Deck 15: Care of the Patient With an Immune Disorder

Question 1

What precautionary safety measure should the nurse take for a patient who is receiving first-time intradermal injections for allergy testing?

A) Take vital signs every 15 minutes for 1 hour after the patient receives the injection.
B) Remind the patient to call the physician if a rash develops.
C) Have the patient remain for 20 minutes after the injection.
D) Instruct the patient to take epinephrine if an allergic reaction occurs.

Answer 1

Have the patient remain for 20 minutes after the injection.

Question 2

A patient, age 42, develops a severe angioedema involving her face, hands, and feet, with burning and stinging of the lesions. During the assessment, which significant risk factor for allergies does the nurse recognize?

A) Family history of allergies
B) History of a recent fungal infection
C) Use of OTC medications
D) Recurrent respiratory infections

Answer 2

Family history of allergies

Question 3

A 72-year-old female patient is admitted with a diagnosis of immunodeficiency disease. The primary nursing goal would be to

A) reduce the risk of her developing an infection.
B) encourage her to provide self-care.
C) plan nutritious meals to provide adequate intake.
D) encourage her to interact with other patients.

Answer 3

reduce the risk of her developing an infection.

Question 4

A cancer patient who has been receiving cytotoxic drugs has been having frequent sinus infections. During planning of his care, the nurse must remember that this frequency of infections is an indication of possible

A) immunotherapy.
B) drug-induced immunosuppression.
C) delayed hypersensitivity.
D) autoimmune disorder.

Question 5

A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, she receives

A) larger doses each week.
B) higher concentrations each week.
C) increased amounts and concentrations in 6-week cycles.
D) the same amount and concentration each visit.

Question 6

The delayed major process that leads to organ transplant rejection is

A) hypersensitivity.
B) cellular immunity.
C) autoimmune factors.
D) immunodeficiency.

Question 7

A patient, age 47, is undergoing skin testing with intracutaneous injections on the forearm to identify allergens to which she is sensitive. Immediately after the nurse administers one of the injections, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially?

A) Elevate the arm above the shoulder.
B) Administer subcutaneous epinephrine.
C) Give 0.2 to 0.5 mL of epinephrine 1:1,000 subcutaneously.
D) Apply a local anti-inflammatory cream to the site.

Question 8

A patient, age 28, is treated at the clinic with an injection of long-acting penicillin for a streptococcal throat infection. Her history reveals that she has received penicillin before with no allergic responses. When the penicillin injection is administered, which information should be given to the patient by the nurse?

A) Because she has taken penicillin before without problems, she can safely take it now.
B) She must wait in the clinic area for 20 minutes before she is discharged.
C) She would have immediate symptoms if she had developed an allergy to penicillin.
D) She should monitor for fever and skin rash typical of serum sickness after taking penicillin.

Question 9

A patient with rheumatoid arthritis is scheduled for plasmapheresis. She asks the nurse why they are going to do this procedure. In forming an answer the nurse must remember that the purpose of plasmapheresis is to

A) add medication to relieve pain symptoms.
B) remove plasma-containing components that may be causing the disease.
C) remove waste products such as urea.
D) add saline or albumin that lubricates joints.

Question 10

A patient comes to the emergency department with dyspnea, wheezing, and urticaria over the arms and face after being stung by a bee. The nurse would begin immediate care for this patient because he or she is having a(n)

A) asthma attack.
B) anaphylactic reaction.
C) pulmonary embolism.
D) acute psychotic episode.

Question 11

A patient is recovering from a kidney transplant. He is receiving cyclosporine after surgery. The purpose of this drug is to

A) promote diuresis.
B) prevent infection.
C) manage pain.
D) suppress the immune response.

Question 12

A patient has been admitted with pernicious anemia and has asked the nurse to tell him what type of disorder pernicious anemia is. The nurse tells him that it is an immune disorder that results from failures of the tolerance to one's "self." Responding immunologically to one's own antigens is called a(n)

A) immunodeficiency disorder.
B) hypersensitivity disorder.
C) desensitization disorder.
D) autoimmune disorder.

Question 13

During a patient history, the nurse notices that the patient has had five upper respiratory infections in the past 18 months. The nurse begins to suspect that the patient may have an immunodeficiency disease because the first evidence of this disease is

A) an increased susceptibility to infection.
B) an increased coagulation problem.
C) a problem with hemostasis.
D) localized edema, raised wheals.

Question 14

A patient comes to the clinic for his weekly "allergy shot." He missed his appointment the week before because of a family emergency. Which action by the nurse is appropriate in administering his injection?

A) Administer the usual dosage of the allergen.
B) Double the dosage to account for the missed injection the previous week.
C) Consult with the physician about decreasing the dosage for this injection.
D) Reevaluate his sensitivity to the allergen with a skin test.

