Chapter 55: Care of the Patient with an Immune Disorder

The nurse stresses that when a person produces his own antibodies against a specific antigen, that process of immunity is immunity

ANS: active acquired When a person's immune system produces specific antibodies against an antigen, that process is an active acquired immunity. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1964 OBJ: 2 TOP: Active immunity KEY: Nursing Process Step: Implementation

A transfusion using blood from one's own blood is a(n) transfusion, which is the best defense against a transfusion reaction.

ANS: autologous An autologous transfusion uses blood from one's own body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1973 OBJ: 9 TOP: Autologous transfusion KEY: Nursing Process Step: N/A

The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is .

ANS: immunization The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is immunization. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 1966-1967 OBJ: 2 TOP: Immunization KEY: Nursing Process Step : N/A

The transfer of tissue between genetically identical individual (twins) is a(n) .

ANS: isograft An isograft is the transfer of tissue between genetically identical individual (twins). PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1973 OBJ: N/A TOP: Isograft KEY: Nursing Process Step: N/A

List the sequence of a plasmapheresis procedure. (Separate letters by a comma and space as follows: A, B, C, D) a. Removal of whole blood in one arm b. Circulation of blood through cell separator c. Remainder of plasma returned through vein in opposite arm d. Separation of plasma and its cellular components e. Replacement of plasma with lactated Ringer f. Removal of undesirable components

ANS: A, B, D, F, C, E The whole blood is drawn out of one arm; circulated through a cell separator; plasma is separated with its cellular components; the undesirable components are removed; the remainder of plasma is returned through a vein in the opposite arm; and the lost plasma is replaced with lactated Ringer, normal saline, frozen plasma, or albumin. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1974 OBJ: 12 TOP: Process of plasmapheresis KEY: Nursing Process Step: N/A

The nurse outlines for a patient who has asthma attacks from pollen that the process from exposure to symptoms follows a systematic sequence. Place the physiologic responses of an allergic asthma attack in sequence. (Separate letters by a comma and space as follows: A, B, C, D) a. Release of histamine b. Edema c. Vasodilation d. Activation of mast cells e. Bronchospasm f. Exposure to pollen

ANS: F, D, A, C, B, E The mast cells in the lungs are activated by the exposure to pollen. Histamine is released causing vasodilation, edema, and bronchospasm for the asthmatic. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1968 OBJ: 5 TOP: Sequence of allergic response KEY: Nursing Process Step: Implementation

A type IV latex allergy is characterized by .

ANS: contact dermatitis Type IV latex allergy is that of a contact dermatitis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1971 OBJ: 8 TOP: Latex allergy KEY: Nursing Process Step: N/A

The purpose of immunotherapy is .

ANS: desensitization The theory behind immunotherapy is to assist the individual to build a tolerance to the allergen without developing fever or increased signs and symptoms. Desensitization is another term used for immunotherapy. REF: Page 1960 TOP: Immunotherapy

A patient, age 42, develops a severe angioedema involving her face, hands, and feet, with burning and stinging of the lesions. During the assessment, which significant risk factor for allergies does the nurse recognize? a. Family history of allergies b. History of a recent fungal infection c. Use of OTC medications d. Recurrent respiratory infections

ANS: A A thorough history is the most important diagnostic tool. There is a genetic link to both well-developed immune systems and poorly developed or compromised immune systems. REF: Page 1961, Health Promotion box TOP: Allergic reaction

The correct nursing intervention for anaphylaxis would be a. assess respiratory status, including dyspnea. b. hypertension and elevated albumin levels. c. assess skin status, including erythema, urticaria, cyanosis, and pallor. d. assess GI status, including nausea, vomiting, diarrhea, incontinence.

ANS: A Anaphylaxis—If moderate to severe signs and symptoms occur, IV therapy may be initiated to prevent vascular collapse and the patient may be intubated to prevent airway obstruction. Nursing interventions and patient teaching—Assess respiratory status, including dyspnea, wheezing, and decreased breath sounds. REF: Page 1963 TOP: Anaphylaxis Step: Assessment

The delayed major process that leads to organ transplant rejection is a. hypersensitivity. b. cellular immunity. c. autoimmune factors. d. immunodeficiency.

