Chapter 18

Which questions are most important for the nurse to ask first to prevent harm for a client who comes to the emergency department with signs of severe angioedema? SATA A. "Are you able to swallow?" B. "When did you last eat or drink?" C. "Do you have an allergy to cortisone?" D. "What drugs do you take on a daily basis?" E. "Is there any possibility that you may be pregnant?" F. "Do any members if your family also have allergies?"

"Are you able to swallow?" "What drugs do you take on a daily basis?"

Which client statement indicates to the nurse that more teaching about systemic lupus erythematosus is needed? A. "During flares, I may need higher doses of my coritcosteroids." B. " I will take walks and stretch my muscles daily even when my joints hurt." C. "If I do not have a flare in over a year. I can stop taking my anti-inflammatory drugs." D. "If my urine becomes bloody or foamy, I will call my rheumatology health care provider immediately."

"If I do not have a flare in over a year. I can stop taking my anti-inflammatory drugs."

What precaution is most important for the nurse to teach the client with systemic lupus erythematosus (SLE) prescribed to take 40 mg of a corticosteroid daily for 2 weeks to manage an SLE flare? A. "Take this drug at bedtime to avoid nausea and vomiting." B. "Avoid crowds and anyone who is ill because this drug reduces your immunity." C. "Drink at least 3 liters of fluid per day because this drug can cause kidney damage." D. "If you are vomiting and cannot take the oral drug, contact your health care provider immediately."

"If you are vomiting and cannot take the oral drug, contact your health care provider immediately."

What is the nurse's best response when client recovering from drug-induced angioedema caused by an ACEI asks why it took 6 months before a reaction occurred? A. "As your blood pressure was reduced, less drug was needed and the excess triggered an allergic response." B. "Possibly when you took your most recent dose you held it in your mouth too long instead of swallowing it, causing a local response." C. "It takes time for a main body chemical causing the reaction to build-up enough to cause symptoms." D. "If you took this drug with grapefruit juice, the two substances together are much more likely to result in an allergic reaction."

"It takes time for a main body chemical causing the reaction to build-up enough to cause symptoms."

Which statement made by a client who is scheduled to undergo diagnostic testing with use of contrast dye requires the nurse to take action to prevent harm? A. "Both diabetes and high blood pressure run in my family." B. "My sister is allergic to the dye that they use for x-ray procedures." C. "I have a lot of seasonal allergies, and they make me pretty miserable." D. "Last year I had a test with dye and my face got so swollen I could not see."

"Last year I had a test with dye and my face got so swollen I could not see."

Systemic lupus erythematosus (SLE)

A chronic and progressive autoimmune disorder in which inflammatory and immune attacks occur against multiple self tissues and organs

Anaphylaxis

A condition in which a type 1 hypersensitivity reaction involves all blood vessels and bronchiolar smooth muscle, causing widespread blood vessel dilation, decreased cardiac output, and bronchoconstriction

Autoimmunity

A process whereby an inappropriate immunity develops to an adult's own tissues

Lyme disease

A reportable systemic infectious disease caused by the spirochete Borrelia burgdorferi

Angioedema

A sever type I hypersensitivity reaction that involves the blood vessels and all laters of the skin, mucous membranes, and subcutaneous tissues in the affected area

Inflammation

A syndrome of normal tissue responses to cellular, injury, allergy, or the inversion of pathogens

When taking the history of a client being treated for angioedema, which information does the nurse consider most relevant to the situation? SATA A. Has long time known allergy to penicillin B. African American C. Has severe hypertension D. Is 52 years old E. Has well-controlled type 2 diabetes mellitus F. Has taken an angiotensin-converting enzyme inhibitor for 8 months G. Takes a beta blocker daily H. Eats a vegan diet

African Americans Has taken an angiotensin-converting enzyme inhibitor for 8 months

Allergen

An antigen that triggers excessive inflammation or immunity overreactions only in susceptible individuals

