The nurse is caring for a patient receiving immunosuppressive therapy. Which assessment finding indicates the presence of an infection? Select all that apply.
Hypotension
Presence of increased leukocytes
Adventitious breath sounds
Presence of lesions on the skin
The nurse in the emergency department is caring for a newly admitted patient. Analyze the information and determine which priority action the nurse should take at 1030.
Deliver the epinephrine dose
The patient presents with signs of a type II hypersensitivity reaction that includes a complement and antibody-mediated inflammation. The patient’s symptoms are blood in the sputum and urine. What should the healthcare team anticipate is the cause?
Goodpasture syndrome
The nurse is caring for a patient with DiGeorge syndrome who has been prescribed calcium supplements. Which statement by the nurse correctly explains the purpose of this supplement?
"It prevents tetany and seizures".
The nurse is teaching a patient diagnosed with type IV hypersensitivity. Which statement made by the patient indicates effective teaching? Select all that apply.
I will wear a medical alert bracelet
"I will use an epinephrine injection if there is an allergic response".
The nurse is caring for a patient with a latex allergy. Which action should the nurse take to prevent a reaction?
Cover skin with a cloth before applying a blood pressure cuff.
The nurse is caring for a patient with Graves’ disease. Arrange the events in the order that they lead to this condition
An autoantibody binds to the thyroid-stimulating hormone receptor sites.
The binding results in continual stimulation of the thyroid cells
The thyroid hormone is produced
The normal feedback system does not work
The patient exhibits severe hyperthyroidism
The nurse is admitting a male patient with immunosuppression to the medical-surgical unit. Which room would be the best to assign?
Room 204-A
Arrange the events in the order in which they occur when a patient receives incompatible blood during a blood transfusion.
Antibodies coat the foreign erythrocytes
Agglutination or clumping takes place
small blood vessels are blocked
Neutrophils and macrophages phagocytize the clumped cells
Hemoglobin is released into the urine and plasma
Vascular spasms occur in the kidney
Acute renal failure occurs due to hemoglobinuria
Coagulation depletes clotting factors
Patient experiences massive bleeding
The nurse is assessing an infant at a well-baby clinic appointment. Which assessment finding does the nurse identify as a warning sign of primary immune deficiency?
The infant has recurrent deep skin abscesses
A patient who is exposed to animal dander reports nasal discharge and watering eyes. The nurse observes edema around the mouth and eyes. Which medication would be most beneficial in relieving the patient’s symptoms? Select all that apply.
Decongestants
Antihistamines
The condition of a patient with type I hypersensitivity progresses to anaphylactic shock and then respiratory arrest. Which intervention is the highest priority for this patient?
Preparing for endotracheal intubation
The nurse is starting a patient on chemotherapy. Which is a priority teaching point for the patient and family? Select all that apply.
Practice good hand washing
Refrain from keeping turtles or reptiles as pets
Take antibiotics or antivirals as prescribed
A patient is diagnosed with systemic lupus erythematosus (SLE). The laboratory report shows increased neutrophils and monocytes. Which type of hypersensitivity reaction might have occurred in the patient?
Type III
The nurse is caring for a patient with immunosuppression from chemotherapy. Which protective device is most appropriate to wear into the patient’s room when performing care?
The mask on the left- The simple mask is appropriate
Which statement would accurately reflect a characteristic of common variable immune deficiency (CVID)?
CVID can be treated with IV immune globulin (IVIG)
A patient has developed contact dermatitis from a latex allergy. Which treatment is most beneficial for this patient?
Skin creams containing steroids
The nurse is making assignments for the nursing unit and considering priorities for infection control. Which patient should not be assigned to the nurse caring for a patient with a contagious infectious disease? Select all that apply.
A patient undergoing chemotherapy
A patient receiving radiation therapy
A patient who had a kidney transplant
A patient who had surgical removal of the spleen
The nurse is providing education to the parents of a child newly diagnosed with DiGeorge syndrome. The parents ask the nurse, “What caused such odd facial features and bone structure?” Which response by the nurse would be appropriate?
"The facial abnormalities are related to the deletion of a specific chromosome in your child's DNA."
The nurse is caring for a 2-year-old patient recently diagnosed with X-linked agammaglobulinemia. Which finding would be consistent with the diagnosis?
History of recurrent pneumonia
Which assessment finding would the nurse anticipate in a patient diagnosed with DiGeorge syndrome?
Fingernail clubbing
When caring for a patient with suspected serum sickness, which finding would confirm the diagnosis?
Patient reports taking penicillin 2 weeks ago
The nurse is reviewing the laboratory and diagnostic reports of a patient with allergic rhinitis. Which finding supports the diagnosis? Select all that apply.
Eosinophils 8%
Positive reaction on the scratch test
The nurse is caring for a patient with hay fever. The nurse identifies the condition as type I hypersensitivity reaction. Which information about this condition is correct?
