Chapter 15 Care of the Patient with an Immune Disorder

Chapter 15  Care of the Patient with an Immune Disorder

MULTIPLE CHOICE

1. A patient has a history of allergic reactions to bee stings. Which actions should the nurse teach to avoid an anaphylactic reaction to bee stings?

1. Limit intake of sweets to reduce attraction of bees.
2. Carry a dose of aminophylline at all times.
3. Take extra precautionary actions when outdoors where bees may be present.
4. Wear a Medic-Alert tag that states the patient is allergic to bee stings.

ANS: C
Teach the patient avoidance of allergens.

DIF: Cognitive Level: Analysis
TOP: Anaphylactic reaction Implementation
MSC: NCLEX: Physiological Integrity

REF: Page 726 OBJ: 8 KEY: Nursing Process Step:

2. A patient comes to the emergency department with dyspnea, wheezing, and urticaria over the arms and face after being stung by a bee. The nurse would begin immediate care for this patient because he or she is having a(n)

1. asthma attack.
2. anaphylactic reaction.
3. pulmonary embolism.
4. acute psychotic episode.

ANS: B
Fatal reactions are associated with a fall in blood pressure, laryngeal edema, and bronchospasm, leading to cardiovascular collapse, myocardial infarction, and respiratory failure. Early recognition of signs and symptoms and early treatment may prevent severe reactions and even death.

DIF: Cognitive Level: Analysis REF: Page 727 OBJ: 8 TOP: Anaphylactic reaction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

3. A patient has been admitted with pernicious anemia and has asked the nurse to tell him what type of disorder pernicious anemia is. The nurse tells him that it is an immune disorder that results from failures of the tolerance to one’s “self.” Responding immunologically to one’s own antigens is called a(n)

1. immunodeficiency disorder.
2. hypersensitivity disorder.

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 15-2

c. desensitization disorder. d. autoimmune disorder.

ANS: D
Autoimmune disorders are failures of the tolerance to “self.” Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish “self” protein from “foreign” protein.

DIF: Cognitive Level: Application REF: Pages 730-731 OBJ: 5 TOP: Autoimmune disorders
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

4. A 72-year-old female patient is admitted with a diagnosis of immunodeficiency disease. The primary nursing goal would be to

1. reduce the risk of her developing an infection.
2. encourage her to provide self-care.
3. plan nutritious meals to provide adequate intake.
4. encourage her to interact with other patients.

ANS: A
Unusually severe infections with complications or incomplete clearing of an infection may also indicate an underlying immunodeficiency.

DIF: Cognitive Level: Analysis REF: Pages 730-731 OBJ: 11 TOP: Immunodeficiency diseases
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment

5. What precautionary safety measure should the nurse take for a patient who is receiving first-time intradermal injections for allergy testing?

1. Take vital signs every 15 minutes for 1 hour after the patient receives the injection.
2. Remind the patient to call the physician if a rash develops.
3. Have the patient remain for 20 minutes after the injection.
4. Instruct the patient to take epinephrine if an allergic reaction occurs.

ANS: C
The patient must always be observed for at least 20 minutes after administration, because hypersensitivity reaction or anaphylaxis may occur.

DIF: Cognitive Level: Application REF: Page 724 OBJ: 5 TOP: Medication KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

6. A patient comes to the clinic for his weekly “allergy shot.” He missed his appointment the week before because of a family emergency. Which action by the nurse is appropriate in administering his injection?

1. Administer the usual dosage of the allergen.
2. Double the dosage to account for the missed injection the previous week.
   Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 15-3

c. Consult with the physician about decreasing the dosage for this injection. d. Reevaluate his sensitivity to the allergen with a skin test.

ANS: C
Interrupted regimens may place the patient at risk for reaction.

DIF: Cognitive Level: Analysis REF: Page 724 TOP: Allergies KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

OBJ: 2