Autoantigens

Antibodies directed against self tissues and cells

Which action is a priority for the nurse to perform before giving the first dose of any drug or therapeutic agent to a client? A. Ask the patient about allergies to drugs or other substances B. Be aware of type of drugs that are likely to cause allergic reactions C. Check the medication administration record for allergic response to drugs D. Make sure that emergency medications are readily available

Ask the patient about allergies to drugs or other substances

Which statement(s) about autoimmunity is/are accurate? SATA A. The basic pathophysiologic changes result in immunosuppresion B. Autoimmune disorders are most common among men over 60 years of age C. With early and appropriate management autoimmune disorders are highly curable D. Clients who have allergies as children usually develop autoimmune disorders as adults E. Autoimmune disorders are caused by excessive or overactive immune and inflammatory responses F. Clients who are most susceptible to developing autoimmune disorders are those who have human leukocyte antigen types DR2, DR3, DRB, DQB, and Cw6.

Autoimmune disorders are caused by excessive or overactive immune and inflammatory responses Clients who are most susceptible to developing autoimmune disorders are those who have human leukocyte antigen types DR2, DR3, DRB, DQB, and Cw6.

Which precautions are most important for the nurse to teach a client newly diagnosed with systemic lupus erythematosus (SLE) to prevent harm? SATA A. Avoiding direct sunlight B. Monitoring urine output C. Keeping open lesions clean and covered D. Avoiding the use of make-up E. Wearing a medical alert bracelet F. Avoiding any form of aerobic exercise G.being immunized yearly against influenza H. Avoiding the use of hair dyes and having permanents

Avoid direct sunlight Monitoring urine output Wearing a medical alert bracelet Being immunized yearly against influenza

Which prescription will the nurse question for a client who has an allergy to penicillin? A. Acetaminophen 650 mg every 4 hours for pain B. Angiotensin-converting enzyme inhibitor (ACEI) daily for hypertension C. Cephalosporin to treat a chronic sinus infection D. Decongestant as needed for rhino rr he's

Cephalosporin to treat a chronic sinus infection

Which nursing response is most likely to cause harm to a client who has anaphylaxis? A. Failing to inform the family about a change in the client's condition B. Using a non rebreather mask to administer oxygen C. Delaying the administration of epinephrine D. Increasing the IV saline flow rate

Delaying the administration of epinephrine

Which statement best describes allergy or hypersensitivity? A. Excessive response to the presence of an antigen B. Excessive response against self cells and their products C. Failure of the immune system to recognize self cells as normal D. Failure of the immune system to recognize pathogenic organisms as non-self

Excessive response to the presence of an antigen

Which new-onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm? A. Increased bruising B. Increased daily output of slightly foamy urine C. Failure to see letters in the middle of a word D. Sensation of nausea within an hour of taking the drug

Failure to see letters in the middle of a word

Which precaution has the highest priority for the nurse to teach a client taking an angiotensin converting enzyme inhibitor (ACE) to prevent harm? A. Go to the emergency department or call 911 if you develop tongue and lip swelling or have difficulty breathing B. Avoid touching this drug with your bare hands to prevent absorbing it through direct skin contact C. Stop taking the drug immediately if you develop a runny nose, itchy eyes, or persistent cough D. Take this drug with food or milk at the same time every day

Go to the emergency department or call 911 if you develop tongue and lip swelling or have difficulty breathing

Which factor for a client who has type 1 diabetes mellitus indicates to the nurse that the disorder most likely has an autoimmune origin rather than a lifestyle basis? A. Is a vegetarian whose diet is high in soy-based proteins B. Works in a large chemical manufacturing plant C. Has an identical twin with Graves' disease D. Has a parent with a severe peanut allergy

Has an identical twin with Graves' disease

Which statement(s) regarding type II hypersensitivity (cytotoxic) reactions is/are true? SATA A. Responses always occur within minutes of exposure to the allergen B. Hemolytic transfusion problems are an example of type II hypersensitivity C. Type II responses are usually directed against self cells attached to non-self cells and the response destroys the self cells. D. Susceptibility for developing a type II hypersensitivity response follows an autosomal dominant pattern of inheritance E. Rashes and blister formation from poison ivy exposure are a typical response for this type of hypersensitivity reaction F. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages G. An effective management strategy may include plasma filtration to remove specific substances

