Question 1

The nurse is providing care to a school-age client with a documented immunodeficiency who is admitted to the general pediatric unit for intravenous medication administration. Which interventions are appropriate for this client? Select all that apply.

Accepted Answer

A positive-pressure room helps protect immunocompromised patients from airborne pathogens. Live vaccines should be avoided in immunodeficient patients due to the risk of infection. Frequent handwashing is crucial to prevent the spread of infections to immunocompromised patients.

Question 2

An HIV-positive mother states she is relieved after the birth of her child to hear that the child is HIV-negative. Which response by the nurse is the most appropriate?

Accepted Answer

HIV transmission from mother to child can occur during pregnancy, delivery, or breastfeeding. Even if initial tests show the child is HIV-negative, symptoms or signs of HIV infection can still appear over time, up to 2 years, as the virus can take time to manifest. This response acknowledges the possibility of late diagnosis and the importance of ongoing vigilance and testing.

Question 3

Parents of a child who experienced a moderately severe allergic reaction after eating peanuts ask the nurse what they can do to help if it happens again. Which response by the nurse is the most appropriate?

Accepted Answer

The most appropriate thing to do in case of a severe allergic reaction is to use an Epi-Pen, which delivers a dose of epinephrine to counteract the reaction. The nurse should teach the parents how to use it. Antihistamines can help with mild allergic reactions but are not effective for severe reactions. Desensitization is a treatment option but requires medical supervision and is not appropriate for every patient.

Question 4

A nurse begins an infusion of intravenous immune globulin (IVIG) to a child who has combined immunodeficiency disease. Which assessment finding indicates that the nurse should stop the infusion?

Accepted Answer

Severe shaking, chills, and fever can indicate an adverse reaction to IVIG, which can include anaphylaxis. The infusion should be stopped immediately and healthcare provider notified. Mild headache and complaints of being "thirsty" are common side effects of IVIG and may not require discontinuation of the infusion. Clear yellow urine is a normal assessment finding and does not indicate a need to stop the infusion.

Question 5

A preschool-age child has just had a moderate reaction to latex. When teaching the parents about latex allergy, the nurse should inform the parents of what common household items that contain latex? Select all that apply.

Accepted Answer

The answer of A preschool-age child has just had a...

Question 6

A child with human immunodeficiency virus is started on sulfamethoxazole and trimethoprim (Bactrim) for Pneumocystis carinii pneumonia (PCP) prophylaxis. The recommended dose is based on the trimethoprim (TMP) component and is 15 to 20 mg TMP/kg/day in divided doses every 6 to 8 hours. The child weighs
6.8 kg. The highest dose of TMP the child can receive a day is ________.
Round your answer to the nearest whole number.

Accepted Answer

The answer of A child with human immunodeficiency virus is...

Question 7

The nurse is providing care to an adolescent client diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of body changes associated with SLE?

Accepted Answer

Discussing the body changes with a peer indicates that the adolescent client is accepting and coping with the changes associated with SLE. Refusing to attend school or social functions may indicate avoidance or denial of the changes, and discussing the changes only with healthcare personnel may indicate a lack of confidence or discomfort in discussing the changes with peers.

Question 8

A child is prescribed Didanosine (Videx), a nucleoside reverse transcriptase inhibitor, for human immunodeficiency virus (HIV). Which lab value will the nurse monitor closely for this child?

Accepted Answer

Didanosine (Videx) can cause bone marrow suppression, leading to anemia. Therefore, monitoring the RBC count is important to detect this potential side effect.

Question 9

The nurse is providing care to a preschool-age client who is diagnosed with acquired immune deficiency syndrome (AIDS). In planning the client's care, which vaccine is inappropriate for the client to receive?

Accepted Answer

The varicella vaccine is a live attenuated virus vaccine, which means it contains weakened virus particles. This type of vaccine is not recommended for individuals with compromised immune systems, such as those with AIDS. The other vaccines listed (DTaP, HIB conjugate, and Hep B) are appropriate for a client with AIDS and may actually be recommended to help prevent additional infections.

Question 10

A child with the diagnosis of Wiskott-Aldrich syndrome has been ordered an IV infusion of gamma globulin. The child weighs 20 pounds. The healthcare provider orders: gamma globulin 2 g/kg IV over 12 hours.
Calculate how many grams of gamma globulin will be given IV.

Accepted Answer

The answer of A child with the diagnosis of Wiskott-Aldrich...

Question 11

A nurse is administering an intramuscular vaccination to an infant diagnosed with Wiskott-Aldrich syndrome (WAS). Which reaction is the infant more at risk for due to the diagnosis of WAS?

Accepted Answer

WAS is a rare inherited disorder that affects blood cells and platelets, leading to increased bleeding and bruising. The infant with WAS is more at risk for bleeding at the injection site due to the diagnosis. It is important to monitor for any signs of bleeding after the injection. Pain, redness, swelling, and mild rash are common reactions to intramuscular vaccinations and do not specifically increase the risk for an infant with WAS.