ANS: A Delayed hypersensitivity reactions occurring 24 to 72 hours after exposure are mediated by T cells accompanied by release of lymphokines. Tissue transplant rejection is another example. REF: Page 1965 TOP: Transplant Step: Planning

The LPN/LVN has arrived at the patient's bedside with a unit of packed cells to be connected to an IV that is infusing. When the RN arrives, what is the first thing the nurses must do? a. Check to ensure that the donor and recipient numbers match according to policy b. Request the patient to sign the card on the packed cells c. Immediately administer the packed cells d. Check the patient's ID bracelet and then administer the packed cells

ANS: A Donor and recipient numbers are specific and must be thoroughly checked and the patient identified with an armband. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1972 OBJ: 9 TOP: Blood transfusion KEY: Nursing Process Step: Implementation

The LPN/LVN has arrived at the patient's bedside with a unit of packed cells to be connected to an IV that is infusing. When the RN arrives, what is the first thing the nurses must do? a. Do the checks to ensure that the donor and recipient numbers match according to policy. b. Leave the packed cells at the bedside until the saline is infused. c. Immediately hang the packed cells to get the infusion started. d. Check the patients ID bracelet and then hang the packed cells.

ANS: A Donor and recipient numbers are specific and must be thoroughly checked and the patient identified with an armband. REF: Page 1965 TOP: Blood transfusion

What should the nurse include to assess for in the plan of care for a patient undergoing plasmapheresis? a. Hypotension b. Hypersensitivity c. Urticaria d. Flank pain

ANS: A Hypotension occurs during plasmapheresis because of transient volume changes in the blood. PTS: 1 DIF: Cognitive Level: Application REF: Page 1975 OBJ: 12 TOP: Plasmapheresis KEY: Nursing Process Step: Planning

A patient is admitted with a secondary immunodeficiency from chemotherapy. The nursing plan of care should include provisions for: a. infection control. b. supporting self-care. c. nutritional education. d. maintaining high fluid intake.

ANS: A Immune deficient persons are at risk for infection and need to be protected aggressively for contagion. PTS: 1 DIF: Cognitive Level: Application REF: Page 1973 OBJ: 10 TOP: Immunodeficiency diseases KEY: Nursing Process Step: Planning

A patient has experienced an anaphylaxis reaction and is being monitored to ensure she is stable. A nursing diagnosis for her will be a. Decreased cardiac output. b. Impaired skin integrity. c. Imbalanced nutrition: less than required. d. Feeding self-care deficit.

ANS: A In a patient suffering an anaphylaxis reaction, a nursing diagnosis is Decreased cardiac output. REF: Pages 1963-1964, Nursing Diagnoses box TOP: Anaphylactic reaction

What is the substance released by the T cells that stimulates the lymphocytes to attack an inflammation? a. Lymphokine b. Epinephrine c. B cells d. Histamine

ANS: A Lymphokines help attract macrophages to the site of the inflammation. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1964 OBJ: 3 TOP: Allergic reaction KEY: Nursing Process Step: N/A

Which symptom would be classified as a mild transfusion reaction? a. Orthopnea b. Tachycardia c. Hypotension d. Wheezing

ANS: A Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1972 OBJ: 9 TOP: Blood transfusion KEY: Nursing Process Step: Assessment

What is the term for transplantation of tissue between members of the same species? a. Allograft b. Autograft c. Isograft d. Homograft

ANS: A The allograft is the transplantation of tissues between members of the same species, such as a graft for full-thickness burns. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1973 OBJ: N/A TOP: Allograft KEY: Nursing Process Step: Implementation

During a patient history, the nurse notices that the patient has had five upper respiratory infections in the past 18 months. The nurse begins to suspect that the patient may have an immunodeficiency disease because the first evidence of this disease is a. an increased susceptibility to infection. b. an increased coagulation problem. c. a problem with hemostasis. d. localized edema, raised wheals.

