Chapter 34: Caring for Clients with Immune-Mediated Disorders
A clinic nurse has been charged with the responsibility of teaching avoidance strategies to an adult patient who has allergic rhinitis. What measure should the nurse recommend to this patient?
"If possible, make sure that no one smokes tobacco in your home."
A home health nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurse's teaching?
"My family needs to understand that I'll probably need lifelong treatment."
Which of the following is the most frequent route of exposure to a latex allergy?
Cutaneous
The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?
Intradermal
Which of the following disorders is characterized by an increased autoantibody production?
Systemic lupus erythematosus (SLE)
A mother has come to the emergency department (ED) with her 2-year-old who appears to be having a hypersensitivity reaction. The ED nurse knows that a hypersensitivity reaction may be characterized by an immediate reaction beginning within minutes of exposure to an antigen. What condition is an example of such a reaction?
Anaphylactic reaction immediately following a bee sting
A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodeficiency disease (SCID). What medication should the nurse administer prior to initiating the infusion?
Diphenhydramine
A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?
Dyspnea, bronchospasm, and/or laryngeal edema.
A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow?
Emergency equipment should be readily available.
Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?
Histamine
A client 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 client will present with what alteration in laboratory values?
Increased eosinophils
An immunocompromised client is being treated in the hospital. The nurse's assessment reveals that the client's submandibular lymph nodes are swollen, a finding that represents a change from the previous day. What is the nurse's most appropriate action?
Inform the client's primary care provider of this finding.
Which intervention is the single most important aspect for the client at risk for anaphylaxis?
Prevention
The nurse is planning the care of a client 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 client's care plan?
Risk for Disturbed Body Image Related to Skin Lesions
A nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care?
Risk for Falls Due to Loss of Muscle Coordination
A client 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?
The client's test should be cancelled until he is off his corticosteroids.
The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family?
The need to report any slight changes in the client's health status
A child has been transported to the emergency department (ED) after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply.
Assess the child's respiratory rate. Measure the child's oxygen saturation by oximeter. Assess breath sounds. Monitor the child's respiratory pattern.
A client with a diagnosis of primary immunodeficiency disease informs the nurse that he has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the client's vital signs are within reference ranges, what action should the nurse take?
Assess the client for signs and symptoms of infection.
The nurse is caring for a client whose most recent laboratory values reveal a neutrophil level of 21,000 mm3. When preparing to assess the client, the nurse should prioritize what assessment?
Assessing the client for signs and symptoms of infection
The nurse is teaching a client after a medication allergic reaction has occurred. What is the most important action for the nurse to teach the client to take to prevent anaphylaxis?
Avoid potential allergens.
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
Bone marrow transplantation
Which allergic reaction is potentially life threatening?
angioedema
Fibromyalgia is a common condition that involves
chronic fatigue, generalized muscle aching, and stiffness.
The nurse is reviewing various medications with a client that can be used to treat allergic disorders. What medication will the nurse identify as an intranasal corticosteroid?
fluticasone
In its attempt to suppress allergic responses, the body releases several chemicals which have a role in mediating physical reactions. Epinephrine, which interferes with vasoactive chemical release from mast cells, is instrumental in suppressing which type of hypersensitivity response?
type I
Family members of an immunocompromised client have asked the nurse why antibiotics are not being given to the client in order to prevent infection. How should the nurse best respond?
"Using antibiotics to prevent infections can cause the growth of drug-resistant bacteria."
Patient teaching regarding infection prevention for the patient with an immunodeficiency includes which of the following guidelines?
Cook all food thoroughly.
The nurse is working with the interdisciplinary team to care for a client who has recently been diagnosed with severe combined immune deficiency (SCID). What treatment is likely of most benefit to this client?
Hematopoietic stem cell transplantation (HSCT)
A client 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?
Immunoglobulin E
After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action?
Jabs the autoinjector into the outer thigh at a 90-degree angle
The parents of a 3-year-old boy have just been informed that allergy testing suggests their son has multiple food allergies. When providing health education for this family, what subject should the nurse prioritize?
Possible sources of food allergens and strategies for avoiding offending foods
A nurse is preparing to discharge a patient with an immunodeficiency. When preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize?
Signs and symptoms of adverse reactions
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a client's plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
Spina bifida
A nurse is providing health education regarding self-care to a patient with an immunodeficiency. What teaching point should the nurse emphasize?
The need for thorough oral hygiene
What education should the nurse provide to the patient taking long-term corticosteroids?
The patient should not stop taking the medication abruptly and should be weaned off of the medication.
A nurse is planning the care of a client who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this client?
Thorough and consistent hand hygiene
A young couple visits the nurse practitioner stating that they want to start a family. The husband states that his brother died of a severe infection at age 6 months. He says he never knew what was wrong but his mother had him undergo "blood testing" as a child. Based on these statements, what health problem should the nurse practitioner suspect?
X-linked agammaglobulinemia
At an office birthday party, one of the executives ate a piece of cake that he was unaware had been made with peanut oil. He begins wheezing, with an inspiratory stridor and air hunger. The occupational health nurse is called to the office. The nurse recognizes he is suffering from which type of hypersensitivity?
Anaphylactic (type 1)
The nurse is evaluating a client's complete blood cell count and differential along with the serum immunoglobulin E (IgE) concentration. Which result might indicate that the client has an allergic disorder?
High IgE concentration
A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"?
Only use the nasal spray for 3 to 4 days once every 12 hours.
The nurse is providing care for a client who has a diagnosis of hereditary angioedema. When planning this client's care, what nursing diagnosis should be prioritized?
Risk for Impaired Gas Exchange Related to Airway Obstruction
A nurse caring for a client who has an immunosuppressive disorder knows that continual monitoring of the client is critical. What is the primary rationale behind the need for continual monitoring?
So that early signs of impending infection can be detected and treated
A nurse is working in a dermatology clinic with clients who have allergies. What is the most important chemical mediator involved in the allergic response?
histamine
A client is distressed and frustrated reporting severe, ongoing fatigue that doesn't subside with rest. The nurse explains that chronic fatigue syndrome results from:
immune system dysregulation.