Peds - Ch. 47: Alteration in Immunity/Immunologic Disorder

A pregnant client who is HIV positive asks the nurse if she will be able to breastfeed the newborn. Which response by the nurse is most appropriate?

"Breastfeeding will increase your newborn'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 newborn. The client should be discouraged from breastfeeding to limit exposure to the newborn. Breastfeeding does provide immunity when the mother is free of infection but not in this scenario. Telling the mother to speak to the health care provider is not the best response as the nurse is able to provide this education to the client.

The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant the child gets a rash. It just does not 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 nurse is completing a care plan for a child who has recently had a bone marrow transplant. Which nursing interventions should the nurse include in the care plan? Select all that apply.

-Administer immunosuppressive medications as ordered. -Perform meticulous hand hygiene and ensure all visitors follow these precautions. -Provide oral care at least every shift, but more often as needed. -Monitor the client for signs and symptoms of graft versus host disease. The client who has had a bone marrow transplant is at high risk for bone marrow rejection and must receive immunosuppressive medications as scheduled to prevent rejection. Protective isolation, not contact precautions, are followed to prevent infection in this immunocompromised client, as does hand hygiene. Oral hygiene prevents infections from beginning in the mouth. Graft versus host disease is an allergic reaction that can occur; early recognition is vital.

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.

-Oral candidiasis (thrush), persistent over the past 6 to 7 months -Recurrent deep abscess of the thigh -Acute otitis media, one episode every 3 to 4 weeks over the past year. 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 candidiasis (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 school-aged child, who is allergic to bee stings, states, "I think I was stung by a bee outside." Which intervention by the school nurse is most appropriate?

Assess the client for signs of anaphylactic shock First, the nurse will assess the client for signs of anaphylactic shock and then administer epinephrine if warranted. Epinephrine counteracts histamine release to decrease bronchospasm and difficulty breathing. If there were no signs of anaphylactic shock, the nurse would determine if the child was actually stung. The nurse would apply ice to promote vasoconstriction once the client was stable.

A nurse instructor is teaching pregnant women how HIV can spread from mother to fetus without treatment. For the untreated child who contracts HIV through placental transmission, when will the child test positive for HIV?

By 6 months of age HIV appears to progress more rapidly in untreated infants and children who contract it through placental transmission. These children usually are HIV positive by 6 months old and develop clinical signs by 1 to 3 years old. If a mother is treated for HIV during pregnancy, the infant will also receive HIV medication for 6 weeks after birth. The infant will need to be tested at 1 month of age and at 4 months of age. This testing will determine the absence of HIV in the infant.

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.

The nurse is providing teaching for the parents of a child with a latex allergy. The nurse tells the client to avoid which food?

bananas The nurse should instruct children and their families to avoid foods with a known cross-reactivity to latex, such as bananas.

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.

The nurse is caring for a 6-month-old infant with Wiskott-Aldrich syndrome. Which teaching does the nurse provide the parent?

"Do not insert anything in the rectum." Children with Wiskott-Aldrich syndrome should not be given rectal suppositories or temperatures since these children are at a high risk for bleeding. Tub baths are not contraindicated. Pacifiers are not contraindicated in Wiskott-Aldrich but should be kept as sanitary as possible to avoid oral infections.

The nurse is speaking with the parent of a child who has experienced an allergic reaction to peanuts. Which statement by the parent would indicate a need for further education?

"If my child has gastrointestinal upset, my child is not having anaphylactic shock." Bloating, abdominal pain, diarrhea and vomiting may be symptoms of anaphylaxis. Shortness of breath as well as itching of the lips, tongue and palate may also be symptoms of anaphylaxis. Hypertension and bradycardia are not associated with anaphylactic shock.

The parents of a 5-month-old infant diagnosed with humoral IgA deficiency question the nurse about why the infant was not diagnosed sooner. Which response by the nurse most appropriate?

"Maternal antibodies crossed the placenta and that prevented infections until now." IgA deficiency does not have a specific treatment, is usually found when evaluating other illnesses, and is associated with allergies. However, the nurse's most appropriate response to the parents' question about why the infant was not diagnosed sooner is to explain how maternal antibodies prevent manifestation of the deficiency until the infant is approximately 4 months old.

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?

"If we need to use the EpiPen® we will need to notify her physician's office the next business day." If an EpiPen® is used, the child still needs immediate medical attention. An EpiPen should be carried with the client at all times. When administering an EpiPen, the grey safety cap should not be removed until immediately prior to use. Medical alert bracelets or necklaces should be worn by all children with severe allergies.

A pediatric client is newly diagnosed with a stinging-insect allergy. Which advice is most appropriate for the nurse to provide this client's parent?

"Obtain your child a medical alert ID bracelet so the presence of the allergy can be identified easily." Stinging-insect allergy can lead to anaphylactic shock. Alerting others to the possibility of an insect sting and allergy is important. To alert others of the allergy, the client should wear a medical alert ID bracelet at all times. A support group may be joined if needed, but is not priority over the client's safety. Genetic testing is not appropriate for allergies. These are tested through allergy testing. It is also not appropriate to recommend testing for foods similar to insect venom.

