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?

Accepted Answer

Diphenhydramine (Benadryl) is an antihistamine commonly used to control itching and other symptoms associated with allergic reactions.

Question 2

While caring for a patient with angioedema, which nursing action would have the highest priority?

Accepted Answer

Monitoring for restlessness is crucial as it can indicate airway obstruction, a life-threatening complication of angioedema, thus requiring immediate intervention.

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?

Accepted Answer

Wearing a mask when mowing the lawn can help prevent exposure to pollen, which can trigger allergies. Gardening on dry, windy days, driving with the windows open during high pollen counts, and taking frequent walks outside during allergy season can all increase exposure to pollen and worsen symptoms.

Question 4

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

Accepted Answer

Hypogammaglobulinemia is a condition in which there is a deficiency in the production of gammaglobulins, also known as antibodies. Antibodies are produced by B cells and mature into plasma cells, which then continuously produce and secrete antibodies. Therefore, the defective cell in hypogammaglobulinemia is the B cell.

Question 5

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

Accepted Answer

Wearing a Medic-Alert identification is important for individuals with severe allergies in case of an emergency so that medical personnel can quickly identify the allergy and provide appropriate treatment. Staying indoors or wearing insect repellent may not be relevant to the patient's specific allergic reaction, and taking corticosteroids before going outdoors may not be appropriate without guidance from a healthcare provider.

Question 6

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

Accepted Answer

The answer of Which nursing action would be most appropriate...

Question 7

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

Accepted Answer

The answer of During data collection, what does the nurse...

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?

Accepted Answer

Covering heating ducts with filters can help trap dust particles and prevent them from circulating throughout the home, reducing exposure and symptoms for the patient. Installing a hot air heater may actually worsen symptoms as it can dry out the air and cause dust to become airborne. Wall-to-wall carpeting and heavy draperies can also trap dust and make it harder to clean effectively.

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?

Accepted Answer

Before administering a transfusion of packed red blood cells, the nurse should verify the blood type of both the patient and the donor to prevent a transfusion reaction. The other options listed are not directly related to the transfusion process.

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?

Accepted Answer

The answer of The nurse is caring for a patient...

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?

Accepted Answer

In Hashimoto's thyroiditis, the initial phase often involves an increase in thyroid hormone production due to the destruction of thyroid cells, leading to a temporary hyperthyroid state before progressing to hypothyroidism.

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?

Accepted Answer

The patient is experiencing symptoms of a possible transfusion reaction, such as a febrile reaction or a hemolytic reaction. The first action the nurse should take is to stop the blood infusion, which is the potential cause of the reaction. Once the blood infusion has been stopped, the nurse can assess the patient further and notify the physician if needed. Starting or preparing a new normal saline infusion may be necessary if the patient's condition warrants it, but stopping the blood infusion takes priority.

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?

Accepted Answer

Severe allergic reactions require immediate treatment with epinephrine via subcutaneous injection, followed by transfer to the emergency department for further management. Oral and intravenous diphenhydramine may be given as adjunctive therapy, but epinephrine is the medication of choice for anaphylaxis. Intramuscular morphine is not indicated for treatment of anaphylaxis.

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?

Accepted Answer

Hives are a common manifestation of an allergic reaction to a wasp sting. Jugular vein distention, pallor around the sting site, and retinal hemorrhage are not commonly associated with an allergic reaction to a wasp sting.

Question 15

Urticaria is classified as what type of hypersensitivity reaction?

Accepted Answer

Urticaria, also known as hives, is a type I hypersensitivity reaction which is mediated by IgE antibodies. It is caused by the release of histamine and other inflammatory mediators from mast cells and basophils.

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?

Accepted Answer

IgA plays a crucial role in the immune function of mucous membranes. The inability to replace IgA can lead to an increased risk of infection, especially in mucosal areas.

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?

Accepted Answer

Serum sickness is an immune complex reaction that can occur after exposure to certain medications, such as penicillin. Cryoprecipitate and factor IX (B) are used for the treatment of bleeding disorders and are not known to cause serum sickness. Transfusions with packed red blood cells (C) can cause transfusion reactions but not serum sickness. Steroids and immunosuppressant therapy (D) are used to prevent rejection of transplanted organs and are not known to cause serum sickness.

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?

Accepted Answer

Urticaria, also known as hives, is a type of skin rash characterized by red, raised, itchy bumps. Relaxation techniques, such as deep breathing and meditation, can help reduce stress and possibly decrease the severity and duration of urticaria episodes. Avoiding triggers, such as certain foods or medications, is also important. Taking aspirin or drinking coffee may actually worsen urticaria symptoms in some individuals. Avoiding tub baths may be recommended in some cases, but it is not a universal recommendation for all patients with urticaria.

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?

Accepted Answer

Vitamin B12 is important for the maintenance of healthy nerve cells and red blood cells. A deficiency can lead to numbness and tingling in the hands and feet, weakness, and glossitis (inflammation of the tongue). The other options are not indicative of a vitamin B12 deficiency.

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?

Accepted Answer

Hemolytic anemia occurs when red blood cells are destroyed faster than they can be produced. In this case, it is caused by an antigen-antibody reaction, which occurs with the administration of penicillin. The antibodies bind to the penicillin and then attach to the patient's red blood cells, causing them to be destroyed by the immune system.

Quiz 19: Nursing Care of Patients With Immune Disorders