-the-counter (OTC) antihistamine with each dose of the antibiotic.

b On discovery of a medication allergy, clients are warned that they have a hypersensitivity to a particular medication and are advised not to take it again. As a result, the client would need to liaise with the primary provider. There is no need for emergency care unless symptoms worsen to involve respiratory function. An antihistamine would not be an adequate or appropriate recommendation from the nurse.

A nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care? a. Fatigue Related to Pernicious Anemia b. Risk for Constipation Related to Decreased Gastric Motility c. Risk for Falls Due to Loss of Muscle Coordination d. Disturbed Kinesthetic Sensory Perception Related to Vascular Changes

c Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination), telangiectasia (vascular lesions caused by dilated blood vessels), and immune deficiency. Decreased coordination is likely to constitute a risk for falls. The patient does not characteristically lose tactile sensation or experience pernicious anemia or constipation.

A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse? a. "You need to come back to the clinic to get a different medication since this one is not working for you." b. "You may be immune to the effects of this medication and will need something else in its place." c. "The full benefit of the medication may take up to 2 weeks to be achieved." d. "I am sorry that you are feeling poorly but this is the only medication that will work for your problem."

c Patients must be aware that full benefit of corticosteroid nasal sprays may not be achieved for several days to 2 weeks.

A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed diagnostic workup that reveals a phagocytic disorder. This patient faces an increased risk of what complication? a. Thrombocytopenia b. HIV/AIDS c. Neutropenia d. Hemophilia

c Patients with phagocytic cell disorders may develop severe neutropenia. None of the other listed health problems is a common complication of phagocytic disorders.

A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is the nurse's priority for health education? a. The need to begin immunotherapy as soon as possible b. The need for the parents to carry an epinephrine pen c. The need to vigilantly maintain the child's immunization status d. The need for the child to avoid all foods that have a high potential for allergies

a All clients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed. The child does not necessarily need to avoid all common food allergens. Immunotherapy is not indicated in the treatment of childhood food allergies. Immunizations are important, but do not address food allergies.

The nurse knows the best strategy for latex allergy is a. corticosteroids. b. avoidance of latex-based products. c. antihistamines. d. epinephrine from an emergency kit.

b The best strategy available for latex allergy is to avoid latex-based products, but this is often difficult because of their widespread use. Antihistamines and an emergency kit containing epinephrine should be provided to these clients, along with instructions about emergency management of latex allergy.

A child has been transported to the emergency department (ED) after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply. a. Facilitate lung function testing. b. Assess breath sounds. c. Measure the child's oxygen saturation by oximeter. d. Monitor the child's respiratory pattern. e. Assess the child's respiratory rate.

b, c, d, e The respiratory status is evaluated by monitoring the respiratory rate and pattern and by assessing for breathing difficulties, low oxygen saturation, or abnormal lung sounds such as wheezing. Lung function testing is a lengthy procedure that is not appropriate in an emergency context.

A nurse is providing health education regarding self-care to a patient with an immunodeficiency. What teaching point should the nurse emphasize? a. The importance of aggressive treatment of acne b. The importance of avoiding alcohol-based cleansers c. The need to keep fingernails and toenails closely trimmed d. The need for thorough oral hygiene

d Many patients develop oral manifestations and need education about promoting good dental hygiene to diminish the oral discomfort and complications that frequently result in inadequate nutritional intake. Alcohol cleansers do not necessarily need to be avoided and nail care is not a central concern. Acne care is not a main focus of education, since it is not relevant to many patients.

The parents of a 3-year-old boy have just been informed that allergy testing suggests their son has multiple food allergies. When providing health education for this family, what subject should the nurse prioritize? a. Alternative nutritional delivery systems b. Coping strategies for the lifestyle changes that their son's diagnosis necessitates c. The appropriate use of antihistamines in pediatric patients d. Possible sources of food allergens and strategies for avoiding offending foods

d A teaching priority for individuals with food allergies surrounds the accurate identification and avoidance of possible allergens. Coping strategies are also likely relevant but avoiding allergens is a priority. Antihistamine use is secondary, and alternative nutritional delivery systems are almost never indicated.

