Chapter 20: Coordinating Care for Patients with Immune Disorders. RE

12. The nurse is providing care to a patient with psoriasis. Which medication should the nurse prepare to teach this patient about based on the diagnosis? 1) Epinephrine 2) Azathioprine 3) Cyclosporine 4) Mycophenolate mofetil

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18. Which respiratory data should the nurse anticipate when assessing a patient diagnosed with X-linked agammaglobulinemia (XLA)? 1) Wheezes 2) Rhonchi 3) Tachypnea 4) Eupnea

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2. The nurse is assessing a patient who is receiving intravenous (IV) antibiotics. Which item in the patient's health history increases the risk for experiencing a hypersensitivity reaction? 1) 26 years of age 2) Caucasian race 3) Previous antibiotic therapy 4) Concurrent chronic illness

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21. Which respiratory manifestation should the nurse anticipate when providing care to a patient diagnosed with DiGeorge's syndrome? 1) Poor muscle tone 2) Failure to thrive 3) Shortness of breath 4) Delayed development

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24. Which should the nurse include in the plan of care for a patient diagnosed with DiGeorge's syndrome to treat gastrointestinal reflux disorder (GERD)? 1) Hand hygiene 2) Reverse isolation 3) Prokinetic agents 4) Droplet precautions

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4. The nurse is caring for a patient in an allergy clinic. After completing the patient history, the nurse selects the nursing diagnosis of Risk for Shock. Which item in the patient's history supports the need for this nursing diagnosis? 1) A history of an anaphylactic reaction to shellfish. 2) A drug reaction to penicillin causing a rash. 3) A history of glomerulonephritis. 4) A history of dermatitis resulting from a response to changing laundry detergent.

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8. A nurse has been providing a young adult patient with a history of hypersensitivity reactions. The nurse is preparing instructions on the correct methods for using an EpiPen. Which patient statement indicates understanding of the proper technique? 1) "I make sure the EpiPen is always available." 2) "It's fine to leave the EpiPen out in the sun." 3) "No one else in my family knows how to use the EpiPen." 4) "I don't need a medical alert tag."

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28. The nurse is providing care to a pediatric patient who is diagnosed with DiGeorge's syndrome. Which data indicates a cardiovascular abnormality? Select all that apply. 1) Murmur 2) Cyanosis 3) Polycythemia 4) Failure to thrive 5) Cleft lip and palate

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17. The nurse is providing care to a patient diagnosed with X-linked agammaglobulinemia (XLA). Which should the nurse include in the patient's plan of care? 1) Immunization with inactivated polio vaccine (IPV) 2) Administration of intravenous immunoglobulin every six months 3) Education regarding the use of high dose prophylactic antibiotics 4) Periodic magnetic resonance imagery (MRI) to monitor for respiratory complications

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19. Which is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia (XLA)? 1) Risk for infection 2) Decreased cardiac output 3) Anticipatory grieving 4) Fatigue

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23. Which is the priority nursing action to decrease the risk for infection for a patient diagnosed with DiGeorge's syndrome? 1) Hand hygiene 2) Reverse isolation 3) Prokinetic agents 4) Droplet precautions

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22. Which should the nurse plan to monitor when providing care to a patient who is diagnosed with DiGeorge's syndrome? 1) Sodium 2) Calcium 3) Potassium 4) Magnesium

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26. A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee stings. Which clinical manifestations would necessitate the need to inject the child with epinephrine (EpiPen)? Select all that apply. 1) Skin that is cold and clammy to the touch 2) Skin that is warm and dry to the touch 3) The child is hyperactive and hyperverbal. 4) Complaints of thirst 5) Restlessness and confusion

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27. The nurse is providing care to a patient who is suspected of having an immune deficiency. Which information in the patient's health history supports this suspected diagnosis? Select all that apply. 1) Persistent oral thrush 2) Tinea infection of the feet 3) One occurrence of pneumonia last year 4) Four or more infections in a one-year period 5) Two serious sinus infections in a one-year period

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10. A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching would the nurse provide to improve this patient's comfort? 1) Keep doors and windows open on high-allergen days to circulate air. 2) Maintain a clean, dust-free environment. 3) Take antihistamine and leukotriene medication as ordered 4) Stop taking oral corticosteroids immediately once symptoms disappear.