The patient has developed rapid allergic reaction
The nurse is explaining the “CATCH” acronym that describes clinical manifestations of DiGeorge syndrome to a nursing student. When asked about what the “C” stands for, which manifestation listed by the student nurse would indicate an understanding of the teaching?
Cleft palate
A patient exposed to pollen dust is seen at the medical clinic with acute symptoms of dyspnea and shortness of breath. Which other symptom might the nurse observe in this patient? Select all that apply.
Angioedema
Hoarseness ans stridor
Swelling below surface of the skin around the mouth and eyes
The nurse is caring for a patient who is treated symptomatically for systemic lupus erythematous (SLE). Which treatment is considered for pruritus?
Antihistamines
Which intervention should be performed first when treating a type III hypersensitivity reaction?
Removal of the offending agent
The nurse on the medical unit is caring for a postoperative patient. Based on the information provided, which priority action the nurse should take next?
Apply oxygen 100% per nonrebreather mask
The emergency department (ED) nurse is caring for a patient involved in a large motor vehicle accident who requires multiple blood transfusions immediately but with an unknown blood type. Which nursing intervention would be the priority?
Administer several units of type O blood immediately
The nurse receives admission orders from the healthcare provider. Which priority should the nurse initiate, based on the prescriptions received?
Ciprofloxacin 400 mg IV bid
When the patient in the emergency department (ED) reports a history of fungal infections of the feet and uncontrollable twitching, which condition would the nurse suspect?
Chronic mucocutaneous candidiasis
The nurse is caring for a child with autosomal dominant genetic inheritance disorder. The father brings in this image from the internet and asks if he was the parent that gave the child this illness. Which is the best response by the nurse?
"This image shows the father as an example, but it could have been from either you or the child's mother".
A patient diagnosed with anaphylaxis is treated with a beta agonist to decrease bronchospasms. Which assessment finding indicates effective outcome of the treatment?
Respiratory rate 16 breaths/min
Assessment data the nurse should anticipate when providing care to a patient diagnosed with DiGeorge syndrome include ?
Recurrent infections
Gastroesophageal reflux.
Cardiac abnormalities
Cleft palate
Can you differentiate assessment data for immunodeficiency
disorders? For each disorder, drag and drop the clinical
manifestations associated with the specific disorder to the box.
Extreme Anaphylactic Reaction
Bronchospasm
Urticaria
Dyspnea
Stridor
Vomiting
The patient may experience bronchospasm with extreme dyspnea, shortness of breath, wheezing, urticaria, pruritus, nausea, vomiting, and diarrhea. Hoarseness and stridor, a high-pitched crowing sound that indicates narrowing of the airways, may also occur.
Severe or untreated reactions result in anaphylactic shock with hypotension and tachycardia due to vasodilation and capillary leakage from the circulatory system to the interstitial space.
Can you differentiate assessment data for immunodeficiency
disorders? For each disorder, drag and drop the clinical
manifestations associated with the specific disorder to the box.
Serum Sickness
Angioedema
Nephritis
Arthralgia
Urticaria
Lymphadenopathy
Clinical manifestations associated with serum sickness include fever, joint pain, lymphadenopathy (swollen lymph nodes), malaise, possible polyarthritis (arthritis in multiple joints), nephritis (inflammation of the nephrons in the kidney), urticaria (hives), a patchy or generalized rash, or extensive edema involving the face, neck, and joints.
Can you differentiate assessment data for immunodeficiency
disorders? For each disorder, drag and drop the clinical
manifestations associated with the specific disorder to the box.
Type I Hypersensitivity Reaction
Bronchial constriction
Anaphylaxis
Allergic rhinitis
Can you differentiate assessment data for immunodeficiency
disorders? For each disorder, drag and drop the clinical
manifestations associated with the specific disorder to the box.
Type II Hypersensitivity Reaction
Transfusion reaction
Goodpasture's syndrome
Autoimmune thrombocytopenia purpura
Can you differentiate assessment data for immunodeficiency
disorders? For each disorder, drag and drop the clinical
manifestations associated with the specific disorder to the box.
Type III Hypersensitivity Reaction
Serum sickness
Rheumatoid arthritis
Systemic Lupus Erythematosus
Can you differentiate assessment data for immunodeficiency
disorders? For each disorder, drag and drop the clinical
manifestations associated with the specific disorder to the box.
Type IV Hypersensitivity Reaction
Latex allergy
Skin rash from poison ivy
Positive reaction to a TB skin test
The nurse is caring for a 2-year-old patient recently diagnosed with X-linked agammaglobulinemia. Which finding would be consistent with the diagnosis?
A. History of recurrent pneumonia
B. Moist mucous membranes
C. Hypothermia
D. Increased appetite
A.History of recurrent pneumonia
A patient with a hemoglobin of 6.2 g/dL who has type A blood receives blood from a donor with type AB blood. Which type of hypersensitivity reaction will most likely be seen in this patient?
A. Type I
B. Type II
C. Type III
D. Type IV
B. Type II