Deck 19: Nursing Care of Patients With Immune Disorders

Question 1

A patient is experiencing an episode of urticaria.Which intervention should the nurse recommend to include in the teaching plan to assist the patient in controlling the symptoms of urticaria?

A) Avoiding tub baths
B) Taking one aspirin daily
C) Using relaxation techniques
D) Drinking decaffeinated coffee

Answer 1

Using relaxation techniques

Question 2

The nurse is assisting in the planning of care for a patient with chronic serum sickness.Which action should be a priority for this patient?

A) Assessing for a decrease in urine output
B) Administration of immunosuppressive medications
C) Closely monitoring the patient during the transfusion of blood products
D) Discussing with the patient and significant other the need for genetic counseling

Answer 2

Assessing for a decrease in urine output

Question 3

The nurse is c caring for a patient with angioedema.Which nursing action should have the highest priority?

A) Monitor for restlessness.
B) Identify cause of the angioedema.
C) Identify the presence of skin lesions.
D) Teach the patient about immunotherapy.

Answer 3

Monitor for restlessness.

Question 4

A patient is to receive a transfusion of packed RBCs.Before administering the transfusion,which action should the nurse take?

A) Verify the patient's kidney function.
B) Verify the patient's hematocrit level.
C) Verify blood type of the patient and donor.
D) Verify the patient's admitting medical diagnosis.

Question 5

The nurse is caring for a patient at risk for infection.Which immunoglobulin should the nurse consider as being the cause of this patient's infection risk?

A) IgA
B) IgE
C) IgG
D) IgM

Question 6

The nurse is caring for a patient with a severe allergic reaction.Which medication should the nurse anticipate being administered to control the itching?

A) Morphine
B) Epinephrine
C) Diphenhydramine (Benadryl)
D) Hydrocortisone sodium succinate (Solu-Cortef)

Question 7

The nurse is caring for a patient who has had a portion of stomach removed.Which manifestations should the nurse expect to determine if the patient has a vitamin B₁₂ deficiency?

A) Fever, malaise, muscle soreness, and diarrhea
B) Numbness and tingling, weakness, and glossitis
C) Urticaria, angioedema, anorexia, pruritus, and blistered lesions
D) Frequent infections, fever, malaise, vertigo, and lymphadenopathy

Question 8

A patient is stabilized after having an allergic reaction.Which preventive instructions should the nurse reinforce with the patient?

A) Wear Medic-Alert identification.
B) Stay indoors as much as possible.
C) Wear insect repellent when outdoors.
D) Take corticosteroids before going outdoors.

Question 9

A patient is receiving a transfusion of packed RBCs.Ten minutes after the infusion begins the patient reports low back pain and a headache.Which action should the nurse take first?

A) Stop the blood infusion.
B) Notify the physician STAT.
C) Start the new 0.9% normal saline infusion.
D) Prepare a new 0.9% normal saline infusion.

Question 10

The nurse contributed to the teaching plan for a patient with a history of allergies to pollen.Which patient action indicates an understanding of how to control this disease?

A) Gardening outdoors on dry, windy days
B) Wearing a mask when mowing the lawn
C) Driving the car with the windows open during high pollen counts
D) Taking frequent walks outside in spring when the weather is warm

Question 11

A patient who developed hemolytic anemia related to the administration of penicillin asks for an explanation of this condition.What is the most appropriate response by the nurse?

A) "The red blood cells are being produced inappropriately."
B) "An antigen-antibody reaction is causing destruction of red blood cells."
C) "An allergy to penicillin is destroying your platelets for unknown reasons."
D) "Allergens are invading the bone marrow and interfering with red blood cell production."

Question 12

A patient is diagnosed with hypogammaglobulinemia.Which of immune cell should the nurse realize is defective in this disorder?

A) T cells
B) B cells
C) Mast cells
D) Plasma cells

Question 13

The nurse is collecting data from a patient with skin eruptions.What should the nurse recall to differentiate urticaria from angioedema?

A) It is less pruritic.
B) It lasts a shorter period of time.
C) It includes mucous membrane edema.
D) It causes more widespread skin lesions.

Question 14

The nurse is contributing to a group of patients care plans.Which patient should the nurse identify as being at risk for developing serum sickness?

A) A patient who receives intravenous (IV) penicillin for an infection
B) A patient who has a transfusion with packed red blood cells (RBCs)
C) A patient who is given cryoprecipitate and factor IX after an abdominal injury
D) A patient given steroids and immunosuppressant therapy after organ transplantation

Question 15

The nurse is contributing to the teaching plan for a patient who is allergic to dust.Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms?

A) Installing a hot air heater
B) Cover heating ducts with filters
C) Installing wall-to-wall carpeting
D) Using heavy draperies on sunny windows

Question 16

The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia.Which action should the nurse include in the plan of care for this patient?

