Nokea
A patient has presented with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient?
- A. Promoting adequate perfusion in affected regions
- B. Promoting safe use of topical antihistamines
- C. Identifying the offending agent, if possible
- D. Teaching the patient to safely use an EpiPen
Correct Answer: C
Rationale: Identifying the offending agent is a priority in the care of a patient with dermatitis. Antihistamines are not administered topically and epinephrine is not used to treat dermatitis. Inadequate perfusion occurs with PAD or vasoconstriction.
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After the completion of testing, a childs allergies have been attributed to her familys cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action?
- A. Removing the cat from the familys home
- B. Administering OTC antihistamines to the child regularly
- C. Keeping the cat restricted from the childs bedroom
- D. Maximizing airflow in the house
Correct Answer: A
Rationale: In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors. Fully removing the cat from the environment is preferable to just keeping the cat out of the childs bedroom. Avoidance therapy does not involve improving airflow or using antihistamines.
A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?
- A. Assess for signs and symptoms of anaphylaxis.
- B. Assess for erythema and urticaria.
- C. Administer an OTC antihistamine.
- D. Administer epinephrine.
Correct Answer: A
Rationale: If a patient is experiencing an allergic response, the nurses initial action is to assess the patient for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction.
A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis?
- A. Foods
- B. Medications
- C. Insect stings
- D. Autoimmunity
- E. Environmental pollutants
Correct Answer: A,B,C
Rationale: Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities.
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect?
- A. Cytotoxic reaction due to contact with the powder in the gloves
- B. Immune complex reaction due to contact with anesthetic gases
- C. Anaphylaxis due to a latex allergy
- D. Delayed reaction due to exposure to cleaning products
Correct Answer: C
Rationale: Immediate hypersensitivity to latex, a type I allergic reaction, is mediated by the IgE mast cell system. Symptoms can include rhinitis, conjunctivitis, asthma, and anaphylaxis. The term latex allergy is usually used to describe the type I reaction. The rapid onset is not consistent with a cytotoxic reaction, an immune complex reaction, or a delayed reaction.
A patient is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the patient begins to exhibit signs and symptoms of a transfusion reaction. The patient is suffering from which type of hypersensitivity?
- A. Anaphylactic (type I)
- B. Cytotoxic (type II)
- C. Immune complex (type III)
- D. Delayed type (type IV)
Correct Answer: B
Rationale: A type II hypersensitivity reaction resulting in red blood cell destruction is associated with blood transfusions. This type of reaction does not result from types I, III, or IV reactions.