Ch. 33: Assessment and Management of Patients with Allergic Disorders

A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse? A) Assess for signs and symptoms of anaphylaxis. B) Assess for erythema and urticaria. C) Administer an OTC antihistamine. D) Administer epinephrine.

Ans: A Feedback: If a patient is experiencing an allergic response, the nurses initial action is to assess the patient for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction.

A patient has sought care, stating that she developed hives overnight. The nurses inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed? A) Type I B) Type II C) Type III D) Type IV

Ans: A Feedback: Urticaria (hives) is a type I hypersensitive allergic reaction

The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction? A) Anaphylactic reaction after a bee sting B) Skin reaction resulting from adhesive tape C) Myasthenia gravis D) Rheumatoid arthritis

Ans: A Feedback: Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by IgE antibodies and requires previous exposure to the specific antigen. Skin reactions are more commonly type IV and myasthenia gravis is thought to be a type II reaction. Rheumatoid arthritis is not a type I hypersensitivity reaction.

A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values? A) Increased eosinophils B) Increased neutrophils C) Increased serum albumin D) Decreased blood glucose

Ans: A Feedback: Higher percentages of eosinophils are considered moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and is found in patients with allergic disorders. Hypersensitivity does not result in hypoglycemia or increased albumin and neutrophil counts.

After the completion of testing, a childs allergies have been attributed to her familys cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action? A) Removing the cat from the familys home B) Administering OTC antihistamines to the child regularly C) Keeping the cat restricted from the childs bedroom D) Maximizing airflow in the house

Ans: A Feedback: In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors. Fully removing the cat from the environment is preferable to just keeping the cat out of the childs bedroom. Avoidance therapy does not involve improving airflow or using antihistamines.

The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patients care plan? A ) Risk for Disturbed Body Image Related to Skin Lesions B) Risk for Disuse Syndrome Related to Dermatitis C) Risk for Ineffective Role Performance Related to Dermatitis D) Risk for Self-Care Deficit Related to Skin Lesions

Ans: A Feedback: The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of patients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit.

An office worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A) Anaphylactic (type 1) B) Cytotoxic (type II) C) Immune complex (type III) D) Delayed-type (type IV)

Ans: A Feedback: The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.

A 5-year-old boy has been diagnosed with a severe food allergy. What is an important parameter to address when educating the parents of this child about his allergy and care? A) Wear a medical identification bracelet. B) Know how to use the antihistamine pen. C) Know how to give injections of lidocaine. D) Avoid live attenuated vaccinations

Ans: A Feedback: The nurse also advises the patient to wear a medical identification bracelet or to carry emergency equipment at all times. Patients and their families do not carry antihistamine pens, they carry epinephrine pens. Lidocaine is not self-administered to treat allergies. The patient may safely be vaccinated.

A nurse has asked the nurse educator if there is any way to predict the severity of a patients anaphylactic reaction. What would be the nurses best response? A) The faster the onset of symptoms, the more severe the reaction. B) The reaction will be about one-third more severe than the patients last reaction to the same antigen. C) There is no way to gauge the severity of a patients anaphylaxis, even if it has occurred repeatedly in the past. D) The reaction will generally be slightly less severe than the last reaction to the same antigen.

Ans: A Feedback: The time from exposure to the antigen to onset of symptoms is a good indicator of the severity of the reaction: the faster the onset, the more severe the reaction. None of the other statements is an accurate description of the course of anaphylactic reactions.

A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurses best response? A) I can only imagine how you feel. Would you like to talk about it? B) Lets find a quiet spot and Ill teach you a few coping strategies. C) Thats the same way that most patients who have a chronic illness feel. D) Do you think that maybe you could be managing things more efficiently?

