Ch. 20 Care of Patients with Immune Function Excess: Hypersensitivity and Autoimmunity
When preparing a client for allergy testing, the nurse provides the client with which instruction? "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." "It is okay to use your fluticasone propionate (Flonase) nasal spray before testing." "Aspirin in a low dose may be taken before testing." "You can take antihistamine nasal sprays before testing."
"Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." **The nurse should tell the client that, "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." Systemic glucocorticoids and antihistamines are discontinued 2 weeks before the test for this reason.Nasal sprays like fluticasone propionate (Flonase) to reduce mucous membrane swelling are permitted, except for sprays that contain an antihistamine. Allergists recommend that aspirin be withheld before testing.
The nurse is reviewing discharge teaching with a client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching? "I must wear a medical alert bracelet stating that I am allergic to bee stings." "I need to carry epinephrine with me." "My spouse must learn how to give me an injection." "I am immune to bee stings now that I have had a reaction."
"I am immune to bee stings now that I have had a reaction." **More teaching is needed if the client states, "I am immune to bee stings now that I have had a reaction." No immunity develops after an anaphylactic reaction. In fact, the next reaction could be more severe.The client should carry epinephrine (EpiPen) at all times and always wear a medical alert bracelet that states all allergies. Someone (spouse, neighbor, or family member) must learn how to give the client an injection in case the client is unable to self-administer the injection.
The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity? "It is a reaction of immunoglobulin G (IgG) with the host cell membrane or antigen." "The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." "It results in release of mediators, especially histamine, because of the reaction of immunoglobulin E (IgE) antibody on mast cells." "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels."
"The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." **The best statement by the student describing type IV hypersensitivity reaction is that the reaction of sensitized T cells with antigen and release of lymphokines is a delayed hypersensitivity reaction, as is seen with poison ivy (type IV hypersensitivity).A reaction of IgG with the host cell membrane or antigen describes a type II hypersensitivity reaction. A release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells describes a type I hypersensitivity reaction. An immune complex of antigen and antibodies deposited in the walls of blood vessels describes a type III hypersensitivity reaction.
Psychological Integrity
* Explain all diagnostic procedures, restrictions, and follow-up care to the pt. scheduled for tests related to hypersensitivities *stay with the pt in anaphylaxis *reassure pts who are in anaphylaxis that the appropriate interventions are being instituted
Physiological Integrity
*Identify pts at risk for hypersensitivity reactions, especially anaphylaxis *Communicate a pt's allergies to all members of the interprofessional health care team *Immediately assess the respiratory status and airway of pts who show any symptoms of an allergic reaction *Immediately discontinue the IV drug or solution of a pt having an anaphylactic reaction to that drug or solution. DO NOT discontinue the IV, but change the IV tubing and hang normal saline *Hold the dose of any prescribed drug when a pt develops angioedema *Give oxygen to any pt in anaphylaxis
Safe and Effective Care Environment
*ensure only latex-free products are used for a patient who has a known latex allergy *verify that all allergies are documented in a prominent place in the pt's MAR or EHR *Keep emergency equipment and drugs in or near the room of a pt. with known sever allergies or hx of anaphylaxis *Teach pts to remove common allergens from the home or avoid direct contact with them
The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. Zafirlukast works by which mechanism? Blocking histamine from binding to receptors Preventing synthesis of mediators Preventing mast cell membranes from opening Blocking the leukotriene receptor
Blocking the leukotriene receptor **Zafirlukast is a leukotriene antagonist that works by preventing the occurrence of allergic rhinitis by blocking the leukotriene receptor.Zafirlukast is not an antihistamine. Antihistamines such as diphenhydramine (Benadryl) block histamines from binding to receptors. Zafirlukast is not a corticosteroid. Corticosteroids prevent synthesis of mediators. Mast cell-stabilizing drugs such as cromolyn sodium (Nasalcrom) prevent mast cell membranes from opening when an allergen binds to immunoglobulin E; zafirlukast is not a mast cell-stabilizing drug.
The nurse plans to assess a client with type I hypersensitivity for which clinical manifestation? Poison ivy Autoimmune hemolytic anemia Allergic asthma Rheumatoid arthritis
Allergic asthma **Allergic asthma is a clinical manifestation of type I hypersensitivity.Poison ivy is a type IV delayed mechanism of hypersensitivity. Autoimmune hemolytic anemia is a type II cytotoxic mechanism of hypersensitivity. Rheumatoid arthritis is a type III immune complex-mediated mechanism of hypersensitivity.