Hemolytic transfusion problems are an example of type II hypersensitivity Type II responses are usually directed against self cells attached to non-self cells and the response destroys the self cells. An effective management strategy may include plasma filtration to remove specific substances

Which vasoactive amine is most responsible for the initial symptoms of inflammation during an allergic reaction? A. Leukotriene B. Bradykinin C. Histamine D. Prostaglandins

Histamine

Which immunoglobulin elevation does the nurse expect to see in the laboratory report of a client who is having a type I hypersensitivity response? A. Immunoglobulin A (IgA) B. Immunoglobulin E (IgE) C. Immunoglobulin G (IgG) D. Immunoglobulin M (IgM)

Immunoglobulin E (IgE)

Which client laboratory test results will the nurse identify as supporting a diagnosis of systemic lupus erythematosus (SLE)? SATA A. Increased erythrocyte sedimentation rate (ESR) B. Decrease erythrocyte sedimentation rate (ESR) C. Increased complement C3 protein levels D. Increased basophils E. Decreased eosinophils F. Increased extra table nuclear protein antibodies

Increased erythrocyte sedimentation rate (ESR) Increased complement C3 protein levels Increased extra table nuclear protein antibodies

Which action will the nurse perform first for a client in anaphylaxis to prevent harm? A. Applying oxygen by non rebreather mask B. Administering IV diphenhydramine C. Injecting epinephrine D. Initiating IV access

Injecting epinephrine

Which client assessment finding indicates to the nurse the possibility of systemic lupus erythematosus (SLE)? A. Use of penicillin prophylactically before dental examinations and procedures B. Intermittent fever and fatigue with no other symptom of infection C. Joint and muscle pain without swelling after exercise D. Oily skin and increased facial acne

Intermittent fever and fatigue with no other symptom of infection

While waiting for the Rapid Response Team to arrive and assist a client with anaphylaxis, which nursing actions will the nurse take to help manage the situation? SATA A. Obtain IV access B. Apply oxygen C. Place the client in trendelenburg position D. Stay with the client E. Ask the client whether he or she has a specific drug allergy F. Ask the client whether other family members have ever had an allergic reaction G. Arrange for arterial blood to be drawn for blood gas evaluation H. Elevate the head of the bed

Obtain IV access Apply oxygen Stay with the client Elevate the head of the bed

Allergy/hypersensitivity

Overactive immunity with excessive inflammation occur in in response to the presence of an antigen to which the patient usually has been previously exposed

Which client symptoms that started after IV administration of a newly prescribed drug prompts the nurse to initiate the rapid response team for possible anaphylaxis? SATA A. Facial flushing B. Bradycardia C. Oxygen saturation of 88% D. Wheezing on exhalation E. Increased deep tendon reflexes F. Hives at the IV site spreading upward

Oxygen saturation of 88% Wheezing on exhalation Hives at the IV site spreading upward

Which drug does the nurse expect to administer first to a client with anaphylaxis? A. Oral diphenhydramine B. Parenteral epinephrine C. Albuterol via high-flow nebulizer D. Intravenous corticosteroids

Parenteral epinephrine

Which adult-onset disorders have an autoimmune component? SATA A. Asthma B. Cardiovascular disease C. Colorectal cancer D. Diabetes mellitus type 2 E. Pernicious anemia F. Psoriasis G. Rheumatoid arthritis H. Systemic lupus erythematosus

Pernicious anemia Psoriasis Rheumatoid arthritis Systemic lupus erythematosus

Which change in a client with angioedema indicates to the nurse that immediate action is needed to prevent harm? A. Systolic blood pressure decrease from 136 mm Hg to 120 mm Hg B. Presence of strider on inhalation and exhaulation C. Mouth breathing because of nasal swelling D. Inability to sip liquids through a straw

Presence of strider on inhalation and exhaustion

Immunity

Protection from illness or disease that is maintained by the body's physiologic defense mechanisms

Antigens

Proteins (usually) considered as non-self by a person's immune system that will stimulate the person's immune system to have an immunity response and make antibodies directed against the antigen

