Lecture 7: Care of the Patient with Altered Immune/Allergic Response
A child weighs 30.8 pounds and is prescribed prednisolone syrup 0.5 mg/kg. The pharmacy delivers a syringe with 15 mg/5 mL. How many mL does the nurse administer? Round your answer to the nearest 10th.
ANS: 2.3333 mL or 2.3 mL First find the weight in kilograms: 30.8/2.2 = 14 kg Multiply 0.5 ´14 = 7 mg Set up equation: 15 mg 7 mg 5 mL = x mL Solve for x: 15x = (7 ´5) = 35 x = 35/15 = 2.333333 mL
Which suggestion is appropriate to teach a mother who has a preschool child who refuses to take the medications for HIV infection? a. Mix medications with chocolate syrup or pudding b. Mix the medications with milk or an essential food. c. Skip the dose of medication if the child protests too much. d. Mix the medication in a syringe, hold the child down firmly, and administer the medication.
ANS: A Adding medication to a small amount of nonessential food the child finds tasty may be helpful in gaining the child's cooperation. Doses of medication should never be skipped. Fighting with the child or using force should be avoided. A nonessential food that will make the taste of the medication more palatable for the child should be the correct action. The administration of medications for the child with HIV becomes part of the family's everyday routine for years.
1. A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies
ANS: A All actions are appropriate for this nursehowever, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses. DIF: Applying/Application REF: 350 KEY: Immune disorders| inflammation| resuscitation| anaphylaxis| medical emergencies| patient safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
The nurse is planning care for an adolescent with AIDS. The priority nursing goal is to a. prevent infection. b. prevent secondary cancers. c. restore immunologic defenses. d. identify sources of infection.
ANS: A As a result of the immunocompromise that is associated with HIV infection, the prevention of infection is paramount. Preventing secondary cancers is not currently possible. Current drug therapy is affecting the disease progression; although not a cure, these drugs can suppress viral replication and prevent further deterioration. Case finding is not a priority nursing goal.
A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6° F (36.4° C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.
ANS: A Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.
8. A nurse has educated a client on an epinephrine autoinjector (EpiPen). What statement by the client indicates additional instruction is needed? a. "I don't need to go to the hospital after using it." b. "I must carry two EpiPens with me at all times." c. "I will write the expiration date on my calendar." d. "This can be injected right through my clothes."-
ANS: A Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment. DIF: Evaluating/Synthesis REF: 352 KEY: Allergic response| epinephrine| patient education MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance
A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis
ANS: A Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.
The nursing student learns how infants acquire immunity. Which statement about this process is correct? a. The infant acquires humoral and cell-mediated immunity in response to infections and immunizations. b. The infant acquires maternal antibodies that ensure immunity up to 12 months age. c. Active immunity is acquired from the mother and lasts 6 to 7 months. d. Passive immunity develops in response to immunizations.
ANS: A Infants acquire long-term active immunity from exposure to antigens and vaccines. Immunity is acquired actively and passively. The term infant's passive immunity is acquired from the mother and begins to dissipate during the first 6 to 8 months of life. Passive immunity is acquired from the mother. Active immunity develops in response to immunizations.
What is the primary nursing concern for a hospitalized child with HIV infection? a. Maintaining growth and development b. Eating foods that the family brings to the child c. Consideration of parental limitations and weaknesses d. Resting for 2 to 3 hours twice a day
ANS: A Maintaining growth and development is a major concern for the child with HIV infection. Frequent monitoring for failure to thrive, neurologic deterioration, or developmental delay is important for HIV-infected infants and children. Nutrition, which contributes to a child's growth, is a nursing concern; however, it is not necessary for family members to bring food to the child. Although an assessment of parental strengths and weaknesses is important, it will be imperative for health care providers to focus on the parental strengths, not weaknesses. This is not as important as the frequent assessment of the child's growth and development. Rest is a nursing concern, but it is not as high a priority as maintaining growth and development. Rest periods twice a day for 2 to 3 hours may or may not be appropriate.
A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. "It increases the elimination of T lymphocytes from circulation." b. "It inhibits cytokine production in most lymphocytes." c. "It prevents DNA synthesis, stopping cell division in activated lymphocytes." d. "It prevents the activation of the lymphocytes responsible for rejection."
