Chapter 76: Management of Clients with Immune Disorders Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 76: Management of Clients with Immune Disorders

MULTIPLE CHOICE

1. The nurse assesses an atopic client who has had serious type 1 hypersensitivity reactions. The nurse recognizes that the most severe form of a type 1 hypersensitivity reaction is

a.

anaphylaxis.

b.

bronchial asthma.

c.

cell-mediated sensitivity.

d.

dermatitis.

ANS: A

Other type 1 hypersensitivity reactions include allergic rhinitis, asthma, and acute allergic drug reactions. The most severe form of type 1 reactions is anaphylaxis. Cell-mediated sensitivity is a type 4 hypersensitivity, as is dermatitis.

DIF: Knowledge/Remembering REF: pp. 2042-2043, 2043-2044

OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. The nurse caring for a client with allergic rhinitis who is using a decongestant nasal spray would determine that teaching goals have been met when the client says

a.

Nasal sprays must be combined with an oral antihistamine to achieve relief.

b.

Overuse can result in nosebleeds and mucosal ulceration.

c.

Rebound rhinitis (rhinitis medicamentosa) is common with continual use.

d.

The spray should be used round-the-clock at equally spaced intervals.

ANS: C

Because the prolonged use of topical nasal sprays can cause rhinitis medicamentosa (recurrence of congestion), it is advisable to limit their use to no more than 3-5 days.

DIF: Application/Applying REF: p. 2047 OBJ: Evaluation

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects/Contraindications

3. The home health care nurse who is teaching the client about home environment modifications to self-manage allergies would focus on eliminating allergens that are

a.

eaten.

b.

inhaled.

c.

injected.

d.

transmitted by direct contact.

ANS: B

Most allergens are inhaled.

DIF: Application/Applying REF: p. 2041 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

4. A client develops a positive reaction to an injection of purified protein derivative, a screening measure for exposure to tuberculosis. The nurse records this reaction as a

a.

type 1 reaction.

b.

type 2 reaction.

c.

type 3 reaction.

d.

type 4 reaction.

ANS: D

Type 4 reactions occur after the intradermal injection of tuberculosis antigen or purified protein derivative. If the client has been sensitized to tuberculosis, sensitized T cells react with the antigen at the injection site.

DIF: Knowledge/Remembering REF: pp. 2042, 2043-2044

OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

5. A nurse would observe the client for how long to determine whether there is an immediate reaction to a skin test?

a.

1 to 2 minutes

b.

2 to 5 minutes

c.

5 to 10 minutes

d.

10 to 20 minutes

ANS: D

Nurses often administer skin tests and interpret test results. An immediate reaction (i.e., appearing within 10 to 20 minutes after the injection), marked by erythema and wheal formation greater than 3 mm of the positive control (usually histamine), denotes a positive reaction.

DIF: Application/Applying REF: p. 2044 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

6. The nurse concerned about safety encourages a client to stop which medication?

a.

Cetirizine (Zyrtec)

b.

Diphenhydramine (Benadryl)

c.

Fexofenadine (Allegra)

d.

Loratadine (Claritin)

ANS: B

Traditional antihistamines such as diphenhydramine cross the blood-brain barrier and can produce significant drowsiness. Clients who choose these medications need to exercise extreme caution when driving or doing other activities that involve machinery or other safety concerns. Because newer agents (cetirizine, fexofenadine, and loratadine) do not cross the blood-brain barrier (or do so poorly), they do not cause the drowsiness that limits the use of older medications. Nurses should teach about safety measures and encourage clients to try the newer antihistamines if drowsiness is a problem.

DIF: Analysis/Analyzing REF: p. 2047 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Accident Prevention

7. The nurse caring for a client with rhinitis would anticipate an order for a/an

a.

antihistamine.

b.

anticholinergic.

c.

corticosteroid.

d.

decongestant.

ANS: C

Corticosteroids are the most effective drug for the treatment of rhinitis.

DIF: Comprehension/Understanding REF: pp. 2047, 2051

OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

8. The nurse instructs the client who has a new prescription for cromolyn sodium (NasalCrom) that the most effective administration schedule is

a.

at the start of allergy season, with once-a-day dosing.

b.

just after manifestations begin, with twice daily dosing.

c.

1 week before allergy season begins, with four to six doses per day.

d.

when manifestations peak only, with two or three doses per day.

ANS: C

Cromolyn sodium should be administered before allergen exposure. It should be started a week before allergy season to be most effective in the treatment of seasonal allergic rhinitis. It must be used on a regular basis and, unfortunately, dosing is required four to six times a day.