ANS: A The first evidence of immunodeficiency disease (an abnormal condition of the immune system in which cellular or humoral immunity is inadequate and resistance to infection is decreased) is an increased susceptibility to infection. REF: Page 1966 TOP: Immunodeficiency

What should the nurse do because of the increasing strength of the dose in the injections for immunotherapy? a. Observe the patient for at least 20 minutes after administration b. Take the vital signs every 10 minutes for an hour c. Have the patient lie down quietly for an hour d. Place a warm compress on the area to speed its absorption

ANS: A The patient should be observed for 20 minutes after the increased dose of the allergen. If anaphylaxis is going to occur, it will do so within that time frame. PTS: 1 DIF: Cognitive Level: Application REF: Page 1967 OBJ: 6 TOP: Anaphylaxis reaction KEY: Nursing Process Step: Assessment

A 72-year-old female patient is admitted with a diagnosis of immunodeficiency disease. The primary nursing goal would be to a. reduce the risk of her developing an infection. b. encourage her to provide self-care. c. plan nutritious meals to provide adequate intake. d. encourage her to interact with other patients.

ANS: A Unusually severe infections with complications or incomplete clearing of an infection may also indicate an underlying immunodeficiency. REF: Pages 1966-1967 TOP: Immunodeficiency diseases Step: Planning

Which of the following are diseases which result from one's own immune system attacking the body? (Select all that apply.) a. Lupus erythematosus b. Glomerulonephritis c. Polio d. Rheumatoid arthritis e. Thrombocytopenic purpura f. Osteoarthritis

ANS: A, B, D, E Autoimmune diseases such as systemic lupus erythematosus, glomerulonephritis, myasthenia gravis, thrombocytopenic purpura, rheumatoid arthritis, and Guillain-Barré syndrome are treated with plasmapheresis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1974 OBJ: 11 TOP: Autoimmune disease KEY: Nursing Process Step: Assessment

Which are autoimmune diseases? (Select all that apply.) a. Lupus erythematosus b. Glomerulonephritis c. Polio d. Rheumatoid arthritis e. Thrombocytopenic purpura f. Osteoarthritis

ANS: A, B, D, E Autoimmune diseases such as systemic lupus erythematosus, glomerulonephritis, myasthenia gravis, thrombocytopenic purpura, rheumatoid arthritis, and Guillain-Barré syndrome are treated with plasmapheresis. REF: Pages 1966-1967 TOP: Autoimmune disorders

What is humoral immunity based on? (Select all that apply.) a. Production of antibodies by B cells b. T cells are activated by an antigen c. The body's response to an antigen d. Sensitized T cells destroy the antigen e. Helper T cells activate phagocytosis

ANS: A, C, E Both types of immunity are in response to an antigen, In the humoral response helper T cells activate phagocytosis and the production of antibodies by the B cells. B cells are the main player in humoral response. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1965 OBJ: 3 TOP: Humoral immunity KEY: Nursing Process Step: Implementation

Which of the following provide the body with innate immunity? (Select all that apply.) a. Skin and mucous membranes b. Lungs c. Heart d. Tears and saliva e. Natural intestinal and vaginal flora f. Stomach acid

ANS: A, D, E, F The innate immune system is composed of the skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissues, and secretions provide biochemical and physical barriers to disease. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1963 Table 54-1 OBJ: 2 TOP: Natural immunity KEY: Nursing Process Step: Assessment

The first line of defense is innate (natural) immunity. Which is part of that protective mechanism against the external environment? (Select all that apply.) a. Skin and mucous membranes b. Lungs c. Heart d. Tears and saliva e. Natural intestinal and vaginal flora f. Stomach acid

ANS: A, D, E, F The innate system is composed of the skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissues, and secretions provide biochemical and physical barriers to disease. REF: Page 1956 TOP: Natural immunity

The patient who had an asthma-like reaction to a desensitization shot was medicated with a subcutaneous injection of epinephrine. What effect should the nurse assure the anxious patient this will have? a. Cause vasodilation b. Produce bronchodilation c. Cause productive coughing d. Reduction of pulse rate

