Chapter 20: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity Nursing School Test Banks

Chapter 20: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

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 nurse; however, 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

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 clients 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 clients 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

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

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
d. White blood cell count: 12,000/mm3
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: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. 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?
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

6. A client with Sjgrens 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 clients Sjgrens 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: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. A client is receiving plasmapheresis as treatment for Goodpastures syndrome. When planning care, the nurse places highest priority on interventions for which client problem?
a. Reduced physical activity related to the diseases effects on the lungs
b. Inadequate family coping related to the clients 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

8. A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
a. I dont 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

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 clients bedside glucose reading.
b. Instruct the client not to get up without help.
c. Monitor the client frequently for tachycardia.
d. Record the clients intake, output, and weight.
ANS: B
Antihistamines can cause drowsiness, so for the clients 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

10. A client is in the hospital and receiving IV antibiotics. When the nurse answers the clients 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 clients 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

11. A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the clients 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 (Solu-Medrol) IV push
ANS: A
The nurse has auscultated wheezing in the clients 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

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: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A client in the family practice clinic reports a 2-week history of an allergy to something. The nurse obtains the following assessment and laboratory data:
Physical Assessment Data Laboratory Results
Reports sore throat, runny nose, headache
Posterior pharynx is reddened
Nasal discharge is seen in the back of the throat
Nasal discharge is creamy yellow in color
Temperature 100.2 F (37.9 C)
Red, watery eyes White blood cell count: 13,400/mm3
Eosinophil count: 11.5%
Neutrophil count: 82%
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

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