Chapter 37: Assessment and management of patients with allergic disorders

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated? A.) IgA B.) IgB C.) IgE D.) IgG

ANSWER: C.) IgE Rationale: Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates complement. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.

The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction? A.) Symptoms are localized to the area of exposure, usually the back of the hands. B.) Symptoms can be eliminated by changing glove brands. C.) Symptoms worsen when hand lotion is applied before donning latex gloves. D.) Symptoms occur within minutes after exposure to latex.

Answer: A.) Symptoms are localized to the area of exposure, usually the back of the hands. Rationale: Clinical manifestations of a delayed hypersensitivity reaction are localized to the area of exposure. Clinical manifestations of an irritant contact dermatitis can be eliminated by changing glove brands or using powder-free gloves. With an irritant contact dermatitis, avoid use of hand lotion before donning gloves; this may worsen symptoms, as lotions may leach latex proteins from the gloves. When clinical manifestations occur within minutes after exposure to latex, which is described as a latex allergy, an immediate hypersensitivity (type I) allergic reaction has occurred.

A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit? A.) type I B.) type II C.) type III D.) type IV

Answer: A.) type I Rationale: There are four types of hypersensitivity responses, three of which are immediate. This is an example of Type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies.

A client has been seeing an allergist for 6 months for treatment of allergies. The client's allergies have been insufficiently controlled by symptomatic treatments and the physician has suggested desensitization. The anticipated outcome of desensitization is that repeated exposure to the: A.) weak antigen promotes the production of IgG, an antibody that blocks IgE so it cannot stimulate mast cells. B.) strong antigen promotes the production of IgE, an antibody that blocks IgG so it cannot stimulate mast cells. C.) weak antigen promotes the production of IgE, an antibody that blocks IgG so it cannot stimulate basophils. D.) strong antigen promotes the production of IgG, an antibody that blocks IgE so it cannot stimulate basophils.

Answer: A.) weak antigen promotes the production of IgG, an antibody that blocks IgE so it cannot stimulate mast cells. rationale: Desensitization is a form of immunotherapy in which a person receives weekly or twice weekly injections of dilute but increasingly higher concentrations of an allergen without interruption. Repeated exposure to the weak antigen promotes the production of IgG, an antibody that blocks IgE so it cannot stimulate mast cells.

A client with an allergic disorder calls the nurse and asks what treatment is available for allergic disorders. The nurse explains to the client that there is more than one treatment available. What treatments would the nurse tell the client about? A.) Sublingual-swallow immunotherapy (SLIT) B.) Desensitization C.) Sublingual-topical immunotherapy (STIT) D.) Resensitization

Answer: B.) Desensitization Rationale: Desensitization is another option. Desensitization is a form of immunotherapy in which a person receives weekly or twice-weekly injections of dilute but increasingly higher concentrations of an allergen without interruption. SLIT is a form of desensitization therapy. Options C and D are distractors for this question.

The nurse knows the best strategy for latex allergy is A.) corticosteroids. B.) avoidance of latex-based products. C.) antihistamines. D.) epinephrine from an emergency kit.

Answer: B.) avoidance of latex-based products. Rationale: The best strategy available for latex allergy is to avoid latex-based products, but this is often difficult because of their widespread use. Antihistamines and an emergency kit containing epinephrine should be provided to these clients, along with instructions about emergency management of latex allergy.

The nurse tells the client that if exposure to an allergen occurs around 8:00 AM, then the client should expect a mild or moderate reaction by what time? A.) 11:00 AM B.) 1:00 PM C.) 10:00 AM D.) 3:00 PM

Answer: C.) 10:00 AM Rationale: Mild and moderate reactions begin within 2 hours of exposure.

Which group of mediators initiates the inflammatory response? A.) Lymphokines B.) Mast cells C.) Leukotrienes D.) Prostaglandins

Answer: C.) Leukotrienes Rationale: Leukotrienes are a group of chemical mediators that initiate the inflammatory response. Lymphokines are substances released by sensitized lymphocytes when they contact specific organs. Mast cells are connective tissue that contains heparin and histamine in their granules. Prostaglandins are unsaturated fatty acids that have a wide assortment of biologic activity.

What is the most common cause of anaphylaxis? A.) Opioids B.) NSAIDs C.) Penicillin D.) Radiocontrast agent

Answer: C.) Penicillin

When assessing the skin of a client with allergic contact dermatitis, the nurse would most likely expect to find irritation at which area? A.) Dorsal aspect of the hand B.) Lower arms C.) Ankles D.) Plantar aspects of the feet

Answer: A.) Dorsal aspect of the hand Rationale: With allergic contact dermatitis, irritation is most common on the dorsal aspects of the hand. Irritant, phototoxic, and photoallergic types of contact dermatitis are commonly seen on the hands and lower arms.

