Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity

Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. Which characteristic is common to all types of hypersensitivity reactions?

a.	Decreased inflammatory responses
b.	Presence of tissue-damaging reactions
c.	Enhanced natural killer cell activity
d.	Inability to recognize extraneous cells

 

 

ANS:  B

The defining difference between a normal immune response and that termed hypersensitivity is that the immune system reacts excessively or inappropriately, with resultant tissue damage and pathology.

 

DIF:    Cognitive Level: Knowledge/Remembering                       REF:   p. 383

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

2. What intervention does the nurse implement to provide for client safety during intradermal allergy testing?

a.	Stay with the client and ensure that emergency equipment is in the room.
b.	Pretreat the skin area to be tested with a cortisone-based cream.
c.	Apply oxygen by mask or nasal cannula before injecting the test agent.
d.	Cover the examination table and pillow with plastic or an ultrafine mesh.

 

 

ANS:  A

Although it is usually a safe procedure, intradermal testing increases the risk for an adverse reaction, including anaphylaxis. Emergency equipment should be available. Pretreating the skin with cortisone will not decrease the risk of anaphylaxis. Applying oxygen will not help prevent a reaction. Covering the examination table will also not prevent allergic reactions.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC:  Integrated Process: Nursing Process (Implementation)

 

3. What is most important for the nurse to teach the client with allergic rhinitis and glaucoma?

a.	“If your heartbeat increases, be sure to contact your health care provider.”
b.	“Avoid allergy drugs containing pseudoephedrine or phenylephrine.”
c.	“Be sure to drink plenty of water with antihistamines.”
d.	“You should use an eye-moistening agent such as Restasis.”

 

 

ANS:  B

Ephedrine, phenylephrine, and pseudoephedrine may cause vasoconstriction, increase blood pressure, and increase intraocular pressure. The client should avoid these drugs. An increased heart rate is not a reason to call the health care provider. The client may be thirstier when on allergy medications, or the client may need an eye-moistening agent, but these are not the most important things for the nurse to teach.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Implementation)

 

4. A client has received diphenhydramine (Benadryl) and is currently oriented but drowsy. What is the best action for the nurse to take?

a.	Perform a neurologic assessment every 2 hours.
b.	Document the response and continue to monitor.
c.	Prepare to administer epinephrine subcutaneously.
d.	Have the nursing assistant stimulate the client every hour.

 

 

ANS:  B

The client is experiencing normal side effects of the medication. The nurse will continue to monitor for additive effects. Performing a neurologic assessment is not necessary, nor is administration of epinephrine. There is no reason for the client to be stimulated hourly.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:   Integrated Process: Nursing Process (Implementation)