Chapter 30: Alterations in Immune Function

A young client is admitted to the hospital directly from the clinic. The physician suspects a problem with the child's immune system. What test does the nurse anticipate the physician will order for this client?A. Urine analysis B. Blood analysis C. EKG D. X-ray

ANS: B Rationale: When there is a deficiency of immunocompetent cells, an assessment will focus on analysis of blood components, particularly white blood cells.

The adoptive parents of a child who is 7 years old and HIV positive are concerned about telling their child about his condition. What information can be provided by the nurse? A. The child should not have information about their health provided at this age. B. Children at this age should have full disclosure of their condition. C. When providing health information to a child of this age it should be simplistic and at the child's level of understanding. D. Once a child is apprised of their health concerns they do not normally experience any after affects.

ANS: C Rationale: When a child has a chronic condition they often realize that they have special concerns even before they are fully able to understand them. Information should be provided that is developmentally appropriate. Excessive information and details should be limited. Children who have this type of information may experience problems anger, depression and difficulty in school.

The nurse is caring for a pediatric client who has a compromised immune system. When reviewing laboratory results, which bone marrow component identifies a dysfunction in bone marrow production? Select all that apply. A. Macrophages B. Antigen C. T lymphocytes D. B lymphocytes E. Haptens

ANS: C, D Rationale: Bone marrow produces B lymphocytes and T lymphocytes. Macrophages are mature white blood cells involved with phagocytosis of an invading pathogen. Antigens are foreign substances capable of stimulating an immune response. Hapten formation occurs when a substance becomes antigenic when it combines with a higher weight molecule, usually a protein.

A nurse is conducting a physical examination of a 12-year-old girl with suspected systemic lupus erythematosus (SLE). How would the nurse best interview the girl? A: "Do you notice any wheezing when you breathe or a runny nose?" B: "Do you have any shoulder pain or abdominal tenderness?" C: "Have you noticed any new bruising or different color patterns on your skin?" D: "Have you noticed any hair loss or redness on your face?"

ANS: D Rationale: Alopecia and the characteristic malar rash (butterfly rash) on the face are common clinical manifestations of SLE. Rhinorrhea, wheezing, and an enlarged spleen are not hallmark manifestations of SLE. Petechiae and purpura are more commonly associated with hematological disorders, not SLE.

The nurse is preparing an educational program for members of the office staff. The topic is the warning signs of primary immunodeficiency. What information should be included? Select all apply. A. Two or more new episodes of acute otitis media in 1 year. B. Two or more episodes of severe sinusitis in 1 year. C. Failure to thrive in an infant. D. Two or more serious infections such as sepsis. E. History of infections requiring IV antibiotics to clear.

ANS: B, C, D, E Rationale: Warning signs of primary immunodeficiency include four, not two, or more new episodes of acute otitis media in 1 year. Other warning signs include failure to thrive in the infant, two or more episodes of severe sinusitis in 1 year, two or more serious infections such as sepsis and/or a history of infections requiring IV antibiotics to clear.

The nurse is instructing parents on how atopic disorders affect the child. For which disorder would the nurse provide information and counseling? Select all that apply. A. Serum sickness B. Allergic rhinitis C. Asthma D. Eczema E. Hay fever

ANS: B, C, D, E Rationale: Hay fever (or allergic rhinitis), asthma, and eczema (or atopic dermatitis) are classified as atopic disorders. Serum sickness is a type III hypersensitivity response of the body to a foreign serum antigen or drug.

A nursing instructor teaching a class about immunity asks the students to identify the organs of the immune system. Which would the nursing instructor want them to include? (Select all that apply.) A. lymph nodes B. bone marrow C. thymus D. liver E. spleen F. tonsils

ANS: A, B, C, E, F Rationale: The organs of the immune system consist of the lymph nodes, bone marrow, thymus, spleen, and tonsils.

