Question 1

A patient is suspected of having an allergic reaction to certain laundry detergents. The nurse recognizes that which diagnostic test result would best confirm a hypersensitivity reaction?

Accepted Answer

A prick test provides direct evidence of an IgE-mediated hypersensitivity reaction by measuring the size of the wheal and erythema (redness and swelling) that results from a small amount of the suspected allergen being introduced under the skin. A larger wheal and erythema indicates a stronger allergic reaction. The other diagnostic tests listed are not specific to hypersensitivity reactions or do not provide direct evidence of an allergic reaction to laundry detergents.

Question 2

A patient is diagnosed with valvular heart disease after having strep throat. The nurse would explain that this condition is the result of which pathophysiology?

Accepted Answer

Molecular mimicry occurs when the immune system mistakes the body's own tissues for foreign pathogens due to similarities in the molecular structures of the pathogen and the host tissues. In the case of valvular heart disease following strep throat, the immune system attacks the heart valves thinking they are streptococcal bacteria, leading to damage. This is a classic example of rheumatic fever, which can occur after an infection with group A Streptococcus.

Question 3

A patient is admitted to receive a kidney transplant from a live sibling. The nurse understands that which condition has been met for this surgery to be planned?

Accepted Answer

The human leukocyte antigens (HLAs) play a crucial role in the body's immune response to foreign tissues. For a kidney transplant to have the best chance of success, the HLAs between the donor and recipient should be very similar to minimize the risk of organ rejection.

Question 4

An HIV-positive patient comes into the clinic complaining of increasing pain in the feet and legs. The nurse realizes that this patient is demonstrating which complication?

Accepted Answer

Pain in the feet and legs is a common manifestation of peripheral neuropathy, which is a nervous system complication commonly seen in individuals with HIV. This may occur due to HIV itself or as a side effect of antiretroviral therapy.

Question 5

The nurse is providing discharge education for a patient who experienced an anaphylactic reaction to a bee sting. To ensure that the patient receives prompt, appropriate medical care in the event of another bee sting, the nurse encourages which actions?. Select all that apply.

Accepted Answer

The answer of The nurse is providing discharge education for...

Question 6

A patient who had a bone marrow transplant 10 days ago develops a maculopapular rash on the palms of both hands and the soles of the feet. The patient complains of severe abdominal pain with bloody diarrhea. The nurse would anticipate providing care for which condition?

Accepted Answer

The symptoms of a maculopapular rash on the palms and soles, as well as abdominal pain and bloody diarrhea, are indicative of graft-versus-host disease (GVHD). GVHD occurs when the transplanted donor cells recognize the host tissues as foreign and attack them. This can manifest in various ways, including skin rashes, gastrointestinal complications, and liver dysfunction. Chronic and acute tissue rejection typically involve different symptoms, such as fever, pain at the transplant site, and decreased organ function. Hyperacute tissue rejection is rare in bone marrow transplants and usually occurs immediately after the transplant, rather than 10 days later.

Question 7

A patient diagnosed with AIDS complains of nausea, fever, severe diarrhea, and anorexia. Which medication would be the most effective to relieve the anorexia and to stimulate the patient's appetite?

Accepted Answer

Megestrol (Megace) is a medication commonly used to stimulate appetite and aid in weight gain, particularly in patients with HIV/AIDS. It has been shown to be effective in improving appetite and increasing weight in these patients. Ciprofloxacin (Cipro) is an antibiotic used to treat bacterial infections, and would not be effective in relieving anorexia or stimulating appetite. Zidovudine (Retrovir, AZT) and Abacavir (Ziagen) are antiretroviral medications used to treat HIV infection, but they do not have appetite-stimulating properties.

Question 8

A patient who believes he has a peanut allergy presents at the emergency department concerned because he has ingested a small amount of commercially prepared food that may have contained peanut oil. Which nursing best addresses the patient's risk for injury?

Accepted Answer

Asking if the patient has previously experienced an allergic reaction to peanuts helps the nurse assess the patient's history and risk of a severe allergic reaction, which is crucial for determining the urgency and type of intervention needed.

Question 9

A patient comes into the emergency department with itching, swelling, and slight shortness of breath after being stung by a bee 20 minutes ago. The nurse bases care of this patient on the pathophysiology of which hypersensitivity reaction?