Question 15

A patient has a history of allergic reactions to bee stings. Which actions should the nurse teach to avoid an anaphylactic reaction to bee stings?

A) Limit intake of sweets to reduce attraction of bees.
B) Carry a dose of aminophylline at all times.
C) Take extra precautionary actions when outdoors where bees may be present.
D) Wear a Medic-Alert tag that states the patient is allergic to bee stings.

Question 16

A patient who has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment?

A) "I need to think about a change in my occupation."
B) "I will learn to administer epinephrine so that I will be prepared if I am stung again."
C) "I should wear a Medic-Alert bracelet indicating my allergy to insect stings."
D) "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."

Question 17

The correct nursing intervention for anaphylaxis would be

A) assess respiratory status, including dyspnea.
B) hypertension and elevated albumin levels.
C) assess skin status, including erythema, urticaria, cyanosis, and pallor.
D) assess GI status, including nausea, vomiting, diarrhea, incontinence.

Question 18

A liver transplant patient is receiving azathioprine (Imuran). What nursing goal is critical for this patient?

A) Maintain bed rest with minimal exertion.
B) Minimize his risk for infection.
C) Allow several visitors.
D) Monitor vital signs every 15 minutes.

Question 19

After a bee sting, a patient's face becomes edematous and she begins to wheeze. Based on this assessment, the nurse would be prepared to administer:

A) aminophylline.
B) diphenhydramine (Benadryl).
C) diazepam (Valium).
D) epinephrine.

Question 20

The nurse has held a unit conference on the specific immune response. Which statement by a colleague indicates an understanding of cell-mediated immune response? "Cell-mediated responses are

A) directed from humorally mediated B cells."
B) the direct attack of activated T-cell lymphocytes."
C) from cells matured in the bone marrow."
D) characterized by antigen-specific immunoglobulins."

Question 21

If a nurse is sensitive to latex gloves, what potential food sensitivities might the nurse develop? (Select all that apply.)

A) Peanuts
B) Avocados
C) Milk
D) Bananas
E) Tomatoes
F) Potatoes

Question 22

A patient has experienced an anaphylaxis reaction and is being monitored to ensure she is stable. A nursing diagnosis for her will be

A) Decreased cardiac output.
B) Impaired skin integrity.
C) Imbalanced nutrition: less than required.
D) Feeding self-care deficit.

Question 23

Which sign and symptom is a sign of a mild reaction as a result of a blood transfusion?

A) Vomiting
B) Urticaria
C) Diaphoresis
D) Sore throat

Question 24

The first line of defense is innate (natural) immunity. Which is part of that protective mechanism against the external environment? (Select all that apply.)

A) Skin and mucous membranes
B) Lungs
C) Heart
D) Tears and saliva
E) Natural intestinal and vaginal flora
F) Stomach acid

Question 25

Once blood is removed from refrigeration, what is the length of time allotted for the blood to be transfused?

A) 2 hours
B) 4 hours
C) 6 hours
D) 3 hours

Question 26

The purpose of immunotherapy is _____________.

Question 27

The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. The next action for the nurse would be to

A) leave and get help.
B) take the patient's temperature.
C) give him his nose spray.
D) stop the transfusion and IV administer saline.

Question 28

When assessing the patient for hypersensitivity, the nurse should

A) review the immunization history.
B) discuss seasonal occurrence of signs and symptoms.
C) evaluate nutritional status.
D) observe the range of joint mobility.

Question 29

Which is a factor that contributes to the extent of an allergic response to an allergen?

A) The integrity of the skin
B) The time of year in which one is exposed
C) The amount of exposure
D) Exposure to one's clothing

Question 30

The LPN/LVN has arrived at the patient's bedside with a unit of packed cells to be connected to an IV that is infusing. When the RN arrives, what is the first thing the nurses must do?

A) Do the checks to ensure that the donor and recipient numbers match according to policy.
B) Leave the packed cells at the bedside until the saline is infused.
C) Immediately hang the packed cells to get the infusion started.
D) Check the patients ID bracelet and then hang the packed cells.

Question 31

Which are autoimmune diseases? (Select all that apply.)

A) Lupus erythematosus
B) Glomerulonephritis
C) Polio
D) Rheumatoid arthritis
E) Thrombocytopenic purpura
F) Osteoarthritis

Question 32

A 25-year-old male patient with severe rhinitis asks the nurse what is causing his nose to run. The symptoms are caused by a reaction to a substance, usually a protein, that causes the formation of an antibody and reacts specifically with an antibody called a(n)

A) proliferation.
B) complement.
C) antigen.
D) lymphokine.