Nokea
A patient who works in a plant nursery and has experienced an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment?
- A. I need to think about a change in my occupation.'
- B. I will learn to administer epinephrine so that I will be prepared if I am stung again.'
- C. I should wear a Medic-Alert bracelet indicating my allergy to insect stings.'
- D. I will need to take maintenance doses of corticosteroids to prevent reactions to further stings.'
Correct Answer: D
Rationale: The nurse?s responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance doses of corticosteroids because this was a short, rapid reaction.
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An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. Which action will be the nurse's first intervention?
- A. Apply cool compresses to urticaria.
- B. Provide oxygen per nonrebreathing mask.
- C. Cover patient with a warm blanket
- D. Prepare for venipuncture for the delivery of IV medication.
Correct Answer: B
Rationale: Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the patient may have to be intubated. Covering the patient with a warm blanket is not wrong, but not an initial intervention.
If a nurse is sensitive to latex gloves, which potential food sensitivities might the nurse have developed?
- A. Peanuts
- B. Avocados
- C. Milk
- D. Bananas
- E. Tomatoes
- F. Melons
Correct Answer: B,D,E,F
Rationale: A person sensitive to latex may also be sensitive to certain foods, including avocados, kiwi, bananas, chestnuts, hazelnuts, tomatoes, and melons.
In which patient will the nurse be most concerned about immunodeficiency disorder?
- A. The patient taking desensitization injections (immunotherapy)
- B. The patient on long-term radiation therapy for cancer
- C. The overweight patient
- D. The patient recently diagnosed with lupus erythematosus
Correct Answer: B
Rationale: Radiation destroys lymphocytes and depletes the stem cells. Prolonged radiation depresses the bone marrow.
The nurse takes into consideration that when the antigen and antibody react, the complement system is activated. This results in which activity?
- A. toughens the cell wall.
- B. generates more T cells.
- C. attracts phagocytes.
- D. makes the antigen resistant.
Correct Answer: C
Rationale: The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes.
Which term is used to describe transplantation of tissue between members of the same species?
- A. Allograft
- B. Autograft
- C. Isograft
- D. Homograft
Correct Answer: A
Rationale: The allograft is the transplantation of tissues between members of the same species, such as a graft for full-thickness burns.