Ans: A Feedback: To assist the patient in adjusting to these modifications, the nurse must have an appreciation of the difficulties encountered by the patient. The patient is encouraged to verbalize feelings and concerns in a supportive environment and to identify strategies to deal with them effectively. The nurse should not suggest that the patient has been mismanaging his health problem and the nurse should not make comparisons with other patients. Further assessment should precede educational interventions.

A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply. A) Foods B) Medications C) Insect stings D) Autoimmunity E) Environmental pollutants

Ans: A, B, C Feedback: Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities.

A patient with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the patient about this treatment? A) The patient will be given a low dose of epinephrine before the treatment. B) The patient will remain in the clinic to be monitored for 30 minutes following the injection. C) Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months. D) The allergen will be administered by the peripheral intravenous route.

Ans: B Feedback: Although severe systemic reactions are rare, the risk of systemic and potentially fatal anaphylaxis exists. Because of this risk, the patient must remain in the office or clinic for at least 30 minutes after the injection and is observed for possible systemic symptoms. Therapeutic failure is evident when a patient does not experience a decrease in symptoms within 12 to 24 months. Epinephrine is not given prior to treatment and the IV route is not used.

A patient is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the patient begins to exhibit signs and symptoms of a transfusion reaction. The patient is suffering from which type of hypersensitivity? A) Anaphylactic (type 1) B) Cytotoxic (type II) C) Immunecomplex (type III) D) Delayed type (type IV)

Ans: B Feedback: A type II hypersensitivity reaction resulting in red blood cell destruction is associated with blood transfusions. This type of reaction does not result from types I, III, or IV reactions.

A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is a priority for health education? A) The need to begin immunotherapy as soon as possible B) The need for the parents to carry an epinephrine pen C) The need to vigilantly maintain the child's immunization status D) The need for the child to avoid all foods that have a high potential for allergies

Ans: B Feedback: All patients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed. The child does not necessarily need to avoid all common food allergens. Immunotherapy is not indicated in the treatment of childhood food allergies. Immunizations are important, but do not address food allergies.

A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurses priority for care? A) Monitor the patients level of consciousness. B) Protect the patients airway. C) Provide psychosocial support. D) Administer medications as ordered.

Ans: B Feedback: Anaphylaxis severely threatens a patients airway; the nurses priority is preserving airway patency and breathing pattern. This is a higher priority than other valid aspects of care, including medication administration, psychosocial support, and assessment of LOC.

A nurse knows of several patients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which patient? A) A patient who has previously been treated for tuberculosis B) A pregnant woman at 30 weeks gestation C) A patient who is on estrogen-replacement therapy D) A patient with a severe allergy to eggs

Ans: B Feedback: Antihistamines are contraindicated during the third trimester of pregnancy. Previous tuberculosis, hormone therapy, and food allergies do not contraindicate the use of antihistamines.

The nurse in an allergy clinic is educating a new patient about the pathology of the patients health problem. What response should the nurse describe as a possible consequence of histamine release? A) Constriction of small venules B) Contraction of bronchial smooth muscle C) Dilation of large blood vessels D) Decreased secretions from gastric and mucosal cells

Ans: B Feedback: Histamines effects during the immune response include contraction of bronchial smooth muscle, resulting in wheezing and bronchospasm, dilation of small venules, constriction of large blood vessels, and an increase in secretion of gastric and mucosal cells.

A patient is learning about his new diagnosis of asthma with the asthma nurse. What medication has the ability to prevent the onset of acute asthma exacerbations? A) Diphenhydramine (Benadryl) B) Montelukast (Singulair) C) Albuterol sulfate (Ventolin) D) Epinephrine

Ans: B Feedback: Many manifestations of inflammation can be attributed in part to leukotrienes. Medications categorized as leukotriene antagonists or modifiers such as montelukast (Singulair) block the synthesis or action of leukotrienes and prevent signs and symptoms associated with asthma. Diphenhydramine prevents histamines effect on smooth muscle. Albuterol sulfate relaxes smooth muscle during an asthma attack. Epinephrine relaxes bronchial smooth muscle but is not used on a preventative basis.