Which nursing diagnosis will the nurse select as appropriate for the child with atopic dermatitis? Select all that apply. A. Impaired skin integrity related to skin barrier function B. Delayed growth related to chronicity of immune disorder C. Ineffective breathing pattern related to allergic bronchospasm D. Anxiety related to continuing or uncontrolled allergic response E. Powerlessness related to difficulty determining cause of allergy

ANS: A, D, E Rationale: Atopic dermatitis (eczema) is a highly pruritic, chronic inflammatory skin disease. Nursing diagnoses should focus on impaired skin integrity, anxiety related to the allergic response, and powerlessness related to knowing cause of allergy. A nursing diagnosis of delayed growth is more appropriate for a child with HIV. A nursing diagnosis of ineffective breathing pattern is more appropriate for a child with asthma.

The nurse is reviewing the immunization schedule with the parent of a child who is HIV positive. What information should the nurse provide? Select all that apply. A: Pneumococcal vaccination can be given. B: The child should receive live vaccines only. C: The human papillomavirus vaccine should not be given. D: The varicella vaccine should not be given if the child is symptomatic. E: If the CD4 count is low, the measles, mumps, and rubella vaccine should not be given.

ANS: A, D, E Rationale: The nurse should emphasize that live vaccines should not be given to those infected with HIV. Children should receive routine immunizations according to the usual schedule with the killed virus vaccines, including pneumococcal and human papillomavirus vaccine. Symptomatic children should not receive the varicella vaccine, and those with low CD4 counts should not receive measles, mumps, and rubella vaccine.

Which nursing intervention is priority when caring for a child with HIV? A. Administer prescribed medications. B. Assist the child with daily activities. C. Assess pain after invasive procedures. D. Review laboratory CD4 counts daily.

ANS: A Rationale: Although assisting with activities, assessing pain, and reviewing CD4 counts are all important, the priority when caring for a child with HIV is to administer prescribed medications. Prescribed medications prevent progressive deterioration of the immune system and provide prophylaxis against opportunistic infections.

A 7-year-old child is rushed into the emergency room after being stung by a yellow jacket. The child is nauseated and vomiting and is experiencing itching and swelling on the arm where stung. He is having trouble breathing. Which type of hypersensitivity response is the child experiencing? A. Type I: anaphylaxis B. Type II: cytotoxic response C. Type III: immune complex D. Type IV: cell-mediated hypersensitivity

ANS: A Rationale: Anaphylactic shock is an immediate, life-threatening, type I hypersensitivity reaction that occurs after exposure to an allergen in a previously sensitized child. Anaphylactic shock must be treated immediately as it can be fatal. Initially, a child may become nauseated, with vomiting and diarrhea, because of the sudden increase in gastrointestinal secretions produced by the stimulation of histamine. This is followed by urticaria (itching) and angioedema (swelling). Bronchospasm can become so severe the child becomes dyspneic, hypoxemic, and then hypoxic.

Nursing students correctly label the group of cells whose job is to ingest, engulf, and neutralize pathogens as: A. macrophages. B. immunogens. C. immunoglobins. D. red blood cells.

ANS: A Rationale: Macrophages (mature white blood cells) engulf, ingest, and neutralize pathogens. Red blood cells do not fight infection. They carry hemoglobin and carry oxygen from the lungs to the tissues. In the immune response, immunoglobulins are antibodies and immunogens are antigens.

The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education? A. "I will make sure my daughter always has her EpiPen® with her all the time." B. "If we need to use the EpiPen® we will need to notify her physician's office the next business day." C. "I have found a website that makes medical alert bracelets in my daughter's favorite color." D. "The grey part of the EpiPen® should never be removed until right before we use it."V

ANS: B Rationale: If an EpiPen® is used, the child still needs immediate medical attention. EpiPens should be carried with the patient at all times. When administering an EpiPen, the grey safety cap should not be removed until immediately prior to using. Medical alert bracelets or necklaces should be worn by all children with severe allergies.

An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE? A. "SLE is a rheumatic disease that mostly affects my joints." B. "SLE is an autoimmune disorder that I will always have, with times of flare- ups and times of minimal to no symptoms." C. "If my SLE has been found early enough in the disease process, there is a good chance that medication can cure it." D. "SLE only affects my skin. It seldom causes problems in any other organs."

