MEDSURG Ch.18 EAQ's
Which statement best describes a type IV hypersensitivity reaction?
"The reaction of sensitized T cells with antigen and release of lymph achenes activate macrophages and inflammation" RATIONALE 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)
Which instruction is appropriate when teaching a patient with a severe food allergy about using an automatic epinephrine injector?
"protect the injector from light and extreme temperatures" RATIONALE When educating a patient about automatic epinephrine injectors, the nurse will tell the patient to protect it from light and extreme temperatures. The patient should keep the injector with him or her at all times, and should use it as soon as one symptom of anaphylaxis is present. The patient can inject him or herself through pants but avoid seams pockets and areas where fabric is thicker
Which type of hypersensitivity occurs when a patient receives the wrong blood type during a transfusion, leading to a hemolytic transfusion reaction?
Cytotoxic reactions RATIONALE When a patient received the wrong blood type during transfusion, the red blood cells given in the transfusion or destroyed with a patient's immune system in a cytotoxic reaction
Which statement indicates inadequate understanding about precautionary measures to take while treating a patient with a history of allergic reaction during an emergency situation?
IV fluid administration is avoided in the patient RATIONALE IV normal saline fluid should be administered before starting an allergy causing substance administration to keep the patient hydrated. After administering the IV fluid, the intubation equipment and a tracheostomy should be placed at the bedside for use in case of an emergency. The patient is premedicated with diphenhydramine or a corticosteroid to suppress the allergic reaction. The allergy causing substance is administered subcutaneously in very dilute concentrations
Which information will the nurse teach a patient about the care and use of the bee sting kit device?
Obtain a replacement device if the drug is discolored RATIONALE The patient should obtain a replacement device if the drug is discolored; the drug must be clear, with sufficient time left before the expiration date. The patient must keep at least two drug field devices on hand in case more than one dose as needed. The drug is injected into the thigh muscle, not the forearm. The patient must go to the nearest hospital for observation for at least 4 to 6 hours after the device is used
When administering an antibiotic IV for the first time, which action is first before checking the five rights?
Review the Clinical records and ask the patient about any known allergies RATIONALE The clinical record should have all known hypersensitivities listed for the patient. The patient should also be asked directly about any known allergies. Checking the patient identification band for allergies is part of the five rights process at the bedside before the medication is given. The pharmacy is not responsible for obtaining information on all of the patient known allergies. Asking the previous nurse is not an appropriate safety measure before medication administration
A patient presents to the clinic after removing several ticks 10 days ago and asks the nurse about vector borne diseases such as Lyme disease. After completing the health history the nurse would assess for which symptom first?
Round, raised bulls-eye rash RATIONALE The first stage of Lyme disease infection should include the presence of a round or oval rash that is raised and shaped like a bull's-eye. Shortness of breath, cardiac dysrhythmias, and facial paralysis happen in stage II, later in the infectious process
Which patient condition or disorder is an example of a type IV hypersensitivity reaction? Select all that apply
Sarcoidosis Poison ivy skin rashes RATIONALE Type IV hypersensitivity reactions or delete hypersensitive reactions. Clinical examples of type IV hypersensitivity reactions include poison ivy and sarcoidosis. Serum sickness is a clinical example of type III hypersensitivity reactions. Graves' disease and myasthenia gravis are examples of type V hypersensitivity reactions.
A patient with systemic lupus erythematosus (SLE) presents to the clinic for a three month follow up visit after beginning treatment with hydroxychloroquine. Which finding would lead the nurse to conclude the patient understands disease maintenance?
Schedule an eye examination in three months RATIONALE Hydroxychloroquine is an anti-malarial drug that can damage the rent now, so the patient should have eye examinations every six months
Which disease can be categorized as an auto immune disease? Select all that apply
Scleroderma Rheumatic fever Goodpasture syndrome RATIONALE Auto immunity is a process in which an individual becomes oversensitive and starts producing antibodies against self-cells or proteins. Scleroderma, rheumatic fever, and Goodpasture syndrome are autoimmune diseases that occur when immune cells start destroying self cells
Which instruction would the nurse give to a patient who has had an allergic reaction to environmental airborne allergens?
Thoroughly clean cloth drapes, carpeting, and upholstered furniture. RATIONALE Thoroughly cleaning (or removing) cloth, drapes, carpet, and upholstery will reduce airborne pollen, dust mites, and mold. This may help prevent further allergic response. Washing fruits and vegetables pertains to food allergies. Patients do not develop immunity to known allergens by direct exposure; common interventions include avoidance therapy, desensitization therapy, and symptomatic therapy. Honey is only said to help some people with allergies to pollen; it does not have an effect on airborne allergies
After teaching a patient with systemic lupus erythematosus ways to manage disease related pain by decreasing inflammation which action made by the patient indicates a need for further instruction?