A patient was prescribed an oral antibiotic for the treatment of sinusitis. The patient has now stopped, stating she developed a rash shortly after taking the first dose of the drug. What is the nurses most appropriate response? A) Encourage the woman to continue with the medication while monitoring her skin condition closely. B) Refer the woman to her primary care provider to have the medication changed. C) Arrange for the woman to go to the nearest emergency department. D) Encourage the woman to take an OTC antihistamine with each dose of the antibiotic.

Ans: B Feedback: On discovery of a medication allergy, patients are warned that they have a hypersensitivity to a particular medication and are advised not to take it again. As a result, the patient would need to liaise with the primary care provider. There is no need for emergency care unless symptoms worsen to involve respiratory function. An antihistamine would not be an adequate or appropriate recommendation from the nurse.

A patient has a documented history of allergies presents to the clinic. She states that she is frustrated by her chronic nasal congestion, anosmia (inability to smell) and inability to concentrate. The nurse should identify which of the following nursing diagnoses? A) Deficient Knowledge of Self-Care Practices Related to Allergies B) Ineffective Individual Coping with Chronicity of Condition and Need for Environmental Modification C) Acute Confusion Related to Cognitive Effects of Allergic Rhinitis D) Disturbed Body Image Related to Sequelae of Allergic Rhinitis

Ans: B Feedback: The most appropriate nursing diagnosis is Ineffective Individual Coping with Chronicity of Condition and Need for Environmental Modification. This nursing diagnosis is all encompassing of the subjective and objective data. Altered body image and acute confusion are not evidenced by the data. The patients condition is not necessary attributable to a knowledge deficit.

A nurse at an allergy clinic is providing education for a patient starting immunotherapy for the treatment of allergies. What education should the nurse prioritize? A) The importance of scheduling appointments for the same time each month B) The importance of keeping appointments for desensitization procedures C) The importance of avoiding antihistamines for the duration of treatment D) The importance of keeping a diary of reactions to the immunotherapy

Ans: B Feedback: The nurse informs and reminds the patient of the importance of keeping appointments for desensitization procedures, because dosages are usually adjusted on a weekly basis, and missed appointments may interfere with the dosage adjustment. Appointments are more frequent than monthly and antihistamines are not contraindicated. There is no need to keep a diary of reactions.

A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site? A) Forearm B) Thigh C) Deltoid muscle D) Abdomen

Ans: B Feedback: The patient is taught to position the device at the middle portion of the thigh and push the device into the thigh as far as possible. The device will autoinject a premeasured dose of epinephrine into the subcutaneous tissue.

A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem? A) Antigens have bound to antibodies and formed inappropriate immune complexes. B) The patients body has mistakenly identified a normal constituent of the body as foreign. C) Sensitized T cells have caused cell and tissue damage. D) Mast cells have released histamines that directly cause cell lysis

Ans: B Feedback: Type II reactions, or cytotoxic hypersensitivity, occur when the system mistakenly identifies a normal constituent of the body as foreign. An example of this type of reaction is Goodpasture syndrome. Type III, or immune complex, hypersensitivity involves immune complexes that are formed when antigens bind to antibodies. Type IV hypersensitivity is mediated by sensitized T cells that cause cell and tissue damage. Histamine does not directly cause cell lysis.

A child has been transported to the emergency department (ED) after a severe allergic reaction. The ED nurse is evaluating the patients respiratory status. How should the nurse evaluate the patients respiratory status? Select all that apply. A) Facilitate lung function testing. B) Assess breath sounds. C) Measure the childs oxygen saturation by oximeter. D) Monitor the childs respiratory pattern. E) Assess the childs respiratory rate.

Ans: B, C, D, E Feedback: The respiratory status is evaluated by monitoring the respiratory rate and pattern and by assessing for breathing difficulties, low oxygen saturation, or abnormal lung sounds such as wheezing. Lung function testing is a lengthy procedure that is not appropriate in an emergency context.

