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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.
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A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the patient to do?
- A. Wear powdered latex gloves when in public.
- B. Wash her hands with antibacterial soap every few hours.
- C. Maintain room temperature at 75 F to 80 F whenever possible.
- D. Keep her hands well-moisturized at all times.
Correct Answer: D
Rationale: Powdered latex gloves can cause contact dermatitis. Skin should be kept well-hydrated and should be washed with mild soap. Maintaining room temperature at 75 F to 80 F is not necessary.
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
- A. Risk for Infection Related to Skin Sloughing
- B. Risk for Acute Pain Related to Loss of Skin Integrity
- C. Risk for Impaired Skin Integrity Related to Cutaneous Lesions
- D. Risk for Impaired Gas Exchange Related to Airway Obstruction
Correct Answer: D
Rationale: Edema of the respiratory tract can compromise the airway in patients with hereditary angioedema. As such, this is a priority nursing diagnosis over pain and possible infection. Skin integrity is not threatened by angioedema.
The nurse in an allergy clinic is educating a new patient about the pathology of the patients health problem. What response should the nurse describe as a possible consequence of histamine release?
- A. Constriction of small venules
- B. Contraction of bronchial smooth muscle
- C. Dilation of large blood vessels
- D. Decreased secretions from gastric and mucosal cells
Correct Answer: B
Rationale: Histamines effects during the immune response include contraction of bronchial smooth muscle, resulting in wheezing and bronchospasm, dilation of small venules, constriction of large blood vessels, and an increase in secretion of gastric and mucosal cells.
A patient has sought care, stating that she developed hives overnight. The nurses inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?
- A. Type I
- B. Type II
- C. Type III
- D. Type IV
Correct Answer: A
Rationale: Urticaria (hives) is a type I hypersensitive allergic reaction.
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, When I was young I used to take antihistamines, but they always put me to sleep. How should the nurse best respond?
- A. Newer antihistamines are combined with a stimulant that offsets drowsiness.
- B. Most people find that they develop a tolerance to sedation after a few months.
- C. The newer antihistamines are different than in years past, and cause less sedation.
- D. Have you considered taking them at bedtime instead of in the morning?
Correct Answer: C
Rationale: Unlike first-generation H1 receptor antagonists, newer antihistamines bind to peripheral rather than central nervous system H1 receptors, causing less sedation, if at all. Tolerance to sedation did not usually occur with first-generation drugs and newer antihistamines are not combined with a stimulant.