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11. The nurse suspects that the patient is experiencing a reaction to a specific antigen. Which laboratory result supports the conclusion made by the nurse? 1) Indirect Coombs' showing no agglutination 2) Patch test with a 1-inch area of erythema 3) 2% eosinophils in the WBC count 4) Rh antigen with negative results

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13. The nurse is providing care to a patient with autoimmune hepatitis. Which medication should the nurse prepare to teach this patient about based on the diagnosis? 1) Epinephrine 2) Azathioprine 3) Cyclosporine 4) Mycophenolate mofetil

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20. Which general manifestation should the nurse anticipate when providing care to a patient diagnosed with DiGeorge's syndrome? 1) Poor muscle tone 2) Failure to thrive 3) Shortness of breath 4) Delayed development

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7. The nurse is caring for a patient with a history of latex allergies. The patient develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which is the priority intervention for this patient? 1) Teach the patient regarding using a kit that contains treatment for allergic reactions. 2) Administer diphenhydramine (Benadryl) by mouth every four hours per the health-care provider's orders. 3) Administer epinephrine 1:1,000 by subcutaneous injection per the health-care provider's orders. 4) Collect a detailed history from the patient regarding the history of latex allergies.

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9. A pediatric patient with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen. Which statement is appropriate for the nurse to include in the discharge instructions for this patient and family? 1) "This medication does not come prefilled and must be measured." 2) "Keep the medication in the car at all times." 3) "Frequently check the expiration date of the medication." 4) "Keep the medication in one location that is easy to remember."

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1. A nurse is caring for a pediatric patient who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the patient is experiencing a type I hypersensitivity reaction? 1) Erythema 2) Fever 3) Joint pain 4) Hypotension

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14. The nurse is providing care to a patient with lupus. Which medication should the nurse prepare to teach this patient about based on the diagnosis? 1) Epinephrine 2) Azathioprine 3) Cyclosporine 4) Mycophenolate mofetil

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15. Which is the priority nursing action to decrease the risk of a transfusion reaction? 1) Assessing the patient's vital signs per policy 2) Documenting the procedure in the medical record 3) Verifying the patient's identity using two identifiers 4) Checking the bag to ensure it is the correct blood type

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16. The nurse is providing care for a patient diagnosed with agammaglobulinemia. Which is the anticipated treatment for this patient? 1) Oral diphenhydramine 2) Topical corticosteroids 3) Subcutaneous epinephrine 4) Intravenous immunoglobulin (IVIG)

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25. Which immune disorder should the nurse include in the plan of care for a patient who is receiving chemotherapeutic agents in the treatment of cancer? 1) B-cell deficiency 2) T-cell deficiency 3) Excessive immune response 4) Secondary immune deficiency

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3. The nurse is admitting a pediatric patient to the hospital with a ventroperitoneal (VP) shunt malfunction. The patient's family speaks very little English. The interpreter has arrived and the nurse is obtaining a health history from the parents and learns that the patient received the shunt at birth after a menigocele repair. Based on this data, which product should be avoided when providing care to this patient? 1) Synthetic rubber gloves 2) Polyethylene gloves 3) Nonpowdered nitrile gloves 4) Latex gloves

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5. The nurse is preparing to assess a patient when one of the patient's family members begins showing symptoms of a latex sensitivity. Which action by the nurse is the most appropriate? 1) Ask the family member to leave the unit 2) Transfer the patient to a department that does not use latex products 3) Wait until Monday to report the problem to the supervisor of the unit 4) Obtain latex-free products for the patient's room

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6. The nurse is caring for a patient who is experiencing anaphylactic shock following the administration of a medication. Which position is the most appropriate for the nurse to place the patient based on this data? 1) Trendelenburg position 2) Flat, with legs slightly elevated 3) Supine position 4) High Fowler position

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