A patient has presented with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient? A) Promoting adequate perfusion in affected regions B) Promoting safe use of topical antihistamines C) Identifying the offending agent, if possible D) Teaching the patient to safely use an EpiPen

Ans: C Feedback: Identifying the offending agent is a priority in the care of a patient with dermatitis. Antihistamines are not administered topically and epinephrine is not used to treat dermatitis. Inadequate perfusion occurs with PAD or vasoconstriction.

A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect? A) Cytotoxic reaction due to contact with the powder in the gloves B) Immune complex reaction due to contact with anesthetic gases C) Anaphylaxis due to a latex allergy D) Delayed reaction due to exposure to cleaning products

Ans: C Feedback: Immediate hypersensitivity to latex, a type I allergic reaction, is mediated by the IgE mast cell system. Symptoms can include rhinitis, conjunctivitis, asthma, and anaphylaxis. The term latex allergy is usually used to describe the type I reaction. The rapid onset is not consistent with a cytotoxic reaction, an immune complex reaction, or a delayed reaction.

A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis? A) Herpes simplex B) HIV C) Spina bifida D) Hypogammaglobulinemia

Ans: C Feedback: Patients with spina bifida are at a particularly high risk for developing a latex allergy. This is not true of patients with herpes simplex, HIV, or hypogammaglobulinemia.

A nurse is aware of the need to assess patients risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis? A) Administration of the measles-mumps-rubella (MMR) vaccine B) Rapid administration of intravenous fluids C) Computed tomography with contrast solution D) Administration of nebulized bronchodilators

Ans: C Feedback: Radiocontrast agents present a significant threat of anaphylaxis in the hospital setting. Vaccinations less often cause anaphylaxis. Bronchodilators and IV fluids are not implicated in hypersensitivity reactions

A child is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are common allergens? A) Citrus fruits and rice B) Root vegetables and tomatoes C) Eggs and wheat D) Hard cheeses and vegetable oils

Ans: C Feedback: The most common causes of food allergies are seafood (lobster, shrimp, crab, clams, fish), legumes (peanuts, peas, beans, licorice), seeds (sesame, cottonseed, caraway, mustard, flaxseed, sunflower seeds), tree nuts, berries, egg white, buckwheat, milk, and chocolate.

A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, When I was young I used to take antihistamines, but they always put me to sleep. How should the nurse best respond? A) Newer antihistamines are combined with a stimulant that offsets drowsiness. B) Most people find that they develop a tolerance to sedation after a few months. C) The newer antihistamines are different than in years past, and cause less sedation. D) Have you considered taking them at bedtime instead of in the morning?

Ans: C Feedback: Unlike first-generation H1 receptor antagonists, newer antihistamines bind to peripheral rather than central nervous system H1 receptors, causing less sedation, if at all. Tolerance to sedation did not usually occur with first-generation drugs and newer antihistamines are not combined with a stimulant.

A patient who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should the nurse implement? A) The patient should take his corticosteroids regularly prior to testing. B) The patient should only be tested for grass, mold, and dust initially. C) The nurse should have an emergency cart available in case of anaphylaxis during the test. D) The patients test should be cancelled until he is off his corticosteroids.

Ans: D Feedback: Corticosteroids and antihistamines, including over-the-counter allergy medications, suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. Emergency equipment must be at hand during allergy testing, but the test would be postponed

A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin? A) Immunoglobulin A B) Immunoglobulin M C) Immunoglobulin G D) Immunoglobulin E

Ans: D Feedback: Atopy refers to allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions

The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized? A) Risk for Infection Related to Skin Sloughing B) Risk for Acute Pain Related to Loss of Skin Integrity C) Risk for Impaired Skin Integrity Related to Cutaneous Lesions D) Risk for Impaired Gas Exchange Related to Airway Obstruction

Ans: D Feedback: Edema of the respiratory tract can compromise the airway in patients with hereditary angioedema. As such, this is a priority nursing diagnosis over pain and possible infection. Skin integrity is not threatened by angioedema.

