143 Mod 4 - Hypersensitivity Reactions (PRACTICE QUESTIONS)

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? A) Hairdressers B) Unhoused people C) Children in day care centers D) Individuals living in a group home

A

A client develops and anaphylactic reaction after receiving morphine. The nurse would take which actions? Select all that apply. A) Administer oxygen B) Quickly assess the client's respiratory status C) Document the event, interventions, and client's response D) Leave the client briefly to contact a primary health care provider E) Keep the client supine regardless of the blood pressure readings F) Start an IV infusion of D5W and administer a 500-mL bolus

A, B, C.

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.

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. A) Use non latex gloves B) Use medications from glass ampules C) Place the client in a private room D) Keep a latex-safe supply cart available in the client's area E) Avoid the use of medication vials that have rubber stoppers F) Use only a blood pressure cuff from an electronic device to measure the blood pressure

A, B, D, E. If a client is allergic to latex and is at high risk for an allergic response, the nurse would use non-latex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with a rubber stopper that requires puncture with a needle. It is not necessary to place the client in a private room.

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. A) Record site, date, and time of the test. B) Give the client a list of potential allergens if identified C) Estimate the size of the wheal and document the finding D) Tell the client to return to have the site inspected only if there is a reaction E) Have the client wait in the waiting room for at least 1-2 hours after injection.

A, B.

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. List symptoms of peanut allergy. B. Food labels on baked items are the only labels that need to be read. C. Identify ways to manage allergy while dining out. D. Carry EpiPen autoinjector at all times. E. Wear a medic alert bracelet.

A, C, D, 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.

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and would incorporate which ation as a priority in the plan? A) Protecting the client from infection B) Providing emotional support to decrease fear C) Encouraging discussion about lifestyle changes D) Identifying factors that decreased the immune function

A.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? A) I need to take hot baths because they are relaxing B) I need to sit whenever possible to conserve my energy C) I need to avoid long periods of rest because it causes joint stiffness D) I need to do some exercises, such as walking, when I am not fatigued.

A.

The nurse is teaching a client about histamine release during an anaphylactic reaction. What does histamine release in anaphylaxis cause? A. nasal congestion B. urinary urgency C. stomach cramps D. feeling of impending doom

A. Histamine release causes sweating, sneezing, shortness of breath, and nasal congestion. Feelings of impending doom are related to activation of IgE and subsequent release of chemical mediators. Urinary urgency and stomach cramps occur from smooth muscle contractions of intestines and bladder.

The nurse is administering intravenous vancomycin. What will the nurse initially assess the client for if an allergic reaction occurs? A. dyspnea, bronchospasm, and/or laryngeal edema B. the presence and location of pruritus C. hypotension and tachycardia D. the severity of cutaneous warmth and flushing

A. Initial nursing assessment and intervention needs to be directed toward evaluating breathing and maintaining an open airway, so the initial assessment will be for dyspnea, bronchospasm, and laryngeal edema. Hypotension, pruritus, and flushing may occur, but the airway is most important.

A nurse comes to the employee health center for evaluation and is diagnosed with allergic contact dermatitis related to latex. What manifestation would the nurse most likely exhibit? A. Blistering B. Laryngeal edema C. Rhinitis D. Angioedema

A. Manifestations associated with allergic contact dermatitis related to latex include blisters, pruritus, erythema, swelling, and crusting or other skin lesions. Laryngeal edema, rhinitis, and angioedema would be noted with a latex allergy.

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. Jabs the autoinjector into the outer thigh at a 90-degree angle B. Maintains pressure on the auto-injector for about 30 seconds after insertion C. Avoids massaging the injection site after administration D. Pushes down on the grey release cap to administer the medication

A. 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 providing care for a client who has experienced a type I hypersensitivity reaction. Which client would have this type of reaction? A. A client 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. A client with rheumatoid arthritis

ANS: A Rationale: Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by immunoglobulin E 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 school nurse is caring for a 10-year-old who appears to be having an allergic response. Which intervention 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.

ANS: A Rationale: 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.

After the completion of testing, a 7-year-old client's allergies have been attributed to the family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote which action? A. Removing the cat from the family's home B. Administering over-the-counter antihistamines to the client regularly C. Keeping the cat restricted from the client's bedroom D. Maximizing airflow in the house

ANS: A Rationale: 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 client's bedroom. Avoidance therapy does not involve improving airflow or using antihistamines.

