PEDS: Ch 25 Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder

The parents of an adolescent tell the nurse, "Our child seems to have allergy symptoms every time we visit our favorite cafe. I don't understand since the only allergy indicated in the testing was to eggs?" How should the nurse respond?

"Does your child get a whipped cream or foam topping on their favorite drink?" Albumin, globulin, ovalbumin should be avoided if allergic to eggs. Some foam toppings for drinks contain these substances and would cause an allergic reaction to the person allergic to eggs. This would be important information to ascertain from the family as they would likely not be aware of this.

The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant he gets a rash. It just doesn't make sense to me." How should the nurse respond?

"Has your child ever been tested for a peanut allergy?" Enchilada sauce is an unexpected food that may contain a form of peanuts (such as peanut oil) that may be causing an allergic reaction in the child.

The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education?

"Humoral immunity is generally functional at birth." Normal immune function is a complex process involving phagocytosis (process by which phagocytes swallow up and break down microorganisms), humoral immunity (immunity mediated by antibodies secreted by B cells), cellular immunity (cell-mediated immunity controlled by T cells), and activation of the complement system. Cellular immunity is generally functional at birth, and as the infant is exposed to various substances over time, humoral immunity develops.

The mother of a child with a possible food allergy asks the nurse for information about how to test for it. Which response by the nurse would be most appropriate?

"The best way is to eliminate the food from the diet and then look for improvement."

The nurse is providing instructions to the parents of a child with a severe peanut allergy. Which statement by the parents indicates a need for further teaching about the use of an epinephrine auto-injector?

"The epinephrine auto-injector should be jabbed into the upper arm." An epinephrine auto-injector should be jabbed into the outer thigh, as this is a larger muscle, at a 90 degree angle, not into the upper arm. The other statements are correct.

The nurse is caring for a child who is receiving an intravenous immunoglobulin treatment. The client calls the nurse and reports she vomited. What action should be completed first?

Discontinue the infusion. Clients receiving intravenous immunoglobulin are at risk for anaphylaxis. Vomiting can signal an allergic response. The first action would be to stop the infusion. The remaining activities are appropriate for inclusion in the plan of care but are not of the highest priority.

Food allergies have become more and more common in the last few decades. What are some common food allergies of childhood? Select all that apply.

Eggs Peanuts Milk

The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of the greatest concern?

Elevated blood pressure Renal complications may result from lupus. This may be accompanied by hypertension making monitoring of blood pressure of the highest importance.

The nurse is monitoring the labs of a child admitted for an exacerbation of juvenile pauciarticular arthritis. Which lab result does the nurse expect to be elevated?

Erythrocyte sedimentation rate (ESR) The erythrocyte sedimentation rate (ESR) is an indicator of inflammation; it would likely be elevated during an exacerbation of arthritis. Immunoglobulin electrophoresis determines the level of individual immunoglobulins; it would not be elevated in an autoimmune disease. Lymphocyte immunophenotyping T-cell quantification measures T-cells; this would be used to monitor immunosuppressive disorders. The radioallergosorbent test measures minute quantities of IgE in the blood; it is used for asthma and food allergy testing.

Place in correct order the steps in the anaphylactic response.

Exposure to allergen Rapid immune response Vasodilation Bronchoconstriction Circulatory collapse Anaphylaxis typically is a very rapid response to exposure to an allergen. Vasodilation leads to potential circulatory collapse. Bronchospasm occurs simultaneously with other system reactions, also contributing to the life-threatening possibility.

When describing anaphylaxis to a group of parents whose children have experienced anaphylaxis from insect stings, the nurse integrates knowledge that this response is related to which immunoglobulin?

IgE Anaphylaxis is an acute IgE-mediated response to an allergen that involves many organ systems and may be life-threatening.

The nurse is caring for a child presenting with eye inflammation, knee pain, poor appetite and poor weight gain. The nurse is aware that this is which type of juvenile idiopathic arthritis?

Pauciarticular (oligoarticular) Pauciarticular or (oligoarticular) arthritis symptoms include involvement of four or fewer joints; quite often the knee is involved, eye inflammation, malaise, poor appetite, poor weight gain. Polyarticular involves five or more joints; frequently involves small joints and often affects the body symmetrically. Systemic includes joint involvement, fever and rash may be present at diagnosis. Rheumatic arthritis typically involves small joints.

