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Immune Disorders Chapter 19 FA Davis

front 1

The nurse is caring for a patient receiving immunosuppressive therapy. Which assessment finding indicates the presence of an infection? Select all that apply.

back 1

Hypotension

Presence of increased leukocytes

Adventitious breath sounds

Presence of lesions on the skin

front 2

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.

back 2

Deliver the epinephrine dose

front 3

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?

back 3

Goodpasture syndrome

front 4

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?

back 4

"It prevents tetany and seizures".

front 5

The nurse is teaching a patient diagnosed with type IV hypersensitivity. Which statement made by the patient indicates effective teaching? Select all that apply.

back 5

I will wear a medical alert bracelet

"I will use an epinephrine injection if there is an allergic response".

front 6

The nurse is caring for a patient with a latex allergy. Which action should the nurse take to prevent a reaction?

back 6

Cover skin with a cloth before applying a blood pressure cuff.

front 7

The nurse is caring for a patient with Graves’ disease. Arrange the events in the order that they lead to this condition

back 7

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

front 8

The nurse is admitting a male patient with immunosuppression to the medical-surgical unit. Which room would be the best to assign?

back 8

Room 204-A

front 9

Arrange the events in the order in which they occur when a patient receives incompatible blood during a blood transfusion.

back 9

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

front 10

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?

back 10

The infant has recurrent deep skin abscesses

front 11

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.

back 11

Decongestants

Antihistamines

front 12

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?

back 12

Preparing for endotracheal intubation

front 13

The nurse is starting a patient on chemotherapy. Which is a priority teaching point for the patient and family? Select all that apply.

back 13

Practice good hand washing

Refrain from keeping turtles or reptiles as pets

Take antibiotics or antivirals as prescribed

front 14

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?

back 14

Type III

front 15

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?

back 15

The mask on the left- The simple mask is appropriate

front 16

Which statement would accurately reflect a characteristic of common variable immune deficiency (CVID)?

back 16

CVID can be treated with IV immune globulin (IVIG)

front 17

A patient has developed contact dermatitis from a latex allergy. Which treatment is most beneficial for this patient?

back 17

Skin creams containing steroids

front 18

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.

back 18

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

front 19

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?

back 19

"The facial abnormalities are related to the deletion of a specific chromosome in your child's DNA."

front 20

The nurse is caring for a 2-year-old patient recently diagnosed with X-linked agammaglobulinemia. Which finding would be consistent with the diagnosis?

back 20

History of recurrent pneumonia

front 21

Which assessment finding would the nurse anticipate in a patient diagnosed with DiGeorge syndrome?

back 21

Fingernail clubbing

front 22

When caring for a patient with suspected serum sickness, which finding would confirm the diagnosis?

back 22

Patient reports taking penicillin 2 weeks ago

front 23

The nurse is reviewing the laboratory and diagnostic reports of a patient with allergic rhinitis. Which finding supports the diagnosis? Select all that apply.

back 23

Eosinophils 8%

Positive reaction on the scratch test

front 24

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?

back 24

The patient has developed rapid allergic reaction

front 25

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?

back 25

Cleft palate

front 26

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.

back 26

Angioedema

Hoarseness ans stridor

Swelling below surface of the skin around the mouth and eyes

front 27

The nurse is caring for a patient who is treated symptomatically for systemic lupus erythematous (SLE). Which treatment is considered for pruritus?

back 27

Antihistamines

front 28

Which intervention should be performed first when treating a type III hypersensitivity reaction?

back 28

Removal of the offending agent

front 29

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?

back 29

Apply oxygen 100% per nonrebreather mask

front 30

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?

back 30

Administer several units of type O blood immediately

front 31

The nurse receives admission orders from the healthcare provider. Which priority should the nurse initiate, based on the prescriptions received?

back 31

Ciprofloxacin 400 mg IV bid

front 32

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?

back 32

Chronic mucocutaneous candidiasis

front 33

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?

back 33

"This image shows the father as an example, but it could have been from either you or the child's mother".

front 34

A patient diagnosed with anaphylaxis is treated with a beta agonist to decrease bronchospasms. Which assessment finding indicates effective outcome of the treatment?

back 34

Respiratory rate 16 breaths/min

front 35

Assessment data the nurse should anticipate when providing care to a patient diagnosed with DiGeorge syndrome include ?

back 35

Recurrent infections

Gastroesophageal reflux.

Cardiac abnormalities

Cleft palate

front 36

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

back 36

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.

front 37

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

back 37

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.

front 38

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

back 38

Bronchial constriction

Anaphylaxis

Allergic rhinitis

front 39

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

back 39

Transfusion reaction

Goodpasture's syndrome

Autoimmune thrombocytopenia purpura

front 40

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

back 40

Serum sickness

Rheumatoid arthritis

Systemic Lupus Erythematosus

front 41

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

back 41

Latex allergy

Skin rash from poison ivy

Positive reaction to a TB skin test

front 42

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

back 42

A.History of recurrent pneumonia

front 43

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

back 43

B. Type II