Chapter 20 - hypersensitivity TB and evolve
The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity?
"The reaction of sensitized T-cells with antigen and release of lymphokines activate macrophages and induce inflammation."
Which patient condition would necessitate the nurse to wear latex-free gloves when providing care?
A patient with spina bifida
The nurse plans to assess a patient with type I hypersensitivity for which clinical manifestation?
Allergic asthma
Which is an example of a type I hypersensitivity reaction?
Angioedema
A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over- the counter antihistamines. What response by the nurse is most appropriate?
Antihistamines do not help poison ivy.
A patient with a type I allergy is treated with antihistamines and corticosteroids. What other measure can help the patient to prevent future recurrence of allergies?
Avoidance therapy
Assessment findings reveal that a patient admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this patient?
Communicate the need for avoidance therapy to the health care team.
The nurse is caring for a patient with a poison ivy skin rash. What type of hypersensitive reaction is the patient experiencing?
Delayed reaction
A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best?
Ensure the information is relayed to the surgical team. A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment.
A patient is experiencing a severe type I hypersensitivity reaction resulting in angioedema. What is the nurse's priority action?
Finding out what medications the patient is taking
The nurse is reviewing the medical record of a patient who is prescribed a decongestant. The nurse plans to contact the patient's health care provider if the patient has which condition?
Hypertension
Which type of hypersensitivity is a cell-mediated immunity with T-lymphocyte as the reactive cell?
Delayed hypersensitivity
A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
I dont need to go to the hospital after using it.
A patient is diagnosed with a type I hypersensitivity. Which antibody level increases during this type of allergy?
IgE
A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important?
Instruct the client not to get up without help.
Which type of hypersensitivity is anaphylaxis?
Rapid hypersensitivity
What is the role of decongestants in the treatment of a type I hypersensitivity?
Reduce edema
During the physical examination, the patient reports a history of latex allergy. Which item may cause this reaction?
Surgical gloves
A patient has developed a type IV hypersensitivity reaction. Which immune cells or components are involved in this type of reaction?
T-cells
Which type of hypersensitivity may be associated with rhinorrhea?
Type I hypersensitivity
A nurse works in an allergy clinic. What task performed by the nurse takes priority?
Checking emergency equipment each morning
A patient is suffering with type I hypersensitivity. Which questions does the nurse ask during the assessment? Select all that apply.
"Do you have any food or drug allergies?" "Do you have any family members with a type I allergy?" "When did this problem begin and how long does each episode last?"
