NUR424 Chapter 36

The nurse is obtaining an assessment and health history from the parents of a 6-month-old infant with an elevated temperature. Which statement by the parents will alert the nurse to a possible immunodeficiency disorder?

Infants with X-linked agammaglobulinemia usually become symptomatic after the natural loss of maternally transmitted immunoglobulins, which occurs at about 5 to 6 months of age. Symptoms of recurrent pyogenic infections usually occur by that time.

T-cell deficiency occurs when which of the following glands fails to develop normally during embryogenesis?

T-cell deficiency occurs when the thymus gland fails to develop normally during embryogenesis.

angioneurotic edema:

condition marked by development of urticaria and an edematous area of skin, mucous membranes, or viscera (i.e., angioedema).

ataxia:

loss of muscle coordination.

immunocompromised host:

person with a secondary immunodeficiency and associated immunosuppression.

When administering intravenous gamma globulin infusion, the nurse recognizes that which of the following complaints, if reported by the client, may indicate an adverse effect of the infusion?

Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma globulin infusion.

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?

Primary immune deficiencies should be not be confused with AIDS. They are not the same condition. In addition, a primary immune disorder does not increase the child's risk for developing AIDS later in life. Primary immune deficiency diseases are serious, but they are rarely fatal and can be controlled.

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?

Ataxia-telangiectasis is characterized by loss of muscle coordination and vascular lesions. Thrombocytopenia and eczema are associated wtih Wiskott-Aldrich syndrome.

A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included?

Be alert for signs and symptoms of infection and report them immediately to the physician.

More than 50% of individuals with this disease develop pernicious anemia:

Common variable immunodeficiency (CVID). More than 50% of clients with CVID develop pernicious anemia. Pernicious anemia is not associated with the other conditions.

A majority of patients with CVID develop which type of anemia?

A majority of patients with CVID develop pernicious anemia, which is caused by a weakened stomach lining or an autoimmune condition. The majority of patients with CVID do not develop the other types of anemia.

A patient with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this patient?

Nursing care must be meticulous. Appropriate infection control precautions and thorough hand hygiene are essential. Institutional policies and procedures related to protective care must be followed scrupulously until definitive evidence demonstrates that precautions are unnecessary.

thymic hypoplasia or DiGeorge syndrome

T-cell deficiency that occurs when the thymus gland fails to develop normally during embryogenesis; also known as DiGeorge syndrome.

Tyler Harris, a 5-year-old male, has recovered from an anaphylactic reaction which brought him to the ED 3 weeks ago. Tyler has begun sensitivity testing to determine the allergen which caused his anaphylactic reaction. In scratch testing, which part of the body is more sensitive to allergens?

The back is more sensitive than the arms. The scratch or prick test involves scratching the skin and applying a small amount of the liquid test antigen to the scratch. The tester applies one allergen per scratch over the client's forearm, upper arm, or back.

Reproductive health education for women who are HIV-positive includes recommending which of the following contraceptives?

The female condom, the first barrier method controlled by women, is the only proven, effective method to prevent the transmission of HIV and sexually transmitted infections (STI).

A nurse is teaching the parents of an infant about primary immunodeficiencies. Which of the following statements verifies that the parents understand the teaching?

The majority of primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1.

A mother brings her young child to the clinic for an evaluation of an infection. The mother states, "He's been taking antibiotics now for more than 2 months and still doesn't seem any better. It's like he's always sick." During the history and physical examination, which of the following would alert the nurse to suspect a primary immunodeficiency?

The mother has already reported one of the warning signs associated with primary immunodeficiencies--the use of antibiotics for 2 or more months with little effect. Another warning sign is eight or more new ear infections within 1 year.

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements?

These disorders may involve one or more components of the immune system. Primary immunodeficiencies are seen primarily in infants and young children. Primary immunodeficiencies are rare disorders with genetic origins.

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements? Primary immunodeficiencies

These disorders may involve one or more components of the immune system. Primary immunodeficiencies are seen primarily in infants and young children. Primary immunodeficiencies are rare disorders with genetic origins.

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?

Treatment options for SCID include stem cell and bone marrow transplantation.

A nurse working in an allergy/immunology office frequently sees clients with different types of allergies, requiring specific medical management. The nurse's most recent client presents with itching, swelling, redness, wheals of superficial skin layers. What is the most likely type of allergy this client is displaying?

Urticaria presents with itching, swelling, redness, wheals of superficial skin layers. Angioedema presents with itching, swelling, redness of deeper tissues and mucous membranes.

A client calls the clinic and asks the nurse if using Afrin nasal spray would be alright to relieve the nasal congestion he is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications?

Using Afrin nasal spray for more than 3 to 5 days can cause rebound congestion so the client should be sure that he is discontinuing use after that time.

severe combined immunodeficiency disease:

disorder involving a complete absence of humoral and cellular immunity resulting from an X-linked or autosomal genetic abnormality.

agammaglobulinemia:

disorder marked by an almost complete lack of immunoglobulins or antibodies.

panhypoglobulinemia

general lack of immunoglobulins in the blood.

Wiskott-Aldrich syndrome:

immunodeficiency characterized by thrombocytopenia and the absence of T and B cells.

hypogammaglobulinemia:

lack of one or more of the five immunoglobulins; caused by B-cell deficiency.

telangiectasia:

vascular lesions caused by dilated blood vessels.

A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?

AIDS, the most common secondary disorder, is perhaps the best-known secondary immunodeficiency disorder. It results from infection with the human immunodeficiency virus (HIV).

A client is given a dose of ketorolac (Toradol), a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do?

Administer epinephrine because patient is having an anaphylaxis allergy, a rapid and profound type I hypersensitivity response.

ataxia-telangiectasia:

autosomal recessive disorder affecting T- and B-cell immunity primarily seen in children and resulting in a degenerative brain disease.