Question 1

A client with immune disorder has been hospitalized. What information should the nurse pay particular attention to during the initial interview of a client with immune disorder?

Accepted Answer

D

Question 2

A client presents at the walk-in clinic with watery eyes, sneezing, itching, and redness in the conjunctiva bilaterally. What might the nurse suspect this client is suffering from?

Accepted Answer

The symptoms are indicative of an allergy, specifically allergic conjunctivitis. Anaphylactic shock and angioedema typically involve more severe symptoms such as difficulty breathing and swelling of the face, while autoimmune disorders may have a variety of symptoms depending on the type of autoimmune disorder.

Question 3

A public health nurse is presenting a workshop for a local Parent Teacher Organization. After the presentation, one of the parents takes the nurse aside and asks her what causes chronic fatigue syndrome. What should the nurse respond?

Accepted Answer

Chronic fatigue syndrome (CFS) is a complex and poorly understood condition. However, research suggests that CFS may be triggered by a viral infection, such as Epstein-Barr virus, human herpesvirus 6, or enterovirus, which can activate T cells in the immune system. Elevated levels of proinflammatory cytokines, such as various interleukins and tumor necrosis factor, may also be present. While there is no definitive answer to what causes CFS, current research points towards a viral infection triggering immune system dysfunction.

Question 4

The nursing instructor is discussing allergic reactions with their clinical group. What allergic reactions would the nursing instructor talk about? Select all that apply.

Accepted Answer

The nursing instructor would talk about cytotoxic, atopic, and immune complex allergic reactions, as these are the three types of allergic reactions recognized by the medical community. Atypical and unmediated reactions are not recognized categories of allergic reactions.

Question 5

A client presents to the walk-in clinic complaining of fatigue, headaches, joint pain and unrefreshing sleep. The client is diagnosed with chronic fatigue syndrome. What other symptoms might the client exhibit?

Accepted Answer

The answer of A client presents to the walk-in clinic...

Question 6

Your client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?

Accepted Answer

Antihistamines and cold preparations can interfere with the results of the skin test and should be avoided for 48 to 72 hours before the test. The other options are not relevant to the skin test for an allergic disorder.

Question 7

What nursing intervention helps reduce itchiness or prevent the client from scratching the skin would you institute with a client who has an allergic reaction and tends to itch due to histamine release?

Accepted Answer

Advising the client to use distracting techniques such as playing games, listening to music, or watching television can help reduce itchiness or prevent scratching, as the client's attention is diverted from the itch. Option B, avoiding superfatted or Castile soap, is a helpful intervention for clients with dry, itchy skin, but may not directly address the histamine release associated with an allergic reaction. Option C, dressing in warm, woolly garments, may exacerbate itchiness if the client has sensitive skin or is experiencing a reaction to wool. Option D, avoiding a humid environment, may be helpful for managing certain skin conditions, but may not necessarily prevent itchiness due to histamine release.

Question 8

Clients with immune-related disorders are told not to include allergenic proteins in their diet. What foods should these clients include in their diet?

Accepted Answer

Soybean oil does not contain allergenic proteins, making it a safe choice for clients with immune-related disorders. Milk, egg whites, and peanuts are all common allergens and should be avoided.

Question 9

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with Multiple Sclerosis which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?

Accepted Answer

An autoimmune disease is a disorder where killer T cells and autoantibodies attack or destroy natural cells-those cells that are "self."

Question 10

The clinic nurse is caring for a 74-year-old who tells the nurse they have chronic fatigue syndrome. What important factors should be considered in the case of an older adult who reports chronic fatigue?

Accepted Answer

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

Question 11

A client with Lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?

Accepted Answer

Antineoplastic drugs can be prescribed for autoimmune disorders because they have immunosuppressant effects. This can help reduce the activity of the immune system and therefore decrease inflammation and symptoms associated with autoimmune disorders. It is important to note, however, that antineoplastic drugs should be used with caution and under close supervision of a healthcare provider due to potential side effects and risks.

