Immunity Sherpath EAQ

The nurse manager reviews the clinical criteria for an anaphylactic reaction when teaching about the importance of checking allergies before giving medication and the signs of anaphylaxis. Which statement made by a nurse indicates a need for further education? a. "The patient must have all three clinical criteria to be diagnosed with anaphylaxis." b. "The systolic blood pressure should be less than 90 mm Hg to meet the third criteria." c. "The onset of symptoms should occur within minutes to hours of taking the medication. d. "The respiratory system is most affected as evidenced by dyspnea, bronchospasms, and stridor."

a. "The patient must have all three clinical criteria to be diagnosed with anaphylaxis."

Which type of hypersensitivity is anaphylaxis? a. Rapid hypersensitivity b. Delayed hypersensitivity c. Cytotoxic hypersensitivity d. Immune-complex mediated hypersensitivity

a. Rapid hypersensitivity

Which nursing action is a priority for a patient having an allergic reaction to penicillin, who has symptoms of swollen lips and tongue, soft palate, and widespread hives with pruritus? a. Administering oral serratiopeptidase b. Administering IV epinephrine c. Administering inhalation of salbutamol d. Administering intramuscular theophylline

b. Administering IV epinephrine

Which nursing action is a priority when caring for a patient who is experiencing a severe type I hypersensitivity reaction resulting in angioedema? a. Finding out how anxious the patient is feeling b. Finding out what medications the patient is taking c. Finding out if the patient has had previous allergic reactions d. Finding out if any family members have had a similar reaction

b. Finding out what medications the patient is taking

Which preventive nursing intervention is best in planning care for a patient admitted to the hospital who has a contact type I hypersensitivity to latex? a. Report the need for desensitization therapy. b. Discuss symptomatic therapy with the health care provider. c. Communicate the need for avoidance therapy to the health care team. d. Convey the need for pharmacologic therapy to the health care provider.

c. Communicate the need for avoidance therapy to the health care team.

A patient is diagnosed with a type I hypersensitivity. Which antibody level increases during this type of allergy? a. IgM b. IgD c. IgE d. IgG

c. IgE

What are the most common triggers for allergic rhinitis? Select all that apply. a. Hay fever b. Latex gloves c. Plant pollens d. Animal dander e. Dust and molds

c. Plant pollens d. Animal dander e. Dust and molds

Which item may cause a reaction in a patient that reports a history of latex allergy? a. Pollen b. Milk products c. Surgical gloves d. Legumes and nuts

c. Surgical gloves

After teaching a patient with systemic lupus erythematosus (SLE) ways to manage disease-related pain by decreasing inflammation, which action made by the patient indicates a need for further instruction? a. Takes frequent rest periods b. Prioritizes essential activities c. Uses acetaminophen for pain d. Asks for help with heavy work

c. Uses acetaminophen for pain

Which information would be included when teaching a group of scouts about ticks and Lyme disease prevention when hiking and camping? Select all that apply. One, some, or ail responses may be correct. a. Walk through leaves. b. Dress in dark clothing. c. Wear closed-toe shoes. d. Squeeze ticks to remove them. e. Use insect repellent with DEET.

c. Wear closed-toe shoes. e. Use insect repellent with DEET.

Which medication would the nurse expect to administer to a patient with a history of asthma that develops shortness of breath and stridor and becomes hypotensive during allergy skin testing? a. Zileuton b. Epinephrine c. Fexofenadine d. Cromolyn sodium

Epinephrine

A patient with a type I allergy is treated with antihistamines and corticosteroids. Which other measure can help the patient to prevent future recurrence of allergies? a. Avoidance therapy b. Increased fluid intake c. Increased rest periods d. Epinephrine drug therapy

a. Avoidance therapy

When caring for a patient admitted with a flare-up of systemic lupus erythematosus (SLE) receiving IV corticosteroids, which assessment would the nurse include related to this medication? Select all that apply. One, some, or all responses may be correct. a. Daily weights b. Blood glucose c. Blood pressure d. Intake and output e. Bowel movements

a. Daily weights b. Blood glucose c. Blood pressure d. Intake and output

The nurse is caring for a patient with a poison ivy skin rash. What type of hypersensitive reaction is the patient experiencing? a. Delayed reaction b. Cytotoxic reaction c. Immediate reaction d. Immune complex-mediated reaction

a. Delayed reaction

Which sign or symptom would the nurse teach a patient newly diagnosed with systemic lupus erythematosus (SLE) to report to the health care provider (HCP)? Select all that apply. One, some, or all responses may be correct. a. Edema b. Weight gain c. Increased thirst d. Decreased output e. Facial butterfly rash