Which assessment findings does the nurse expect in a client who is having a localized reaction to an environmental allergen? A. Hypotension B. Blood clotting C. Persistent constipation D. Redness and swelling in contact areas

Redness and swelling in contact areas

What role do T-regulatory lymphocytes (Tregs) have in the development of autoimmune disease? A. Reduced numbers of Tregs lead to loss of self-tolerance B. The presence of Tregs inhibit secretion of tumor necrosis factor (TNF) C. Tregs secrete autoantibodies directed against one or more types of normal self cells D. Increased numbers of Tregs stimulate excessive amounts of cytokines that damage normal healthy tissues

Reduced numbers of Tregs lead to loss of self-tolerance

Which action does the nurse perform first to prevent harm when a client receiving IV penicillin reports difficulty breathing and feeling dizzy about 15 minutes after the infusion is started? A. Stop the infusion B. Initiate the rapid response team C. Assess the client's blood pressure D. Ask whether the client is allergic to penicillin

Stop the infusion

Which client symptom appearing 2 weeks after an extended camping trip does the nurse associate with the possibility of Lyme disease? A. Acute confusion B. Sudden onset of difficulty swallowing C. Sudden onset of painful, swollen joints D. Persistent watery diarrhea and weight loss

Sudden onset of painful, swollen joints

Which specific information will the nurse teach to the client with systemic lupus erythematosus newly prescribed belimumab therapy? A. Avoid injecting it in a site near a cutaneous lesion B. The drug can only be given by a health care professional C. Do not chew, crush, or split the tablet containing this drug D. The drug must be taken at bedtime because it causes extreme drowsiness

The drug can only be given by a health care professional

Which statement(s) regarding hypersensitivity reactions is/are accurate? SATA A. The predisposition to develop hypersensitivity is genetic B. Allergies to specific antigens (allergens) are directly inherited C. Hypersensitivity symptoms are triggered by excessive inflammation D. Avoidance of an antigen (allergen) reduces an adult's existing sensitivity to it E. A client may have more than one type of hypersensitivity reaction at the same time F. A person can develop hypersensitivity to almost any substance at any time during the lifespan

The predisposition to develop hypersensitivity is genetic Hypersensitivity symptoms are triggered by excessive inflammation A client may have more than one type of hypersensitivity reaction at the same time A person can develop hypersensitivity to almost any substance at any time during the lifespan

Which statement(s) regarding type 1, hypersensitivity reactions is/are true? SATA A. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine. B. The response is characterized by the five cardinal symptoms of inflammation C. Types I responses are usually directed against non-self but the response is excessive D. Susceptibility for developing a type I hypersensitivity response follows an X-linked recessive pattern of inheritance. E. This type of hypersensitivity reaction is most strongly associated with systemic lupus erythematosus F. Responses always occur within minutes of exposure to the allergen G. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema

The response is characterized by the five cardinal symptoms of inflammation Types I responses are usually directed against non-self but the response is excessive The second phase of the reaction with accumulation of excess bradykin is responsible for development of angioedema

Self-tolerance

The special ability of immune system cells to recognize self versus non-self and avoid actions that would harm self cells

Which statement(s) regarding type III hypersensitive reactions is/are true? SATA A. Type III responses are usually directed against self cells and tissues B. Susceptibility for developing a type III hypersensitivity response follows an autosomal dominant pattern of inheritance C. The hypersensitivity starts as a type II reaction that progresses to a type III reaction D. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages E. Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity F. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema

Type III responses are usually directed against self cells and tissues Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity

Human leukocyte antigens (HLAs)

Unique surface proteins present on all of a person's cells that are specific to him or her. Also known as a person's tissue type

Which actions will the nurse recommend to the client who has systemic lupus erythematosus (SLE) for relief of general joint and muscle pain? A. Warm, moist heat B. Medical marijuana C. Avoidance of all exercise D. Application of ice packs

Warm, moist heat

Five cardinal symptoms of inflammation

Warmth Redness Swelling Pain Decreased function