Chapter 42
Which immune cells are disrupted when a child is infected with human immunodeficiency virus (HIV)? Select all that apply.
-T cells -B cells -Phagocytes
Which client will the nurse assess first after receiving shift report?
A client with human immunodeficiency virus (HIV) whose temperature is 102.2°F (39°C Of the immunologic disorders, HIV infection is the most serious. This client is also exhibiting an unexpected manifestation, which could indicate an infection. The clients with serum sickness and dermatitis are exhibiting expected findings and would be seen last. The client newly diagnosed needs to be seen second to have the medication started and receive education.
(ALLERGIC RHINITIS) A child with a known allergy to bees is stung while on the playground at school. The school nurse is the first to arrive and notes the child is wheezing and begins vomiting. What will the nurse do first?
Administer epinephrine. The nurse's first action when a child is experiencing an allergic reaction is to administer epinephrine to reverse the effects. After administering epinephrine, the nurse should call an ambulance, apply ice, and administer an antihistamine, such as diphenhydramine.
A nurse instructor is teaching pregnant women how HIV can spread from mother to fetus without treatment. For the untreated child who contracts HIV through placental transmission, when will the child test positive for HIV?
By 6 months of age HIV appears to progress more rapidly in untreated infants and children who contract it through placental transmission. These children usually are HIV positive by 6 months old and develop clinical signs by 1 to 3 years old. If a mother is treated for HIV during pregnancy, the infant will also receive HIV medication for 6 weeks after birth. The infant will need to be tested at 1 month of age and at 4 months of age. This testing will determine the absence of HIV in the infant.
(ALLERGIC RHINITIS) The nurse is educating a child with a peanut allergy about the signs and symptoms of an anaphylactic reaction. The nurse realizes additional teaching is needed when the child identifies which sign/symptom?
Constipation Signs and symptoms of an anaphylactic allergic reaction include nausea, anxiety, and itchy mouth. Diarrhea, rather than constipation, is a sign of an allergic reaction.
Atopic Dermatitis (Infantile Eczema) The parents of a 3-month-old infant report concerns the infant is irritable, feeds poorly, and has a rash. The nurse notes weeping, crusty lesions on the infant's cheeks and neck. Which action by the nurse is most appropriate?
Contact the health care provider to request treatment Infants that feed poorly, are irritable, and have a weeping, crusty rash on the checks and neck may have atopic dermatitis (infantile eczema). The nurse should contact the health care provider to request treatment, which may include methods to avoid allergens. Although reducing exposure to identified allergens is important, a 3-month-old infant should not be eating peanuts, so this information would not be appropriate at this time.
Atopic Dermatitis (Infantile Eczema) A 30-year-old female is diagnosed with allergic contact dermatitis of the face, likely due to a nickel allergy from the frames of her glasses. What treatment would you recommend other than avoidance of nickel?
Corticosteroid cream. A topical corticosteroid works by decreasing certain immune responses, which reduces redness and itching of skin. ---Erythromycin gel is a topical macrolide antibiotic that is thought to improve acne by slowing the growth of bacteria on the skin, which causes acne. ---Fluconazole is a topical anti-fungal medication used to treat skin conditions such as ringworm or psoriasis. --Ketoconazole is used to treat skin infections such as athlete's foot, jock itch, ringworm, and certain kinds of dandruff.
(ALLERGIC RHINITIS) The school nurse is walking through the lunchroom when one of the children says she started to feel strange after trading lunches with a friend. Which assessment would be most important?
Determining if her throat itches
(ALLERGIC RHINITIS) The school nurse is teaching a child with stinging-insect allergies how to avoid insects while on the class trip. Which instruction will the nurse provide?
Do not sit by the garbage can. Because garbage attracts insects, being aware of where garbage cans are placed can decrease exposure and limit contact. Any time outside throughout the day can place someone at risk, not just during the heat of the day. Perfume and cologne both have a scent that can attract insects. Wearing a hair net that contains the hair still allows scents of shampoo or hairspray to be circulated and is not the most helpful advice.
A nurse is preparing a plan of care for a child with a primary immunodeficiency. Which nursing diagnosis is the priority?
Ineffective protection related to impaired humoral defenses The child with a primary immunodeficiency lacks the necessary immune responses that provide protection from infection. Therefore, the priority nursing diagnosis would be ineffective protection. Imbalanced nutrition and risk for delayed growth and development may be appropriate, but these would not be the priority. Acute pain would be more appropriate for a child with juvenile idiopathic arthritis.