a. Edema b. Weight gain d. Decreased output

Thirty minutes after receiving medication, a patient reports a ticklish feeling at the back of the throat with minor lip swelling. Which additional clinical manifestation would lead the nurse to call the Rapid Response Team? a. Laryngeal stridor b. Nasal congestion c. Oxygen saturation 95% d. Diminished lung sounds

a. Laryngeal stridor

Which food item may cause anaphylaxis in some individuals? Select all that apply. One, some, or all responses may be correct. a. Nuts b. Eggs c. Peanuts d. Shellfish e. Potatoes

a. Nuts b. Eggs c. Peanuts d. Shellfish

Which role will decongestants play in the treatment of a type I hypersensitivity? a. Reduce edema. b. Clear the allergen. c. Prevent the release of vasoactive amines. d. Prevent the synthesis of vasoactive amines.

a. Reduce edema.

Which patient condition or disorder is an example of a type IV hypersensitivity reaction? Select all that apply. One, some, or all responses may be correct. a. Sarcoidosis b. Serum sickness c. Graves disease d. Myasthenia gravis e. Poison ivy skin rashes

a. Sarcoidosis e. Poison ivy skin rashes

Which hypersensitivity reaction symptom requires the most immediate action by the nurse? a. Stridor b. Pruritus c. Urticaria d. Anxiousness

a. Stridor

Which immune cell or component is involved in a type IV hypersensitivity reaction? a. T-cells b. Self cells c. Antibodies d. Complement

a. T-cells

Which type of hypersensitivity may be associated with rhinorrhea? a. Type I hypersensitivity b. Type II hypersensitivity c. Type III hypersensitivity d. Type IV hypersensitivity

a. Type I hypersensitivity

Which type of hypersensitivity is cell-mediated immunity with T-lymphocyte as the reactive cell? a. Rapid hypersensitivity b. Delayed hypersensitivity c. Cytotoxic hypersensitivity d. Immune complex-mediated hypersensitivity

b. Delayed hypersensitivity

A patient has developed a type II hypersensitivity. Which mechanism is involved in this type of allergic reaction? a. Activation of T-cells c. Stimulation of thyroid cells d. Secretion of histamines from mast cells

b. Phagocytosis of self cells

Epinephrine administration is essential during anaphylaxis. What is the mechanism of action of this drug? a. Inhibits mast cells degranulation b. Stimulates the alpha- and beta-adrenergic receptors c. Blocks the effects of histamines on the gastrointestinal tract d. Blocks the alpha-adrenergic receptors

b. Stimulates the alpha- and beta-adrenergic receptors

After the initial treatment, a patient with Lyme disease reports dizziness, and on examination the nurse notes an irregular heart rhythm. Which question would the nurse ask the patient to determine causative factors? a. "When did you first notice the dizziness?" b. "Are you taking any medication for pain?" c. "Did you complete your course of antibiotics?" d. "Have you experienced any other symptoms?"

c. "Did you complete your course of antibiotics?"

The nurse is reviewing discharge teaching with a patient who suffered an anaphylactic reaction to a bee sting. Which statement by the patient indicates the need for further teaching? a. "I need to carry epinephrine with me." b. "My spouse must learn how to give me an injection." c. "I am immune to bee stings now that I have had a reaction." d. "I must wear a medical alert bracelet stating that I am allergic to bee stings."

c. "I am immune to bee stings now that I have had a reaction."

What nursing intervention is the immediate priority when caring for a patient with the following symptoms: wheezing, difficulty breathing, angioedema, blood pressure (BP) of 70/52 mm Hg, and apical pulse of 122 beats/min that is irregular? a. Raise the lower extremities. b. Start IV administration of normal saline. c. Apply oxygen using a high-flow nonrebreather mask at 90% to 100%. d. Reassure the patient that appropriate interventions are being instituted.

c. Apply oxygen using a high-flow nonrebreather mask at 90% to 100%.

Which condition is associated with a type I hypersensitivity reaction? a. Hay fever b. Sarcoidosis c. Serum sickness d. Autoimmune hemolytic anemia

d. Autoimmune hemolytic anemia

Which assessment finding will the nurse anticipate for a patient with allergic rhinitis? a. The presence of fever b. Glowing skin over the sinuses c. Yellow drainage from the nose d. Runny nose with itchy, watery eyes

d. Runny nose with itchy, watery eyes