Chapter 47- Nursing Care of the Child With an Alteration in Immunity or Immunologic Disorder

1. While providing care to a 5-month-old girl whose family has a history of food allergies, the nurse instructs the parents about foods to be avoided in the first year of life. Which response by the parents indicates a need for further teaching?

"Any kind of fruit is acceptable."

6. The nurse is providing home care instructions for a 13-year-old girl recently diagnosed with systemic lupus erythematosus. Which response by the girl indicates a need for further teaching?

"I need to wear sunscreen in the summer to prevent rashes."

The nurse is providing a class for a group of childcare providers. When discussing allergic reactions, which statement by a participant indicates the need for further instruction?

"If a child has previously eaten a food and not had a reaction they are not 'truly' allergic to it."

The mother of a 5-year-old child with allergies to a variety of foods including eggs, milk, peanuts and shellfish, asks if her child will "always have these problems." What response by the nurse is most accurate?

"In most cases allergies to peanuts and shellfish persist into adulthood but the others may diminish and disappear."

2. A nurse is caring for a 12-year-old girl with a severe peanut allergy. The girl's parents are upset because the school does not permit her to carry her EpiPen with her. It must remain in the school's office per school regulations. Which response by the nurse would be most appropriate?

"She is allowed by law to carry her EpiPen with her; I will talk to school authorities."

A 16-year-old client has just been diagnosed with HIV. Which statement by the parent indicates understanding of the diagnosis?

"We don't want to face the fact that it is likely our child contracted HIV through sexual contact or IV drug use."

23. The nurse is talking to the parents of a child who has been diagnosed with severe combined immune deficiency. Which statement by the parents best indicates that they understand their child's condition?

"We'll need to prepare him and ourselves for a bone marrow transplant.'

10. The nurse is administering intravenous immune globulin (IVIG). The nurse assesses vital signs and for adverse reactions every 15 minutes for the first hour of administration. After the first hour, the nurse most likely would continue to assess the child at which frequency?

Every 30 minutes

4. The nurse is caring for a child who is having an anaphylactic reaction with bronchospasm. The nurse would expect to administer which of the following for bronchospasm as ordered?

Albuterol

8. The school nurse is walking through the lunchroom when one of the children says she feels strange after switching her lunch with her friend. Which assessment would be most important?

Determining if her throat itches

12. Which of the following would the nurse expect to find in a male infant with Wiskott- Aldrich syndrome?

Eczema

24. The nurse is assessing a child with pauciarticular-type juvenile idiopathic arthritis. Which of the following would the nurse expect to assess?

Eye inflammation

13. After teaching a class about humoral and cellular immunity, the nurse recognizes that the additional teaching is needed when the class states which of the following?

Cellular immunity recognizes antigens.

22. A child is diagnosed with a food allergy to milk. When teaching the parents about this allergy, which of the following would the nurse suggest as possible substitutions? Select all answers that apply.

Fruit juice Rice milk Soy milk

14. When teaching a group of new parents about newborn care and development, which immunoglobulin would the nurse explain as being primarily responsible for the passive immunity exhibited by newborns?

IgG

18. A nurse is preparing a plan of care for a child with a primary immunodeficiency. Which nursing diagnosis would the nurse most likely identify as the priority?

Ineffective protection related to impaired humoral defenses

25. A child with systemic lupus erythematosus is receiving high-dose corticosteroid therapy over the long term. The nurse would instruct the parents and child to report which of the following?

Joint pain

9. The nurse is caring for a child who has undergone stem cell transplantation for severe combined immune deficiency. Which of the following would the nurse interpret as indicative of graft-versus-host disease?

Maculopapular rash

16. A child is diagnosed with juvenile idiopathic arthritis and is receiving several different medications listed in the medication administration record. Which agent would the nurse identify as being used to prevent disease progression?

Methotrexate

26. A nurse is assessing a child who may have a latex allergy. The nurse asks the child about allergic reactions with certain foods. Which foods if identified by the child as experiencing an allergic reaction would help support the suspected latex allergy? Select all answers that apply.

Peaches Plums Carrots Tomatoes

21. The nurse is reviewing the laboratory test results of a child who is suspected of having systemic lupus erythematosus (SLE). Which of the following would the nurse identify as supporting this diagnosis? Select all answers that apply.

Positive antinuclear antibody (ANA) Thrombocytopenia Leukopenia/decreased C4 cells

5. The nurse is caring for a child undergoing highly active antiretroviral therapy (HAART) for HIV infection. The nurse is preparing to administer the prescribed medication. In addition to the nucleoside analog reverse transcriptase inhibitors (NRTIs) and the nonnucleoside analog reverse transcriptase inhibitors (NNRTIs), the nurse is cognizant that the child will be taking which additional medication as part of the three-drug regimen?

Protease inhibitors

19. A child with hypogammaglobulinemia is to receive intravenous immunoglobulin (IVIG). Which of the following would be least appropriate for the nurse to do?

Shake the vial after reconstituting it

15. Which exercise would the nurse suggest as most helpful to maintain mobility in a child with juvenile idiopathic arthritis?

Swimming

17. A group of nursing students are reviewing information about humoral and cellular immunity. The students demonstrate understanding of this material when they identify which of the following as involved in cellular immunity?

T cells

7. The nurse is caring for a child who is taking corticosteroids for systemic lupus erythematosus. The nurse closely monitors the child based on the understanding that corticosteroids exert which major action?

They can mask signs of infection.

11. When reviewing the history of a child with suspected primary immunodeficiency, which of the following would the nurse be least likely to find?

Weight appropriate for height

20. A nursing student is reviewing information about primary immunodeficiencies. The student demonstrates understanding of the material by identifying which of the following as affecting only males? Select all answers that apply.

X-linked agammaglobulinemia Wiskott-Aldrich syndrome X-linked hyper-IgM syndrome

3. The nurse is caring for a newborn whose mother is HIV positive. The nurse would expect to administer a 6-week course of which medication?

Zidovudine

While performing an assessment of a client who is immunocompromised, the nurse notes the child to have thrush in the mouth, tenderness over the spleen upon palpation, and a white blood cell count of 3,000. Which nursing diagnoses will the nurse include in the care plan of this child based on these findings? Select all that apply.

ineffective protection risk for imbalanced nutrition, less than body requirements pain