Atopic Dermatitis (Infantile Eczema) A 25-year-old female presents to you with a rash over her eyelids after using a new cosmetic brand. What is the BEST test to confirm the cause of the rash?
Patch testing. Patch testing on the skin with suspected offending agents may clarify the diagnosis of contact dermatitis. Immunofluorescence (IF) or cell imaging techniques rely on the use of antibodies to label a specific target antigen with a fluorescent dye (also called fluorophores or fluorochromes) such as fluorescein isothiocyanate (FITC). Skin prick testing or SPT demonstrates an allergic response to a specific allergen. Punch biopsy is considered the primary technique to obtain diagnostic, full-thickness skin specimens.
Atopic Dermatitis (Infantile Eczema) A 6-month-old girl is diagnosed as having atopic dermatitis. When interviewing her parents, they describe the following care measures. Which one would lead you to think more health teaching is needed?
To dry lesions, the father applies alcohol to lesions daily. Alcohol would be painful against open lesions.
(ALLERGIC RHINITIS) A child with allergic rhinitis (hay fever) is prescribed a nasal antihistamine spray. When advising parents about the use of such sprays, the nurse would tell them about a rebound phenomenon. This phenomenon results in:
an increase in nasal secretions after an initial decrease. Nasal antihistamine sprays reduce inflammation at first; after 3 days, they actually cause inflammation.
(ALLERGIC RHINITIS) Nursing students correctly label the group of cells whose job is to ingest, engulf, and neutralize pathogens as:
macrophages. Macrophages (mature white blood cells) engulf, ingest, and neutralize pathogens. Red blood cells do not fight infection. They carry hemoglobin and carry oxygen from the lungs to the tissues. In the immune response, immunoglobulins are antibodies and immunogens are antigens.
(ALLERGIC RHINITIS) A 5-year-old has allergic rhinitis. It would be most appropriate to collect information regarding the child's exposure to which substances?
pollens Allergic rhinitis (hay fever) occurs most often in response to inhalation of pollens.
The most accurate screening test for the presence of HIV antigen in young children is:
polymerase chain reaction (PCR). PCR tests directly for the HIV antigen.
(ALLERGIC RHINITIS) The nurse is reviewing a child's chart and notes hypersensitivity reactions under the diagnosis section. Which additional diagnosis would confirm a type III hypersensitivity reaction? Select all that apply.
rheumatoid arthritis and systemic lupus erythematosus Examples of type III hypersensitivity include rheumatoid arthritis and systemic lupus erythematosus. Contact dermatitis is an example of a type IV hypersensitivity reaction. Asthma and atopic dermatitis are examples of type I hypersensitivity reactions
(ALLERGIC RHINITIS) A child's mother asks the nurse how likely it is the child will develop asthma because the child's father has asthma. Which response by the nurse is most appropriate?
"Immune responses can be genetic and run in the family." The nurse's most appropriate response is to explain that there are familial tendencies with allergic responses but not all family members manifest the symptoms in the same way. For example, if the father has asthma, the child may have allergic rhinitis. Asthma cannot be prevented by avoiding allergens; however, asthma symptoms can be managed by avoiding allergens.
(ALLERGIC RHINITIS) A child allergic to insect stings presents to the school nurse stating, "A bee stung me on the playground." Which action by the nurse is priority?
Assess the client's airway and breathing rate The nurse would be concerned that the client may experience an anaphylactic reaction and would first assess the client's airway and breathing. If needed, the nurse would then administer epinephrine, a vasopressor which reverses the effects of histamine, which can cause severe bronchospasm and edema in clients. The nurse would assess the site and remove the stinger and notify caregivers and the primary health care provider once the client is determined to be stable
(ALLERGIC RHINITIS) Food allergies have become more and more common in the last few decades. What are some common food allergies of childhood? Select all that apply
Eggs, Peanuts, Milk, Shrimp Allergies to eggs, peanuts, and milk are common in childhood. Cheerios are made of oats and are not known to be allergenic. Apples also are not allergenic, unlike bananas, which can cause problems for children who have latex allergies.