A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"? a. Be sure to use the nasal spray for at least 10 days to ensure the stuffiness is gone. b. Use the medication every 4 hours to prevent congestion from recurring. c. Drink plenty of fluids. d. Only use the nasal spray for 3 to 4 days once every 12 hours.

d Adrenergic agents, which are vasoconstrictors of mucosal vessels, are used topically in nasal (oxymetazoline [Afrin]) and ophthalmic (brimonidine [Alphagan P]) formulations in addition to the oral route (pseudoephedrine [Sudafed]). The topical route (drops and sprays) causes fewer side effects than oral administration; however, the use of drops and sprays should be limited to a few days to avoid rebound congestion.

A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines? a. Diarrhea b. Anorexia c. Palpitations d. Sedation

d Antihistamines are the major class of medications prescribed for the symptomatic relief of allergic rhinitis. The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines.

Which intervention is the single most important aspect for the client at risk for anaphylaxis? a. Use of antihistamines b. Desensitization c. Wearing a medical alert bracelet d. Prevention

d Clients who have experienced food, medication, idiopathic, or exercise-induced anaphylactic reactions should always carry an emergency kit containing epinephrine for injection to prevent the onset of the reaction upon exposure. While helpful, there must be no lapses in desensitization therapy because this may lead to the reappearance of an allergic reaction when the medication is reinstituted. A medical alert bracelet will assist those rendering aid to a client who has experienced an anaphylactic reaction.

A nurse is planning the care of a client who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this client? a. Administration of IVIG b. Antibiotic administration c. Appropriate use of gloves and goggles d. Thorough and consistent hand hygiene

d Hand hygiene is usually considered the most important aspect of infection control. IVIG and antibiotics are not considered infection control measures, though they enhance resistance to infection and treat infection. Gloves and goggles are sometimes indicated but are less effective than hand hygiene.

The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as a. urticaria. b. contact dermatitis. c. pitting edema. d. angioneurotic edema.

d The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit. Urticaria (hives) is characterized as edematous skin elevations that vary in size and shape, itch, and cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema is the result of increased interstitial fluid and associated with disorders such as congestive heart failure.

A client is experiencing an acute hemolytic reaction. What actions should the nurse take? Select all that apply. a. Discontinue the intravenous line the blood was transfusing through. b. Dispose of the blood container and tubing. c. Check for low back pain. d. Assess for anxiety and mental status changes. e. Notify the health care provider.

c, d, e The intravenous line is needed to give fluids and medications through. The blood container and tubing need to be sent back to the blood bank for repeat typing and culture. Low back pain is a symptom of acute hemolytic reaction. Anxiety and mental status changes are symptoms of acute hemolytic reaction. The health care provider needs to be notified because he/she may need to see the client and order further treatments.

A client has begun sensitivity testing to determine the allergen which caused an anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more sensitive to allergens? a. back b. forearm c. upper arm d. chest

a The scratch or prick test involves scratching the skin and applying a small amount of the liquid test antigen to the scratch. The tester applies one allergen per scratch over the client's forearm, upper arm, or back. The back is more sensitive than the arms.

A nurse has created a plan of care for an immunodeficient client, specifying that care providers take the client's pulse and respiratory rate for a full minute. What is the rationale for this aspect of care? a. Respirations affect heart rate in immunodeficient clients. b. These clients' blunted inflammatory responses can cause subtle changes in status. c. Hemodynamic instability is one of the main complications of immunodeficiency. d. Immunodeficient clients are prone to ventricular tachycardia and atrial fibrillation.

b Pulse rate and respiratory rate should be counted for a full minute, because subtle changes can signal deterioration in the client's clinical status. The rationale for this action is not because of the relationship between heart rate and respirations. These clients do not have a greatly increased risk of hemodynamic instability or dysrhythmias.

The nurse is preparing to administer IVIG to a patient who has an immunodeficiency. What nursing guideline should the nurse apply? a. Do not exceed an infusion rate of 300 mL/hr. b. Slow the infusion rate if the patient exhibits signs of a transfusion reaction. c. Weigh the patient immediately after the infusion is complete. d. Administer pretreatment medications as ordered 30 minutes prior to infusion.

d The nurse should administer pretreatment acetaminophen and diphenhydramine as prescribed 30 minutes before the start of the infusion. The patient should be weighed prior to the treatment and the IV infusion rate should not exceed 200 mL/hour. The nurse should stop the transfusion in the event of any signs of a reaction.