Uses acetaminophen for pain RATIONALE The pain of SLE is related to inflammation. Acetaminophen does not decrease inflammation. Therefore the nurse shouldn't struck the patient on the use of NSEDS to manage pain. The patient is managing pain by taking frequent rest periods, prioritizing essential activities, and asking for help with heavy work
Which information would be included when teaching a group of scouts about ticks in Lyme disease prevention one hiking and camping? select all that apply
Wear closed toe shoes Use insect repellent with DEET RATIONALE The nurse should instruct the scouts to wear closed toe shoes and use insect repellent with DEET to prevent ticks from attaching. The nurse should instruct the scouts to walk on the center of the trail and avoid areas with thick under brush. The scout should dress in light colored clothing so ticks can be seen easier. Ticks should be removed with tweezers without squeezing
Which is an example of type I hypersensitivity reaction?
angioedema RATIONALE Type I hypersensitivity reactions are caused by over active immunity and result from increase production of immunoglobulin E. Examples of type I reactions include angioedema, anaphylaxis, and allergic asthma. Rheumatoid arthritis is an example of a type III hypersensitivity reaction. Immune hemolytic anemia is a form of type II reaction (cytotoxic reaction)
Which type of hypersensitivity is anaphylaxis?
rapid hypersensitivity RATIONALE Type I hypersensitivity is also known as rapid hypersensitivity. Anaphylaxis is an example of type I hypersensitivity reaction which occurs rapidly and systemically. Anaphylaxis is as a result of the reaction of immunoglobulin E (IgE) antibodies on mast cells with antigen, resulting in the release of mediators, especially histamine, which cause the allergic reaction.
After the initial treatment, a patient with Lyme disease report to dizziness, and an examination the nurse notes irregular heart rhythm. Which question would the nurse ask the patient to determine causative factors?
"Did you complete your course of antibiotics?" RATIONALE If the patient with Lyme disease does not complete treatment, it will progress to stage II, which is manifested by dizziness and dysrhythmias, facial paralysis, and peripheral neuritis
Which medication would the nurse expect to administer to a patient with history of asthma that develop shortness of breath and stridor and becomes hypotensive during allergies contesting?
Epinephrine RATIONALE The patient is experiencing an anaphylactic reaction, and upper nephron is a first line sympathomimetic used to treat anaphylaxis
Which nursing action is first when caring for a patient that is experiencing reduce chest movement and impaired airflow, Hypotension, and a rapid, weak, irregular pulse?
Assessing gas exchange RATIONALE Assessing gas exchange should be the nurses first priority since emergency respiratory management is critical during an anaphylactic reaction
Which complication would be evident in a patient with type II hypersensitivity?
Allergic asthma
Which hypersensitivity reaction is characterized by the antigen antibody complex formation that gives rise to an inflammatory response? Select all that apply
Anaphylaxis Serum sickness Rheumatoid arthritis Immune hemolytic anemia RATIONALE These are all hypersensitivity reactions that occur when excess antigens cause immune complexes to form in the blood, triggering information that results in tissue or vessel damage
Which action would the nurse take immediately when caring for a patient experiencing an anaphylactic reaction to an IV infusion?
Apply oxygen using a high flow nonrebreather mask
What nursing intervention is the immediate priority when caring for a patient with the following symptoms: wheezing, difficulty breathing, Angioedema, blood pressure of 70/52, and apical pulse of 122 bpm that is irregular?
Apply oxygen using a high flow nonrebreather mask at 90% to 100% RATIONALE Oxygen application helps provide adequate oxygenation for the patient who is in respiratory distress. Assessing respiratory status is an immediate priority
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?
Avoidance therapy RATIONALE The best way to prevent future recurrence of a type of allergy is to avoid non-causative allergens whenever possible. Exposure to these agents may lead to an immunoglobulin E (IgE)- mediated immune response.
A patient's serum contains a highly elevated level of immunoglobulin E (IgE) antibodies(140IU/mL). What could be the possible effects of this elevated IgE? Select all that apply
Capillary leak Pruritus and inflammation Excessive release of histamine RATIONALE A patient's blood with a type I hypersensitivity contains elevated levels of serum IgE. These antibodies bind to the basophil, or mast cell, and stimulates the release of vasoactive agents (e.g. histamines) in response to the allergen. Histamine causes capillary leaks, pruritus, erythem, and inflammation
Which medication is most likely to have caused a hypersensitivity reaction of severe angioedema of the lips, face, and tongue?
Benazepril RATIONALE The drugs most commonly associated with angioedema are angiotensin converting enzyme inhibitors such as benazepril
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?
Communicate the need for avoidance therapy to the healthcare team RATIONALE Contact hypersensitivity can occur with latex, pollen, foods, and environmental proteins. Avoidance therapy is the recommended nursing intervention. Desensitization therapy is administered through allergy shots when allergens have been identified and cannot easily be avoided. Symptomatic therapy intervention such as an epinephrine pen, anti-histamines, and corticosteroids are effective only after the hypersensitivity reaction has already occurred.
When caring for a patient admitted with a flareup of systemic lupus erythematosus receiving IV corticosteroids, which assessment with a nurse include related to this medication? Select all that apply
Daily weights. Blood glucose. Blood pressure. Intake and output RATIONALE Prednisone is a corticosteroid used to decrease the inflammatory process in patients with SLE. However, it has many side effects, including hyperglycemia, hypertension, and fluid retention.