A client with a family history of allergies has experienced an allergic response based on a genetic predisposition. This atopic response is usually mediated by which immunoglobulin (Ig)? A. IgA B. IgM C. IgG D. IgE

ANS: D Rationale: Atopy refers to allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions. IgE (0.004% of total Ig) appears in serum; takes part in allergic and some hypersensitivity reactions; and combats parasitic infections. IgA (15% of total Ig) appears in body fluids (blood, saliva, tears, and breast milk, as well as pulmonary, gastrointestinal, prostatic, and vaginal secretions); protects against respiratory, gastrointestinal, and genitourinary infections; prevents absorption of antigens from food; and passes to neonate in breast milk for protection. IgM (10% of total Ig) appears mostly in intravascular serum; appears as the first Ig produced in response to bacterial and viral infections; and activates the complement system. IgG (75% of total Ig) appears in serum and tissues (interstitial fluid); assumes a major role in bloodborne and tissue infections; activates the complement system; enhances phagocytosis; and crosses the placenta.

The nurse is providing care for a client who has a diagnosis of hereditary angioedema. When planning this client's care, what nursing diagnosis should be prioritized? A. Risk for infection related to skin sloughing B. Risk for acute pain related to loss of skin integrity C. Risk for impaired skin integrity related to cutaneous lesions D. Risk for impaired gas exchange related to airway obstruction

ANS: D Rationale: Edema of the respiratory tract can compromise the airway in clients with hereditary angioedema. As such, this is a priority nursing diagnosis over pain and possible infection. Skin integrity is not threatened by angioedema.

The nurse is providing health education to the parents of a 3-year-old who has been diagnosed with food allergies. Which statement should the nurse make when teaching this family about the child's health problem? A. Food allergies are a lifelong condition, but most families adjust well to the necessary lifestyle changes. B. Consistent use of over-the-counter antihistamines can often help a child overcome food allergies. C. Make sure that you carry a steroid inhaler with you at all times, especially when you eat in restaurants. D. Many children outgrow their food allergies in a few years if they avoid the offending foods.

ANS: D Rationale: Many food allergies disappear with time, particularly in children. About one third of proven allergies disappear in 1 to 2 years if the client carefully avoids the offending food. Antihistamines do not cure allergies, and an EpiPen is carried for clients with food allergies, not a steroid inhaler.

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.

ANS: D Rationale: 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.

A patient tells the nurse that he had a tuberculin test several months ago, and the site of injection became very red and inflamed. How should the nurse interpret this information? 1. This Arthus reaction is common with tuberculin tests. 2. This type IV hypersensitivity response indicates the tuberculin test was positive. 3. Since this type II hypersensitivity response occurred, the patient should never have another tuberculin test. 4. The patient will require chest x-ray confirmation of this type I hypersensitivity response.

Answer: 2 Explanation: 1. An Arthus reaction is a localized skin reaction in which antigen-antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. Tuberculin testing does not result in Arthus reaction. 2. A type IV hypersensitivity response is seen in the induration of a positive tuberculin test. 3. This is not a type II hypersensitivity response. 4. This is not a type I hypersensitivity response.

A patient receiving a blood transfusion reports nausea and back pain 10 minutes into the transfusion. The nurse realizes the patient is experiencing which type of hypersensitivity response? 1. Type I 2. Type III 3. Type IV 4. Type II

Answer: 4 Explanation: 1. A type I hypersensitivity response occurs after repeated exposure to an allergen that causes an allergen-antigen response. 2. A type III hypersensitivity response is also an allergen-antigen response; however, the complexes are found in tissues. Organ rejection is an example of this type of response. 3. A type IV hypersensitivity response is a delayed response seen after an insect bite or with poison ivy. 4. A hemolytic transfusion reaction is a major example of a type II hypersensitivity response. The reaction will occur within minutes of beginning the transfusion and is an emergency.