IVIG has been ordered for the treatment of a patient with an immunodeficiency. Which of the following actions should the nurse perform before administering this blood product? a. Ensure that the patient has a patent central line. b. Ensure that the IVIG is appropriately mixed with normal saline. c. Administer furosemide before IVIG to prevent hypervolemia. d. Weigh the patient before administration to verify the correct dose.

d The nurse should obtain height and weight before treatment to verify accurate dosing. IVIG can be administered through a peripheral line. Diuretics are not normally given prior to administration, and IVIG is not mixed with normal saline.

A patient with severe environmental allergies is scheduled for the first in a planned series of immunotherapy injections. What should be included in teaching the patient about the injection? a. The injection will cure the response to the allergen within 6 to 8 weeks. b. The patient will remain in the clinic to be monitored for 30 minutes following the injection. c. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months. d. Injections are usually administered twice weekly.

b Although severe systemic reactions are rare, the risk of systemic and potentially fatal anaphylaxis exists. It tends to occur most frequently at the induction or "up-dosing" phase. Therefore, the patient must be monitored after administration of immunotherapy. Because of the risk of anaphylaxis, injections should not be administered by a lay person or by the patient. The patient must remain in the office or clinic for at least 30 minutes after the injection, and is observed for possible systemic symptoms. Therapeutic failure is evident when a patient does not experience a decrease in symptoms within 12 to 24 months. Maintenance booster injections are administered at 2- to 4-week intervals, frequently for a period of several years, before maximum benefit is achieved.

A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment? a. Dyspnea, bronchospasm, and/or laryngeal edema. b. Hypotension and tachycardia c. The presence and location of pruritus d. The severity of cutaneous warmth and flushing

a Severe systemic, anaphylactic reactions have an abrupt onset with the same signs and symptoms described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.

The nurse teaches the client with allergies about anaphylaxis, including which statement? a. The most common cause of anaphylaxis is penicillin. b. Anaphylactoid (anaphylaxis-like) reactions are commonly fatal. c. The most common food item that causes anaphylaxis is chocolate. d. Systemic reactions include urticaria and angioedema.

a The most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the United States, is penicillin. Although possibly severe, anaphylactoid reactions are rarely fatal. Food items that are common causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Local reactions usually involve urticaria and angioedema at the site of the antigen exposure. Systemic reactions occur within about 30 minutes of exposure involving cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.

The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. a. Using appropriate personal protective equipment b. Placing clients in negative pressure isolation rooms c. Placing clients in positive pressure isolation rooms d. Using safe injection practices e. Performing hand hygiene

a, d, e Some of the key elements of standard precautions include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions.

A patient's primary immunodeficiency disease is characterized by the inability of white blood cells to initiate an inflammatory response to infectious organisms. What is this patient's most likely diagnosis? a. Chronic granulomatous disease b. Wiskott-Aldrich syndrome c. Hyperimmunoglobulinemia E syndrome d. Common variable immunodeficiency

c In one rare type of phagocytic disorder, hyperimmunoglobulinemia E syndrome (formerly known as Job syndrome), white blood cells cannot initiate an inflammatory response to infectious organisms. The other listed health problems do not have this pathology.

The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. What client is having this type of reaction? a. A child with an anaphylactic reaction after a bee sting b. A client with a skin reaction resulting from adhesive tape c. A client with a diagnosis of myasthenia gravis d. An older adult with rheumatoid arthritis

a Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by IgE antibodies and requires previous exposure to the specific antigen. Skin reactions are more commonly type IV and myasthenia gravis is thought to be a type II reaction. Rheumatoid arthritis is not a type I hypersensitivity reaction.

A nurse is caring for a client who has allergic rhinitis. What intervention would be most likely to help the client meet the goal of improved breathing pattern? a. Teach the client to take deep breaths and cough frequently. b. Use antihistamines daily throughout the year. c. Teach the client to seek medical attention at the first sign of an allergic reaction. d. Modify the environment to reduce the severity of allergic symptoms.

