Hypersensitivity

4) The nurse is caring for a client in an allergy clinic. After completing the client history, the nurse selects the nursing diagnosis of Risk for Shock. Which item in the client's history supports the need for this nursing diagnosis? A) Anaphylactic reaction to shellfish B) A drug reaction to penicillin causing a rash C) Glomerulonephritis D) Dermatitis resulting from a response to laundry detergent

Answer: A Explanation: A) Type I hypersensitivities, such as anaphylactic reactions, occur immediately and may be life-threatening. Because the client has a history of this type of reaction, Risk for Shock is an appropriate nursing diagnosis. The other items would not necessitate the need for this nursing diagnosis.

10) A pediatric client with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen. Which statements are appropriate for the nurse to include in the discharge instructions for this client and family? Select all that apply. A) "It is recommended that the child wear a medical alert bracelet." B) "This medication does not come prefilled and must be measured." C) "Keep the medication in the car at all times." D) "Frequently check the expiration date of the medication." E) "Keep the medication in one location that is easy to remember."

Answer: A, D Explanation: A) An EpiPen is a prefilled syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provide thorough teaching regarding use of the EpiPen. The nurse should recommend that the client wear a medical alert bracelet. The medication should not be kept in the car at all times, as it needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. Also, the EpiPens' expiration dates should be checked frequently to ensure accurate strength.

8) A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee stings. Which clinical manifestations would necessitate injecting the child with epinephrine (EpiPen)? Select all that apply. A) Skin that is cold and clammy to the touch B) Skin that is warm and dry to the touch C) Hyperverbal behavior D) Extreme anxiety and agitation E) Facial swelling

Answer: A, D, E Explanation: A) General symptoms of shock that would necessitate an epinephrine injection include cold and clammy skin (which is indicative of decreased perfusion), extreme anxiety and agitation, and facial angioedema. Clients who are experiencing shock are unlikely to be hyperverbal due to respiratory symptoms that make breathing and speaking difficult.

14) Why are second-generation antihistamines often preferred to first-generation histamines in the treatment of hypersensitivity reactions? A) Second-generation antihistamines are faster acting than first-generation antihistamines. B) Second-generation antihistamines are less likely than first-generation antihistamines to cause drowsiness. C) Second-generation antihistamines are available over the counter, whereas first-generation antihistamines require a prescription. D) Second-generation antihistamines can be administered either orally or parenterally, whereas first-generation antihistamines can only be given via the oral route.

Answer: B An important difference between first- and second-generation antihistamines is that unlike the first-generation drugs, the newer second-generation drugs do not cause drowsiness. Both first- and second-generation antihistamines are available by prescription and over the counter. The preferred route of administration for both first- and second-generation antihistamines is oral, although diphenhydramine (a first-generation drug) and some other medications may be given parenterally. Second-generation antihistamines are not universally faster-acting than their first-generation counterparts.

9) Which of the following statements is true with regard to food allergies and children? A) Over the past decade, the prevalence of peanut allergy has decreased in the pediatric population. B) Many children eventually outgrow egg, milk, and soy allergies. C) Teenagers with food allergies are at lower risk for an allergic reaction than younger clients because they are more aware of their trigger foods and how to avoid them. D) Peanut allergies are most common in pediatric clients over 5 years of age.

Answer: B Explanation: A) It is not uncommon for people to outgrow allergies to egg, milk, soy, and wheat as they age; however, allergies to shellfish, peanuts, and fish usually persist throughout an individual's life. Among pediatric clients, the prevalence of peanut allergy has increased in recent years, with children under age 3 most commonly affected. As compared to younger children, teenagers with food allergies have the highest risk for an allergic reaction because they have a greater tendency to eat meals outside the home and are less likely to carry their medication.

12) The nurse suspects that the client is experiencing a reaction to a specific antigen. Which laboratory result supports the conclusion made by the nurse? A) Indirect Coombs test showing no agglutination B) Patch test with a 1-inch area of erythema C) 2% eosinophils in the WBC count D) Rh antigen test with negative results

Answer: B Explanation: An area of erythema after a patch test indicates a positive response to a specific antigen. In contrast, an indirect Coombs test detects the presence of circulating antibodies against RBCs; no agglutination is considered a normal finding. Similarly, an eosinophil count of 2% is within the normal range. Finally, an Rh antigen test with a negative result indicates that the client does not carry the antigen; accordingly, this result is not an indicator of a reaction to a specific antigen.

11) A nurse is caring for a client with seasonal hypersensitivity reactions. What teachings should the nurse provide to improve this client's comfort? Select all that apply. A) Keep doors and windows open on high-allergen days to circulate air. B) Remain indoors if possible on high-allergen days. C) Maintain a clean, dust-free environment. D) Take antihistamine and leukotriene medications as ordered. E) Stop taking oral corticosteroids immediately once symptoms disappear.