The nurse is preparing to administer the child's dose of intravenous immune globulin (IVIG). Which actions should the nurse take? Select all that apply.

Take baseline vital signs and monitor the vital signs during the infusion Prepare to give acetaminophen to the child Prepare to give diphenhydramine to the child IVIG should be given only intravenously and should not be given as an intramuscular injection. IVIG cannot be mixed with other medications. The nurse should closely monitor the child's vital signs during the infusion of the IVIG. The child may require an antipyretic and/or an antihistamine during infusion to help with fever and chills.

The nurse is caring for a child with juvenile idiopathic arthritis (JIA). There is involvement of five or more small joints and it is affecting the body symmetrically. This tells the nurse that the child:

has polyarticular JIA. Polyarticular JIA is defined by the involvement of five or more joints, frequently the small joints, and affects the body symmetrically. Pauciarticular JIAs is defined by the involvement of four or fewer joints. Systemic JIA presents with fever and rash in addition to join involvement at the time of diagnosis. The child with JIA is not at greater risk for anaphylaxis.

An HIV positive woman has asked about breastfeeding her son. What response by the nurse is appropriate?

"Breastfeeding will increase your child's risk of contracting HIV." HIV can be transmitted by breastfeeding. A newborn who received the recommended plan of drug treatment has a reduced risk for contracting the infection. Contracting HIV is not an absolute for this infant. The client should be discouraged from breastfeeding. Breastfeeding does provide immunity when the mother is free of infection but not in this scenario. Telling the mother that this is not a good idea is not the best response as it does not take advantage of the opportunity to provide education and improve client outcomes.

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?

"I can use the egg white when baking, but not the yolk." The parents must understand that their child cannot consume any part of an egg in any form. The other statements are accurate.

The nurse is speaking with a teenager who has requested HIV testing. Which is the best statement by the nurse regarding HIV testing?

"The ELISA method detects antibodies so a person may have a false negative test for up to six months after exposure. ELISA method detects only antibodies, so the test may remain negative for several weeks up to 6 months (false-negative) after exposure. A false-positive may result with autoimmune disease. The ELISA test requires serial testing. HIV test results are confidential.

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?

1300/mm3 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.

What would best identify foods to which a child is allergic?

Elimination diet Elimination diets involve adding foods slowly to a child's diet so foods to which the child is allergic can be identified.

An infant born to a mother who was HIV positive was tested at birth and found to be negative. The infant is scheduled for follow-up testing. Which test would the nurse expect to be performed?

Polymerase chain reaction (PCR) test The PCR is the preferred test to determine HIV infection in infants over 1 month of age. The ELISA is positive in infants of HIV-infected mothers because of transplacentally received antibodies. These antibodies may persist and remain detectable up to 24 months of age, making the ELISA test less accurate at detecting HIV infection in infants and toddlers than the PCR. The platelet count would provide no information about the infant's HIV status. CD4 counts would be used to monitor HIV infection but not to confirm whether the infant is positive or negative for the virus.

The nurse is administering the drug cyclophosphamide (Cytoxan) to a child who has severe systemic lupus erythematosis (SLE). What body system is the nurse most concerned with adverse effects immediately after administration of this drug?

Renal Cyclophosphamide (Cytoxan) is a cytotoxic drug that interferes with normal function of DNA by alkylation, and is given for treatment of severe SLE. The medication is very nephrotoxic; therefore, the nurse must provide adequate hydration and have child void frequently during and after infusion to decrease risk of hemorrhagic cystitis.

A nurse is providing care to a child with HIV who is prescribed therapy with a nucleoside reverse transcriptase inhibitor. What would the nurse expect to administer?

Zidovudine Zidovudine is a nucleoside reverse transcriptase inhibitor. Nevirapine and efavirenz are classified as nonnucleoside reverse transcriptase inhibitors. Ritonavir is a protease inhibitor.

To avoid anaphylactic reactions in children, which question would be most important to ask a parent before administering penicillin to her infant?