The client is instructed and assisted to modify the environment to reduce the severity of allergic symptoms or to prevent their occurrence. Deep breathing and coughing are not indicated unless an infection is present. Anaphylaxis requires prompt medical attention, but a minority of allergic reactions is anaphylaxis. Overuse of antihistamines reduces their effectiveness.

Which of the following disorders is characterized by an increased autoantibody production? a. Systemic lupus erythematosus (SLE) b. Scleroderma c. Rheumatoid arthritis (RA) d. Polymyalgia rheumatic

a SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

Reproductive health education for women who are HIV-positive includes recommending which of the following contraceptives? a. Oral estrogen contraceptives b. An intrauterine device (IUD) c. A diaphragm d. The female condom

d The female condom, the first barrier method controlled by women, is the only proven, effective method to prevent the transmission of HIV and sexually transmitted infections (STI).

The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply. a. Wear a medic alert bracelet. b. List symptoms of peanut allergy. c. Identify ways to manage allergy while dining out. d. Food labels on baked items are the only labels that need to be read. e. Carry EpiPen autoinjector at all times.

a, b, c, e Wearing a medic alert bracelet allows others to be alerted of the allergy. Listing symptoms of the allergy makes the client aware of the allergic reaction if symptoms are being experienced. Identifying ways to manage allergies while dining out allows the client to be safe from a potential reaction. All food labels should be read not only baked items. The EpiPen autoinjector should be carried at all times in case it needs to be administered because of an allergic reaction.

A mother has come to the emergency department (ED) with her 2-year-old who appears to be having a hypersensitivity reaction. The ED nurse knows that a hypersensitivity reaction may be characterized by an immediate reaction beginning within minutes of exposure to an antigen. What condition is an example of such a reaction? a. Anaphylactic reaction immediately following a bee sting b. Skin reaction from tape adhesive c. Hay fever d. Rheumatoid arthritis

a Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by IgE antibodies and requires previous exposure to the specific antigen. Type II reactions, or cytotoxic hypersensitivity, occur when the system mistakenly identifies a normal constituent of the body as foreign. Type III, or immune complex hypersensitivity, occurs as the result of two factors, the increased amount of circulating complexes and the presence of vasoactive amines. Type IV, or delayed-type hypersensitivity, occurs 24 to 72 hours after exposure to an allergen and is mediated by sensitized T-cells and macrophages.

A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include a. adrenal suppression. b. diuresis. c. hypoglycemia. d. hypotension.

a The nurse should instruct the client that side effects of oral corticosteroid therapy include adrenal suppression, fluid retention, weight gain, glucose intolerance, hypertension, and gastric irritation.

Grace Walters, a 73-year-old female, is a client on the surgical floor where you practice nursing. She is returning from surgical hip repair and has an adhesive patch covering her incision. She has a history of an allergic disorder. Which of the following nursing actions is most important when assessing the dressing site of Mrs. Walters? a. Observe Mrs. Walters for signs of allergic reaction. b. Apply moisturizer to the site before sticking the patch. c. Apply pressure to ensure that the patch is firmly in place. d. Ensure that Mrs. Walters is lying down in a comfortable position.

a Though it is important to ensure that the client is comfortable and the patch is firmly in place, it is not as essential as observing for an allergic reaction. Applying moisturizer to the site may interfere with the results of the patch test.

A home health nurse will soon begin administering IVIG to a new client on a regular basis. What teaching should the nurse provide to the client? a. The need for a sterile home environment b. Complementary alternatives to IVIG c. Expected benefits and outcomes of the treatment d. Technique for managing and monitoring daily fluid intake

c The client who is to receive IVIG at home will need information about the expected benefits and outcomes of the treatment as well as expected adverse reactions and their management. The home environment cannot be sterile, and complementary alternatives to IVIG have not been identified. Fluid management is not a central concern.