ANS: B Rationale: SLE is a systemic autoimmune disease that can effect any organ system, including the skin. There is no cure for SLE, but with proper treatment and if the client cares for themselves properly, theNdiUseRaSseIcNanG-haTvEe SpeTriBoAdsNoKf.reCmOisMsion and fewer flare-ups.

The nurse is providing teaching about food substitutions when cooking for the child with an allergy to eggs. Which response indicates a need for further teaching? A: "I must not feed my child eggs in any form." B: "I can use the egg white when baking, but not the yolk." C: "1 tsp yeast and 1/4 cups warm water is a substitute in baked goods." D: "1.5 Tbsp each water and oil plus 1 tsp baking powder equals one egg in a recipe."

ANS: B Rationale: The parents must understand that their child cannot consume any part of an egg in any form. The other statements are accurate.

The child has a peanut allergy and accidentally ate food that contained peanuts. Which clinical manifestations of anaphylaxis should the nurse expect to find? Select all that apply. A: The child's pulse is 52 beats per minute. B: The child states that his tongue feels "too big" for his mouth. C: The child has developed hives on his face and trunk. D: The child states he feels like he might "throw up". E: The child states that he feels like he might faint.

ANS: B, C, D, E Rationale: The following are common signs and symptoms of anaphylaxis: tongue edema, urticaria, nausea, vomiting, and syncope. Typically, the child who has developed anaphylaxis will be tachycardic.

The client has been prescribed antihistamines and a round of corticosteroids to treat an allergic reaction to an unknown food source. Which statement by the client indicates he understands the allergic condition and medication regimen? A. "The antihistamine will help the nasal swelling I am having." B. "Corticosteroids help the inflammation that goes along with an allergy." C. "I can stop taking my steroids as soon as I feel better in a couple of days." D. "I may have to undergo intradermal testing to determine what I am allergic to." E. "Once we figure out what I am allergic to, it is important for me to avoid that allergen."

ANS: B, D, E Rationale: Nasal swelling is seen with allergic rhinitis, not usually with a food allergy. The antihistamine is given to block histamine that is released when exposed to an allergen. It treats a rash or a hive that may occur with a food allergy. Corticosteroids help with inflammation cause by an allergic reaction, but they should always be tapered in order to prevent acute adrenal insufficiency. Skin testing to determine the allergan, then avoidance of the allergen is advised.

A child with allergic rhinitis is prescribed a nasal antihistamine spray. When advising the parents about the use of the sprays, what should the nurse explain about the rebound phenomenon? A: It causes a permanent increase in nasal secretions. B: It causes reflux of gastric contents into the esophagus. C: It causes an increase in nasal secretions after an initial decrease. D: It causes a decrease in histamine release after an initial increase.

ANS: C Rationale: Review with the parents that if nasal antihistamine sprays are given for more than 3 days, a rebound effect can occur. The nasal mucosa becomes more edematous rather than less edematous, and symptoms will appear to worsen rather than improve. The rebound phenomenon does not cause a permanent increase in nasal secretions, reflux of gastric contents into the esophagus, or a decrease in histamine release after an initial increase.

The nurse is monitoring the CD4 count of an infant who has contracted HIV from the mother in utero. The nurse is concerned that treatment with antiretroviral therapy is not effective when noting which CD4 level? A. 1900/mm3 B. 1700/mm3 C. 1500/mm3 D. 1300/mm3

ANS: D Rationale: The number of CD4 T lymphocytes in the blood helps to determine the effectiveness of antiretroviral therapy. Normal is 1500/mm3 in the infant, so anything below that number may indicate that the therapy is not effective.

The nurse is caring for a child and notes periorbital edema on the left eye with urticaria. Which action by the nurse is priority? A. Administer a corticosteroid. B. Ask if the child has allergies. C. Evaluate fluid volume status. D. Assess lung sounds bilaterally.

ANS: D Rationale: When a child has signs of angioedema, the nurse's priority is to ensure the airway is patent, by assessing breathing sounds, because angioedema can cause laryngeal obstruction and asphyxiation. Evaluating fluid volume status, asking about allergies, and administering a corticosteroid are all actions that could be performed after first ensuring the child was breathing.