week 8- chapter 30- immune disorders
A pregnant client who is HIV positive asks the nurse if she will be able to breastfeed the newborn. Which response by the nurse is most appropriate?
"Breastfeeding will increase your newborn's risk of contracting HIV."
To avoid anaphylactic reactions in children, which question would be most important to ask a parent before administering penicillin to her infant?
"Has she ever had penicillin before?"
The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant the child gets a rash. It just does not make sense to me." How should the nurse respond?
"Has your child ever been tested for a peanut allergy?"
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."
The nurse is providing a class for a group of child care providers. When discussing allergic reactions, which statement by a participant indicates the need for further instruction?
"If a child has previously eaten a food and not had a reaction they are not 'truly' allergic to it.
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.
A parent states to the nurse, "I feel that my child picks up every virus and bacteria that is going around. My child has been sick several times ever since being diagnosed with asthma." After listening to the parent's statement and reviewing the asthma treatment, which statement by the nurse indicates the likely reason for the child's virus susceptibility?
"The child is on oral medications to suppress the inflammatory response."
A nurse is preparing a plan of care for a child with a primary immunodeficiency. Which nursing diagnosis is the priority?
Ineffective protection related to impaired humoral defenses
The nurse is teaching the parents of a 4-year-old client with a peanut allergy about dietary restrictions. Which response by the parents indicates a need for further teaching?
"We cannot go wrong with barbeque and french fries."
When assessing environmental factors that may cause a pediatric client's contact dermatitis, which instruction(s) will the nurse provide to the parent? Select all that apply.
1,2,3
The nurse is preparing an informational brochure about risk factors for immune disorders. Which disease process can indicate a potential underlying immunologic disorder? Select all that apply.
1,2,4
Which immune cells are disrupted when a child is infected with human immunodeficiency virus (HIV)? Select all that apply.
1,2,4
A child is diagnosed with a food allergy to milk. When teaching the parents about this allergy, what would the nurse suggest as a possible substitution(s) for milk? Select all that apply.
1,2,5
Which interventions will the nurse include when caring for a child with an infectious disorder? Select all that apply.
1,3,4,5
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.
A 7-year-old client presents to the emergency room (ER) after experiencing an allergic reaction to a bee sting. The client is breathing and able to verbally communicate. The nurse notes the client's pulse 90 beats/minute, respirations are 23 breaths/minute, blood pressure is 100/60 mm Hg, lungs are clear. Which nursing action is priority?
Ask if any medications were given before arriving to the ER.
The school nurse is walking through the lunchroom when one of the children says she started to feel strange after trading lunches with a friend. Which assessment would be most important?
Determining if her throat itches
When providing discharge instructions to a child who was admitted to the hospital following stridor, wheezing, and urticaria after taking penicillin, which nursing action is priority?
Encourage the child to wear a medical alert bracelet for penicillin.
The nurse on a pediatric unit finds a child having extreme shortness of breath, a swollen tongue, and urticaria on the face and neck. The nurse notices the lunch tray to have a half-eaten peanut butter and jelly sandwich. Which action will the nurse take first?
Give the child an epinephrine injection.
The nurse is preparing educational materials for a group of new parents about allergic reactions. Which specific immunoglobulin should the nurse emphasize as being responsible for these types of reactions?
IgE
The nurse is caring for a child undergoing highly active antiretroviral therapy (HAART) for HIV infection. The nurse is preparing to administer the prescribed medication. In addition to the nucleoside analog reverse transcriptase inhibitors (NRTIs) and the nonnucleoside analog reverse transcriptase inhibitors (NNRTIs), the nurse is cognizant that the child will be taking which additional medication as part of the three-drug regimen?
Protease inhibitors
The nurse is caring for a preschool-age child who has been seen in the emergency department for an allergic reaction to stinging insects twice in the past month. What teaching should the nurse provide the parents to help reduce the child's exposure to insects?
Remove flowering plants from the patio deck.
A group of nursing students are reviewing information about humoral and cellular immunity. The students demonstrate understanding of this material when they identify what as being involved in cellular immunity?
T cells
A nurse is promoting vaccine administration. When instructing on the physiological changes, which statement best explains what occurs in the child when vaccines are administered?
The child develops an active immunity.
The nurse is caring for a child who is taking corticosteroids for systemic lupus erythematosus. The nurse closely monitors the child based on the understanding that corticosteroids exert which major action?
They can mask signs of infection.
The nurse is caring for a newborn whose mother is HIV positive. The nurse would expect to administer a 6-week course of which medication?
Zidovudine
The nurse is administering intravenous immune globulin (IVIG). The nurse assesses vital signs and adverse reactions every 15 minutes for the first hour of administration. After the first hour, the nurse will continue to assess the child at which frequency?
every 30 minutes
A client presents to the clinic for allergy testing. The nurse is reviewing current medications taken within the past 5 to 7 days. Which classification of medication, if taken by the client, will cause the nurse to reschedule the allergy testing appointment?
antihistamine
The nurse is assessing a child with pauciarticular-type juvenile idiopathic arthritis. What would the nurse expect to assess?
eye inflammation
The nurse is providing teaching for the parents of a child with a latex allergy. The nurse tells the client to avoid which food?
bananas
The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of greatest concern?
elevated blood pressure
The nurse is monitoring the labs of a child admitted for an exacerbation of juvenile pauciarticular arthritis. Which lab result does the nurse expect to be elevated?
erythrocyte sedimentation rate (ESR)
The nurse is discussing infection control with the parents of an immunocompromised child. Which causative factors should be presented as the most effective means to prevent infection?
handwashing
The nurse is instructing a group of parents about transmission of infectious diseases in children. Which would the nurse cite as the primary method for prevention?
immunization
Which of the following is inconsistent with the mode of transmission of HIV?
skin contact
A nurse is reviewing the medical record of an infant whose mother is HIV positive. Which factor in the maternal history would the nurse interpret as helping to decrease the infant's risk for HIV transmission?
use of zidovudine therapy during pregnancy
A school nurse is called to the school cafeteria after a 13-year-old child is reported to have sudden difficulty breathing. The child has a history of asthma and allergies to peanuts. The focused nursing assessment reveals difficulty breathing, inspiratory and expiratory wheezing, swelling of lips, and a rash on the face. The child reports feeling nauseated, having chest tightness, and feeling faint.
wheezing; swelling of lips