DIF: Application/Applying REF: p. 2047 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

9. A client with a history of type 1 hypersensitivity reaction is receiving immunotherapy (or desensitization therapy). The nurse administering the allergen injection at 1:00 PM would ask the client to remain in the office until

a.

1:10 PM.

b.

1:20 PM.

c.

1:40 PM.

d.

2:15 PM.

ANS: C

Clients are asked to wait at least 30 to 40 minutes after receiving the injections so that immediate reactions can be treated.

DIF: Application REF: p. 2045 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Unexpected Response to Therapies

10. A client will undergo testing for possible food allergy to chocolate. The nurse teaches the client to eliminate chocolate from the diet before the testing for

a.

1 to 2 days.

b.

3 to 5 days.

c.

5 to 10 days.

d.

10 to 14 days.

ANS: D

The suspected food is eliminated from the diet for 10 to 14 days.

DIF: Comprehension/Understanding REF: p. 2048 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

11. In teaching self-care measures, the nurse would teach the client who has atopic dermatitis to avoid

a.

applying a lubricant after bathing.

b.

bathing in hot water.

c.

keeping fingernails trimmed.

d.

using gentle soaps.

ANS: B

Teach the client general skin care measures, such as how to maintain good skin hydration by bathing in lukewarm water; to use gentle soaps; apply a lubricant like Alpha Keri, petroleum jelly, Eucerin, or Aquaphor to the skin immediately after bathing; avoid scratching; and keep fingernails trimmed to avoid infection.

DIF: Application/Applying REF: p. 2049 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

12. The nurse instructs a client diagnosed with urticaria on common self care measures, which include

a.

antihistamines.

b.

corticosteroids.

c.

nonsteroidal anti-inflammatory drugs (NSAIDs).

d.

warm oatmeal baths.

ANS: A

Antihistamines are the mainstay of therapy for urticaria. Corticosteroids should only be used for short-term therapy during an acute exacerbation. NSAIDs should be avoided because they may exacerbate the hives. Skin care involves using mild soaps, avoiding irritants, and using moisturizing lotions after bathing while the skin is still damp.

DIF: Comprehension/Understanding REF: p. 2049 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

13. A client has anaphylaxis. Which action by the nurse takes highest priority?

a.

Administering oxygen

b.

Giving epinephrine

c.

Maintaining an open airway

d.

Starting an IV

ANS: C

Anaphylaxis is treated by subcutaneous epinephrine injection, removing or discontinuing the causative agent, administering emergency oxygen, maintaining an open airway, placing the client in the Trendelenburg position, and giving supportive IV fluids, such as 0.9% normal saline or lactated Ringers solution as necessary. The priority intervention is maintaining an airway, because without an airway the client will be hypoxic despite being treated correctly.

DIF: Analysis/Analyzing REF: p. 2045 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

14. The nurse explains that in step 1 (sensitization) of becoming allergic, the body,

a.

develops immunoglobulin E (IgE) antibodies.

b.

forms mast cells.

c.

produces basophils.

d.

reacts with rhinitis, urticaria, asthma, or gastrointestinal (GI) manifestations.

ANS: A

In the first step of a two-step process, the body reacts to the exposure to an allergen by the production of IgE antibodies.

DIF: Comprehension/Understanding REF: p. 2040 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

15. The nurse reminds a client that a delayed inflammatory response can occur 2 to 8 hours after exposure to an allergen and is governed by

a.

basophils.

b.

eosinophils.

c.

mast cells.

d.

T cells.

ANS: D

T cells govern the delayed response that occurs about 2 to 8 hours after mast cells have been activated by the initial allergen exposure.

DIF: Comprehension/Understanding REF: p. 2042 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

16. The nurse explains that a type 2 hypersensitivity reaction results in

a.

antibody formation.

b.

cell destruction.

c.

mast cell production.

d.

T-cell stimulation.

ANS: A

In the type 2 hypersensitivity reaction, the antigen-antibody binding results in activation of the complement system and destroys the cell on which the antigen is bound.

DIF: Comprehension/Understanding REF: p. 2043 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

17. A client with urticaria is frustrated with the chronic nature of the problem. To enhance coping, which intervention by the nurse would be most effective?

a.

Assist the client in identifying and eliminating triggers for outbreaks.

b.

Demonstrate to the client measures to increase comfort.

c.

Let the client vent frustrations and remain supportive.

d.

Teach the client the proper way to take antihistamines.

ANS: A

All options are important interventions; however, if the client can identify and eliminate some triggers, the client can be more in control of the disease process and being in control may reduce his/her frustrations.

DIF: Application/Applying REF: p. 2049 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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