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 administering nevirapine to an adolescent client diagnosed with HIV. The client asks the nurse how this medication helps fight HIV. How should the nurse respond?

"The medication disrupts the virus life cycle of HIV. This prevents the disease from progressing." Nevirapine is a nonnucleoside analog reverse transcriptase inhibitor (NNRTIs) that binds to HIV-1 reverse transcriptase, blocking DNA polymerase activity and disrupting the virus life cycle. It's used for treatment of HIV-1 infection as part of a three-drug regimen.

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.

-Peanuts -Shrimp -Eggs 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.

The nurse in the emergency department is examining an 18-month-old child who recently received a first dose of penicillin. The nurse notes lip edema, urticaria, stridor, and tachycardia. Which action will the nurse take next?

Administer epinephrine The nurse would suspect the child is experiencing anaphylaxis and administer epinephrine. Lip edema, urticaria, stridor, and tachycardia are common clinical manifestations of anaphylaxis. CPR is not indicated; the child is still breathing and has a heart rate at this time. The nurse would want to ensure IV access is obtained and have intubation equipment at hand; however, these are not priority.

Which nursing intervention is priority when caring for a child with HIV?

Administer prescribed medications. 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.

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.

A nurse is providing education to pregnant women diagnosed with HIV. Which statement indicates the need for further teaching?

Pregnancy will accelerate the progression of the disease. Of the nearly 1,000,000 people in the United States infected with HIV, 25% are female. There isn't any research showing pregnancy accelerates the progression of the disease. Women with HIV should not breastfeed, because they could transmit the virus to the baby via the breastmilk. Early use of antiretroviral medications are effective in reducing transmission, and a cesarean birth may be scheduled to reduce potential transmission to the newborn.

The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of 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 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 JIA 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.

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 measure the levels of the four subclasses of IgG and are used to determine immunodeficiencies. Immunoglobulin electrophoresis is ordered for immunodeficiency and autoimmune disorders, not to monitor systemic lupus erythematosus.

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.

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.

-Through breastfeeding -Perinatally from mother to fetus -Sharing contaminated needles -Exposure to blood and body fluids through sexual contact -Transfusion of contaminated blood 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. It cannot be contracted by using the same bathroom. It must be direct contact.

The nurse is teaching the parents of a child with a suspected diagnosis of juvenile idiopathic arthritis about the disease. Which statement by the parents demonstrates the need for further teaching?

"If our child does not have a positive rheumatoid factor, our child does not have the disease." Unlike adult rheumatoid arthritis, few types of juvenile arthritis actually demonstrate a positive rheumatoid factor. Therapeutic management focuses on inflammation control, pain relief, promotion of remission, and maintenance of mobility. The parents can promote sleep and comfort with a warm bath at bedtime and warm compresses to affected joints or massage. Swimming is a particularly useful exercise to maintain joint mobility without placing pressure on the joints.

The nurse is working with a pregnant client who is HIV positive and has been prescribed oral zidovudine. Which statement by the nurse explains the primary rationale for taking this medication?

"It is to help prevent transmission of the disease to your infant." 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 or indinavir, in conjunction with a nucleoside reverse transcriptase inhibitor (NRTI). Kaposi sarcoma is normally treated with chemotherapy. Women may need a platelet transfusion close to birth to restore coagulation ability. This medication has no affect on the fetus's growth and development.

The parents are concerned their child with atopic dermatitis is having an allergic reaction to diphenhydramine because the child became "sleepy and has a dry throat" after receiving the medication. Which education provided to the parents by the nurse is most important?

"Side effects, such as drowsiness and dryness, do not indicate an allergy." Although children with atopic dermatitis (eczema) are more likely to develop a medication allergy, side effects of diphenhydramine (drowsiness, dry mouth, constipation, etc.) can occur normally alongside the therapeutic effect of the medication. Common side effects do not indicate a toxic amount of the medication was given. Signs of an allergic reaction to a medication include: urticaria, angioedema, allergic contact dermatitis, flushing, pruritus, purpura, wheezing and/or rhinitis.

The parents of a 3-month-old infant report concerns the infant is irritable, feeds poorly, and has a rash. The nurse notes weeping, crusty lesions on the infant's cheeks and neck. Which action by the nurse is most appropriate?

Contact the health care provider to request treatment. Infants that feed poorly, are irritable, and have a weeping, crusty rash on the checks and neck may have atopic dermatitis (infantile eczema). The nurse should contact the health care provider to request treatment, which may include methods to avoid allergens. Although reducing exposure to identified allergens is important, a 3-month-old infant should not be eating peanuts, so this information would not be appropriate at this time.

The nurse is preparing to administer intravenous immune globulin (IVIG) to a pediatric client. The nurse reviews the primary health care provider's prescription which states: Give 400 mg/kg IVIG subcutaneously. Which action will the nurse take next?

