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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.
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The nurse is creating a care plan for a patient suffering from allergic rhinitis. Which of the following outcomes should the nurse identify?
- A. Appropriate use of prophylactic antibiotics
- B. Safe injection of corticosteroids
- C. Improved skin integrity
- D. Improved coping with lifestyle modifications
Correct Answer: D
Rationale: The goals for the patient with allergies may include restoration of normal breathing pattern, increased knowledge about the causes and control of allergic symptoms, improved coping with alterations and modifications, and absence of complications. Antibiotics are not used to treat allergies and corticosteroids, if needed, are not administered parenterally. Allergies do not normally threaten skin integrity.
An adolescent patients history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient consequently faces an increased risk of what health problem?
- A. Bronchitis
- B. Systemic lupus erythematosus (SLE)
- C. Rheumatoid arthritis
- D. Asthma
Correct Answer: D
Rationale: Nurses should be aware that atopic dermatitis is often the first step in a process that leads to asthma and allergic rhinitis. It is not linked as closely to bronchitis, SLE, and RA.
A patient who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should the nurse implement?
- A. The patient should take his corticosteroids regularly prior to testing.
- B. The patient should only be tested for grass, mold, and dust initially.
- C. The nurse should have an emergency cart available in case of anaphylaxis during the test.
- D. The patients test should be cancelled until he is off his corticosteroids.
Correct Answer: D
Rationale: Corticosteroids and antihistamines, including over-the-counter allergy medications, suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. Emergency equipment must be at hand during allergy testing, but the test would be postponed.
The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patients care plan?
- A. Risk for Disturbed Body Image Related to Skin Lesions
- B. Risk for Disuse Syndrome Related to Dermatitis
- C. Risk for Ineffective Role Performance Related to Dermatitis
- D. Risk for Self-Care Deficit Related to Skin Lesions
Correct Answer: A
Rationale: The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of patients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit.
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
- A. Forearm
- B. Thigh
- C. Deltoid muscle
- D. Abdomen
Correct Answer: B
Rationale: The patient is taught to position the device at the middle portion of the thigh and push the device into the thigh as far as possible. The device will autoinject a premeasured dose of epinephrine into the subcutaneous tissue.