The nurse explains to a client that immunotherapy initially starts with injections at which interval? A.) Daily B.) Weekly C.) Bi-monthly D.) Monthly

Answer: B.) Weekly Rationale: Typically, immunotherapy begins with very small amounts and gradually increases, usually at weekly intervals until a maximum tolerated dose is attained. Then maintenance booster injections are administered at 2- to 4-week intervals, frequently for a period of several years.

Which allergic reaction is potentially life threatening? A.) angioedema B.) urticaria C.) contact dermatitis D.) None of the listed allergic reactions is potentially life threatening.

Answer: A.) angioedema Rationale: Angioedema is potentially life threatening. Medical management would include intubation, subcutaneous epinephrine, and aminophylline in severe reactions.

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder? A.) To decrease the body's risk of infection B.) Because an autoimmune disease is a neoplastic disease C.) So the client has strong drug therapy D.) For their immunosuppressant effects

Answer: D.) For their immunosuppressant effects Rationale: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not ordered just so the client has strong drug therapy.

Which term refers to an incomplete antigen? A.) Hapten B.) Allergen C.) Antigen D.) Antibody

Answer: A.) Hapten Rationale: A hapten is an incomplete antigen. An allergen is a substance that causes manifestations of allergy. An antigen is a substance that induces the production of antibodies. An antibody is a protein substance developed by the body in response to and interacting with a specific antigen.

A patient with a history of allergies comes to the clinic for an evaluation. The following laboratory test findings are recorded in a patient's medical record: Total serum IgE levels: 2.8 mg/mL White blood cell count: 5,100/cu mm Eosinophil count: 4% Erythrocyte sedimentation rate: 20 mm/h The nurse identifies which result as suggesting an allergic reaction? A.) Serum IgE level B.) White blood cell count C.) Eosinophil count D.) Erythrocyte sedimentation rate

Answer: A.) Serum IgE level Rationale: Normally, serum IgE levels are below 1.0 mg/mL. The patient's level is significantly elevated suggesting allergic reaction. The other values are within normal parameters.

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.) A disorder where the body has too many immunoglobulins. B.) A disorder where histocompatible cells attack the immunoglobulins. C.) A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." D.) A disorder where the body does not have enough immunoglobulins.

Answer: C.) A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Rationale: Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells-those cells that are "self." Autoantibodies, antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder.

Which intervention is the single most important aspect for the client at risk for anaphylaxis? A.) Use of antihistamines B.) Desensitization C.) Wearing a medical alert bracelet D.) Prevention

Answer: D.) Prevention Rationale: Prevention involves strict avoidance of potential allergens for the individual at risk for anaphylaxis. If avoidance of or exposure to allergens is impossible then the individual should be prepared with an emergency kit containing epinephrine for injection to prevent the onset of the reaction upon exposure. While helpful, there must be no lapses in desensitization therapy because this may lead to the reappearance of an allergic reaction when the medication is reinstituted. A medical alert bracelet will assist those rendering aid to a client who has experienced an anaphylactic reaction. antihistamines may not be effective in preventing anaphylaxis.

The nurse is teaching a client about allergic rhinitis and its triggers. What is the most common trigger for the respiratory allergic response? A.) animal dander B.) dust mites C.) mold spores D.) plant pollen

Answer: D.) plant pollen Rationale: Plant pollen (from trees, grass, and other plants) causes the most common form of allergic rhinitis, which is known as hay fever. Animal dander, dust mites, and mold spores can be triggers, but are not the most common causes.

A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment? A.) Dyspnea, bronchospasm, and/or laryngeal edema. B.) Hypotension and tachycardia C.) The presence and location of pruritus D.) The severity of cutaneous warmth and flushing

Answer: A.) Dyspnea, bronchospasm, and/or laryngeal edema. Rationale: Severe systemic, anaphylactic reactions have an abrupt onset with the same signs and symptoms described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.

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? A.) High IgE concentration B.) High neutrophil count C.) Low eosinophil count D.) Low white blood cell count

Answer: A.) High IgE concentration Rationale: A high total IgE concentration and/or a high percentage of eosinophils may indicate an allergic disorder. However, normal IgE levels do not exclude the diagnosis of an allergic disorder. The amounts of neutrophils and white blood cells are not affected by allergic disorders.

A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines? A.) Diarrhea B.) Anorexia C.) Palpitations D.) Sedation

Answer: D.) Sedation Rationale: Antihistamines are the major class of medications prescribed for the symptomatic relief of allergic rhinitis. The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines.

The nurse is teaching a group of health care workers about latex allergies. What reaction will the nurse teach the workers to be most concerned about with laryngeal edema? A.) irritant contact B.) allergic contact C.) IgE-mediated hypersensitivity D.) IgG antibodies

Answer: C.) IgE-mediated hypersensitivity Rationale: A type I, IgE-mediated hypersensitivity can cause severe reaction symptoms such as laryngeal edema and bronchospasm. Irritant and allergic contact dermatitis result in more localized skin reactions. IgG antibodies are important in fighting viral and bacterial infections.