Question 12

The nurse is providing discharge teaching to a school-age client who was recently diagnosed with a latex allergy. Which product will the nurse educate the client and family to avoid?

Accepted Answer

Chewing gum may contain latex as a stabilizer, so it should be avoided by individuals with a latex allergy.

Question 13

The nurse is caring for an adolescent client diagnosed with rheumatoid arthritis. Which nonpharmacological measure to reduce joint pain is most appropriate for the nurse to recommend to this client?

Accepted Answer

Moist heat can help reduce joint pain and stiffness, making it the most appropriate nonpharmacological measure to recommend to the client. Elevation, massage, and immobilization may be beneficial in certain situations but are not typically recommended for reducing joint pain in clients with rheumatoid arthritis.

Question 14

The nurse is caring for the adolescent with systemic lupus erythematosus (SLE). What nursing diagnoses would the nurse address? Select all that apply.

Accepted Answer

The answer of The nurse is caring for the adolescent...

Question 15

A child with human immunodeficiency virus (HIV) also has oral candidiasis. Which type of mouth care solution will the nurse teach the child to use?

Accepted Answer

Normal saline can help maintain oral hygiene and moisten the oral mucosa without causing irritation. It is a safe and effective solution for patients with oral candidiasis, especially those with HIV who may have other comorbidities. Listerine and Scope may contain alcohol or other harsh ingredients that can exacerbate the condition. Viscous lidocaine is not a mouth care solution but a local anesthetic that is used for pain relief.

Question 16

A school-age child diagnosed with rheumatoid arthritis asks the nurse to recommend an exercise activity. Which activity is most appropriate for this child?

Accepted Answer

Swimming is a low-impact exercise that is gentle on the joints and can help improve strength and flexibility without exacerbating the child's rheumatoid arthritis. Softball, football, and basketball involve higher impact activities that may be too strenuous and could potentially cause further joint damage.

Question 17

A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child?

Accepted Answer

The highest priority for a child with HIV is the risk for infection, as their compromised immune system puts them at a much higher risk for contracting infections. The other options listed may also be relevant to the child's care, but addressing the risk for infection is the top priority.

Question 18

A child comes to the clinic for an assessment 20 days post-bone marrow transplant. Which system should receive the highest priority during the nursing assessment?

Accepted Answer

The answer of A child comes to the clinic for...

Quiz 22: Alterations in Immune Function

The nurse is providing care to a school-age client with a documented immunodeficiency who is admitted to the general pediatric unit for intravenous medication administration. Which interventions are appropriate for this client? Select all that apply.

An HIV-positive mother states she is relieved after the birth of her child to hear that the child is HIV-negative. Which response by the nurse is the most appropriate?

Parents of a child who experienced a moderately severe allergic reaction after eating peanuts ask the nurse what they can do to help if it happens again. Which response by the nurse is the most appropriate?

A nurse begins an infusion of intravenous immune globulin (IVIG) to a child who has combined immunodeficiency disease. Which assessment finding indicates that the nurse should stop the infusion?

A preschool-age child has just had a moderate reaction to latex. When teaching the parents about latex allergy, the nurse should inform the parents of what common household items that contain latex? Select all that apply.

The nurse is providing care to an adolescent client diagnosed with systemic lupus erythematosus (SLE) . Which action by the client indicates acceptance of body changes associated with SLE?

A child is prescribed Didanosine (Videx) , a nucleoside reverse transcriptase inhibitor, for human immunodeficiency virus (HIV) . Which lab value will the nurse monitor closely for this child?

The nurse is providing care to a preschool-age client who is diagnosed with acquired immune deficiency syndrome (AIDS) . In planning the client's care, which vaccine is inappropriate for the client to receive?

A child with the diagnosis of Wiskott-Aldrich syndrome has been ordered an IV infusion of gamma globulin. The child weighs 20 pounds. The healthcare provider orders: gamma globulin 2 g/kg IV over 12 hours. Calculate how many grams of gamma globulin will be given IV.

A nurse is administering an intramuscular vaccination to an infant diagnosed with Wiskott-Aldrich syndrome (WAS) . Which reaction is the infant more at risk for due to the diagnosis of WAS?

The nurse is providing discharge teaching to a school-age client who was recently diagnosed with a latex allergy. Which product will the nurse educate the client and family to avoid?

The nurse is caring for an adolescent client diagnosed with rheumatoid arthritis. Which nonpharmacological measure to reduce joint pain is most appropriate for the nurse to recommend to this client?

The nurse is caring for the adolescent with systemic lupus erythematosus (SLE) . What nursing diagnoses would the nurse address? Select all that apply.

A child with human immunodeficiency virus (HIV) also has oral candidiasis. Which type of mouth care solution will the nurse teach the child to use?

A school-age child diagnosed with rheumatoid arthritis asks the nurse to recommend an exercise activity. Which activity is most appropriate for this child?

A nurse is planning care for a child with human immunodeficiency virus (HIV) . Which nursing diagnosis is the highest priority for this child?

A child comes to the clinic for an assessment 20 days post-bone marrow transplant. Which system should receive the highest priority during the nursing assessment?