ANS: A Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.
A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes
ANS: A Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.
What is the most common mode of transmission of human immunodeficiency virus (HIV) in the pediatric population? a. Perinatal transmission b. Sexual abuse c. Blood transfusions d. Poor handwashing
ANS: A Perinatal transmission accounts for the highest percentage (91%) of HIV infections in children. Infected women can transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breastfeeding. Cases of HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV infections. Although in the past some children became infected with HIV through blood transfusions, improved laboratory screening has significantly reduced the probability of contracting HIV from blood products. Poor handwashing is not an etiology of HIV infection.
A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. "Avoid large crowds and people who are ill." b. "Check over-the-counter meds for acetaminophen." c. "Take this medicine exactly as prescribed." d. "You have a higher risk of developing cancer."
ANS: A Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).
5. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with overthecounter antihistamines. What response by the nurse is most appropriate? a. "Antihistamines do not help poison ivy." b. "There are different antihistamines to try." c. "You should be seen in the clinic right away." d. "You will need to take some IV steroids."-
ANS: A Since histamine is not the mediator of a type IV reaction such as with poison ivy, antihistamines will not provide relief. The nurse should educate the client about this. The client does not need to be seen right away. The client may or may not need steroids they may be given either IV or orally. DIF: Understanding/Comprehension REF: 356 KEY: Hypersensitivities| immunity| antibodies| antihistamines MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils
ANS: A The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.
A nurse in a well-child clinic is teaching parents about their child's immune system. Which statement by the nurse is correct? a. The immune system distinguishes and actively protects the body's own cells from foreign substances. b. The immune system is fully developed by 1 year of age. c. The immune system protects the child against communicable diseases in the first 6 years of life. d. The immune system responds to an offending agent by producing antigens.
ANS: A The immune system responds to foreign substances, or antigens, by producing antibodies and storing information. Intact skin, mucous membranes, and processes such as coughing, sneezing, and tearing help maintain internal homeostasis. Children up to age 6 or 7 years have limited antibodies against common bacteria. The immunoglobulins reach adult levels at different ages. Immunization is the basis from which the immune system activates protection against some communicable diseases. Antibodies are produced by the immune system against invading agents, or antigens.
11. A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the client's lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer? (Click the media button to hear the audio clip.) a. Albuterol (Proventil) via nebulizer b. Diphenhydramine (Benadryl) IM c. Epinephrine 1:10,000 5 mg IV push d. Methylprednisolone (SoluMedrol) IV push-
ANS: A The nurse has auscultated wheezing in the client's lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid. DIF: Analyzing/Analysis REF: 354 KEY: Anaphylaxis| bronchodilator| nursing assessment| medication administration| respiratory system| respiratory assessment MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
The nurse observes a rash on a teen's face which is characteristic of systemic lupus erythematosus (SLE). What action by the nurse is most appropriate? a. Teach the teen about using sunscreen. b. Prepare the teen for a bone marrow biopsy. c. Educate the teen on proper use of antibiotics. d. Demonstrate how to use an Epi-pen.
ANS: A The nurse needs to provide education on managing the disease; one facet includes minimizing sun exposure so the nurse teaches the teen about the correct use of sunscreen. The teen will not have a bone marrow biopsy, need antibiotics, or have to use an Epi-pen.
A nurse is working in an allergy clinic and has performed skin testing on an adolescent. Seventeen minutes after the procedure, the nurse note the presence of a wheal at one of the sites. What conclusion does the nurse make about this response? a. The child is allergic to that substance. b. This result is indeterminate. c. The testing should be redone in another location. d. Anaphylaxis is imminent.
ANS: A The presence of a wheal within 30 minutes of skin testing is indicative of an allergy to the substance used. The test does not need to be repeated, and anaphylaxis is not imminent.
For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells
ANS: A, B, C The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.