A client is experiencing an acute hemolytic reaction. What actions should the nurse take? Select all that apply. - Discontinue the intravenous line the blood was transfusing through. - Dispose of the blood container and tubing. - Check for low back pain. - Assess for anxiety and mental status changes. - Notify the health care provider.

Answer: - Check for low back pain. - Assess for anxiety and mental status changes. - Notify the health care provider. Rationale: The intravenous line is needed to give fluids and medications through. The blood container and tubing need to be sent back to the blood bank for repeat typing and culture. Low back pain is a symptom of acute hemolytic reaction. Anxiety and mental status changes are symptoms of acute hemolytic reaction. The health care provider needs to be notified because he/she may need to see the client and order further treatments.

A patient comes to the clinic with pruritus and nasal congestion after eating shrimp for lunch. The nurse is aware that the patient may be having an anaphylactic reaction to the shrimp. These symptoms typically occur within how many hours after exposure? A.) 2 hours B.) 6 hours C.) 12 hours D.) 24 hours

Answer: A.) 2 hours rationale: Mild systemic, anaphylactic reactions consist of peripheral tingling and a sensation of warmth, possibly accompanied by a sensation of fullness in the mouth and throat. Nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes can also be expected. Onset of symptoms begins within the first 2 hours after exposure.

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? A.) Avoids massaging the injection site after administration B.) Jabs the autoinjector into the outer thigh at a 90-degree angle C.) Pushes down on the grey release cap to administer the medication D.) Maintains pressure on the auto-injector for about 30 seconds after insertion

Answer: B.) Jabs the autoinjector into the outer thigh at a 90-degree angle Rationale: To self-administer epinephrine, the client should remove the autoinjector from its carrying tube, grasp the unit with the black tip (injecting end) pointed downward, form a fist around the device, and remove the gray safety release cap. Then the client should hold the black tip near the outer thigh and swing and jab firmly into the outer thigh at a 90-degree angle until a click is heard. Next, the client should hold the device firmly in place for about 10 seconds, remove the device, and massage the site for about 10 seconds.

When evaluating a client's knowledge about use of antihistamines, what statement indicates further education is required? A.) "This medication may be taken with food." B.) "Hard candy will relieve my dry mouth." C.) "If I am pregnant, I should take half the dose." D.) "I should be careful when driving."

Answer: C.) "If I am pregnant, I should take half the dose." Rationale: Antihistamines are contraindicated during the third trimester of pregnancy, in nursing mothers and newborns, in children and elderly people, and in patients whose conditions may be aggravated by muscarinic blockade (e.g., asthma, urinary retention, open-angle glaucoma, hypertension, prostatic hyperplasia). The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines. Additional side effects include nervousness, tremors, dizziness, dry mouth, palpitations, anorexia, nausea, and vomiting.

A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse? A.) "You need to come back to the clinic to get a different medication since this one is not working for you." B.) "You may be immune to the effects of this medication and will need something else in its place." C.) "The full benefit of the medication may take up to 2 weeks to be achieved." D.) "I am sorry that you are feeling poorly but this is the only medication that will work for your problem."

Answer: C.) "The full benefit of the medication may take up to 2 weeks to be achieved." Rationale: Patients must be aware that full benefit of corticosteroid nasal sprays may not be achieved for several days to 2 weeks.

After receiving a dose of penicillin, a client develops dyspnea and hypotension and the nurse suspects the client is experiencing anaphylactic shock. What is the nurse's first action? A.) Page an anesthesiologist immediately. B.) Administer epinephrine, as ordered. C.) Continue to monitor the client's vital signs. D.) Insert an indwelling urinary catheter.

ANSWER: B.) Administer epinephrine, as ordered. Rationale: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator, as ordered. The health care provider is likely to order additional medications, such as antihistamines and corticosteroids; if the medications don't relieve the respiratory compromise associated with anaphylaxis. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring with a Foley catheter; however, administering epinephrine is the first priority.

T-cell deficiency occurs when which gland fails to develop normally during embryogenesis? A.) Thyroid B.) Thymus C.) Pituitary D.) Adrenal

Answer: B.) Thymus

Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle? A.) Histamine B.) Bradykinin C.) Serotonin D.) Prostaglandin

Answer: A.) Histamine Rationale: When cells are damaged, histamine is released. Bradykinin is a polypeptide that stimulates nerve fibers and causes pain. Serotonin is a chemical mediator that acts as a potent vasoconstrictor and bronchoconstrictor. Prostaglandins are unsaturated fatty acids that have a wide assortment of biologic activities.