The nurse is conducting a community education program on allergies and anaphylactic reactions. The nurse determines that the participants understand the education when they make which statement about anaphylaxis? a. The most common cause of anaphylaxis is penicillin. b. Anaphylactoid (anaphylaxis-like) reactions are commonly fatal. c. The most common food item that causes anaphylaxis is chocolate. d. Systemic reactions include urticaria and angioedema.

a The most common cause of anaphylaxis is penicillin, accounting for about 75% of fatal anaphylactic reactions in the United States. Although possibly severe, anaphylactoid reactions are rarely fatal. Food items that are common causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Local reactions usually involve urticaria and angioedema at the site of the antigen exposure. Systemic reactions, which occur within about 30 minutes of exposure, involve cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.

The nurse is creating a care plan for a client suffering from allergic rhinitis. What outcome should the nurse identify? a. Appropriate use of prophylactic antibiotics b. Safe injection of corticosteroids c. Improved skin integrity d. Improved coping with lifestyle modifications

d The goals for the client with allergies may include restoration of normal breathing pattern, increased knowledge about the causes and control of allergic symptoms, improved coping with alterations and modifications, and absence of complications. Antibiotics are not used to treat allergies and corticosteroids, if needed, are not given parenterally. Allergies do not normally threaten skin integrity.

A nurse is caring for a patient with a phagocytic cell disorder. The patient states, "My specialist says that I will likely be cured after I get my treatment tomorrow." To what treatment is the patient most likely referring? a. Treatment with granulocyte-macrophage colony-stimulating factor (GM-CSF) b. Hematopoietic stem cell transplantation c. Treatment with granulocyte colony-stimulating factor (G-CSF) d. Brachytherapy

b Hematopoietic stem cell transplantation (HSCT), another form of cell therapy, has proven to be a successful curative modality. Treatment with GM-CSF or G-CSF is not curative. Brachytherapy is not a treatment for immunodeficiency.

Patient teaching regarding infection prevention for the patient with an immunodeficiency includes which of the following guidelines? a. Cook all food thoroughly. b. Refrain from using creams or emollients on skin. c. Maintain contact only with individuals who have recently been vaccinated. d. Take OTC vitamin supplements consistently.

a All foods must be cooked to avoid food-borne illness. The patient should avoid contact with individuals who have recently been ill or vaccinated. The nurse should apply creams and emollients to any dry, chaffed, or cracked skin. Vitamin supplements may or may not be indicated.

Family members of an immunocompromised client have asked the nurse why antibiotics are not being given to the client in order to prevent infection. How should the nurse best respond? a. "Using antibiotics to prevent infections can cause the growth of drug-resistant bacteria." b. "If an antibiotic is given to prevent a bacterial infection, the client is at risk for a viral infection." c. "Antibiotics can never prevent an infection; they can only cure an infection that is fully developed." d. "Antibiotics cannot resolve infections in people who are immunocompromised."

a Although prophylactic drug treatment effectively prevents some bacterial and fungal infections, it must be used with caution because it has been implicated in the emergence of resistant organisms. Use of antibiotics does not directly increase the risk of viral infections.

Which allergic reaction is potentially life threatening? a. angioedema b. urticaria c. contact dermatitis d. None of the listed allergic reactions is potentially life threatening.

a Angioedema is potentially life threatening. Medical management would include intubation, subcutaneous epinephrine, and aminophylline in severe reactions.

In its attempt to suppress allergic responses, the body releases several chemicals which have a role in mediating physical reactions. Epinephrine, which interferes with vasoactive chemical release from mast cells, is instrumental in suppressing which type of hypersensitivity response? a. type I b. type II c. type III d. type IV

a Epinephrine interferes with the release of vasoactive chemicals from mast cells which cause vasodilation during anaphylaxis, also known as a Type I response.

Fibromyalgia is a common condition that involves a. chronic fatigue, generalized muscle aching, and stiffness. b. pain, viral infection, and tremors. c. diminished vision, chronic fatigue, and reduced appetite. d. generalized muscle aching, mood swings, and loss of balance.

a Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. The cause is unknown, and no pathological characteristics specific for the condition have been identified. Treatment consists of attention to the specific symptoms reported by the client. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals.