"Has she ever had penicillin before?" Penicillin is a drug frequently involved in allergic reactions. The reaction occurs after the child has first been sensitized to the drug.

The nurse is reviewing the medical history of a 4-year-old child. What would the nurse identify as potentially indicative of a primary immunodeficiency? Select all that apply.

Acute otitis media, one episode every 3 to 4 weeks over the past year. Recurrent deep abscess of the thigh Oral thrush, persistent over the past 6 to 7 months Warning signs associated with primary immunodeficiency include four or more new episodes of acute otitis media in 1 year, recurrent deep skin or organ abscesses, persistent oral thrush or skin candidiasis after 1 year of age. A history of infections requiring IV antibiotics to heal and two or more episodes of pneumonia in 1 year are also warning signs.

A child with primary immune deficiency is about to receive an infusion of IVIG. What is the most appropriate premedication to minimize the reaction?

Diphenhydramine Diphenhydramine and acetaminophen are the most commonly used medications for this purpose. Nonsteroidals and steroids typically are not used for this indication.

A nurse is preparing a presentation for a group of new parents and is planning to discuss nutrition during the first year. As part of the presentation, the nurse is planning to address foods that should be avoided to reduce the risk of possible food allergies. Which foods would the nurse most likely include? Select all that apply.

Eggs Shrimp Peanuts Foods that should be avoided in children younger than 1 year of age include cow's milk, eggs, peanuts, tree nuts, sesame seeds, and fish and shellfish (i.e., shrimp). Carrots, potatoes, and bananas are not considered problematic.

A nurse is caring for an infant whose mother is human immunodeficiency (HIV) positive. The nurse knows that which diagnostic test result will be positive even if the child is not infected with the virus?

Enzyme-linked immunosorbant assay (ELISA) The ELISA test will be positive in infants of HIV-infected mothers because of trans-placentally received antibodies. These antibodies may persist and remain detectable up to 24 months of age, making the ELISA test less accurate in detecting true HIV infection in infants and toddlers than the polymerase chain reaction (PCR). The PCR test is positive in infected infants over the age of 1 month. The erythrocyte sedimentation rate would be ordered for an immune disorder initial workup or ongoing monitoring of autoimmune disease. Immunoglobulin electrophoresis would be ordered to test for immune deficiency and autoimmune disorders.

A nurse is giving a talk to high school students about preventing the spread of human immunodeficiency virus (HIV). What does the nurse identify as ways in which HIV is spread? Select all that apply.

Exposure to blood and body fluids through sexual contact Sharing contaminated needles Transfusion of contaminated blood Perinatally from mother to fetus Through breastfeeding HIV is spread by exposure to blood and other body fluids through sexual contact, sharing of contaminated needles for injection, transfusion of contaminated blood, perinatally from mother to fetus, and through breastfeeding.

The nurse is caring for a child with HIV. The doctor will most likely order which test to monitor the child's progress?

Lymphocyte immunophenotyping T-cell quantification Lymphocyte immunophenotyping T-cell quantification is for ongoing monitoring of progressive depletion of CD4 T lymphocytes in HIV disease. The nurse would expect the physician to order a complement assay (C3 and C4) for ongoing monitoring of systemic lupus erythematosus. IgG subclasses measures the levels of the four subclasses of IgG and is used to determine immunodeficiencies. Immunoglobulin electrophoresis is ordered for immunodeficiency and autoimmune disorders, not to monitor systemic lupus erythematosus.

The nursing instructor is describing the events of anaphylaxis. Place the assessment findings in the order that they would occur from first to last.

Nausea, vomiting, diarrhea Urticaria, angioedema Bronchospasm Hypoxia Seizures Initially, a child may be nauseous, with vomiting and diarrhea, because of the sudden increase in gastrointestinal secretions produced by the stimulation of histamine. This is followed by urticaria and angioedema. Bronchospasm can become so severe the child becomes dyspneic and hypoxemic. Continued bronchospasm leads to hypoxia. As blood vessels dilate, the blood pressure and pulse rate fall. Seizures and death may follow as soon as 10 minutes after the allergen is introduced into the child's body.