A client calls the nurse in the emergency department and reports being just stung by a bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction a week ago. Which action would the nurse take? A) Advise the client to soak the site in hydrogen peroxide B) Ask the client if they've ever sustained a bee sting in the past C) Tell the client to call an ambulance for transport to the emergency department D) Tell the client not to worry about the sting unless difficulty with breathing occurs

B

A client has been transported to the emergency department 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 client's oxygen saturation by oximeter. D. Monitor the client's respiratory pattern. E. Assess the client'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 client presents at the clinic with an allergic disorder. The client asks the nurse what an allergic disorder means. What would be the nurse's best response? A. It means you are very sensitive to something inside of yourself. B. It is a hyperimmune response to something in the environment that is usually harmless. C. It is a harmless reaction to something in the environment. D. It is a muted response to something in the environment.

B. An allergic disorder is characterized by a hyperimmune response to weak antigens that usually are harmless. The antigens that can cause an allergic response are called allergens.

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. skin reactions. B. route of exposure. C. respiratory symptoms. D. systemic effects.

B. 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.

Which intervention is the single most important aspect for the client at risk for anaphylaxis? A. Use of antihistamines B. Prevention C. Desensitization D. Wearing a medical alert bracelet

B. Prevention involves strict avoidance of potential allergens for the individual at risk for anaphylaxis. If avoidance of or exposure to allergens is impossible then the individual should be prepared with 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. antihistamines may not be effective in preventing anaphylaxis.

Which of the following is the most frequent route of exposure to a latex allergy? A. Parenteral B. Cutaneous C. Mucosal D. Inhalation

B. Routes of exposure to latex products can be cutaneous, percutaneous, mucosal, parenteral, or aerosol. Allergic reactions are more likely with parenteral or mucous membrane exposure but can also occur with cutaneous contact or inhalation. The most frequent source of exposure is cutaneous, which usually involves the wearing of natural latex gloves.

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. pitting edema. B. angioneurotic edema. C. contact dermatitis. D. urticaria.

B. 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.

The nurse is working with a client with allergies. What will the nurse use to confirm allergies and decrease the risk of anaphylaxis? A. nasal smear B. intradermal testing C. punch biopsy D. peripheral blood smears

B. The diagnosis of anaphylaxis risk is determined by prick and intradermal skin testing. Skin testing of patients who have clinical symptoms consistent with a type I, IgE-mediated reaction has been recommended. A nasal smear, punch biopsy, and peripheral blood smear would not be used for allergy testing.

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 IV B. type I C. type III D. type II

B. 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.

The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution? A. Intravenous B. Subcutaneous C. Intradermal D. Intramuscular

C, The intradermal route is the correct route of administration for skin testing and therefore a safe route. Another safe route is epicutaneous. The type of skin testing being performed determines whether the nurse will administer the solution via the epicutaneous or intradermal route.

A client is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurse's priority for care? A. Provide psychosocial support. B. Administer medications as prescribed. C. Protect the client's airway. D. Monitor the client's level of consciousness (LOC).

C. Anaphylaxis severely threatens a client's airway; the nurse's priority is preserving airway patency and breathing pattern. This is a higher priority than other valid aspects of care, including medication administration, psychosocial support, and assessment of LOC.

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 IV B. type III C. type I D. type II

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

What type of hypersensitivity reaction is exhibited by a client that has been diagnosed with rheumatoid arthritis? A) Type I reaction B) Type II reaction C) Type III reaction D) Type IV reaction

C. Hypersensitivity reactions are immune responses that are exaggerated or inappropriate against an antigen or allergen. In a type III reaction, excess antigens cause immune complexes to form in the blood. These can precipitate in various tissues, such as skin, kidneys, joints, and the small blood vessels. These immune complexes that are deposited trigger inflammation resulting in damage to the tissue or vessel. Examples of type III reaction include: rheumatoid arthritis, systemic lupus erythematosus, and glomerulonephritis.

Which type of hypersensitivity reaction involves immune complexes forming when antigens bind to antibodies? A. Type I B. Type II C. Type III D. Type IV

C. Type III hypersensitivity is associated with systemic lupus erythematosus, rheumatoid arthritis, serum sickness, certain types of nephritis, and some types of bacterial endocarditis. Type I, or anaphylactic hypersensitivity, is an immediate reaction, beginning within minutes of exposure to an antigen. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Type IV, or delayed-type, hypersensitivity occurs 24 to 72 hours after exposure to an allergen.

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse would question the client about an allergy to which food item? A) Eggs B) Milk C) Yogurt D) Bananas

D.

The nurse is teaching a group of health care workers about latex allergies. What reaction will the nurse teach the workers to be most concerned about with laryngeal edema? A. IgG antibodies B. allergic contact C. irritant contact D. IgE-mediated hypersensitivity

D. A type I, IgE-mediated hypersensitivity can cause severe reaction symptoms such as laryngeal edema and bronchospasm. Irritant and allergic contact dermatitis result in more localized skin reactions. IgG antibodies are important in fighting viral and bacterial infections.

What statement made by the student best explains type II reaction, as with a hemolytic blood transfusion? A) The body develops inflammation to excess antigens that cause immune complexes to form. B) The body responds hours to days after the exposure by the release of sensitized T-cells. C) The body responds within minutes to the antigen due to a previous exposure. D) The body makes special autoantibodies directed against self cells.

D. Hypersensitivity reactions are immune responses that are exaggerated or inappropriate against an antigen or allergen. In type II reaction, the body makes special autoantibodies directly against self cells. These self cells have a foreign protein attached to it. These autoantibodies attach to the self cells and form an immune complex. This results in the destruction of the self cells and the attached foreign protein. Examples of type II reaction include: hemolytic anemia, thrombocytopenic purpura, and hemolytic transfusion reaction (receiving the wrong blood type).

The nurse knows the best strategy for latex allergy is A. antihistamines. B. corticosteroids. C. epinephrine from an emergency kit. D. avoidance of latex-based products.

D. 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.

Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle? A. Serotonin B. Bradykinin C. Prostaglandin D. Histamine

D. 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.

An office worker eats a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger, and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed-type (type IV)

ANS: A Rationale: The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.

A 5-year-old client has been diagnosed with a severe food allergy. Which instruction should the nurse include when educating the parents about this client's allergy and care? A. Wear a medical identification bracelet. B. Know how to use the antihistamine pen. C. Know how to give injections of lidocaine. D. Avoid live attenuated vaccinations.

ANS: A Rationale: The nurse also advises the parents to have the client wear a medical identification bracelet and to be able to identify symptoms of food allergy. Clients and their families do not carry antihistamine pens, they carry epinephrine pens. Lidocaine is not self-administered to treat allergies. The client may safely be vaccinated.

A nurse has asked the nurse educator if there is any way to predict the severity of a client's anaphylactic reaction. Which response by the nurse educator would be best? A. The faster the onset of symptoms, the more severe the reaction. B. The reaction will be about one-third more severe than the client's last reaction to the same antigen. C. There is no way to gauge the severity of a client's anaphylaxis, even if it has occurred repeatedly in the past. D. The reaction will generally be slightly less severe than the last reaction to the same antigen.

ANS: A Rationale: The time from exposure to the antigen to onset of symptoms is a good indicator of the severity of the reaction: the faster the onset, the more severe the reaction. None of the other statements is an accurate description of the course of anaphylactic reactions.

A junior nursing student is having an observation day in the operating room. Early in the day, the student reports eye swelling and dyspnea to the OR nurse. What should the nurse suspect? A. Cytotoxic reaction due to contact with the powder in the gloves B. Immune complex reaction due to contact with anesthetic gases C. Anaphylaxis due to a latex allergy D. Delayed reaction due to exposure to cleaning products

ANS: C Rationale: Immediate hypersensitivity to latex, a type I allergic reaction, is mediated by the IgE mast cell system. Symptoms can include rhinitis, conjunctivitis, asthma, and anaphylaxis. The term latex allergy is usually used to describe the type I reaction. The rapid onset is not consistent with a cytotoxic reaction, an immune complex reaction, or a delayed reaction.

A client is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. Which food items would the nurse inform the client are common allergens? A. Citrus fruits and rice B. Root vegetables and tomatoes C. Eggs and wheat D. Hard cheeses and vegetable oils

ANS: C Rationale: The most common food allergens are seafood (lobster, shrimp, crab, clams, fin fish), peanuts, tree nuts, eggs, wheat, milk, and soy. Citrus fruits, rice, root vegetables, tomatoes, hard cheeses, and vegetable oils are not common allergens.