A) Assist with ambulation.
B) Teach good hand hygiene.
C) Avoid intramuscular injections.
D) Obtain manual blood pressures.

Question 17

The nurse is caring for a patient with a severe allergic reaction.Which medication and route should the nurse anticipate being ordered for this patient?

A) Intramuscular morphine
B) Subcutaneous epinephrine
C) IV diphenhydramine
D) Oral diphenhydramine (Benadryl)

Question 18

The nurse is reinforcing teaching provided to a patient with Hashimoto's thyroiditis.What should the nurse explain as occurring initially in this health problem?

A) Thyroid hormone production increases.
B) Thyroid hormone production decreases.
C) Thyroid-stimulating hormone production increases.
D) Thyroid-stimulating hormone production decreases.

Question 19

A patient is diagnosed with urticaria.For which type of hypersensitivity reaction should the nurse plan care for this patient?

A) Type I
B) Type II
C) Type III
D) Type IV

Question 20

The nurse is caring for a patient who is stung by a wasp.Which manifestation should the nurse expect if an allergic reaction develops?

A) Hives
B) Retinal hemorrhage
C) Jugular vein distention
D) Pallor around the sting sites

Question 21

The nurse is reviewing data collected on several patients.Which patient should the nurse identify as being most likely to exhibit signs and symptoms of systemic lupus erythematosus?

A) A 16-year-old Caucasian man
B) A 20-year-old Hispanic woman
C) A 45-year-old Caucasian woman
D) A 42-year-old Asian American man

Question 22

The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus.Which adverse effect should the nurse encourage the patient to report when taking this medication?

A) Tarry stools
B) Vision changes
C) Any weight gain
D) Changes in joint movement

Question 23

The nurse recommends the diagnosis Disturbed Body Image for a patient with systemic lupus erythematosus.What would be an appropriate long-term outcome for this patient?

A) Engages in diversional activities
B) Uses normal coping mechanisms
C) Returns to previous social involvement
D) Verbalizes feelings about body changes

Question 24

The nurse is caring for a patient who had a kidney transplant 5 days ago.The patient had been very outgoing and jovial,but this morning the patient is very quiet and refusing breakfast,and ambulation.What would be the most appropriate nursing action at this time?

A) Notify the physician for laboratory orders.
B) Notify the social worker for discharge follow-up care.
C) Inform the patient that kidney rejection signs are appearing.
D) Spend extra time with the patient, allowing verbalization of feelings.

Question 25

The nurse is reinforcing teaching about potential triggers with a patient experiencing allergic rhinitis.What should the nurse include in the teaching? (Select all that apply.)

A) Dust
B) Penicillin
C) Ragweed
D) Pet dander
E) Topical lotion
F) Oral multivitamin

Question 26

A patient is being started on a blood transfusion.For how many minutes should the nurse stay with the patient during this transfusion?

A) 5
B) 10
C) 15
D) 20

Question 27

A patient with lupus erythematosis is prescribed a corticosteroid.What side effects of this medication should the nurse review with the patient? (Select all that apply.)

A) Tinnitus
B) Facial hair
C) Moon face
D) Mood changes
E) Increased weight
F) Rash and pruritus

Question 28

The nurse is contributing to a staff education program about nursing care for hypersensitivity reactions.Which should the nurse include as examples of type I hypersensitivity reactions? (Select all that apply.)

A) Anaphylaxis
B) Angioedema
C) Serum sickness
D) Allergic rhinitis
E) Contact dermatitis
F) Hypogammaglobulinemia

Question 29

The nurse notes that a patient has an elevated lactate dehydrogenase,fragmented RBCs seen on microscopic examination,and low RBC count,hematocrit (Hct),and hemoglobin (Hgb)levels.For which health problem should the nurse consider planning care for this patient?

A) Serum sickness
B) Pernicious anemia
C) Hemolytic transfusion reaction
D) Idiopathic autoimmune hemolytic anemia

Question 30

The nurse has been caring for a patient with pernicious anemia.Which finding should indicate to the nurse that treatment has been successful?

A) Decreased folic acid level and an increase in enlarged RBCs
B) A decrease in intrinsic factor and increased vitamin B₁₂ excreted in the urine
C) An increase in vitamin B₁₂ levels and decrease in number of enlarged RBCs
D) A decrease in hydrochloric acid levels in gastric secretion and decrease in production of RBCs

Question 31

A patient comes into the emergency department with a fear of developing poison ivy after falling while walking through a wooded area earlier in the day.What should the nurse instruct the patient to do if exposure to poison ivy occurs again?

A) Flood the area with cold water.
B) Wrap the area with a thick towel.
C) Cover the area with cotton gauze.
D) Wash the area with brown soap or any soap.

