prepu chapter 34
A client is distressed and frustrated reporting severe, ongoing fatigue that doesn't subside with rest. The nurse explains that chronic fatigue syndrome results from:
All options are correct.
A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?
Assess for signs and symptoms of anaphylaxis.
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
Bone marrow transplantation
The nurse is preparing to administer a medication that has an affinity for H1 receptors. Which medication would the nurse administer?
Diphenhydramine
Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?
Histamine
The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?
Intradermal
A nurse is providing health education regarding self-care to a patient with an immunodeficiency. What teaching point should the nurse emphasize?
The need for thorough oral hygiene
The nurse is caring for a patient who has a diagnosis of paroxysmal nocturnal hemoglobinuria. When planning this patient's care, the nurse should recognize the patient's heightened risk of what complication?
Venous thromboembolism
The nurse explains to a client that immunotherapy initally starts with injections at which interval?
Weekly
A client has begun sensitivity testing to determine the allergen which caused an anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more sensitive to allergens?
back
An infant that is 10 hours postdelivery is observed to have tetanic contractions. What symptom does the nurse recognize can indicate DiGeorge syndrome?
Hypocalcemia
A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?
IgE
A nurse is preparing to discharge a patient with an immunodeficiency. When preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize?
Signs and symptoms of adverse reactions
The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply.
Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Carry EpiPen autoinjector at all times.
A young couple visits the nurse practitioner stating that they want to start a family. The husband states that his brother died of a severe infection at age 6 months. He says he never knew what was wrong but his mother had him undergo "blood testing" as a child. Based on these statements, what health problem should the nurse practitioner suspect?
X-linked agammaglobulinemia
The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. What client is having this type of reaction?
A child with an anaphylactic reaction after a bee sting
The nurse is preparing to administer IVIG to a patient who has an immunodeficiency. What nursing guideline should the nurse apply?
Administer pretreatment medications as ordered 30 minutes prior to infusion.
The nurse is evaluating a client's readiness for allergy skin testing. The nurse determines that the testing will need to be postponed when it is revealed that the client took which classification of medication the night before?
Antihistamine
What type of immunoglobulin is most likely involved with allergic reactions?
IgE
A nurse is providing education to a client scheduled for diagnostic skin testing. Which medication will the nurse advise the client to cease administration of for 5 days before testing?
cetirizine
A clinic nurse has been charged with the responsibility of teaching avoidance strategies to an adult patient who has allergic rhinitis. What measure should the nurse recommend to this patient?
"If possible, make sure that no one smokes tobacco in your home."
A nurse practitioner who works in an inner-city health clinic would recommend HIV testing to the patient who is most likely to have a diagnosis of HIV. Which of the following is most likely to have this diagnosis?
African American gay man
A client has developed an allergic response to an unknown allergen and is seeking information. How can an allergic response manifest?
All options are correct.
A patient is admitted for the treatment of a primary immunodeficiency and intravenous immunoglobulin (IVIG) is ordered. What should the nurse monitor for as a potential adverse effect of IVIG administration?
Anaphylaxis
The nurse is educating a client about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms to report. Which COX-2 inhibitor is the nurse educating the client about?
Celecoxib
Patient teaching regarding infection prevention for the patient with an immunodeficiency includes which of the following guidelines?
Cook all food thoroughly.
A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodeficiency disease (SCID). What medication should the nurse administer prior to initiating the infusion?
Diphenhydramine
A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?
Dyspnea, bronchospasm, and/or laryngeal edema.
For a client with chronic fatigue syndrome (CFS), what should the nurse emphasize during client teaching?
Ensure a balance of activity and rest.
What does the nurse understand will result if the patient has a deficiency in the normal level of complement?
Increased susceptibility to infection
An immunocompromised client is being treated in the hospital. The nurse's assessment reveals that the client's submandibular lymph nodes are swollen, a finding that represents a change from the previous day. What is the nurse's most appropriate action?
Inform the client's primary care provider of this finding.
An infant is born to a mother who had no prenatal care during her pregnancy. What type of hypersensitivity reaction does the nurse understand may have occurred?
Rh-hemolytic disease
A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment?
The client will remain in the clinic to be monitored for 30 minutes following the injection.
A client who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should the nurse implement?
The client's test should be cancelled until he is off his corticosteroids
Allergy testing has revealed that an elementary school-aged child has a severe hypersensitivity to insect stings. When conducting health education with the child's parents, the nurse should address which of the following subjects?
The need for the child to carry an EpiPen
The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family?
The need to report any slight changes in the client's health status
The nurse is conducting an assessment on a client that has acute irritant contact dermatitis. What signs and symptoms would the nurse expect to see upon assessment? Select all that apply.
edema redness
A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow?
Emergency equipment should be readily available.
The nurse is evaluating a client's complete blood cell count and differential along with the serum immunoglobulin E (IgE) concentration. Which result might indicate that the client has an allergic disorder?
High IgE concentration
A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"?
Only use the nasal spray for 3 to 4 days once every 12 hours.
A child has been transported to the emergency department (ED) after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply.
Assess breath sounds. Measure the child's oxygen saturation by oximeter. Monitor the child's respiratory pattern. Assess the child's respiratory rate.
A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?
"If I notice tingling in my lips or mouth, gargling may help the symptoms."
Which of the following individuals would be the most appropriate candidate for immunotherapy?
A client with severe allergies to grass and tree pollen
The nurse is caring for a client with myasthenia gravis. The nurse generates a plan of care for the client based on which type of hypersensitivity reaction?
Cytotoxic
A nurse is caring for a patient with a phagocytic cell disorder. The patient states, "My specialist says that I will likely be cured after I get my treatment tomorrow." To what treatment is the patient most likely referring?