4. A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole
ANS: A, B, C, E The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign. DIF: Remembering/Knowledge REF: 367 KEY: Cancer| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance
The mother of an HIV-positive infant who is 2 months old questions the nurse about which childhood immunizations her child will be able to receive. Which immunizations should an HIV-positive child be able to receive? (Select all that apply.) a. Hepatitis B b. DTaP c. MMR d. IPV e. HIB
ANS: A, B, D, E Routine immunizations are appropriate. The MMR vaccination is not given at 2 months of age. If it were indicated, CD4+counts are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the child's CD4+ counts. Only IPV should be used for HIV-infected children.
Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization
ANS: A, B, D, E The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.
MULTIPLE RESPONSE 1. The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I - Examples include hay fever and anaphylaxis b. Type II - Mediated by action of immunoglobulin M (IgM) c. Type III - Immune complex deposits in blood vessel walls d. Type IV - Examples are poison ivy and transplant rejection e. Type V - Examples include a positive tuberculosis test and sarcoidosis
ANS: A, C, D Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves' disease and B-cell gammopathies. DIF: Remembering/Knowledge REF: 349 KEY: Immunity| immune disorders| immunoglobulins| inflammation MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
Which home care instructions should the nurse provide to the parents of a child with acquired immunodeficiency syndrome (AIDS)? (Select all that apply.) a. Give supplemental vitamins as prescribed. b. Yearly influenza vaccination should be avoided. c. Administer any antibiotics as prescribed. d. Notify the provider if the child develops a cough or congestion. e. Missed doses of antiretroviral medication should just be skipped.
ANS: A, C, D The parents are taught that vitamins are important, to have the child take all antibiotics (if prescribed) as ordered, and to notify the provider of coughs or congestion. The child should have yearly influenza vaccination, and if missed medication doses are noticed close to their scheduled time, they should be taken.
The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.
ANS: A, C, D, E Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.
The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth
ANS: A, D, E The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.
3. The nurse is caring for clients on the medical surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client-
ANS: B A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity. DIF: Applying/Application REF: 355 KEY: Hypersensitivities| inflammation| immunity| autoimmune disorder MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. A client with Sjögren's syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest? a. Frequent eyedrops b. Home humidifier c. Strong moisturizer d. Tear duct plugs-
ANS: B A humidifier will help relieve many of the client's Sjögren's syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin. DIF: Understanding/Comprehension REF: 357 KEY: Autoimmune disorders| skin| patient education| nonpharmacologic comfort interventions MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
A young child with HIV is receiving several antiretroviral drugs. What is the purpose of these drugs? a. Cure the disease. b. Delay disease progression. c. Prevent the spread of disease. d. Treat Pneumocystis jirovecipneumonia.
ANS: B Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune system, and delay disease progression. At this time, cure is not possible. These drugs do not prevent the spread of the disease.Pneumocystis jiroveciprophylaxis is accomplished with antibiotics
9. A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the client's bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the client's intake, output, and weight.
ANS: B Antihistamines can cause drowsiness, so for the client's safety, he or she should be instructed to call for assistance prior to trying to get up. Hyperglycemia and tachycardia are side effects of sympathomimetics. Fluid and sodium retention are side effects of corticosteroids. DIF: Applying/Application REF: 354 KEY: Allergic response| antihistamines| patient safety| falls MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site
ANS: B During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.
What is the primary nursing concern for a child having an anaphylactic reaction? a. Identifying the offending allergen b. Ineffective breathing pattern c. Increased cardiac output d. Positioning to facilitate comfort
ANS: B Laryngospasms resulting in ineffective breathing patterns is a life-threatening manifestation of anaphylaxis. The primary action is to assess airway patency, respiratory rate and effort, level of consciousness, oxygen saturation, and urine output. Determining the cause of an anaphylactic reaction is important to implement the appropriate treatment, but the primary concern is the airway. During anaphylaxis, the cardiac output is decreased. Positioning for comfort is not a primary concern during a crisis.
Which is the Centers for Disease Control and Prevention (CDC, 2009) recommendation for immunizing infants who are HIV positive? a. Follow the routine immunization schedule. b. Routine immunizations are administered; assess CD4+counts before administering the MMR and varicella vaccinations. c. Do not give immunizations because of the infant's altered immune status. d. Eliminate the pertussis vaccination because of the risk of convulsions.