A patient who is receiving an IV antibiotic begins to cough and state, "my throat feels like it is swelling" Which action will the nurse take next?
Discontinue infusing the antibiotic RATIONALE Because the antibiotic is the most likely cause of the patient's anaphylactic reaction, the nurses first action should be to discontinue the antibiotic. The nurse must first assess the patient
Which question will the nurse ask during an assessment of a patient who is suffering from type I hypersensitivity? Select all that apply
Do you have any food or drug allergies? Do you have any family members with a type I allergy? When did this problem begin and how long does each episode last? RATIONALE To identify the causative allergen, the nurse asks if the patient has any allergy to some food, drugs, or other chemical compounds. The exposure to such compounds can result in mild to severe type I reactions. This type of hypersensitivity can be a hereditary problem. To understand the severity of the disease, information about onset and duration can be beneficial
Which sign or symptom would the nurse teach a patient newly diagnosed with systemic lupus erthyematosus to report to the healthcare provider? Select all that apply
Edema weight gain decreased output RATIONALE Two major complications of SLE are kidney and cardiovascular disease. Therefore the nurse should instruct the patient report edema, weight gain, and decreased output as these clinical manifestations occur with both diseases. Increased thirst can be related to medications. A facial butterfly rash is a hallmark sign of SLE and need not be reported
Which nursing intervention is a priority for a patient who is experiencing an anaphylactic reaction, is hypotensive, and has a rapid, weak, and a regular pulse?
Elevate the legs and feet RATIONALE Because the patient is hypotensive and has a rapid, week, and an irregular pulse, the priority is to elevate the legs and feet, leaving the head of the bed elevated to about 10°. The nurse administers beta adrenergic agonist metaproterenol to decrease mucus secretion if a patient has bronchospasms. Dive fin hydramine is an antihistamine agent administered if the patient has symptoms of angioedema and urticaria
Which nursing action is a priority when caring for a patient who is experiencing a severe type I hypersensitivity reaction resulting in angioedema?
Finding out what medications the patient is taking RATIONALE It is most important to find out what medication to the patient is taking. Although other information might be helpful to the assessment; time is important since laryngeal edema can result in loss of airway. The patient with angioedema will most likely feel frightened and anxious, and it will improve is the angioedema resolves. Hereditary angioedema will result in recurring angioedema not associated with a specific drug, but asking about recurrence in family history is a secondary consideration after asking about medications
A patient presents to the emergency department with facial swelling, difficulty breathing, and difficulty speaking. Based on these findings and a diagnosis of an anaphylactic reaction, which action would the nurse initially perform? Select all that apply
Give epinephrine Administer oxygen RATIONALE The nurses initial interventions should be to give epinephrine and administer oxygen. Once the patient is stabilized, the healthcare provider can determine the cause. If the initial interventions are unsuccessful, the nurse should then prepare for a tracheostomy. A CBC should not be a priority at this time
Which event occurs in a type II hypersensitivity reaction?
Immunoglobulin G (IgG) antibody reacts with host cell membrane RATIONALE Type II hypersensitivity reactions are also called cytotoxic reactions. The mechanisms involved in type II hypersensitivity reactions include the reaction of the IgG antibodies with a host cell membrane or antigen being absorbed by the cell membrane
Which information would the nurse include when teaching a patient newly diagnosed with the stomach lupus erythematosus (SLE) about managing the disease in preventing setbacks? Select all that apply
Include aerobic exercise plan frequent rest periods avoid crowded public areas stay in shady areas outdoors use mild, non-astringent soap
Which action is most beneficial to a patient with severe pet induced allergy who has two pet dogs?
Keep the pets out of the house RATIONALE The nurse should suggest to the patient with pet induced allergy to keep the pets out of the house to reduce exposure to allergens. This type of avoidance therapy is most beneficial to a patient with severe pet induced allergy
30 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?
Laryngeal stridor RATIONALE Stridor is a high-pitched sound made during inspiration when the trachea and airways are obstructed.
Which symptom is associated with an anaphylactic reaction? Select all that apply
Red blotches Itching and urticaria Erythema and angioedema RATIONALE These are all common symptoms associated with anaphylactic reaction and during this reaction vasodilation occurs and blood is lost from the vascular system therefore the patient becomes hypotensive
Which hypersensitivity reaction symptom requires the most immediate action by the nurse?
Stridor RATIONALE Stridor indicates airway involvement and warrants immediate intervention, such as use of oxygen and administration of epinephrine
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 the nurse indicates a need for further education?
The patient must have all three clinical criteria to be diagnosed with anaphylaxis RATIONALE The nurse stating the patient must meet all three criteria is incorrect, and the statement indicates a need for further education. The third criteria is hypotension with a systolic blood pressure less than 90 mm Hg. Symptoms occur within minutes to hours of taking the medication the patient is allergic to. The respiratory system is most affected with dyspnea, bronchospasms, and stridor