Question 12

You are caring for a client with chronic fatigue syndrome. What is a realistic nursing intervention when taking care of a client with this diagnosis?

Accepted Answer

Educating the client about the disease process is a realistic nursing intervention for someone with chronic fatigue syndrome. It helps the client understand their condition, manage symptoms, and make informed decisions about their care and lifestyle adjustments. The other options are not specifically recommended interventions for chronic fatigue syndrome. Moderate exertion, within the client's tolerance, is often part of a graded exercise therapy. There's no general advice to reduce potassium-rich foods for chronic fatigue syndrome patients. Avoiding crowds isn't a standard recommendation unless it's to reduce stress or exposure to infections based on individual health concerns.

Question 13

The clinic nurse is caring for a client with an allergic disorder who has received the first sensitizing dose of a new drug. Now, the client is given a second dose. What nursing action is most important at this stage of transition?

Accepted Answer

The most important nursing action at this stage of transition is to monitor the client for reactions as they have already received the first sensitizing dose and could potentially develop an allergic reaction with subsequent administration. The other options are not directly related to monitoring for an allergic reaction.

Question 14

A student nurse is caring for a client in the clinic diagnosed with chronic fatigue syndrome. The student asks the client what their original symptoms were. What might the client say?

Accepted Answer

Myalgia (muscle pain) is a common symptom of chronic fatigue syndrome. Refreshing sleep (A), red, swollen joints (C), and hypersensitive gastrointestinal tract (D) are not typically associated with chronic fatigue syndrome.

Question 15

A client being treated for an allergy has been prescribed antihistamines. The Kardex of this client reads as follows:Age: 32; Profession: Carpenter; Lifestyle & diet: Lives alone, average smoker, nonalcoholic, no food preferences, practices yoga; Medical history: Suffers from hay fever, recent urinary tract infection that has been treated successfully.What information from the Kardex is likely to have the greatest implication in educating the client about antihistamine administration?

Accepted Answer

The answer of A client being treated for an allergy...

Question 16

You are caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?

Accepted Answer

Autoimmune disorders are characterized by unrelenting, progressive tissue damage without any verifiable etiology. This means that the body's immune system mistakenly attacks its own tissues, causing damage and inflammation. The exact cause of autoimmune disorders is not yet fully understood.

Question 17

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?

Accepted Answer

An allergic disorder is a hyperimmune response to something in the environment that is usually harmless, such as pollen or certain foods. This exaggerated response can cause a range of symptoms from mild itching or sneezing to severe anaphylaxis.

Question 18

Chronic fatigue syndrome is thought by some to be a disorder resulting from which of the following?

Accepted Answer

Chronic fatigue syndrome is thought to be caused by immune-system dysregulation, as well as dysfunction in the hypothalamic-pituitary-adrenal axis and autonomic nervous system. There is some evidence of chronic viral inflammation, but it is not yet clear if it is a cause or an effect of the disorder. There may also be alterations in cytokine levels, but this is still an area of active research. There is no evidence to suggest a decrease in interleukins as a cause of chronic fatigue syndrome.

Question 19

The clinic nurse is caring for a client with episodic periods of acute exacerbations. The client has reacted well to the prescribed medications and is now in a state of remission. What advice should the nurse give this client?

Accepted Answer

The nurse should advise the client to continue administering the prescribed medication as it has been effective in achieving a state of remission. Discontinuing the medication or altering the dosage without consulting the physician could lead to a relapse of symptoms. Therefore, the client should continue taking the medication as prescribed and follow up with the physician for any necessary adjustments to the treatment plan.

Question 20

A client with an allergic disorder calls the nurse and asks what treatment is available for allergic disorders. The nurse explains to the client that there is more than one treatment available. What treatments would the nurse tell the client about?

Accepted Answer

The answer of A client with an allergic disorder calls...

Quiz 34: Caring for Clients With Immune-Mediated Disorders