Hematopoietic stem cell transplantation
The nurse is working with the interdisciplinary team to care for a client who has recently been diagnosed with severe combined immune deficiency (SCID). What treatment is likely of most benefit to this client?
Hematopoietic stem cell transplantation (HSCT)
Which is a primary chemical mediator of hypersensitivity?
Histamine
After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action?
Removing the cat from the family's home
The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan?
Risk for Disturbed Body Image Related to Skin Lesions
Reproductive health education for women who are HIV-positive includes recommending which of the following contraceptives?
The female condom
A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse?
The full benefit of the medication may take up to 2 weeks to be achieved."
A nurse is planning the care of a client who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this client?
Thorough and consistent hand hygiene
Which allergic reaction is potentially life threatening?
angioedema
A client with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurse's best response?
"I can only imagine how you feel. Would you like to talk about it?"
The nurse is educating a client about allergy management at home. What client statements indicate no further teaching is required? Select all that apply.
"I have pull shades on all of my windows." "I bought a wooden chair for my living room."
Family members of an immunocompromised client have asked the nurse why antibiotics are not being given to the client in order to prevent infection. How should the nurse best respond?
"Using antibiotics to prevent infections can cause the growth of drug-resistant bacteria."
A patient comes to the clinic with pruritus and nasal congestion after eating shrimp for lunch. The nurse is aware that the patient may be having an anaphylactic reaction to the shrimp. These symptoms typically occur within how many hours after exposure?
2 hours
An office worker takes a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity?
Anaphylactic (type 1)
A junior nursing student is having an observation day in the operating room. Early in the day, the student reports eye swelling and dyspnea to the OR nurse. What should the nurse suspect?
Anaphylaxis due to a latex allergy
A 20-year-old patient with an immunodeficiency is admitted to the unit with an acute episode of upper airway edema. This is the fifth time in the past 3 months that the patient has had such as episode. As the nurse caring for this patient, you know that the patient may have a deficiency of what?
C1esterase inhibitor
A client with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin?
Immunoglobulin E
After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action?
Jabs the autoinjector into the outer thigh at a 90-degree angle
The nurse is caring for a teenage girl who has had an anaphylactic reaction after being stung by a wasp. The nurse is providing patient teaching prior to the patient's discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
Thigh
The best treatment for latex allergy is
avoidance of latex-based products.
A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?
type I
A 10-year-old boy has been brought to the emergency department (ED) by ambulance in apparent anaphylaxis after accidentally eating a snack bar that contained peanuts. The ED nurse should be aware that this patient's signs and symptoms are attributable to:
A massive release of histamine
A male patient is prescribed antihistamines. He asks the nurse about antihistamine administration and its adverse effects. Which of the following choices should the nurse instruct this patient to avoid?
Alcohol
What is the most common cause of anaphylaxis?
Penicillin
A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines?
Sedation
Fibromyalgia is a common condition that involves
chronic fatigue, generalized muscle aching, and stiffness.
A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid:
alcohol.
A home health nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurse's teaching?
"My family needs to understand that I'll probably need lifelong treatment."
A nurse is teaching a client how to use their EpiPen autoinjector. What client statements indicates no further teaching is required? Select all that apply.
"The EpiPen autoinjector needs to be pointed downward." "The needle needs to be at a 90-degree angle." "After I administer the injection, I will massage the area for 10 seconds."
A client is experiencing an acute hemolytic reaction. What actions should the nurse take? Select all that apply.
Check for low back pain. Assess for anxiety and mental status changes. Notify the health care provider.
Which of the following is the most frequent route of exposure to a latex allergy?
Cutaneous
A child is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are common allergens?
Eggs and wheat
A patient who has received a heart transplant is taking cyclosporine, an immunosuppressant. What should the nurse emphasize during health education about infection prevention?
Perform frequent handwashing.
The parents of a 3-year-old boy have just been informed that allergy testing suggests their son has multiple food allergies. When providing health education for this family, what subject should the nurse prioritize?
Possible sources of food allergens and strategies for avoiding offending foods
A client with Wiskott-Aldrich syndrome is admitted to the medical unit. The nurse caring for the client should prioritize which of the following?
Protective isolation
A nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care?
Risk for Falls Due to Loss of Muscle Coordination
The nurse is providing care for a client who has a diagnosis of hereditary angioedema. When planning this client's care, what nursing diagnosis should be prioritized?
Risk for Impaired Gas Exchange Related to Airway Obstruction
Which of the following disorders is characterized by an increased autoantibody production?
Systemic lupus erythematosus (SLE)
What education should the nurse provide to the patient taking long-term corticosteroids?
The patient should not stop taking the medication abruptly and should be weaned off of the medication.
A patient with severe environmental allergies is scheduled for the first in a planned series of immunotherapy injections. What should be included in teaching the patient about the injection?
The patient will remain in the clinic to be monitored for 30 minutes following the injection.
The nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency diseases?
They have a genetic origin.
T-cell deficiency occurs when which gland fails to develop normally during embryogenesis?
Thymus
A mother has come to the emergency department (ED) with her 2-year-old who appears to be having a hypersensitivity reaction. The ED nurse knows that a hypersensitivity reaction may be characterized by an immediate reaction beginning within minutes of exposure to an antigen. What condition is an example of such a reaction?
Anaphylactic reaction immediately following a bee sting
The nurse is caring for a client whose most recent laboratory values reveal a neutrophil level of 21,000 mm3. When preparing to assess the client, the nurse should prioritize what assessment?
Assessing the client for signs and symptoms of infection
