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A client comes to the clinic and reports having had a mild case of the flu a couple of months ago and not having felt well since. The client expresses feeling fatigued that gets worse after any physical activity and having a recurrent sore throat and joint pain. What does the nurse recognize these symptoms may indicate?
- A. Chronic fatigue syndrome
- B. Rheumatoid arthritis
- C. Ulcerative colitis
- D. Recurrent flu
Correct Answer: A
Rationale: Many clients with CFS report having had a recent illness with flulike symptoms or an upper respiratory infection. Despite having been uncomfortable, most clients do not describe their initial symptoms as being extraordinarily severe. Severe, ongoing fatigue lasts for at least 6 months without any explanation. Even though the fatigue is constant, it worsens after physical activity. The fatigue is so debilitating that it usually interferes with a person's ability to work in or outside the home. Rheumatoid arthritis and ulcerative colitis are autoimmune disorders with symptoms that are more specific than CFS and can be diagnosed with diagnostic testing and laboratory studies. The symptoms that the client is having are not characteristic of the flu.
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The nursing instructor is discussing hypersensitivity responses with a clinical group. What allergic reaction(s) would the nursing instructor talk about? Select all that apply.
- A. Typical
- B. Unmediated
- C. Cytotoxic
- D. Atopic
- E. Immune complex
Correct Answer: C,D,E
Rationale: Once sensitization occurs, one of four types of hypersensitivity responses can occur. These may be immediate or delayed depending on the time it takes for the immune system to mount a response. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly. There are three types of immediate hypersensitivity responses: type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies; type II, cytotoxic, which is mediated by immunoglobulin M or G (IgM or IgG) antibodies; and type III, immune complex, which is mediated by IgG antibodies. The first two types of responses occur within minutes; type III responses reach a peak within 6 hours after exposure to an allergen. The nurse would not discuss atypical and unmediated hypersensitivity responses in this scenario.
A client is in treatment for an allergic disorder. What might the treatment be?
- A. Autoimmune therapy
- B. Hypersensitive therapy
- C. Desensitization therapy
- D. Drug therapy for symptoms
Correct Answer: D
Rationale: Besides avoiding the allergen if possible, many clients experience symptomatic relief with drug therapy. It is not likely the client would be in autoimmune, hypersensitive, or desensitization therapy for an allergic disorder.
The nurse is collecting data from a client with the autoimmune disorder endocarditis. What does the nurse recognize as symptom of an acute exacerbation?
- A. Temperature of 100.9?°F
- B. Respiratory rate of 20 breaths/minute
- C. Constipation
- D. Nausea
Correct Answer: A
Rationale: Periods of acute flare-ups (known as exacerbations) are completely unpredictable. During acute exacerbations, clients often experience a low-grade fever, malaise, or fatigue. They also may lose weight. A respiratory rate of 20 breaths/minute is within normal range. Constipation and nausea are not characteristic of a flare-up of endocarditis.
A client is scheduled to have a prick test to determine what specific allergens are creating problems for the client. What should the nurse inform the client is involved with the testing?
- A. A concentrated form of the substance is applied to the skin and covered with an occlusive dressing for 48 hours and then examined.
- B. A dilute solution of an antigen is injected intradermally and observed for a wheal.
- C. The skin will be scratched, a small amount of the liquid test antigen will be applied to the scratch, usually on the back.
- D. The client will taste several different possible antigens and observe for wheals.
Correct Answer: C
Rationale: The scratch or prick test involves scratching the skin and applying a small amount of the liquid test antigen to the scratch. The tester applies one allergen per scratch over the client's forearm, upper arm, or back. The back is more sensitive than the arm. Results of the test are identifiable in as little as 20 minutes. If a raised wheal with localized erythema appears, the tester measures its length and width in millimeters. The client does not taste in any of the skin tests.
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client reports being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
- A. Apply an allergy bracelet and flag the chart.
- B. Tape an EpiPen to the head of the bed.
- C. Inform the client not to take any medications with those substances in them.
- D. Call the physician.
Correct Answer: A
Rationale: The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged.