ch 13 Immune Responses

symptoms of anaphylactic shock: respiratory (5)

-dyspnea -hoarseness -coughing -wheezing -tachypnea

drugs for anaphylactic reaction (2)

-epinephrine -diphenhydramine (Benadryl)

symptoms of anaphylactic shock: CNS (3)

-headache -dizziness -feeling of impending doom

symptoms of anaphylactic shock: cardiovascular (4)

-hypotension -rapid, weak pulse -tachycardia -dysrhythmias

symptoms of anaphylactic shock: integumentary (3)

-pruritus (itching) -urticaria -angioedema

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? (Select all that apply) 1. administer oxygen 2. quickly assess the client's respiratory status 3. document the event, interventions, and client's response 4. leave the client briefly to contact a health care provider 5. keep the client supine regardless of the blood pressure readings 6. start an IV infusion of D5W and administer a 500-mL bolus

1. administer oxygen 2. quickly assess the client's respiratory status 3. document the event, interventions, and client's response NCLEX

A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reactions because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? 1. advise the client to soak the site in hydrogen peroxide 2. ask the client if he ever sustained a bee sting in the past 3. tell the client to call an ambulance for transport to the emergency department 4. tell the client not to worry about the sting unless difficulty with breathing occurs

2. ask the client if he ever sustained a bee sting in the past (in some types of allergies, a reaction occurs only on the second and subsequent contacts with the allergen) NCLEX

The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action? a. Administer IV diphenhydramine. b. Administer nitroprusside as soon as possible. c. Anticipate tracheostomy with laryngeal edema. d. Place the patient recumbent and elevate the legs.

d. Place the patient recumbent and elevate the legs. (to treat hypotension) MS

Which T lymphocytes are involved in direct attack and destruction of foreign pathogens? a. dendritic cells b. natural killer cells c. T helper (CD4) cells d. T cytotoxic (CD8) cells

d. T cytotoxic (CD8) cells workbook

The nurse is alerted to possible anaphylactic shock immediately after a pt has received IM penicillin by the development of: a. edema and itching at the injection site b. sneezing and itching of the nose and eyes c. a wheal-and-flare reaction at the injection site d. chest tightness and production of thick sputum

a. edema and itching at the injection site MS

A pt was given an IM injection of penicillin in the gluteus maximus and developed dyspnea and weakness within minutes following the injection. Which additional assessment findings indicate that the pt is having an anaphylactic reaction? (Select all that apply) a. wheezing b. hypertension c. rash on arms d. constricted pupils e. slowed strong pulse f. feeling of impending doom

a. wheezing f. feeling of impending doom other common anaphylactic responses: -hypotension -dilated pupils -rapid, weak pulse -edema and itching at injection site workbook

The pt is admitted from a nearby park with an apparent anaphylactic reaction to a bee sting. He is experiencing dyspnea and hypotension with swelling at the site. Number the following in the order of priority that the nurse should implement the actions for this pt: a. remove the stinger b. ensure a patent airway c. prepare to administer epinephrine d. start IV fluid and medication access e. anticipate intubation with severe respiratory distress f. have diphenhydramine (Benadryl) and nebulized albuterol available

b, e, a, d, c, f 1. b. ensure a patent airway 2. e. anticipate intubation with severe respiratory distress 3. a. remove the stinger 4. d. start IV fluid and medication access 5. c. prepare to administer epinephrine 6. f. have diphenhydramine (Benadryl) and nebulized albuterol available workbook

A patient being tested for multiple allergies develops localized redness and swelling in reaction to a patch skin test. Which intervention by the nurse would have the highest priority? a. Notify the health care provider. b. Administer oral diphenhydramine. c. Apply a topical antiinflammatory cream. d. Remove the patch and extract from the skin.

d. Remove the patch and extract from the skin. MS

initial symptoms of an anaphylactic reaction

edema and itching at the site of exposure to the allergen