After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action? a. Removing the cat from the family's home b. Administering over-the-counter (OTC) antihistamines to the child regularly c. Keeping the cat restricted from the child's bedroom d. Maximizing airflow in the house

a In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors. Fully removing the cat from the environment is preferable to just keeping the cat out of the child's bedroom. Avoidance therapy does not involve improving airflow or using antihistamines.

A patient is admitted for the treatment of a primary immunodeficiency and intravenous immunoglobulin (IVIG) is ordered. What should the nurse monitor for as a potential adverse effect of IVIG administration? a. Anaphylaxis b. Hypertension c. Hypothermia d. Joint pain

a Potential adverse effects of an IVIG infusion include hypotension, flank pain, chills, and tightness in chest, terminating with a slightly elevated body temperature and anaphylactic reaction. Hypertension, hypothermia, and joint pain are not usual adverse effects of IVIG.

An experienced medical nurse has provided care for patients who have immunodeficiencies that are primary, as well as for patients who have secondary immunodeficiencies. Which of the following individuals is most clearly exhibiting secondary immunodeficiency? a. A woman whose diagnosis of sepsis is attributable to her recent chemotherapy b. An elderly resident of a long-term care facility who has been diagnosed with the Norwalk virus c. A child who had an allergic reaction to a scheduled immunization d. A man who developed deep vein thrombosis (DVT) after being immobilized during recovery from orthopedic surgery

a Secondary immunodeficiencies affect the normal immune system of the patient, resulting in increased susceptibility to infection and certain types of cancer. Chemotherapy is an example of a factor that can precipitate this susceptibility. Development of postoperative DVT and allergic reactions are not example of secondary immunodeficiency. Infection often results from a secondary immunodeficiency, but not every infection is attributable to this factor.

The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan? a. Risk for Disturbed Body Image Related to Skin Lesions b. Risk for Disuse Syndrome Related to Dermatitis c. Risk for Ineffective Role Performance Related to Dermatitis d. Risk for Self-Care Deficit Related to Skin Lesions

a The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of clients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit.

A home health nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurse's teaching? a. "My family needs to understand when I can go get the seasonal flu shot." b. "I need to know how to treat my infections in a home setting." c. "I need to understand how to give my platelet transfusions." d. "My family needs to understand that I'll probably need lifelong treatment."

a The patient must be made aware that all health-related instructions are lifelong. Immunizations may be contraindicated and infection usually requires inpatient treatment. Platelet transfusions are not indicated for most patients who have immunodeficiencies.

A client with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurse's best response? a. "I can only imagine how you feel. Would you like to talk about it?" b. "Let's find a quiet spot and I'll teach you a few coping strategies." c. "That's the same way that most clients who have a chronic illness feel." d. "Do you think that maybe you could be managing things more efficiently?"

a To assist the client in adjusting to these modifications, the nurse must have an appreciation of the difficulties encountered by the client. The client is encouraged to verbalize feelings and concerns in a supportive environment and to identify strategies to deal with them effectively. The nurse should not suggest that the client has been mismanaging his health problem and the nurse should not make comparisons with other patients. Further assessment should precede educational interventions.

Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle? a. Histamine b. Bradykinin c. Serotonin d. Prostaglandin

a When cells are damaged, histamine is released. Bradykinin is a polypeptide that stimulates nerve fibers and causes pain. Serotonin is a chemical mediator that acts as a potent vasoconstrictor and bronchoconstrictor. Prostaglandins are unsaturated fatty acids that have a wide assortment of biologic activities.

The nurse is caring for a client with an immunodeficiency who has experienced sudden malaise. The nurse's colleague states, "I'm pretty sure that it's not an infection, because the most recent blood work looks fine." What principle should guide the nurse's response to the colleague? a. Immunodeficient clients will usually exhibit subtle and atypical signs of infection. b. Infections in immunodeficient clients have a slower onset but a more severe course. c. Laboratory blood work is often inaccurate in immunodeficient clients. d. Immunodeficient clients do not develop symptoms of infection.

a Immunodeficient clients often lack the typical objective and subjective signs and symptoms of infection. However, this does not mean that they wholly lack symptoms. Infections do not normally have a slower onset. Blood work may not be a reliable diagnostic tool, but that does not mean that the results are inaccurate.