Contact the primary health care provider. After reviewing the prescription, the nurse would contact the health care provider. IVIG can only be administered IV and should not be given subcutaneously or intramuscularly. Clarification is needed before the nurse proceeds. The nurse would need to weight the client as this medication dosage is weight-based. Epinephrine should be readily available during administration of IVIG in case the client has a reaction. The client's vital signs should be assessed to determine a baseline prior to starting the medication.

The nurse is providing education regarding 2020 Health Goals to reduce the incidence of acquired immunodeficiency syndrome (AIDS) within the community. Which goal will the nurse choose as a primary prevention strategy?

Provide education to sexually active females about proper condom usage. Primary prevention strategies focus on preventing a disease before it occurs, which includes condom usage to prevent being exposed to AIDS. Screening for the presence of AIDS is a secondary prevention strategy because it does not prevent an individual from contracting AIDS, but would allow for early identification. Improving air quality and reducing allergens are goals to prevent allergies.

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 registered nurse (RN) and unlicensed assistive personnel (UAP) are caring for a pediatric client with an immune disorder receiving a stem cell transplant. Which action by the UAP will cause the RN to intervene?

The UAP takes a rectal temperature on the client. Precautions must be taken to protect the client from infection. The RN would intervene if the UAP takes a rectal temperature because this increases the client's risk for infection. The client should not receive rectal suppositories as well. The RN would ensure meticulous oral care is provided and encourage appropriate and adequate nutrition. Delivering a meal tray, wearing a mask when entering the room, and assisting the client to ambulate in the room are all appropriate actions by the UAP.

The nurse is educating a child with a peanut allergy about the signs and symptoms of an anaphylactic reaction. The nurse realizes additional teaching is needed when the child identifies which sign/symptom?

constipation Signs and symptoms of an anaphylactic allergic reaction include nausea, anxiety, and itchy mouth. Diarrhea, rather than constipation, is a sign of an allergic reaction.

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. The is having trouble breathing. Which type of hypersensitivity response is the child experiencing?

Type I: anaphylaxis 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.

The nurse is helping the parents of a toddler identify foods that are causing allergic symptoms in the child. Which strategy should the nurse encourage the parents to use?

Elimination diet An elimination diet is a traditional method to detect food allergens. Parents feed the child only foods that rarely cause allergy, such as rice, lamb, carrots, peas, and sweet potatoes, for about 7 days. Then they add, one by one, at 2- to 3-day intervals, foods that are suspected of causing allergy. When a food is introduced this way, the child must be encouraged to eat a lot of it that day. If symptoms occur, the food is then eliminated from the child's meals on a permanent basis. If no symptoms occur, the child can continue to eat the food. Hyposensitivity testing is unreliable with food allergies. Corticosteroids delay hypersensitivity reactions. It is difficult to totally eliminate protein from the diet, and this is not a method to determine the cause of food allergies in the toddler.

The nurse is caring for a child who is receiving a skin test to determine the presence of allergies. A positive skin test for one particular allergen shows the mediation of which type of immune globulin?

IgE Skin testing is done to detect the presence of IgE in the skin that responds to a particular allergen. IgM is part of the body's primary response, and IgG is part of the body's secondary response to infection. IgA is present in the mucous membranes of the body to fight against infection.

Which immunoglobin occurs most frequently in plasma and is the major immunoglobulin synthesized during secondary response?

IgG IgG is the most frequent antibody in plasma and is the major immunoglobin to be synthesized during the secondary response. IgG represents about 75% of all serum antibodies. Most of the newborn's IgG is transferred via the placenta to the fetus. The infant develops passive immunity to antigens in which the mother has developed antibodies. The infant begins to manufacture IgG after about 6 months of age. IgG reaches 50% of its adult level at 1 year of age and full adult level at age 7 years. IgD is only found in about 1% of plasma. Its function is to signal for B cells to be activated. IgA protects the mucous membranes against the invasion of microbes. IgM is the first antibody to respond to infection.

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.

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." Food allergies are best identified by eliminating a suspected food from the diet and observing whether symptoms improve. After a time of improvement, the food is reintroduced and if the child is allergic to the food, the symptoms will return. Skin testing with either a patch or intracutaneous injection is ineffective for determining food allergies. Serum antibody levels can be measured but are not specific in helping to determine food allergies.

When providing discharge instructions to a child who was admitted to the hospital following stridor, wheezing, and urticaria after taking penicillin, which nursing action is priority?

Encourage the child to wear a medical alert bracelet for penicillin. Oral medications most likely to cause an allergic reaction include antibiotics, acetylsalicylic acid (aspirin), and NSAIDs. Children experiencing stridor, wheezing, and urticaria after taking a medication most likely have an allergy to that medication. The priority nursing action for discharge education is to prevent the child from being exposed to penicillin again, which could be accomplished by encouraging the child to wear a medical alert bracelet. Although children with atopic diseases are more likely to have medication allergies, requesting parents have the child evaluated is not a priority. Questioning the child about the amount of penicillin taken and educating parents about the side effects of penicillin is not a priority.