An alert, middle-aged client is admitted to the emergency department with wheezing, difficulty breathing, angioedema, blood pressure of 70/52 mm Hg, and apical pulse of 122 beats/min and irregular. The nurse makes an immediate assessment using the "ABCs" for any client experiencing anaphylaxis. What nursing intervention is the immediate priority? Raise the lower extremities. Start intravenous (IV) administration of normal saline. Reassure the client that appropriate interventions are being instituted. Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.
Apply oxygen using a high-flow non-rebreather mask at 40% to 60%. **The most immediate priority is for the nurse to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Assessing respiratory status is the most important assessment priority.Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.
Immunosuppesnt problems
Decrease immunity, so increase risk of infection -avoid crowds and ill people -notify doctor at first sign of infection
A client who is receiving an intravenous antibiotic begins to cough and states, "My throat feels like it is swelling." Which action does the nurse take next? Infuse normal saline at 200 mL/hr. Administer epinephrine (Adrenalin) 1:1000, 0.3 mL subcutaneously. Discontinue infusing the antibiotic. Give diphenhydramine (Benadryl) 100 mg IV.
Discontinue infusing the antibiotic. **The nurse's first action should be to discontinue the antibiotic. The antibiotic is the most likely cause of the client's apparent anaphylactic reaction.Infusing normal saline and administering epinephrine and diphenhydramine may be indicated, but these are not the nurse's first action.
A client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? Epinephrine (Adrenalin) Fexofenadine (Allegra) Cromolyn sodium (Nasalcrom) Zileuton (Zyflo)
Epinephrine (Adrenalin) **The most appropriate drug for the nurse to give in this situation is epinephrine (Adrenalin). The client is experiencing an anaphylactic reaction, and epinephrine is a first-line sympathomimetic drug used to treat anaphylaxis.Fexofenadine (Allegra) is a nonsedating antihistamine and is not a first-line drug to treat anaphylaxis. Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug used to prevent symptoms of allergic rhinitis. It is not useful during an acute episode. Zileuton (Zyflo) is a leukotriene antagonist also used to prevent symptoms of allergic rhinitis, but is also not useful during an acute episode.
A client is prescribed prednisone for treatment of a type I hypersensitivity reaction. The nurse plans to monitor the client for which adverse effects? Select all that apply. Fluid retention Gastric distress Hypotension Infection Osteoporosis
Fluid retention Gastric distress Infection Osteoporosis **Prednisone is a corticosteroid that may cause fluid and sodium retention. It can cause gastric distress and irritation and usually is taken with food or an antacid. Prednisone decreases the immune response, increasing the susceptibility for infection. It can also cause osteoporosis.Hypertension (not hypotension) is an adverse effect of prednisone.
A client has been ordered norepinephrine (Levophed) for treatment of severe hypotension. The nurse plans to monitor the client for which adverse effect? Bradycardia Headache Infection Metabolic alkalosis
Headache **A client complaint of a headache is an adverse effect of norepinephrine (Levophed). This drug is a vasopressor and can cause headache.Norepinephrine does not suppress the immune system. Tachycardia, not bradycardia, and metabolic acidosis, not alkalosis, are adverse effects of norepinephrine.
The nurse is reviewing the medical record of a client who is prescribed a decongestant. The nurse plans to contact the client's health care provider if the client has which condition? Cataracts Crohn's disease Diabetes mellitus Hypertension
Hypertension **The health care professional should be notified if the client has hypertension because decongestants have actions similar to adrenergic drugs, causing vasoconstriction and increasing blood pressure.Decongestants are not contraindicated in clients with cataracts, Crohn's disease, or diabetes mellitus.
Antiproliferative problem
Poor pregnancy outcomes -2 forms of reliable contraception
A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? Anxiety Urticaria Pruritus Stridor
Stridor **The symptom that requires the most immediate action by the nurse is stridor which indicates airway involvement and warrants immediate intervention, such as use of oxygen and administration of epinephrine. Maintaining the client's airway is the highest priority.Anxiety, urticaria, and pruritus may be symptoms of a reaction, but are not the nurse's highest priority when the client is in respiratory distress.