A nurse is teaching a client about allergic rhinitis. What client statements indicate teaching has been effective? Select all that apply. a. "I should use my medication for allergy exacerbation only when my allergy is apparent." b. "I am allowed to miss only one desensitization appointment before my treatment is affected." c. "I can only have one alcoholic drink while I am taking my antihistamine." d. "I need to reduce my exposure to people that have upper respiratory infections." e. "I will remove as much carpet from my house as I can."

a, d, e The client should only use their medication when allergy is apparent so they do not develop a tolerance, which can occur when the medication is used all the time. The client should reduce their exposure to people that have upper respiratory infections because they are more susceptible to getting sick. Removing as much carpet from the house as possible will help reduce allergens. The client cannot miss any desensitization appointments because it will interfere with dosage adjustments. While taking an antihistamine, alcohol cannot be consumed at all, as antihistamines can exaggerate the effects of alcohol.

A nurse knows of several clients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which client? a. A client who has previously been treated for tuberculosis b. A pregnant woman at 30 weeks' gestation c. A client who is on estrogen-replacement therapy d. A client with a severe allergy to eggs

b Antihistamines are contraindicated during the third trimester of pregnancy. Previous tuberculosis, hormone therapy, and food allergies do not contraindicate the use of antihistamines.

The nurse in an allergy clinic is educating a new client about the pathology of the client's health problem. What response should the nurse describe as a possible consequence of histamine release? a. Constriction of small venules b. Contraction of bronchial smooth muscle c. Dilation of large blood vessels d. Decreased secretions from gastric and mucosal cells

b Histamine's effects during the immune response include contraction of bronchial smooth muscle, resulting in wheezing and bronchospasm, dilation of small venules, constriction of large blood vessels, and an increase in secretion of gastric and mucosal cells.

A nurse is caring for a patient who has an immunodeficiency. What assessment finding should prompt the nurse to consider the possibility that the patient is developing an infection? a. Uncharacteristic aggression b. Persistent diarrhea c. Pruritis (itching) d. Constipation

b Persistent diarrhea is among the varied signs and symptoms that may suggest infection in an immunocompromised patient. Aggression, pruritis, and constipation are less suggestive of an infectious etiology.

A patient was seen in the clinic for hypertension and received a prescription for a new antihypertensive medication. The patient arrived in the emergency department a few hours after taking the medication with severe angioedema. What medication prescribed may be responsible for the reaction? a. Beta blocker b. Angiotensin-converting enzyme (ACE) inhibitor c. Angiotensin receptor blocker d. Vasodilator

b Several frequently prescribed medications, such as angiotensin-converting enzyme inhibitors and penicillin, may cause angioedema. The nurse needs to be aware of all medications the patient is taking and be alert to the potential of angioedema as a side effect.

A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education? a. "I may experience itching and irritation at the site of the testing." b. "If I notice tingling in my lips or mouth, gargling may help the symptoms." c. "I'll go directly to the pharmacy with my EpiPen prescription." d. "The test may be mildly uncomfortable."

b The client requires further teaching if the client states, "I will gargle to help alleviate tingling in the lips or mouth." Allergy testing introduces potentially irritating substances to the client. Tingling in the mouth, lips, or throat indicates the onset of a severe reaction and the need for immediate medical intervention. The testing may cause irritation and itching at the test site. The health care provider may order an epinephrine pen (EpiPen) for the client to self-administer epinephrine if the client experiences an allergic reaction away from the office setting.

A nurse is preparing to discharge a patient with an immunodeficiency. When preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize? a. Sterile technique for establishing a new IV site b. Signs and symptoms of adverse reactions c. Formulas for calculating daily doses d. Technique for adding medications to the IVIG

b The patient who is to receive IVIG at home will need information about adverse reactions and their management. A patient would not start a new IV site independently and the patient does not calculate changes in dose independently. Medications are not added to IVIG.

An infant that is 10 hours postdelivery is observed to have tetanic contractions. What symptom does the nurse recognize can indicate DiGeorge syndrome? a. Chronic diarrhea b. Hypocalcemia c. Neutropenia d. Pernicious anemia

b Thymic hypoplasia, also known as DiGeorge syndrome, is associated with recurrent infections, hypoparathyroidism, hypocalcemia, tetany, convulsions, congenital heart disease, possible renal abnormalities, and abnormal facies.

