Deck 19: Nursing Care of Patients With Immune Disorders

Question 1

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

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

Answer 1

Diphenhydramine (Benadryl)

Question 2

While caring for a patient with angioedema, which nursing action would 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 2

Monitor for restlessness.

Question 3

The nurse contributed to the teaching plan for a patient who has a history of allergies to pollen. Which of these actions by the patient would indicate understanding of how to control this disease?

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

Answer 3

Wearing a mask when mowing the lawn

Question 4

Which of these immune cells is the defective cell in hypogammaglobulinemia?

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

Question 5

A patient is stabilized after having an allergic reaction. Which of these preventive instructions should be reinforced by the nurse now?

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

Question 6

Which nursing action would be most appropriate for a patient with chronic serum sickness?

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

Question 7

During data collection, what does the nurse understand differentiates urticaria from angioedema?

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

Question 8

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

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

Question 9

A patient is to receive a transfusion of packed red blood cells. Before administering the transfusion, which of these actions should the nurse take?

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

Question 10

The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which of the following actions would be appropriate to include in the plan of care for this patient?

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

Question 11

The nurse is reinforcing teaching to a patient with Hashimoto's thyroiditis. Which of the following would the nurse explain occurs initially in Hashimoto's thyroiditis?

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

Question 12

A patient is receiving a transfusion of packed red blood cells. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Which of these actions should the nurse take first?

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

Question 13

The nurse is caring for a patient with a severe allergic reaction. Which of the following medications and route would the nurse anticipate being ordered?

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

Question 14

The nurse is caring for a patient who is stung by a wasp. Which of these manifestations would the nurse expect if an allergic reaction develops?

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

Question 15

Urticaria is classified as what type of hypersensitivity reaction?

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

Question 16

The nurse recognizes that the patient is at increased risk of infection due to the inability to replace which of these types of immunoglobulins?

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

Question 17

The nurse is contributing to a patient's plan of care and would recognize that which of the following individuals is at risk for developing serum sickness?

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

Question 18

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

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

Question 19

The nurse is caring for a patient who has had a portion of stomach removed. For which of the following findings would the nurse monitor to detect a vitamin B12 deficiency?

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

Question 20

The nurse is caring for a patient who developed hemolytic anemia related to the administration of penicillin and asks what this condition is. What is the most appropriate response by the nurse?

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

Question 21

The nurse would recognize which immune system disorder as being characterized by elevated lactate dehydrogenase, fragmented red blood cells (RBCs) seen with microscopic examination, and low red blood cell count, hematocrit (Hct), and hemoglobin (Hgb)?

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

Question 22

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

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

Question 23

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

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

Question 24

The nurse recognizes that which of the following individuals is most likely to exhibit signs and symptoms of systemic lupus erythematosus?

A)A 45-year-old Caucasian woman
B)A 16-year-old Caucasian man
C)A 20-year-old Hispanic woman
D)A 42-year-old Asian American man
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 25

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

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

Question 26

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

Question 27

The nurse is reinforcing teaching for a patient with allergic rhinitis about potential triggers. Which of the following would the nurse include in the teaching? (Select all that apply.?

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

Question 28

Which of these types of immunity is most affected in hypogammaglobulinemia?

A)Passive natural immunity
B)Cell-mediated immunity
C)Passive active immunity
D)Humoral immunity

Question 29

Which of the following information should the nurse recommend be included in the patient's teaching plan for a nursing diagnosis of Risk for Impaired Skin Integrity due to contact dermatitis? (Select all that apply.?

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

Question 30

A patient is receiving a transfusion of packed red blood cells. 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. ___ Start the new 0.9% normal saline infusion.
b. ___ Prepare a new 0.9% normal saline infusion.
c. ___ Notify the physician stat.
d. ___ Stop the blood infusion.
e. ___ Obtain vital signs and assess patient..

Question 31

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 of the following self-care instructions should the nurse recommend? (Select all that apply.?

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

Question 32

Which of the following findings would indicate to the nurse that the treatment for pernicious anemia has been successful?

A)Decreased folic acid level and an increase in enlarged red blood cells
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 red blood cells
D)A decrease in hydrochloric acid levels in gastric secretion and decrease in production of red blood cells

Question 33

A nurse is assisting in the care of a patient with ankylosing spondylitis who is to receive a single dose of biologic therapy given intravenously. Which of the following would the nurse expect to find in the patient's collaborative plan of care? (Select all that apply.?

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

Question 34

Which of these is the most common irritant causing contact dermatitis? (Select all that apply.?

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

Question 35

The nurse should stay at the bedside with a patient for the first ________________minutes of any blood transfusion to detect signs of a reaction.Other

Question 36

The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus. Which of the following is important for the nurse to tell the patient to report regarding this particular medication?

A)Blurred vision
B)Any weight gain
C)Tarry stools
D)Changes in joint movement

Question 37

Which of the following possible side effects should the nurse discuss with a patient prescribed a corticosteroid for lupus erythematosus? (Select all that apply.?

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

Question 38

The nurse is caring for a patient with an autoimmune disorder. The patient asks, "What might cause my body to do this to itself?" Which of the following responses by the nurse would be appropriate for factors that alter or influence the self-recognition portion of the immune system? (Select all that apply.?

A)Bacterial infections
B)Viral infections
C)Drugs
D)Hormones
Completion
Complete each statement.