Atopic Dermatitis (Infantile Eczema) A 28 yr-old nurse has complaints of itching and a rash of both hands. Contact dermatitis is initially suspected. The diagnosis is confirmed if the rash appears:
Erythematous with raised papules. Contact dermatitis is caused by exposure to a physical or chemical allergen, such as cleaning products, skin care products, and latex gloves. Initial symptoms of itching, erythema, and raised papules occur at the site of the exposure and can begin within 1 hour of exposure. Allergic reactions tend to be red and not scaly or flaky. Weeping, crusting lesions are also uncommon unless the reaction is quite severe or has been present for a long time. Excoriation is more common in skin disorders associated with a moist environment.
The nurse is instructing a group of women of childbearing age about human immunodeficiency virus (HIV) during pregnancy. What would be a priority recommendation in this setting?
Screening for HIV No screening mandate has been put forth for HIV, but all pregnant women should be encouraged to undergo this test. Prophylactic treatment would be initiated only once the woman has been screened. Screening for STIs and ensuring proper nutrition are also part of health promotion for women in this age group, but they are of lower priority than identifying HIV-positive individuals.
A nurse is providing education to pregnant women diagnosed with HIV. Which statement indicates the need for further teaching?
Pregnancy will accelerate the progression of the disease. Of the nearly 1,000,000 people in the United States infected with HIV, 25% are female. There isn't any research showing pregnancy accelerates the progression of the disease. Women with HIV should not breastfeed, because they could transmit the virus to the baby via the breastmilk. Early use of antiretroviral medications are effective in reducing transmission, and a cesarean birth may be scheduled to reduce potential transmission to the newborn.
(ALLERGIC RHINITIS) A child comes to the emergency department with difficulty breathing from severe bronchoconstriction. The parent informs the nurse that the child ate a peanut, to which the child is allergic. Which type of reaction is this client having?
Type I: anaphylaxis Anaphylaxis is an acute reaction characterized by extreme vasodilatation that leads to circulatory shock and extreme bronchoconstriction, which in turn decreases the airway
Atopic Dermatitis (Infantile Eczema) Contact dermatitis is a type of hypersensitivity:
Type IV. ---Type IV hypersensitivity is a delayed hypersensitivity reaction that are inflammatory in nature initiated by mononuclear leukocytes. ---Type I hypersensitivity is triggered by an innocuous foreign substance (like dust, pollen or animal dander) that would cause no problems in the majority of people. ---Type II hypersensitivity is the process by which IgG or IgM binds to a cell to cause injury or death (Antibody Dependent Cytotoxicity). ---Type III hypersensitivity is tissue damage created by immune complexes, which are aggregations of antigen and antibodies.
(ALLERGIC RHINITIS) To avoid anaphylactic reactions in children, which question would be most important to ask a parent before administering penicillin to her infant?
"Has she ever had penicillin before?" Penicillin is a drug frequently involved in allergic reactions. The reaction occurs after the child has first been sensitized to the drug.
The nurse is working with a pregnant client who is HIV positive and has been prescribed oral zidovudine. Which statement by the nurse explains the primary rationale for taking this medication?
"It is to help prevent transmission of the disease to your infant." A goal of therapy during pregnancy is to maintain the CD4 cell count at greater than 500 cells/mm3 by administering oral zidovudine, which helps halt maternal/fetal transmission dramatically along with one or more protease inhibitors, such as ritonavir or indinavir, in conjunction with a nucleoside reverse transcriptase inhibitor (NRTI). ---Kaposi sarcoma is normally treated with chemotherapy. Women may need a platelet transfusion close to birth to restore coagulation ability. This medication has no affect on the fetus's growth and development.
Atopic Dermatitis (Infantile Eczema) The parents are concerned their child with atopic dermatitis is having an allergic reaction to diphenhydramine because the child became "sleepy and has a dry throat" after receiving the medication. Which education provided to the parents by the nurse is most important?
"Side effects, such as drowsiness and dryness, do not indicate an allergy." Although children with atopic dermatitis (eczema) are more likely to develop a medication allergy, side effects of diphenhydramine (drowsiness, dry mouth, constipation, etc.) can occur normally alongside the therapeutic effect of the medication. Common side effects do not indicate a toxic amount of the medication was given. Signs of an allergic reaction to a medication include: urticaria, angioedema, allergic contact dermatitis, flushing, pruritus, purpura, wheezing and/or rhinitis.