A nurse should prioritize and closely monitor a client for a potentially severe anaphylactic reaction after the client has received which medical intervention? A. Measles-mumps-rubella vaccine B. Rapid administration of intravenous fluids C. Computed tomography with contrast solution D. Nebulized bronchodilator

ANS: C Rationale: The most severe anaphylaxis, sometimes referred to as anaphylactic shock, is caused by antibiotics and radiocontrast agents. The computed tomography scan with contrast dye uses these agents. Vaccines can produce an anaphylactic reaction but are usually localized and not severe. Intravenous fluid and bronchodilators may be used to manage anaphylaxis in clients with symptoms of bronchospasm or hypotension, but they are not typically associated with triggering anaphylactic shock themselves.

A client has sought care, stating that the client developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the client developed? A. Type I B. Type II C. Type III D. Type IV

ANS: A Rationale: Type I hypersensitivity reactions are unanticipated severe allergic reactions that are rapid in onset, characterized by edema in many tissues, including the larynx, and often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Urticaria (hives) is a type I hypersensitive allergic reaction of the skin that is characterized by the sudden appearance of intensely pruritic pink or red discrete papules that progress to wheals of variable size. Type II, or cytotoxic, hypersensitivity reactions occur when antibodies are directed against antigens on cells or basement membranes of tissues. Examples of type II reactions are myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction, and thrombocytopenia. Type III, or immune complex, hypersensitivity reactions are damaging inflammatory reactions caused by the insoluble immune complexes formed by antigens that bind to antibodies. Examples of type III reactions include systemic lupus erythematosus, serum sickness, nephritis, and rheumatoid arthritis. Type IV, or delayed, hypersensitivity reactions are T cell-mediated immune reactions that typically occur 24 to 48 hours after exposure to an antigen. Examples of type IV reactions include contact dermatitis, graft-versus-host disease, Hashimoto's thyroiditis, and sarcoidosis.

A client has been brought to the emergency department after being found unresponsive, and anaphylaxis is suspected. The care team should attempt to assess for which potential causes of anaphylaxis? Select all that apply. A. Foods B. Medications C. Insect stings D. Autoimmunity E. Environmental pollutants

ANS: A, B, C Rationale: Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities.

A client is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the client begins to exhibit signs and symptoms of a transfusion reaction. The client is suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed type (type IV)

ANS: B Rationale: A type II hypersensitivity reaction resulting in red blood cell destruction is associated with blood transfusions. This type of reaction does not result from types I, III, or IV reactions.

DELETE

ANS: B Rationale: 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 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

ANS: B Rationale: 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 client 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 explains that the client should self-administer epinephrine at which site? A. Forearm B. Thigh C. Deltoid muscle D. Abdomen

ANS: B Rationale: 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 muscle of the lateral thigh is the best site to administer epinephrine because it is one of the largest muscles in the body and has significant blood flow, which allows more rapid absorption of the medication than in the smaller muscles in the forearm or shoulder (deltoid) or subcutaneously in the abdomen.

A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a client's plan of care. The presence of which chronic health problem would most likely prompt this diagnosis? A. Herpes simplex B. Human immunodeficiency virus (HIV) C. Spina bifida D. Hypogammaglobulinemia

ANS: C Rationale: Clients with spina bifida are at a particularly high risk for developing a latex allergy. Clients with spina bifida are at high risk because they have had multiple surgeries, multiple urinary catheterization procedures, and other treatments involving use of latex products, and latex allergy develops as a result of repeated exposure to the proteins and polypeptides in natural rubber latex. Clients with herpes simplex, HIV, or hypogammaglobulinemia (decreased level of gamma immunoglobulins) are less likely than clients with spina bifida to have as many surgeries or other treatments that would expose them to latex.

A client has presented with signs and symptoms that are consistent with contact dermatitis. Which aspect of care should the nurse prioritize when working with this client? A. Promoting adequate perfusion in affected regions B. Promoting safe use of topical antihistamines C. Identifying the offending agent, if possible D. Teaching the client to safely use an EpiPen

ANS: C Rationale: Identifying the offending agent is a priority in the care of a client with dermatitis. This provides a cure via removal of the offending agent, rather than being limited to treating the symptoms. Topical antihistamines can provide some relief from itching, especially with allergic dermatitis, but identifying and removing the offending agent takes is a higher priority, as it would allow the client to not need to use a topical antihistamine. An epinephrine auto injector (EpiPen) is typically used to treat anaphylaxis, not contact dermatitis. Inadequate perfusion occurs with peripheral artery disease or vasoconstriction but is not associated with contact dermatitis.