ANS: B The drug epinephrine is given in the case of anaphylaxis because it is a quick-acting drug that produces bronchodilation and vasoconstriction, which relieves respiratory distress. The drug can be ordered to be repeated every 20 minutes. The patient may experience an increase in heart rate. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1970 OBJ: 3 TOP: Anaphylaxis KEY: Nursing Process Step: Implementation

What would the nurse recommend for a 94-year-old home health patient with deteriorated cell-mediated immunity? a. Avoiding the influenza vaccine b. Getting pneumonia vaccine c. Having skin tests for all antigens d. Taking large doses of beta-carotene

ANS: B As the older adult loses some of the cell-mediated immunity, especially against pneumonia and influenza, it is recommended that they acquire the immunization. PTS: 1 DIF: Cognitive Level: Application REF: Page 1966 OBJ: 3 TOP: Age-related changes KEY: Nursing Process Step: Implementation

What timeframe must blood be transfused within once it has been removed from refrigeration? a. 2 hours b. 4 hours c. 6 hours d. 3 hours

ANS: B Blood must be administered within 4 hours after removal from refrigeration, and blood components within 6 hours of removal. PTS: 1 DIF: Cognitive Level: Application REF: Page 1972 OBJ: 9 TOP: Blood products KEY: Nursing Process Step: Planning

Once blood is removed from refrigeration, what is the length of time allotted for the blood to be transfused? a. 2 hours b. 4 hours c. 6 hours d. 3 hours

ANS: B Blood must be administered within 4 hours of refrigeration, and blood components within 6 hours of refrigeration. REF: Page 1965 TOP: Blood products Step: Planning

The nurse has held a unit conference on the specific immune response. Which statement by a colleague indicates an understanding of cell-mediated immune response? "Cell-mediated responses are a. directed from humorally mediated B cells." b. the direct attack of activated T-cell lymphocytes." c. from cells matured in the bone marrow." d. characterized by antigen-specific immunoglobulins."

ANS: B Cell-mediated immunity (the mechanism of acquired immunity characterized by the dominant role of small T cells) results when T cells are activated by an antigen. REF: Page 1958 TOP: Immune response

What is the major negative effect of cell-mediated immunity? a. Depression of bone marrow b. Rejection of transplanted tissue c. Activation of the T cells d. Stimulation of the B cells

ANS: B Cell-mediated immunity has the negative effect of rejection of transplanted tissue. Activation of T cells and stimulation of B cells are the positive basis of the cell-mediated immunity. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1965 OBJ: 3 TOP: Hypersensitivity KEY: Nursing Process Step: Implementation

When assessing the patient for hypersensitivity, the nurse should a. review the immunization history. b. discuss seasonal occurrence of signs and symptoms. c. evaluate nutritional status. d. observe the range of joint mobility.

ANS: B Common offenders include pollens, spores, dusts, food, drugs, and insect venoms. Many, but not all, offenders are seasonal in nature. REF: Page 1960, Box 55-4 TOP: Hypersensitivity

A cancer patient who has been receiving cytotoxic drugs has been having frequent sinus infections. During planning of his care, the nurse must remember that this frequency of infections is an indication of possible a. immunotherapy. b. drug-induced immunosuppression. c. delayed hypersensitivity. d. autoimmune disorder.

ANS: B Drug-induced immunosuppression is the most common type of secondary immunodeficiency disorder. Immunosuppression is a serious side effect of cytotoxic drugs used in cancer chemotherapy. REF: Page 1966 TOP: Immunosuppression Step: Planning

A patient comes to the emergency department with dyspnea, wheezing, and urticaria over the arms and face after being stung by a bee. The nurse would begin immediate care for this patient because he or she is having a(n) a. asthma attack. b. anaphylactic reaction. c. pulmonary embolism. d. acute psychotic episode.

ANS: B Fatal reactions are associated with a fall in blood pressure, laryngeal edema, and bronchospasm, leading to cardiovascular collapse, myocardial infarction, and respiratory failure. Early recognition of signs and symptoms and early treatment may prevent severe reactions and even death. REF: Page 1963 TOP: Anaphylactic reaction

A liver transplant patient is receiving azathioprine (Imuran). What nursing goal is critical for this patient? a. Maintain bed rest with minimal exertion. b. Minimize his risk for infection. c. Allow several visitors. d. Monitor vital signs every 15 minutes.