Accepted Answer

The symptoms described are consistent with a type I IgE-mediated hypersensitivity reaction, which is an immediate hypersensitivity reaction that occurs within minutes to hours of exposure to an allergen such as a bee sting. This type of reaction involves the release of histamine and other mediators from mast cells and basophils, leading to the symptoms of itching, swelling, and shortness of breath.

Question 10

A patient with a history of latex allergy has developed itching and hives after being admitted for a fractured left femur. What initial nursing action is indicated?

Accepted Answer

The initial nursing action should be to assess the patient's airway and breathing, as difficulty breathing can indicate a severe allergic reaction or anaphylaxis, which requires immediate intervention.

Question 11

A patient with an autoimmune disorder tells the nurse, "My family keeps telling me I don't look sick." The nurse would choose which nursing diagnosis to help this patient?

Accepted Answer

The answer of A patient with an autoimmune disorder tells...

Question 12

Which statement by a patient who has HIV would the nurse evaluate as indicating additional health care teaching is necessary?

Accepted Answer

Using an oil-based lubricant can weaken the latex in condoms, increasing the risk of breakage and transmission of HIV. The correct choice would be to use a water-based lubricant with condoms.

Question 13

A patient who is immunosuppressed asks the nurse why she is experiencing so many illnesses. How should the nurse respond?

Accepted Answer

Immunosuppressed patients have a weakened immune system, making it difficult for them to develop immunity to common bacteria, leading to more frequent illnesses.

Question 14

The nurse is performing an admission assessment on a patient with AIDS. Which would best evaluate the patient's risk of contracting an opportunistic infection?

Accepted Answer

CD4 and T cell counts are used to assess the immune function of patients with AIDS and can indicate their risk of developing opportunistic infections. Option B asks about recent symptoms, which may not necessarily give a comprehensive understanding of the patient's overall immune status. Option C asks about the patient's knowledge of symptoms but does not provide objective data. Option D asks about sexual activity but does not directly address the patient's immune function or risk of opportunistic infections.

Question 15

A patient diagnosed with AIDS has developed oral candidiasis. The home health nurse would agree with which actions by the family to help manage this opportunistic infection?. Select all that apply.

Accepted Answer

The answer of A patient diagnosed with AIDS has developed...

Question 16

A patient develops a fever, rash, joint and muscle pain, and swollen lymph nodes after receiving a sulfonamide for a urinary tract infection (UTI). The nurse anticipates providing care for which condition?

Accepted Answer

The symptoms described are indicative of serum sickness, a type III hypersensitivity reaction that can occur as an adverse effect of sulfonamide therapy. Symptoms typically develop 7-14 days after beginning therapy and can include fever, rash, joint and muscle pain, and lymphadenopathy. Worsening of the infection would not present with these symptoms, and respiratory involvement or subacute rheumatoid arthritis are not associated with sulfonamide therapy.

Question 17

A patient is diagnosed with a type IV delayed hypersensitivity reaction. Which patient reaction is an example of this type of reaction?

Accepted Answer

Type IV delayed hypersensitivity reactions are cell-mediated immune responses that occur days after exposure to an antigen. The symptoms described in option A, such as dry, red, swollen, and itchy hands occurring 2 days after wearing a latex costume, are consistent with this type of reaction.

Question 18

A patient is demonstrating signs of anaphylactic shock. Which action should the nurse take first to assist this patient?

Accepted Answer

Maintaining an airway is the first priority in the management of anaphylactic shock as airway obstruction can lead to severe hypoxia or even death. Administering subcutaneous epinephrine would be the second priority. Providing calm reassurance and placing the patient on a cardiac monitor can be done after the airway is secured and epinephrine is administered.

Question 19

The nurse is instructing a patient diagnosed with AIDS regarding food choices that will increase caloric intake. Which meal choice would indicate that the patient understands the dietary instruction?

Accepted Answer

This meal includes a variety of calorie-dense options such as meat sauce, butter, vanilla milkshake (with Ensure), and pecan pie. The patient also has a balanced meal with a carbohydrate (spaghetti and roll), protein (meat sauce), and fruit/vegetable (raisin salad).

Question 20

A patient is experiencing symptoms of exposure to environmental ragweed. The nurse should instruct the patient on the use of which class of medications?

Accepted Answer

Antihistamines are the class of medication used to treat symptoms of exposure to environmental allergens such as ragweed. Antibiotics, antiviral medications, and antifungal medications are not effective in treating allergic reactions.

Quiz 53: Caring for the Patient With Immune Response Disorders