The client with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed? Cromolyn sodium (Nasalcrom) Desloratadine (Clarinex) Fexofenadine (Allegra) Zafirlukast (Accolate)
Zafirlukast (Accolate) **The nurse anticipates that zafirlukast (Accolate) will be prescribed. Zafirlukast is a leukotriene receptor antagonist; it works by blocking the leukotriene receptor and is used to prevent allergic rhinitis.Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug. Desloratadine (Clarinex) and fexofenadine (Allegra) are nonsedating antihistamines.
cross-sensitivity to latex
Bananas, kiwis, avocados, nuts
Health Promotion and Maintenance
*urge all pts with severe allergies or those who have a hx of anaphylaxis to wear a medical alert bracelet *teach pt and family about symptoms of allergic reactions and when to seek medical help *teach pt who has known drug allergy about which other drugs are likely to stimulate the same reactions *teach the pt who carries an automatic epinephrine injector how to care for, assemble, and use device. Obtain a return demonstration.
The nurse is assessing a client with suspected serum sickness. Which symptoms are consistent with serum sickness? Select all that apply. Arthralgia Blurred vision Lymphadenopathy Malaise Ptosis
Arthralgia Lymphadenopathy Malaise **Serum sickness is a group of symptoms that occur after receiving serum or certain drugs. Symptoms include arthralgia (achy joints), lymphadenopathy (enlarged lymph nodes), fever, rash, malaise, and possibly polyarthritis and nephritis.Blurred vision and ptosis are not symptoms of serum sickness.
What a nurse should do when pt. getting a scratch test
Ask client about previous reactions to allergens Ask client about meds taken in the past several days Inform pt to expect itching at one site Obtain emergency resuscitation equipment
Assessment findings reveal that a client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client? "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." "It is okay to use your fluticasone propionate (Flonase) nasal spray before testing." "Aspirin in a low dose may be taken before testing." "You can take antihistamine nasal sprays before testing."
Communicate the need for avoidance therapy to the health care team. **The best nursing action is to communicate the need for avoidance therapy to the health care team. Contact hypersensitivities can occur with latex, pollens, foods, and environmental proteins.Desensitization therapy is administered via allergy shots when allergens have been identified and cannot easily be avoided. Discussing the need for pharmacologic therapy might be indicated if signs of type I or type IV hypersensitivity exist, but this is not a preventive measure. Symptomatic therapy interventions such as an epinephrine pen, antihistamines, and corticosteroids are not preventive but are effective only after the hypersensitivity reaction has already occurred.
A client is admitted to the hospital with suspected Goodpasture's syndrome. Which findings does the nurse expect to observe? Bradycardia Hemoptysis Increased urine output Weight gain
Hemoptysis **Hemoptysis (bloody sputum) is a manifestation of Goodpasture's syndrome. Goodpasture's syndrome usually is not diagnosed until serious lung and kidney problems are present.Tachycardia and not bradycardia, decreased and not increased urine output, and weight loss and not weight gain are manifestations of Goodpasture's syndrome.
Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? Plan the schedule for desensitization therapy for a client with allergies. Monitor the client who has just received skin testing for signs of anaphylaxis. Educate a client with a latex allergy about other substances with cross-sensitivity to latex. Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.
Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing. **The most appropriate action for the allergy clinic nurse to delegate to a nursing assistant is to remind the client about safety policies. This is within the scope of practice of a nursing assistant.Planning care and assessing for complications require broader education and scope of practice and should be done by the registered nurse. Client education is a registered nursing responsibility, requiring broader education and scope of practice.
A client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client's discharge teaching plan? Wash fruits and vegetables with mild soap and water before eating. Intermittent exposure to known allergens will produce immunity. Remove cloth drapes, carpeting, and upholstered furniture. Be cautious when eating unprocessed honey.
Remove cloth drapes, carpeting, and upholstered furniture. **The most important discharge instruction to give this client is to remove cloth drapes, carpet, and upholstery in order to reduce airborne pollen, dust mites, and mold.Washing fruits and vegetables pertains to food allergies. Clients do not develop immunity to known allergens by direct intermittent exposure. Some common interventions include avoidance therapy, desensitization therapy, and symptomatic therapy. Honey is said to help some people with allergies to pollen only; it does not have an impact on airborne allergens.
A client recently admitted to the hospital with a UTI is to receive the first dose of an antibiotic intravenously. Before checking the five rights prior to administration, what is the nurse's first action? Review the clinical records and ask the client about any known allergies. Check with the pharmacy for any known allergies for this client. Check the client's identification band for any allergies. Ask the nurse who previously cared for the client about any known allergies.
Review the clinical records and ask the client about any known allergies. **The nurse's first action is to check the client's clinical record for any known hypersensitivities as well as asking the client about any known allergies.The pharmacy is not responsible for obtaining information on all of the client's known allergies. Checking the client's identification band for allergies is part of the "five rights" process at the bedside before the medication is given. Asking the previous nurse is not an appropriate safety measure before medication administration.