ANS: B Graft rejection is slowed through the use of chemical agents that interfere with the immune response process. Included are corticosteroids, cyclosporine (Neoral, Sandimmune), and azathioprine (Imuran). This chemical therapy is referred to as immunosuppressive (the administration of agents that significantly interfere with the ability of the immune system to respond to antigenic stimulation by inhibition of cellular and humoral immunity) therapy. REF: Page 1966 TOP: Transplant Step: Planning

Immediately after the nurse administers an intradermal injection of a suspected antigen during allergy testing, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially? a. Elevate the arm above the shoulder b. Administer subcutaneous epinephrine c. Apply a warm compress to area d. Apply a local anti-inflammatory cream to the site

ANS: B Injection of subcutaneous epinephrine should be given at the first sign of allergy. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1967 OBJ: 7 TOP: Anaphylactic reaction treatment KEY: Nursing Process Step: Implementation

Which sign and symptom is a sign of a mild reaction as a result of a blood transfusion? a. Vomiting b. Urticaria c. Diaphoresis d. Sore throat

ANS: B Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. REF: Page 1965 TOP: Blood transfusion

What is the purpose of plasmapheresis in the treatment of rheumatoid arthritis? a. To add corticosteroids to relieve pain b. To remove pathologic substances present in the plasma c. To remove waste products such as urea and albumin d. To add antinuclear antibodies

ANS: B Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1974 OBJ: 12 TOP: Plasmapheresis KEY: Nursing Process Step: Planning

A patient with rheumatoid arthritis is scheduled for plasmapheresis. She asks the nurse why they are going to do this procedure. In forming an answer the nurse must remember that the purpose of plasmapheresis is to a. add medication to relieve pain symptoms. b. remove plasma-containing components that may be causing the disease. c. remove waste products such as urea. d. add saline or albumin that lubricates joints.

ANS: B Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease. REF: Page 1967 TOP: Plasmapheresis Step: Planning

An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurse's first intervention? a. Apply cool compresses to urticaria b. Provide oxygen per non-rebreathing mask c. Cover patient with a warm blanket d. Prepare for venipuncture for the delivery of IV medication

ANS: B Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the patient may have to be intubated. Covering the patient with a warm blanket is not wrong, but not an initial intervention. PTS: 1 DIF: Cognitive Level: Application REF: Page 1971 OBJ: 6 TOP: Anaphylactic reaction KEY: Nursing Process Step: Implementation

In which patient should the nurse be most concerned about immunodeficiency disorder? a. The patient taking desensitization injections (immunotherapy) b. The patient on long-term radiation therapy for cancer c. The overweight patient d. The patient recently diagnosed with lupus erythematosus

ANS: B Radiation destroys lymphocytes and depletes the stem cells. Prolonged radiation depresses the bone marrow. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1974 OBJ: N/A TOP: Immunosuppression KEY: Nursing Process Step: Planning

A patient, age 28, is treated at the clinic with an injection of long-acting penicillin for a streptococcal throat infection. Her history reveals that she has received penicillin before with no allergic responses. When the penicillin injection is administered, which information should be given to the patient by the nurse? a. Because she has taken penicillin before without problems, she can safely take it now. b. She must wait in the clinic area for 20 minutes before she is discharged. c. She would have immediate symptoms if she had developed an allergy to penicillin. d. She should monitor for fever and skin rash typical of serum sickness after taking penicillin.

ANS: B The patient must always be observed for at least 20 minutes after administration, because hypersensitivity reaction or anaphylaxis may occur. REF: Page 1960 TOP: Medication

To provide examples of an active acquired immunity, the nurse uses the example of a person who has acquired immunity from measles because that person has had: (Select all that apply.) a. Chickenpox and mumps b. Measles c. An extremely healthy immune system d. An inoculation against measles e. Maternal antibodies against measles

ANS: B, D Active or acquired or adaptive immunity occurs from having had disease or having had an immunization against that specific disease. PTS: 1 DIF: Cognitive Level: Application REF: Pages 1963 Table 54-1 OBJ: 2 TOP: Acquired immunity KEY: Nursing Process Step: Implementation