Question 32

The nurse is caring for a patient with severe ankylosing spondylitis.What nursing action would be most appropriate?

A) Provide tepid tub soaks.
B) Encourage a high-fiber diet.
C) Provide activity every 2 hours.
D) Administer narcotic analgesics.

Question 33

The nurse is reinforcing teaching provided to a patient with pernicious anemia.Which patient statement indicates that teaching has been effective?

A) "I can miss a month or two of injections if I am feeling better."
B) "I will need to take vitamin B₁₂ injections for the rest of my life."
C) "I will take the vitamin B₁₂ injections until my strength returns."
D) "I can take a vitamin B₁₂ injection when I feel tired or fatigued."

Question 34

The nurse is contributing to the teaching plan for a patient diagnosed with Hashimoto's thyroiditis who has progressed to hypothyroidism with a goiter.Which self-care instructions should the nurse recommend? (Select all that apply.)

A) Eat a soft diet.
B) Increase activity slowly.
C) Eat more foods high in iodine.
D) Keep home at a cool temperature.
E) Eat a high-carbohydrate, high-protein diet.
F) During low-energy periods, use anti-embolism stockings.

Question 35

The nurse is participating in a teaching plan to address Risk for Impaired Skin Integrity for a patient with contact dermatitis.Which information should the nurse recommend be included in this plan? (Select all that apply.)

A) Keep fingernails short.
B) Take baths with an oatmeal solution.
C) Use oil-in-water lubricants for skin dryness.
D) Rub affected area roughly, but do not scratch.
E) Avoid washing affected area with brown soap.
F) Use cool washcloths over affected area to ease itching.

Question 36

The nurse is assisting in an educational seminar on common allergens.What should the nurse include as the most common irritant causing contact dermatitis? (Select all that apply.)

A) Bleach
B) Rubber
C) Fire ants
D) Poison ivy
E) Poison oak

Question 37

The nurse is assisting in the care of a patient with ankylosing spondylitis.What should the nurse expect to find in the patient's collaborative plan of care? (Select all that apply.)

A) Physical therapy daily
B) Sitz baths three times daily
C) Tylenol #3 every 4 hours prn pain
D) Administer Remicade as prescribed
E) Activity as tolerated; up with assistance

Question 38

A patient is suspected as having a blood transfusion reaction.Which laboratory test should the nurse expect to be done to confirm this diagnosis?

A) Skin testing
B) Direct Coombs' test
C) White blood cell count
D) C-reactive protein level

Question 39

The nurse is contributing to the plan of care for a patient with systemic lupus erythematosus (SLE).Which interventions should the nurse recommend for this patient? (Select all that apply.)

A) Eat a balanced diet.
B) Report "foamy urine" to physician.
C) Take cool showers or baths to relieve joint stiffness.
D) Avoid naps and obtain a minimum of 6 hours of sleep.
E) Exercise when pain and inflammation in joints is increased.
F) Use a daily personal schedule to plan activities to reduce fatigue.

Question 40

The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how the disease process occurred.What should the nurse explain to the mother?

A) It rarely occurs in males.
B) It occurs after exposure to pesticides.
C) It is because the infant was premature.
D) There are no known causes for this disorder.

Question 41

A patient with an autoimmune disorder asks,"What might cause my body to do this to itself?" What should the nurse state as reasons for the body to have lost the ability to recognize self? (Select all that apply.)

A) Drugs
B) Hormones
C) Vaccinations
D) Viral infections
E) Bacterial infections

Question 42

A patient is receiving a transfusion of packed RBCs.Ten minutes after the infusion begins,the patient reports low back pain and a headache.Place the actions in order (1-5)of importance of performance.

A) ___ Stop the blood infusion.
B) ___ Notify the physician stat.
C) ___ Obtain vital signs and assess patient.
D) ___ Start the new 0.9% normal saline infusion.
E) ___ Prepare a new 0.9% normal saline infusion.

Question 43

The nurse is experiencing severe skin blisters after wearing latex gloves at work.Which treatment should the nurse expect to be prescribed by the health care provider for these skin lesions? (Select all that apply.)

A) Oral antibiotics
B) Topic drying agent
C) Oral antihistamines
D) Topical corticosteroid
E) Topical immunomodulators

Question 44

The nurse applies clean white cotton socks over the hands of a patient with contact dermatitis.What should the nurse explain to the patient about the purposes of this intervention? (Select all that apply.)

A) Cotton allows air movement.
B) White cotton has no dye in the material.
C) White cotton prevents the wounds from spreading.
D) The cotton will absorb the drainage from the wounds.
E) Scratching is less during sleep when the area is covered.

Question 45

A patient with systemic lupus erythematosis is prescribed Prednisone,60 mg PO,in three equal doses.If using 5 mg tablets,how many tables should the nurse provide for each dose?