ATI Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity, Questions and Answers with Explanations

1. Which characteristic is common to all types of hypersensitivity reactions?

a.

Decreased inflammatory responses

b.

Presence of tissue-damaging reactions

c.

Enhanced natural killer cell activity

d.

Inability to recognize extraneous cells

ANS: B

The defining difference between a normal immune response and that termed hypersensitivity is that the immune system reacts excessively or inappropriately, with resultant tissue damage and pathology.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 383

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. What intervention does the nurse implement to provide for client safety during intradermal allergy testing?

a.

Stay with the client and ensure that emergency equipment is in the room.

b.

Pretreat the skin area to be tested with a cortisone-based cream.

c.

Apply oxygen by mask or nasal cannula before injecting the test agent.

d.

Cover the examination table and pillow with plastic or an ultrafine mesh.

ANS: A

Although it is usually a safe procedure, intradermal testing increases the risk for an adverse reaction, including anaphylaxis. Emergency equipment should be available. Pretreating the skin with cortisone will not decrease the risk of anaphylaxis. Applying oxygen will not help prevent a reaction. Covering the examination table will also not prevent allergic reactions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

3. What is most important for the nurse to teach the client with allergic rhinitis and glaucoma?

a.

If your heartbeat increases, be sure to contact your health care provider.”

b.

Avoid allergy drugs containing pseudoephedrine or phenylephrine.”

c.

Be sure to drink plenty of water with antihistamines.”

d.

You should use an eye-moistening agent such as Restasis.”

ANS: B

Ephedrine, phenylephrine, and pseudoephedrine may cause vasoconstriction, increase blood pressure, and increase intraocular pressure. The client should avoid these drugs. An increased heart rate is not a reason to call the health care provider. The client may be thirstier when on allergy medications, or the client may need an eye-moistening agent, but these are not the most important things for the nurse to teach.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

4. A client has received diphenhydramine (Benadryl) and is currently oriented but drowsy. What is the best action for the nurse to take?

a.

Perform a neurologic assessment every 2 hours.

b.

Document the response and continue to monitor.

c.

Prepare to administer epinephrine subcutaneously.

d.

Have the nursing assistant stimulate the client every hour.

ANS: B

The client is experiencing normal side effects of the medication. The nurse will continue to monitor for additive effects. Performing a neurologic assessment is not necessary, nor is administration of epinephrine. There is no reason for the client to be stimulated hourly.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

5. Which condition is a type II hypersensitivity reaction?

a.

Allergic rhinitis

b.

Positive purified protein derivative (PPD) test for tuberculosis

c.

Transfusion reaction to improper blood type

d.

Serum sickness after receiving immune globulin

ANS: C

Common clinical situations caused by type II hypersensitivities include hemolytic transfusion reactions. Type II hypersensitivity reactions are caused by antibodies directed against body tissues that have some form of non-self (foreign) protein attached to them. Allergic rhinitis is an example of a type I hypersensitivity. A positive PPD test is an example of a type IV reaction. Serum sickness is a type III reaction.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 391

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

6. A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate?

a.

Elevate the head of the client’s bed to 45 degrees.

b.

Have another nurse call the Rapid Response Team.

c.

Prepare to administer diphenhydramine (Benadryl).

d.

Slow the rate of the IV infusion.

ANS: B

This client has early signs of anaphylaxis. The nurse must notify the Rapid Response Team but also needs to stay with the client in case of cardiovascular collapse. The nurse’s best action is to ask another nurse to call the Team while he or she continues to assess the client. The nurse will prepare to administer epinephrine. Slowing the IV rate will not help the situation; if the client is reacting to the antibiotic, the nurse should change the IV tubing and solution. If the client is not hypotensive, the nurse can raise the head of the bed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

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Category ATI
Release date 2021-09-14
Pages 14
Language English
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