Atopic Dermatitis (Infantile Eczema) A nurse is preparing a teaching plan for the parents of an infant with atopic dermatitis. Which topics are essential to ensure appropriate care? Select all that apply
-It tends to occur more frequently in formula-fed infants. --Soap has a tendency to increase the pruritus. ---The scalp and forehead are commonly affected. Atopic dermatitis is more problematic in the winter months when additional irritating clothing is present. Dermatitis tends to improve in the summer months. Atopic dermatitis is found more frequently in formula-fed infants. Sweating, heat, tight clothing, and contact irritants such as soap increase the pruritus. The common sites for lesions include the scalp, forehead, cheeks, neck, behind the ears, and extensor surfaces of the extremities. Skin testing is ineffective because the allergen causing the condition is often a food allergen.
(ALLERGIC RHINITIS) The nurse is helping the parents of a toddler identify foods that are causing allergic symptoms in the child. Which strategy should the nurse encourage the parents to use?
Elimination diet An elimination diet is a traditional method to detect food allergens. Parents feed the child only foods that rarely cause allergy, such as rice, lamb, carrots, peas, and sweet potatoes, for about 7 days. Then they add, one by one, at 2- to 3-day intervals, foods that are suspected of causing allergy. When a food is introduced this way, the child must be encouraged to eat a lot of it that day. If symptoms occur, the food is then eliminated from the child's meals on a permanent basis. If no symptoms occur, the child can continue to eat the food. Hyposensitivity testing is unreliable with food allergies. Corticosteroids delay hypersensitivity reactions. It is difficult to totally eliminate protein from the diet, and this is not a method to determine the cause of food allergies in the toddler.
(ALLERGIC RHINITIS) A 9-year-old client presents to the emergency department after a bee sting and experiencing bouts of nausea and vomiting. The nurse notes the client's blood pressure is 68/40 mm Hg, pulse is 48 beats/minute, O2 saturation is 86%, and the child is dyspneic. Which action will the nurse take?
Give epinephrine. The child is having an anaphylactic reaction; therefore, epinephrine is needed immediately. It works by relaxing the muscles in the airways and tightening the blood vessels. Benadryl in not needed until the client's airway is established. The nurse can look for the stinger and remove and apply ice to the site (decrease inflammation and constrict vessels) after the client's airway is secured.
(ALLERGIC RHINITIS) When describing anaphylaxis to a group of parents whose children have experienced anaphylaxis from insect stings, the nurse integrates knowledge that this response is related to which immunoglobulin?
IgE Anaphylaxis is an acute IgE-mediated response to an allergen that involves many organ systems and may be life-threatening.
(ALLERGIC RHINITIS) When providing discharge instructions to a child who was admitted to the hospital following stridor, wheezing, and urticaria after taking penicillin, which nursing action is priority?
Encourage the child to wear a medical alert bracelet for penicillin. Oral medications most likely to cause an allergic reaction include antibiotics, acetylsalicylic acid (aspirin), and NSAIDs. Children experiencing stridor, wheezing, and urticaria after taking a medication most likely have an allergy to that medication. The priority nursing action for discharge education is to prevent the child from being exposed to penicillin again, which could be accomplished by encouraging the child to wear a medical alert bracelet. Although children with atopic diseases are more likely to have medication allergies, requesting parents have the child evaluated is not a priority. Questioning the child about the amount of penicillin taken and educating parents about the side effects of penicillin is not a priority.
A client in the fourth month of pregnancy has recently learned that the sexual partner is HIV-positive. The client agrees to be tested for the virus but asks, " If I am positive, how will it change my birth plan?" How will the nurse respond?
You may want to consider a cesarean birth. The pregnant client will be screened for HIV immediately to determine HIV status. If positive, it is helpful in planning in case the newborn needs immediate antiviral therapy. Though pregnancy does not appear to accelerate the progression of the disease, it can affect the birthing plan. To prevent the transmission of the disease through vaginal birth, a client may be offered a cesarean birth. An epidural may be discouraged due to the presence of thrombocytopenia associated with the disease process. There is no need for antibiotics because HIV is a virus. Unless born in distress, newborns are able to remain within their birth parent following the birth process.
(ALLERGIC RHINITIS) The nurse is caring for a child who is receiving a skin test to determine the presence of allergies. A positive skin test for one particular allergen shows the mediation of which type of immune globulin?
IgE Skin testing is done to detect the presence of IgE in the skin that responds to a particular allergen. IgM is part of the body's primary response, and IgG is part of the body's secondary response to infection. IgA is present in the mucous membranes of the body to fight against infection.