Answer: B, C Explanation: A) A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include information about taking antihistamine and antileukotriene medications, not leukotriene medications. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.

2) The nurse is assessing a client who is receiving IV antibiotics. Which item in the client's health history increases the risk for experiencing a hypersensitivity reaction? A) 26 years of age B) Caucasian race C) Previous antibiotic therapy D) Concurrent chronic illness

Answer: C Explanation: Anyone can have a hypersensitivity reaction. However, risk generally increases with previous exposure, because antigens must be formed with the first exposure before hypersensitivity is likely to occur. Age, sex, concurrent illnesses, and previous reactions to related substances have all been identified as having a role in risk for hypersensitivity; however, previous exposure presents the greatest risk.

7) The nurse is caring for a client with a history of latex allergies. The client develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which of the following is the priority intervention for this client? A) Teach the client regarding use of a kit that contains treatment for allergic reactions. B) Administer diphenhydramine (Benadryl) by mouth every 4 hours per the healthcare provider's orders. C) Administer epinephrine 1:1000 by subcutaneous injection per the healthcare provider's orders. D) Collect a detailed history from the client regarding the history of latex allergies.

Answer: C Explanation: For reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the nature and severity of symptoms. Diphenhydramine may also be given, but it would likely be administered by injection rather than mouth due to the need for rapid drug onset. Although providing client teaching and collecting a detailed history are also important, the nurse does not have time to do these things until the client's immediate and potentially dangerous physical symptoms are addressed.

13) In what ways do type IV hypersensitivity reactions differ from other types of hypersensitivity reactions? A) Unlike other types of hypersensitivity reactions, type IV reactions are antibody-mediated responses and develop almost immediately. B) Unlike other types of hypersensitivity reactions, type IV reactions are cell-mediated responses and develop almost immediately. C) Unlike other types of hypersensitivity reactions, type IV reactions are antibody-mediated responses and take 24 hours or more to develop. D) Unlike other types of hypersensitivity reactions, type IV reactions are cell-mediated responses and take 24 hours or more to develop.

Answer: D Explanation: A) Type IV reactions differ from other hypersensitivity responses in two ways. First, they are cell-mediated immune responses, not antibody-mediated responses, that involve the T cells of the immune system. Second, type IV reactions are delayed rather than immediate, developing 24-48 hours after exposure to an antigen.

1) A nurse is caring for a pediatric client who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the client is experiencing a type I hypersensitivity reaction? A) Erythema B) Fever C) Joint pain D) Hypotension

Answer: D Explanation: Clinical manifestations associated with a type I hypersensitivity reaction include hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria. Erythema and fever are associated with type IV hypersensitivity reactions. Fever and joint pain are associated with type III hypersensitivity reactions.

3) The nurse is admitting a pediatric client to the hospital with a ventriculoperitoneal (VP) shunt malfunction. When gathering the history, the nurse learns that the client received the shunt at birth after a meningocele repair. Based on this data, which product should be avoided when providing care to this client? A) Synthetic rubber gloves B) Polyethylene gloves C) Non-powdered nitrile gloves D) Latex gloves

Answer: D Explanation: Meningocele is a form of spina bifida, and clients with a history of spina bifida are at increased risk for latex allergy. Thus, it is important for the nurse and other healthcare providers to use latex alternative products on this client, such as synthetic rubber gloves, polyethylene gloves, and non-powdered nitrile gloves.

6) The nurse is caring for a client who is experiencing anaphylactic shock following the administration of a medication. Based on this data, which position is the most appropriate for the nurse to place the client? A) Trendelenburg position B) Flat, with legs slightly elevated C) Supine position D) High-Fowler position

Answer: D Explanation: The Trendelenburg position elevates the foot of the bed and is no longer recommended for the treatment of shock, as it causes the abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. Lying flat is not recommended. A person in a supine position may not be able to maintain an open airway. Instead, placing the client in Fowler or high-Fowler position allows optimal lung expansion and ease of breathing.

5) The nurse is preparing to assess a client when one of the client's family members begins showing symptoms of latex sensitivity. Which action by the nurse is the most appropriate? A) Ask the family member to leave the unit. B) Transfer the client to a department that does not use latex products. C) Wait until Monday to report the problem to the unit supervisor. D) Obtain latex-free products for the client's room.

Answer: D Explanation: When symptoms of sensitivity to latex occur on exposure, latex-free products should be supplied. Transferring the client to a department that does not use latex products is unrealistic because the family member might experience exposure on another unit. (No hospital unit can be completely latex-free.) Waiting until Monday does not solve the problem. Asking the family member to leave would be a violation of the client's rights.