Nokea
For early detection of an anaphylactic reaction in a patient who has received allergen testing using the cutaneous scratch method, which of the following actions should the nurse take first?
- A. Check blood pressure and pulse rate.
- B. Auscultate the lung sounds bilaterally.
- C. Monitor pupil size and reaction to light.
- D. Assess the arm at the site of the skin testing.
Correct Answer: D
Rationale: The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis.
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The nurse is caring for a patient who has experienced Goodpasture's syndrome. Which of the following adverse effects should the nurse be aware of?
- A. Thrombocytopenia
- B. Leukopenia
- C. Angioedema
- D. Pulmonary hemorrhage
Correct Answer: D
Rationale: Goodpasture's syndrome is a rare disorder involving the lungs and the kidneys. An antibody-mediated autoimmune reaction occurs involving the glomerular and alveolar basement membranes. The circulating antibodies combine with tissue antigen to activate the complement system which causes deposits of IgG to form along the basement membranes of the lungs or the kidneys. This reaction may result in pulmonary hemorrhage and glomerulonephritis.
The nurse is caring for a patient who had a bone marrow transplant for treatment of leukemia and has developed a skin rash 10 days after the transplant. The nurse recognizes this reaction as an indication of which of the following?
- A. Donor T cells are attacking the patient's skin cells.
- B. The patient's antibodies are rejecting the donor bone marrow.
- C. The patient is experiencing a delayed hypersensitivity reaction.
- D. The patient will need treatment to prevent hyperacute rejection.
Correct Answer: A
Rationale: The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.
The nurse is completing an assessment and health history with a patient. Which of the following statements made by the patient should alert the nurse to a possible immunodeficiency disorder?
- A. I take one baby Aspirin every day to prevent stroke.'
- B. I usually eat eggs or meat for at least two meals a day.'
- C. I had my spleen removed many years ago after a car accident.'
- D. I had a chest x-ray 6 months ago when I had walking pneumonia.'
Correct Answer: C
Rationale: Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily Aspirin use does not impact immune function. A chest x-ray does not have enough radiation to suppress immune function.
The nurse is caring for a patient in the outpatient clinic who has an immune deficiency involving the T-lymphocytes. Which of the following areas should the nurse teach the patient about the need for more frequent screening?
- A. Allergies
- B. Malignancy
- C. Antibody deficiency
- D. Autoimmune disorders
Correct Answer: B
Rationale: Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by humoral immunity.
The nurse is admitting a patient to the hospital with a diagnosis of acute rejection of a kidney transplant. Which of the following actions should the nurse anticipate implementing?
- A. Administration of immunosuppressant medications
- B. Insertion of an arteriovenous graft for hemodialysis
- C. Placement of the patient on the transplant waiting list
- D. Drawing blood for human leukocyte antigen (HLA) and ABO compatibility
Correct Answer: A
Rationale: Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is reversible, there is no indication that the patient will require another transplant, hemodialysis, or HLA/ABO testing.