Nokea
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.
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After being stung by a wasp, a patient is brought to the clinic by a coworker. Upon arrival the patient is anxious and having difficulty breathing. Which of the following actions is priority for the nurse to implement?
- A. Have the patient lie down.
- B. Assess the patient's airway.
- C. Administer high-flow oxygen.
- D. Remove the stinger from the site.
Correct Answer: B
Rationale: The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance.
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.
The nurse is admitting a patient to hospital who has acute rejection of an organ transplant. Which of the following patients is the most appropriate roommate?
- A. A patient who has viral pneumonia
- B. A patient with second-degree burns
- C. A patient who is recovering from an anaphylactic reaction to a bee sting
- D. A patient with graft-versus-host disease after a recent bone marrow transplant
Correct Answer: C
Rationale: Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient with anaphylaxis.
The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with which of the following types of immunity?
- A. Innate
- B. Active
- C. Passive
- D. Cell-mediated
Correct Answer: C
Rationale: Colostrum provides passive immunity through antibodies from the mother; these antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Innate immunity is present at birth and occurs without exposure to an antigen. Active immunity requires that the infant manufacture antibodies after exposure to an antigen. Cell-mediated immunity is acquired through T-lymphocytes and is a form of active immunity.
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.