ANS: B Routine immunizations are appropriate. CD4+cells are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the child's CD4+counts. Only inactivated polio virus (IPV) should be used for HIV-infected children. The pertussis vaccination is not eliminated for an infant who is HIV positive.
4. A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition? a. Blood urea nitrogen: 12 mg/dL b. Creatinine: 3.2 mg/dL c. Hemoglobin: 8.2 mg/dL 3 d. White blood cell count: 12,000/mm
ANS: B The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related. DIF: Analyzing/Analysis REF: 355 KEY: Hypersensitivities| immunity| antibodies MSC: IntegratedProcess:NursingProcess:Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling
ANS: B The recipient's immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.
A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.
ANS: B, C, D, E Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.
2. A client in the family practice clinic reports a 2week history of an "allergy to something." The nurse obtains the following assessment and laboratory data: About what medications and interventions does the nurse plan to teach this client? (Select all that apply.) a. Elimination of any pets b. Chlorpheniramine (Chlor-Trimaton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics-
ANS: B, C, D, E This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature. DIF: Analyzing/Analysis REF: 349 KEY: Infection| inflammation| white blood cell count| allergic response| histamine blockers| decongestants| patient education MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) a. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention c. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer e. Teaching teens the dangers of tanning booths
ANS: B, C, E Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods. DIF: Applying/Application REF: 368 KEY: Cancer| primary prevention| secondary prevention| patient education MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance
The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance
ANS: C The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.
A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. Blood urea nitrogen (BUN) of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr
ANS: C A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.
What disorder is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+T cells? a. Raynaud phenomenon b. Idiopathic thrombocytopenic purpura c. Acquired immunodeficiency syndrome (AIDS) d. Severe combined immunodeficiency disease
ANS: C Acquired immunodeficiency is caused by the human immunodeficiency virus (HIV), which primarily attacks the CD4+T cells. The other disorders are not viral in nature.
A 5-year-old child has acquired immunodeficiency syndrome (AIDS). What statement by the mother indicates good understanding of medications used for this condition? a. "When my child's pain increases, I double the recommended dosage of antiretroviral medication." b. "Addiction is a risk, so I only use the medication as ordered." c. "Doses of the antiretroviral medication are selected on the basis of my child's age and growth." d. "By the time my child is an adolescent she will not need her antiretroviral medications any longer."
ANS: C Doses of antiretroviral medication to treat HIV infection for infants and children are based on individualized age and growth considerations. Antiretroviral medications are not administered for pain relief. Addiction is not a realistic concern with antiretroviral medications. Antiretroviral medications are still needed during adolescence.
What is the drug of choice the nurse should administer in the acute treatment of anaphylaxis? a. Diphenhydramine b. Histamine inhibitor (cimetidine) c. Epinephrine d. Albuterol
ANS: C Epinephrine is the first drug of choice in immediate treatment of anaphylaxis. Treatment must be initiated immediately because it may only be a matter of minutes before shock occurs. Diphenhydramine and cimetidine may be used, but the drug of choice is epinephrine. Albuterol is not usually indicated.
Children receiving long-term systemic corticosteroid therapy are most at risk for which condition? a. Hypotension b. Dilation of blood vessels in the cheeks c. Growth delays d. Decreased appetite and weight loss
ANS: C Growth delay is associated with long-term steroid use. Hypertension is a clinical manifestation of long-term systemic steroid administration. Dilation of blood vessels in the cheeks is associated with an excess of topically administered steroids. Increased appetite and weight gain are clinical manifestations of excess systemic corticosteroid therapy.
The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive
ANS: C Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. "Inflammatory" is not a type of immunity.
Which intervention is appropriate for a child receiving high doses of steroids? a. Limit activity and receive home schooling. b. Increase the amount of carbohydrates in the diet. c. Substitute a killed virus vaccine for live virus vaccines. d. Monitor for seizure activity.
ANS: C The child on high doses of steroids should not receive live virus vaccines because of immunosuppression. Limiting activity and home schooling are not routine for a child receiving high doses of steroids. Children on high doses of steroids sometimes get carbohydrate intolerance; the diet should not contain high levels of carbohydrates. Children on steroids are not typically at risk for seizures.
