chapter 47
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."
The nurse is administering Viramune (nevirapine) to an adolescent client diagnosed with HIV. The client asks the nurse how this medication helps fight the HIV. How should the nurse respond?
"The medication disrupts the virus life cycle of HIV. This prevents the disease from progressing."
The nurse is providing discharge instructions for a client taking a corticosteroid. Which statements by the parents alert the nurse that clarification of instructions is needed?
"We should be sure to administer the medication on an empty stomach so the medication will be absorbed better." "If the medication doesn't seem to be working, we can stop giving it to our child at any time."
The nurse is caring for a child who is receiving an intravenous immunoglobulin treatment. The client calls the nurse and reports she vomited. What action should be completed first?
Discontinue the infusion.
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.
The registered nurse (RN) and unlicensed assistive personnel (UAP) are caring for a pediatric client with an immune disorder receiving a stem cell transplant. Which action by the UAP will cause the RN to intervene?
The UAP takes a rectal temperature on the client.
The nurse is caring for a child with HIV. Which assessment finding will require immediatenotification of the healthcare provider?
multiple purpura that do not blanch with pressure
The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant he gets a rash. It just doesn't make sense to me." How should the nurse respond?
"Has your child ever been tested for a peanut allergy?"
The nurse is caring for a 6-month-old infant with Wiskott-Aldrich syndrome. Which teaching does the nurse provide the parent?
"Do not insert anything in the rectum"
A nurse is conducting a physical examination of a 12-year-old girl with suspected systemic lupus erythematosus (SLE). How would the nurse best interview the girl?
"Have you noticed any hair loss or redness on your face?"
The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education?
"If we need to use the EpiPen® we will need to notify her physician's office the next business day."
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."
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)
The nurse in the emergency department is examining an 18-month-old child who recently received a first dose of penicillin. The nurse notes lip edema, urticaria, stridor, and tachycardia. Which action will the nurse take next?
Administer epinephrine
Which nursing intervention is priority when caring for a child with HIV?
Administer prescribed medications.
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.
The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of the greatest concern?
Elevated blood pressure
The nurse is providing education regarding 2020 Health Goals to reduce the incidence of acquired immunodeficiency syndrome (AIDS) within the community. Which goal will the nurse choose as a primary prevention strategy?
Provide education to sexually active females about proper condom usage.
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.
Which immunoglobin occurs most frequently in plasma and is the major immunoglobulin synthesized during secondary response?
IgG
The nurse is caring for a school-age child recently diagnosed with an allergy to peanuts. Which nursing action is a priority?
Include the child when discussing foods that contain peanuts.
While obtaining a health history on a 3-year-old child, the nurse finds what information a concern? Select all that apply.
Parents report the child has had recurrent bacterial infections. Parents report the child as an infant had failure to thrive. Parents report the child didn't start walking until 1 ½ years old. Parents report the child didn't sit up by herself until 9 months old.
The nurse is preparing a care plan for a 4-year-old client newly diagnosed with severe combined immune deficiency. What is the priority goal for this client?
The client will remain free from infection.
The nurse is providing instructions to the parents of a child with a severe peanut allergy. Which statement by the parents indicates a need for further teaching about the use of an epinephrine auto-injector?
The epinephrine auto-injector should be jabbed into the upper arm."
The nurse is preparing an educational program for members of the office staff. The topic is the warning signs of primary immunodeficiency. What information should be included? Select all apply.
Two or more episodes of severe sinusitis in 1 year. History of infections requiring IV antibiotics to clear. Two or more serious infections such as sepsis. Failure to thrive in an infant.
The nurse is educating an immunocompromised child about the organs that assist in the immune process. The nurse recognizes teaching was effective when the child identifies which organs? Select all that apply.
liver spleen thymus bone marrow
The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education?
"Humoral immunity is generally functional at birth."
Susie is a 3-year-old with a history of neonatal transmission of HIV and recent diagnosis of AIDS, as manifested by M. tuberculosis infection. To date, Susie has been relatively healthy with few illnesses associated with high fever; she has been developing appropriately and is at the 5th percentile for height and weight. Susie is at risk for all of the following diagnoses. Prioritize the order of urgency of these diagnoses based on the scenario provided.
Altered family coping related to new presentation of significant illness Altered comfort related to severity of new illness Inadequate adherence to medication regimen related to side effects Inadequate nutrition related to side effects of medication Delayed growth and development related to frequent infections
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
The nurse is monitoring the CD4 count of an infant who has contracted HIV from the mother in utero. The nurse is concerned that treatment with antiretroviral therapy is not effective when noting which CD4 level?
1300/mm3
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."
A pediatric client is admitted to the hospital. The primary health care provider suspects a problem with the child's immune system. The nurse anticipates preparing this client for which test initially?
serum blood testing
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
