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

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

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A nurse works in an allergy clinic. What task performed by the nurse takes priority?
   1. Checking emergency equipment each morning
   2. Ensuring informed consent is obtained as needed
   3. Providing educational materials in several languages
   4. 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?
   1. Assess that the client has been NPO as directed.
   2. Communicate this information with dietary staff.
   3. Document the information in the client’s chart.
   4. 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

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?

1. Administering steroids for severe serum sickness
2. Correctly identifying the client prior to a blood transfusion
3. Keeping the client free of the offending agent
4. 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?
   1. Blood urea nitrogen: 12 mg/dL
   2. Creatinine: 3.2 mg/dL
   3. Hemoglobin: 8.2 mg/dL
   4. 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?
   1. “Antihistamines do not help poison ivy.”
   2. “There are different antihistamines to try.”
   3. “You should be seen in the clinic right away.”
   4. “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