What advice would be most appropriate for the child with a stinging-insect allergy?

Obtain a medical alert ID bracelet so the presence of the allergy can be identified easily. Stinging-insect allergy can lead to anaphylactic shock. Alerting health care personnel to the possibility of an insect sting is important.

The most accurate screening test for the presence of HIV antigen in young children is

PCR PCR tests directly for the HIV antigen. ELISA and the Western blot test detect the presence of HIV antibodies. The CD4 count is used as a measure of disease status and progression.

The nurse is instructing a group of women of childbearing age about human immunodeficiency virus (HIV) during pregnancy. What would be a priority recommendation in this setting?

Screening for HIV No screening mandate has been put forth for HIV, but all pregnant women should be encouraged to undergo this test. Prophylactic treatment would be initiated only once the woman has been screened. Screening for STIs and ensuring proper nutrition are also part of health promotion for women in this age group, but they are of lower priority than identifying HIV-positive individuals.

The nurse is discussing food allergies with parents of a young child. She explains that a very effective way to determine which foods a child may be allergic to is to implement:

an elimination diet. The food diary may identify foods the child does not tolerate well, but it lacks the objectivity of the elimination diet. Skin testing usually involves whole proteins and will not test for reactions to food breakdown products. A raw food diet does not apply to allergy identification.

The nurse is preparing to administer IVIG to a child who has not received the medication before. What medication should the nurse expect to administer prior to the infusion?

Diphenhydramine Premedication with diphenhydramine or acetaminophen may be indicated in children who have never received IVIG, have not had an infusion in more than 8 weeks, have had a recent bacterial infection, have a history of serious infusion-related adverse reactions, or are diagnosed with agammaglobulinemia or hypogammaglobulinemia. Aspirin, ibuprofen and prednisone would not routinely be administered prior to IVIG.

A client was admitted to the medical unit for exacerbation (flare-up) of symptoms of systemic lupus erythematosis (SLE). When reviewing the client's chart the nurse notices that the he has a "butterfly rash." The nurse will assess for this rash on what area of the client's body?

Face A malar rash (a butterfly-shaped rash over the cheeks) is a common occurrence with SLE

The nurse is explaining patterns of incidence and transmission of HIV to a group of adolescent girls. She explains that the risks for this population are much higher because of the possibility of both vertical and horizontal transmission. Horizontal transmission refers to transmission of the disease during:

sexual contact. Horizontal transmission refers to person-to-person transfer of the virus. Transmission by feeding with breast milk, birthing, and pregnancy are all examples of vertical transmission.

The nurse is caring for a child who is receiving naproxen for treatment of juvenile idiopathic arthritis. What interventions should the nurse include in this client's care plan?

Administer the medication with food Monitor lab results for an increase in liver enzymes Monitor renal labs for a decrease in renal function Naproxen is a nonsteroidal anti-inflammatory drugs (NSAID) that acts by inhibiting prostaglandin synthesis. Side effects include GI upset or bleeding (administering with food helps prevent GI side effects); decreased liver and renal function. Extended release preparations cannot be crushed as this disrupts the extended release action. Muscle strength is not typically affected by naproxen.

After teaching a class of nursing students about acquired immunodeficiency, the instructor determines that the teaching was effective when the students identify what as a contributing factor? Select all that apply.

Cancer Immunosuppressive drugs Malnutrition Factors contributing to secondary (acquired) immunodeficiency include severe systemic infection, cancer, renal disease, radiation therapy, severe stress, malnutrition, immunosuppressive therapy, and aging.

The nurse is assessing a child with a complex medical history that includes fatigue, Raynaud phenomenon, anemia and photosensitivity. The nurse should anticipate that this child may require which treatment?

Corticosteroid therapy This child's symptoms are consistent with systemic lupus erythematosus (SLE), which is usually treated with corticosteroids. Antiretrovirals, IVIG and phototherapy are of no benefit in the treatment of SLE.

The parents of a 10-year-old with HIV have never told their child that he has the virus. The child asks the nurse why he is "on so many medications." What action should the nurse take?