After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action? a. Avoids massaging the injection site after administration b. Jabs the autoinjector into the outer thigh at a 90-degree angle c. Pushes down on the grey release cap to administer the medication d. Maintains pressure on the auto-injector for about 30 seconds after insertion

b To self-administer epinephrine, the client should remove the autoinjector from its carrying tube, grasp the unit with the black tip (injecting end) pointed downward, form a fist around the device, and remove the gray safety release cap. Then the client should hold the black tip near the outer thigh and swing and jab firmly into the outer thigh at a 90-degree angle until a click is heard. Next, the client should hold the device firmly in place for about 10 seconds, remove the device, and massage the site for about 10 seconds.

The nurse is creating a discharge teaching plan for a client with a latex allergy. Which information should be included? Select all that apply. a. Radioallergosorbent testing (RAST) b. Avoidance of latex-based products c. Administration of antihistamines d. Administration of emergency epinephrine

b, c, d The nurse should include in the discharge teaching plan avoidance of latex-based products. Additionally, the nurse should include administration of antihistamines and an emergency epinephrine. RAST testing would not be indicated; it is a diagnostic test for allergies, and the client's latex allergy is already diagnosed.

The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family? a. How to promote immune function through nutrition b. The importance of maintaining the client's vaccination status c. How to choose antibiotics based on the client's symptoms d. The need to report any slight changes in the client's health status

d They must be informed of the need for continuous monitoring for subtle changes in the client's physical health status and of the importance of seeking immediate health care if changes are detected. Nutrition is important, but infection control is the priority. Clients and families do not choose antibiotics independently. Vaccinations are often contraindicated in immunocompromised clients.

A client with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin? a. Immunoglobulin A b. Immunoglobulin M c. Immunoglobulin G d. Immunoglobulin E

d Atopy refers to allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions.

A client who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should the nurse implement? a. The client should take his corticosteroids regularly prior to testing. b. The client should only be tested for grass, mold, and dust initially. c. The nurse should have an emergency cart available in case of anaphylaxis during the test. d. The client's test should be cancelled until he is off his corticosteroids.

d Corticosteroids and antihistamines, including over-the-counter (OTC) allergy medications, suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. Emergency equipment must be at hand during allergy testing, but the test would be postponed.

A camp nurse has been rushed to a playing field where a girl appears to be experiencing an anaphylactic reaction. The nurse has had the child rushed to the camp's infirmary. What action should the nurse prioritize in the immediate care of this child? a. Administer analgesics if available. b. Closely monitor the girl's heart rate. c. Position the girl in high Fowler's. d. Maintain the patency of the girl's airway.

d In the management of an anaphylactic reaction, interventions such as epinephrine administration are performed with the primary goal of maintaining the patient's airway and facilitating ventilation and perfusion. Heart rate monitoring is necessary but secondary. Analgesia is not a priority, and it is unnecessary to position the patient upright.

An immunocompromised client is being treated in the hospital. The nurse's assessment reveals that the client's submandibular lymph nodes are swollen, a finding that represents a change from the previous day. What is the nurse's most appropriate action? a. Administer a PRN dose of acetaminophen as ordered. b. Monitor the client's vital signs q2h for the next 24 hours. c. Inform the client's primary care provider of this finding. d. Implement standard precautions in the client's care.

d Swollen lymph nodes are suggestive of infection and warrant prompt medical assessment and treatment. Acetaminophen is an ineffective response. The nurse should monitor the client's vital signs closely, but the physician should also be informed. Standard precautions should be in place regardless of the client's status.

The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as a. urticaria. b. contact dermatitis. c. pitting edema. d. angioneurotic edema.

d The area of skin demonstrating angioneurotic edema may appear normal, but often has a reddish hue and does not pit. Urticaria (hives) is characterized as edematous skin elevations that vary in size, shape, and itch, which cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema, the result of increased interstitial fluid, is associated with disorders such as congestive heart failure.