A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow? A) The patient must not have received an immunization within 7 days. B) The nurse should administer albuterol 30 to 45 minutes prior to the test. C) Prophylactic epinephrine should be administered before the test. D) Emergency equipment should be readily available.

Ans: D Feedback: Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing.

The nurse is providing health education to the parents of a toddler who has been diagnosed with food allergies. What should the nurse teach this family about the childs health problem? A) Food allergies are a life-long condition, but most families adjust quite well to the necessary lifestyle changes. B) Consistent use of over-the-counter antihistamines can often help a child overcome food allergies. C) Make sure that you carry a steroid inhaler with you at all times, especially when you eat in restaurants. D) Many children outgrow their food allergies in a few years if they avoid the offending foods.

Ans: D Feedback: Many food allergies disappear with time, particularly in children. About one-third of proven allergies disappear in 1 to 2 years if the patient carefully avoids the offending food. Antihistamines do not cure allergies and an EpiPen is carried, not a steroid inhaler.

An adolescent patients history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient consequently faces an increased risk of what health problem? A) Bronchitis B) Systemic lupus erythematosus (SLE) C) Rheumatoid arthritis D) Asthma

Ans: D Feedback: Nurses should be aware that atopic dermatitis is often the first step in a process that leads to asthma and allergic rhinitis. It is not linked as closely to bronchitis, SLE, and RA

A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the patient to do? A) Wear powdered latex gloves when in public. B) Wash her hands with antibacterial soap every few hours. C) Maintain room temperature at 75F to 80F whenever possible. D) Keep her hands well-moisturized at all times.

Ans: D Feedback: Powdered latex gloves can cause contact dermatitis. Skin should be kept well-hydrated and should be washed with mild soap. Maintaining roomtemperature at 75F to 80F is not necessary.

Which of the following individuals would be the most appropriate candidate for immunotherapy? A) A patient who had an anaphylactic reaction to an insect sting B) A child with allergies to eggs and dairy C) A patient who has had a positive tuberculin skin test D) A patient with severe allergies to grass and tree pollen

Ans: D Feedback: The benefit of immunotherapy has been fairly well established in instances of allergic rhinitis and bronchial asthma that are clearly due to sensitivity to one of the common pollens, molds, or household dust. Immunotherapy is not used to treat type I hypersensitivities. A positive tuberculin skin test is not an indication for immunotherapy.

The nurse is creating a care plan for a patient suffering from allergic rhinitis. Which of the following outcomes should the nurse identify? A) Appropriate use of prophylactic antibiotics B) Safe injection of corticosteroids C) Improved skin integrity D) Improved coping with lifestyle modifications

Ans: D Feedback: The goals for the patient with allergies may include restoration of normal breathing pattern, increased knowledge about the causes and control of allergic symptoms, improved coping with alterations and modifications, and absence of complications. Antibiotics are not used to treat allergies and corticosteroids, if needed, are not administered parenterally. Allergies do not normally threaten skin integrity.

A nurse is caring for a patient who has allergic rhinitis. What intervention would be most likely to help the patient meet the goal of improved breathing pattern? A) Teach the patient to take deep breaths and cough frequently. B) Use antihistamines daily throughout the year. C) Teach the patient to seek medical attention at the first sign of an allergic reaction. D) Modify the environment to reduce the severity of allergic symptoms.

Ans: D Feedback: The patient is instructed and assisted to modify the environment to reduce the severity of allergic symptoms or to prevent their occurrence. Deep breathing and coughing are not indicated unless an infection is present. Anaphylaxis requires prompt medical attention, but a minority of allergic reactions are anaphylaxis. Overuse of antihistamines reduces their effectiveness.