The nurse should encourage the child to talk with his parents about his medications Generally, children older than 6 years of age will eventually need to have their diagnosis disclosed to them in an age-appropriate manner. They begin to ask questions and often seem to sense that something is going on other than what they've been told so far. Encouraging discussion with the parents is the best first step.

A 5-year-old is hospitalized after an asthma attack at school. The child tells the nurse that the janitor was cleaning in the classroom prior to the attack and that a lot of dust was in the air. The dust that likely caused the attack is known as a (an):

allergen. Mediating substances that are released and cause tissue injury and allergic symptoms are called allergens. An antigen is any foreign substance capable of stimulating an immune response. An antigen that can be readily destroyed by an immune response is called an immunogen. Macrophages are mature white blood cells.

While obtaining a health history on a 3-year-old child, the nurse finds what information a concern? Select all that apply.

Parents report the child as an infant had failure to thrive. Parents report the child has had recurrent bacterial infections. Parents report the child didn't start walking until 1 ½ years old. Parents report the child didn't sit up by herself until 9 months old. When collecting health history the nurse must be attuned to reports that may signal underlying conditions. A child who has experienced failure to thrive, repeated bacterial infections and developmental delays with regard to walking and sitting up presents the need for further investigation. These are consistent with an autoimmune disorder.

The nurse is providing discharge teaching to the client with myasthenia gravis. Which statements by the parents of the client demonstrate knowledge of proper care? Select all that apply.

"If my child shows signs of an upper respiratory infection I will contact our physician right away." "We love to take family vacations to Florida, but we will have to find a new vacation spot." "I picked up our child's medical alert bracelet today." Anticholinergic drugs should be given 30 to 45 minutes before meals, on time and exactly as ordered. Difficulty swallowing may occur from a myasthenic crisis. Infections can exacerbate the disease so the physician should be notified immediately if signs of infection are present. Heat can also exacerbate symptoms so avoidance of high temperatures is important. A medical alert bracelet is helpful for when the family is not present.

The nurse is working with a pregnant client with HIV who is receiving oral zidovudine. What is the primary rationale for this intervention?

To help prevent transmission of the disease to the fetus A goal of therapy during pregnancy is to maintain the CD4 cell count at greater than 500 cells/mm3 by administering oral zidovudine which helps halt maternal/fetal transmission dramatically along with one or more protease inhibitors, such as ritonavir (Norvir) or indinavir (Crixivan), in conjunction with an NRTI. If P. carinii pneumonia develops, a woman is treated with trimethoprim with sulfamethoxazole. Kaposi's sarcoma is normally treated with chemotherapy. Women may need a platelet transfusion close to birth to restore coagulation ability.

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?

"Have you noticed any hair loss or redness on your face?" 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.

A mother, who is HIV positive, is distraught when she learns that her 6-month-old baby is also human immunodeficiency virus (HIV) positive. The child had undergone open heart surgery as a newborn and had received numerous blood transfusions. The nurse recognizes that the most likely means of transmission of the disease to this child was:

placental spread during pregnancy Although it is decreasing in incidence, transmission of HIV from mother to child by placental spread is still the most common reason for childhood HIV infection in the United States. Children with hemophilia no longer have a high incidence of the disease because blood products are now screened for the virus. HIV is not transmitted by animals or through usual casual contact, such as shaking hands or kissing, or in households, day care centers, or schools. Infection via breast milk is possible but less likely that via placental spread.

The mother of a child with myasthenia gravis has called the clinic and reports her child appears very anxious and the child's heart is beating very fast. What action by the nurse is indicated?

Instruct the child be brought to the emergency department promptly. Myasthenia gravis is an autoimmune disorder that is characterized by weakness and fatigue. There is no cure. The disease may be aggravated by stress, exposure to extreme temperatures, and infections, resulting in a myasthenic crisis. Myasthenic crisis is a medical emergency with symptoms including sudden respiratory distress, dysphagia, dysarthria, ptosis, diplopia, tachycardia, anxiety, and rapidly increasing weakness. The symptoms reported are consistent with a crisis and prompt care is indicated. Waiting 24 hours to have the child seen by the physician is not appropriate. Questions about changes in routine and medication compliance may be asked but the first priority is to have the child seen