Chapter 34: Caring for Clients with Immune- Mediated Disorders

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?

"It is a hyperimmune response to something in the environment that is usually harmless."

The nurse has four clients who are scheduled to see the physician for "fatigue" and other general symptom complaints. Which client does the nurse determine is at most risk for having chronic fatigue syndrome?

Caucasian female, age 47 years

A client comes to the clinic to see the physician with the complaint of "I think I ate something that I am allergic to." What symptoms would be appropriate for the nurse to ask the questions about?

Diarrhea and abdominal cramping

A client calls the clinic and asks the nurse if using Afrin nasal spray would be alright to relieve the nasal congestion he is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications?

Do not use Afrin for longer than 3 to 5 days in a row or rebound congestion can occur.

The clinic nurse is caring for a client with an allergic disorder who has received the first sensitizing dose of a new drug. What nursing action is most important at this point?

Monitor the client for reactions

A client injured the left eye while playing basketball when another player hit him in the eye with his elbow. The client complained that although the right eye was not affected, he is having difficulty now with the vision in that eye too. What does the nurse understand this phenomenon is known as?

Sympathetic uveitis

What data does the nurse monitor during a tilt- table test?

Temperature and pulse

A client is scheduled to have a prick test to determine what specific allergens are creating problems for the client. What should the nurse inform the client is involved with the testing?

The skin will be scratched, and applying a small amount of the liquid test antigen to the scratch, usually on the back.

What is the best nursing explanation for why antihistamines are used cautiously in older men with prostatic hypertrophy?

They may experience difficulty voiding

The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states he is allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?

Apply an allergy bracelet and flag the chart

A client presents to the clinic with complaints that he began to itch and break out in hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?

Diphenhydramine (Benadryl)

What is the most appropriate information for the nurse to give a client with an autoimmune disorder who is taking a corticosteroid such as prednisone (Medicorten)?

Do not stop taking the drug suddenly

A client is scheduled for diagnostic skin testing in 1 week. What should the nurse be sure to instruct the client prior to the scheduled appointment?

Do not take prescribed or over-the-counter antihistamines or cold preparations for at least 72 hours before testing.

What is the role of nurse during the scratch test to detect allergies?

Document the findings

A client with an allergic disorder is in treatment for his disorder. What might the treatment be?

Drug therapy for symptoms

You are caring for a client with chronic fatigue syndrome. What is a realistic nursing intervention when taking care of a client with this diagnosis?

Educate the client about the disease process

Which of the following is the most important nursing action in the management of a client with CFS?

Educating the client about the disease and its limitations

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?

For their immunosuppressant effects

The client is scheduled for a tilt-table test to assist in the diagnosis of chronic fatigue syndrome (CFS). What is the nurse's responsibility while the client is having the test?

Position the client while monitoring blood pressure and pulse.

You are caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?

Progressive tissue damage without any verifiable etiology

A client comes to the clinic and informs the nurse that he feels as though he has allergies. What laboratory test results will be a positive indicator for an allergic disorder?

Radioallergosorbent blood test (RAST) of 3

A client with Crohn's disease, an autoimmune disorder, informs the nurse that he has not had any symptoms of the disease in 8 months. What does the nurse understand this asymptomatic period is referred to?

Remission

A client is taking oral corticosteroids after having an exacerbation of asthma. What should the nurse be sure to include when instructing the client how to take the medication?

Take the medication in the morning with food.

The nurse is collecting data from a client with the autoimmune disorder, endocarditis. What does the nurse recognize as symptom of an acute exacerbation?

Temperature of 100.9° F

The nurse is instructing a client with chronic fatigue syndrome about what type of dietary sources are the best to eat to supply eicosapentaenoic acid (EPA). What statement by the client demonstrates the instruction is understood?

"Fresh salmon is one of my favorites, and I will eat it twice a week."

A client is taking the immunosuppressant medication, azathioprine (Imuran), for the treatment of Crohn's disease. What statement made by the client demonstrates an understanding of the side effects of this medication?

"I will notify the doctor if I have a fever or any other signs of infection."

A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse?

"It is important that you continue to take your medication to avoid an acute exacerbation."

A client comes to the clinic and states he has "broken out in hives and itching since eating strawberries this morning." The client states he has never had problems with strawberries before. What is the best response by the nurse?

"It is possible to develop an allergic reaction to something you have had prior exposure to previously."

A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse?

"The doctor could prescribe anti-inflammatory drugs."

A client is given a dose of ketorolac (Toradol), a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do?

Administer epinephrine

The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?

Airway obstruction

Which of the following is the most severe complication the nurse can expect among clients with allergies, regardless of the type?

Anaphylaxis

A client has been having joint pain and swelling in the left foot and is diagnosed with rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and the client has significant joint destruction. What type of disease is this considered?

Autoimmune

Your client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?

Avoid antihistamines and cold preparations for 48 to 72 hours before the test.

A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included?

Be alert for signs and symptoms of infection and report them immediately to the physician.

A client informs the nurse that he is very allergic to poison ivy but loves to go camping and has several camping trips planned for the summer months. What suggestions can be made to protect against poison ivy?

Bentoquatam 5% (Ivy Block) applied 15 minutes prior to exposure and every 4 hours

A client comes to the clinic and informs the nurse that he had a mild case of the flu a couple of months ago and "hasn't felt well since." The client tells the nurse that he is fatigued and it gets worse after any physical activity and a recurrent sore throat and joint pain. What does the nurse recognize these symptoms may indicate?

Chronic fatigue syndrome

A client is experiencing itching and redness of the eyes. Which of the following would be the best nursing recommendation?

Consult an ophthalmologist for evaluation

When a client is diagnosed with an autoimmune disorder, which of the following statements by the nurse is accurate?

These disorders may have remissions

What is the best nursing responses when a client asks for the reason he or she must avoid taking antihistamine or cold preparations for at least 24 to 72 hours before undergoing a diagnostic skin test?

They may cause false- negative test results

A client has an allergic reaction to seafood with generalized edema and informs the nurse that he is unable to get his wedding ring off and it is too tight. The client was unable to remove it with soap and water. What action by the nurse can facilitate removal of the ring without damaging it?

Use twine to wrap the finger and, when the tissue is compressed, pull the free end of the twine and remove the ring.

A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring?

Delayed hypersensitivity response

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?

A disorder where killer T cells and autoantibodies attack or destroy natural cells— those cells that are "self."

The nursing instructor is discussing allergic reactions with her clinical group. What allergic reactions would the nursing instructor talk about? Select all that apply.

Cytotoxic Atopic Immune complex