The nurse outlines the functions of the immune system as those actions which: (Select all that apply.) a. Prevention of hemorrhage b. Protection of the body's internal environment c. Maintenance of hemoglobin level d. Maintenance of homeostasis by removing damaged cells e. Destruction of growth of abnormal cells

ANS: B, D, E The three main functions of the immune system are to protect the body's internal environment by destroying antigens and pathogens, maintenance of homeostasis by removing damaged cells, and the destruction of abnormal growth in the body. PTS: 1 DIF: Cognitive Level: Application REF: Page 1962 OBJ: N/A TOP: Purpose of immune system KEY: Nursing Process Step: Implementation

If a nurse is sensitive to latex gloves, what potential food sensitivities might the nurse develop? (Select all that apply.) a. Peanuts b. Avocados c. Milk d. Bananas e. Tomatoes f. Potatoes

ANS: B, D, E, F A person sensitive to latex may also be sensitive to certain foods, including avocados, kiwi, guava, bananas, water chestnuts, hazelnuts, tomatoes, potatoes, peaches, grapes, and apricots. REF: Page 1964 TOP: Latex allergy

A 25-year-old male patient with severe rhinitis asks the nurse what is causing his nose to run. The symptoms are caused by a reaction to a substance, usually a protein, that causes the formation of an antibody and reacts specifically with an antibody called a(n) a. proliferation. b. complement. c. antigen. d. lymphokine.

ANS: C An antigen is referred to as an allergen (a substance that can produce hypersensitive reaction in the body but is not necessarily inherently harmful) when symptoms of allergy occur. REF: Page 1958 TOP: Allergic reaction

What is B-cell proliferation dependent on? a. Presence of NK (natural killer) cells b. Complement system c. Antigen stimulation d. Lymphokines

ANS: C Antigen stimulation is the sole focus of B-cell proliferation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1964 OBJ: 3 TOP: B-cell proliferation KEY: Nursing Process Step: Implementation

A patient, age 47, is undergoing skin testing with intracutaneous injections on the forearm to identify allergens to which she is sensitive. Immediately after the nurse administers one of the injections, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially? a. Elevate the arm above the shoulder. b. Administer subcutaneous epinephrine. c. Give 0.2 to 0.5 mL of epinephrine 1:1,000 subcutaneously. d. Apply a local anti-inflammatory cream to the site.

ANS: C At the first sign of reaction, 0.2 to 0.5 mL of epinephrine 1:1,000 is given subcutaneously. REF: Page 1963 TOP: Anaphylactic reaction

Because the older adult has decreased production of saliva and gastric secretions, they are at risk for: a. mouth ulcers. b. fissures in corners of the mouth. c. gastrointestinal infections. d. bloating.

ANS: C Deficient saliva and gastric secretions make the older adult prone to gastrointestinal infections. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1968 OBJ: N/A TOP: Age-related changes KEY: Nursing Process Step: Planning

Which of the following is an example of immunocompetence? a. A child that is immune to measles because of an inoculation b. A person who has seasonal allergies every fall c. When the symptoms of a common cold disappear in 1 day d. A neonate having a natural immunity from maternal antibodies

ANS: C Immunocompetence is demonstrated by the immune system responding appropriately to a foreign stimulus and the body's integrity is maintained as with cold symptoms that resolve with residual illness. PTS: 1 DIF: Cognitive Level: Application REF: Page 1962 OBJ: 1 TOP: Immunocompetence KEY: Nursing Process Step: Implementation

A patient comes to the clinic for his weekly "allergy shot." He missed his appointment the week before because of a family emergency. Which action by the nurse is appropriate in administering his injection? a. Administer the usual dosage of the allergen. b. Double the dosage to account for the missed injection the previous week. c. Consult with the physician about decreasing the dosage for this injection. d. Reevaluate his sensitivity to the allergen with a skin test.

ANS: C Interrupted regimens may place the patient at risk for reaction. REF: Page 1960 TOP: Allergies Step: Planning

The nurse takes into consideration that when the antigen and antibody react, the complement system is activated which: a. toughens the cell wall. b. generates more T cells. c. attracts phagocytes. d. makes the antigen resistant.