What should the nurse include in a teaching plan for the mother of a toddler who will be taking prednisone for several months? a. The medication should be taken between meals. b. The medication needs to be discontinued if side effects appear. c. The medication should not be stopped abruptly. d. The medication may lower blood glucose.
ANS: C The dosage must be tapered before the drug is discontinued to allow the gradual return of function in the pituitary-adrenal axis. Prednisone should be taken with food to minimize or prevent gastrointestinal bleeding. Although there are adverse effects from long-term steroid use, the medication must not be discontinued without consulting a physician. Acute adrenal insufficiency can occur if the medication is withdrawn abruptly. The dosage needs to be tapered. The medication puts the child at risk for hyperglycemia.
10. A client is in the hospital and receiving IV antibiotics. When the nurse answers the client's call light, the client presents an appearance as shown below: What action by the nurse takes priority? a. Administer epinephrine 1:1000, 0.3 mg IV push immediately. b. Apply oxygen by facemask at 100% and a pulse oximeter. c. Ensure a patent airway while calling the Rapid Response Team. d. Reassure the client that these manifestations will go away.
ANS: C The nurse should ensure the client's airway is patent and either call the Rapid Response Team or delegate this to someone else. Epinephrine needs to be administered right away, but not without a prescription by the physician unless standing orders exist. The client may need oxygen, but a patent airway comes first. Reassurance is important, but airway and calling the Rapid Response Team are the priorities. DIF: Analyzing/Analysis REF: 353 KEY: Rapid Response Team| critical rescue| anaphylaxis| resuscitation| epinephrine MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. 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? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the client's chart. d. Ensure the information is relayed to the surgical team.
ANS: D 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. Ensuring the client's NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority. DIF: Applying/Application REF: 352 KEY: Allergic response| communication| patient safety| immune disorders MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
An older adult has a mild temperature, night sweats, and productive cough. The client's tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).
ANS: D Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the client's TB test could be a false negative.
A nurse is teaching parents about the importance of immunizations for infants because of immaturity of the immune system. The parents demonstrate that they understand the teaching if they make which statement? a. "We plan to opt out of most childhood vaccinations." b. "There are only a few diseases that have effective immunizations." c. "Babies are born with a sophisticated immune system so they need few, if any, immunizations." d. "Newborns have a hard time fighting infection so they need vaccinations."
ANS: D Immaturity of the immune system places an infant and young child a greater risk of infection, so they need protection through a scheduled series of immunizations. Parents can opt out of many vaccinations, but the nurse should investigate why they plan to do so. Most communicable disease of childhood have immunizations.
7. A client is receiving plasmapheresis as treatment for Goodpasture's syndrome. When planning care, the nurse places highest priority on interventions for which client problem? a. Reduced physical activity related to the disease's effects on the lungs b. Inadequate family coping related to the client's hospitalization c. Inadequate knowledge related to the plasmapheresis process d. Potential for infection related to the site for organism invasion
ANS: D Physical diagnoses take priority over psychosocial diagnoses, so inadequate family coping and inadequate knowledge are not the priority. The client has a potential for infection because plasmapheresis is an invasive procedure. Reduced activity is manifested by changes in vital signs, oxygenation, or electrocardiogram, and/or reports of chest pain or shortness of breath. There is no information in the question to indicate that the client is experiencing reduced physical activity. DIF: Applying/Application REF: 357 KEY: Autoimmune disorder| infection| nursing diagnosis MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells
ANS: D Suppressor T cells help prevent hypersensitivity to one's own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.
Which organs and tissues control the two types of specific immune functions? a. The spleen and mucous membranes b. Upper and lower intestinal lymphoid tissue c. The skin and lymph nodes d. The thymus and bone marrow
ANS: D The thymus controls cell-mediated immunity (cells that mature into T lymphocytes). The bone marrow controls humoral immunity (stem cells for B lymphocytes). Both the spleen and mucous membranes are secondary organs of the immune system that act as filters to remove debris and antigens and foster contact with T lymphocytes. Gut-associated lymphoid tissue is a secondary organ of the immune system. This tissue filters antigens entering the gastrointestinal tract. The skin and lymph nodes are secondary organs of the immune system.