ANS: C The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1966 OBJ: 3 TOP: Complement system KEY: Nursing Process Step: Implementation

How does normal aging change the immune system? a. Depresses bone marrow b. T cells become hyperactive c. B cells show deficiencies in activity d. Increase in the size of the thymus

ANS: C Normal aging causes deficiencies in both B and T cell activation, but the bone marrow is essentially uncompromised. The thymus decreases in size. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1966 OBJ: N/A TOP: Age-related changes KEY: Nursing Process Step: Planning

A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, what should the patient receive? a. Larger doses each week b. Higher concentrations each week c. Increased amounts and concentrations in 6-week cycles d. The same amount and concentration each visit

ANS: C Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better effect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1967 OBJ: N/A TOP: Immunotherapy KEY: Nursing Process Step: Planning

A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, she receives a. larger doses each week. b. higher concentrations each week. c. increased amounts and concentrations in 6-week cycles. d. the same amount and concentration each visit.

ANS: C Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better effect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period. REF: Pages 1960-1961 TOP: Immunotherapy

A patient has a history of allergic reactions to bee stings. Which actions should the nurse teach to avoid an anaphylactic reaction to bee stings? a. Limit intake of sweets to reduce attraction of bees. b. Carry a dose of aminophylline at all times. c. Take extra precautionary actions when outdoors where bees may be present. d. Wear a Medic-Alert tag that states the patient is allergic to bee stings.

ANS: C Teach the patient avoidance of allergens. REF: Page 1962 TOP: Anaphylactic reaction

Which is a factor that contributes to the extent of an allergic response to an allergen? a. The integrity of the skin b. The time of year in which one is exposed c. The amount of exposure d. Exposure to one's clothing

ANS: C The five factors influencing hypersensitivity response include host response to allergen, exposure amount, nature of the allergen, route of allergen entry, and repeated exposure. REF: Page 1961, Box 55-3 TOP: Hypersensitivity

What precautionary safety measure should the nurse take for a patient who is receiving first-time intradermal injections for allergy testing? a. Take vital signs every 15 minutes for 1 hour after the patient receives the injection. b. Remind the patient to call the physician if a rash develops. c. Have the patient remain for 20 minutes after the injection. d. Instruct the patient to take epinephrine if an allergic reaction occurs.

ANS: C The patient must always be observed for at least 20 minutes after administration, because hypersensitivity reaction or anaphylaxis may occur. REF: Page 1960 TOP: Medication

A patient who has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment? a. "I need to think about a change in my occupation." b. "I will learn to administer epinephrine so that I will be prepared if I am stung again." c. "I should wear a Medic-Alert bracelet indicating my allergy to insect stings." d. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."

ANS: D The nurse's responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance dosages of corticosteroids because this was a short, rapid reaction. REF: Pages 1964-1965 TOP: Allergic reaction Step: Evaluation

The nurse recommends to the busy mother of three that the antihistamine fexofenadine (Allegra) would be more beneficial than diphenhydramine (Benadryl) because Allegra: a. is inexpensive. b. contains a stimulant for an energy boost. c. does not dry out the mucous membranes. d. does not induce drowsiness.

ANS: D Allegra does not induce drowsiness as does Benadryl. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1969 OBJ: N/A TOP: Antihistamines KEY: Nursing Process Step: Implementation

After a bee sting, a patient's face becomes edematous and she begins to wheeze. Based on this assessment, the nurse would be prepared to administer: a. aminophylline. b. diphenhydramine (Benadryl). c. diazepam (Valium). d. epinephrine.

ANS: D At the first sign of reaction, 0.2 to 0.5 mL of epinephrine 1:1,000 is given subcutaneously. REF: Pages 1960, 1963 TOP: Allergic reaction

A patient has been admitted with pernicious anemia and has asked the nurse to tell him what type of disorder pernicious anemia is. The nurse tells him that it is an immune disorder that results from failures of the tolerance to one's "self." Responding immunologically to one's own antigens is called a(n) a. immunodeficiency disorder. b. hypersensitivity disorder. c. desensitization disorder. d. autoimmune disorder.

ANS: D Autoimmune disorders are failures of the tolerance to "self." Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish "self" protein from "foreign" protein. REF: Pages 1966-1967 TOP: Autoimmune disorders

What is the etiology of autoimmune diseases based on? a. Reaction to a "superantigen" b. Immune system producing no antibodies at all c. T cells destroying B cells d. B and T cells producing autoantibodies

ANS: D Autoimmune disorders are failures of the tolerance to "self." B and T cells produce autoantibodies that can cause pathophysiologic tissue damage. Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish "self" protein from "foreign" protein. PTS: 1 DIF: Cognitive Level: Application REF: Page 1974 OBJ: 1 TOP: Autoimmune disorders KEY: Nursing Process Step: Implementation

The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. What should be the nurse's initial action? a. Cover with a warm blanket b. Take the patient's temperature c. Elevate the head of the bed d. Stop the transfusion and continue with saline

ANS: D Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, and cough The initial intervention should be to stop the transfusion and continue with saline. Elevation of the head, taking vital signs, and covering with a warm blanket are not wrong, but are not of primary importance at this time. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1972 OBJ: 9 TOP: Blood transfusion KEY: Nursing Process Step: Implementation

The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. The next action for the nurse would be to a. leave and get help. b. take the patient's temperature. c. give him his nose spray. d. stop the transfusion and IV administer saline.

ANS: D Mild transfusion reactions signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. Treatment includes stopping the transfusion and administering saline. REF: Page 1965 TOP: Blood transfusion

Health care facilities have reduced the incidence of serious latex reactions by: a. Having local and injectable corticosteroids on hand for employees b. Desensitizing staff who are allergic c. Supplying extra handwashing stations in the halls d. Using only powder-free gloves

ANS: D Powder inside gloves can become aerosolized and cause inhalant reactions. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1971 OBJ: 8 TOP: Latex allergic reaction KEY: Nursing Process Step: N/A

Which person is most at risk for a hypersensitivity reaction? a. 26-year-old receiving his second desensitization injection b. 35-year-old starting back on birth control tablets c. The 52-year-old started on a new series of Pyridium for cystitis d. The 84-year-old receiving penicillin for an annually recurring respiratory infection

ANS: D The 84-year-old with the deteriorated immune system is a prime candidate for a delayed hypersensitivity reaction. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1960, Box 54-4 OBJ: 5 TOP: Delayed hypersensitivity KEY: Nursing Process Step: Assessment

A patient who works in a plant nursery and has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment? a. "I need to think about a change in my occupation." b. "I will learn to administer epinephrine so that I will be prepared if I am stung again." c. "I should wear a Medic-Alert bracelet indicating my allergy to insect stings." d. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."

ANS: D The nurse's responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance doses of corticosteroids because this was a short, rapid reaction. PTS: 1 DIF: Cognitive Level: Application REF: Page 1970 OBJ: 5 TOP: Allergic reaction KEY: Nursing Process Step: Evaluation

A patient is recovering from a kidney transplant. He is receiving cyclosporine after surgery. The purpose of this drug is to a. promote diuresis. b. prevent infection. c. manage pain. d. suppress the immune response.

ANS: D Tissue reaction does not occur immediately after transplantation. It takes several days for vascularization to occur. Seven to ten days after blood supply is adequately established, sensitized lymphocytes appear in sufficient numbers for sloughing to occur at the site. Graft rejection is slowed through the use of chemical agents that interfere with the immune response process. REF: Pages 1965-1966 TOP: Transplant

The nurse explains that when the patient received tetanus antitoxin with the antibodies in it, the patient received a type of immunity. a. Active natural b. Passive natural c. Active artificial d. Passive artificial

ANS: D When a person receives an inoculation of antibodies from another source, as with tetanus antitoxin, it is considered a passive artificial immunity. PTS: 1 DIF: Cognitive Level: Application REF: Page 1960, Box 54-1 OBJ: 2 TOP: Immunity KEY: Nursing Process Step: Implementation