Nokea
The nursing instructor is discussing hypersensitivity responses with a clinical group. What allergic reaction(s) would the nursing instructor talk about? Select all that apply.
- A. Typical
- B. Unmediated
- C. Cytotoxic
- D. Atopic
- E. Immune complex
Correct Answer: C,D,E
Rationale: Once sensitization occurs, one of four types of hypersensitivity responses can occur. These may be immediate or delayed depending on the time it takes for the immune system to mount a response. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly. There are three types of immediate hypersensitivity responses: type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies; type II, cytotoxic, which is mediated by immunoglobulin M or G (IgM or IgG) antibodies; and type III, immune complex, which is mediated by IgG antibodies. The first two types of responses occur within minutes; type III responses reach a peak within 6 hours after exposure to an allergen. The nurse would not discuss atypical and unmediated hypersensitivity responses in this scenario.
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A client is taking oral corticosteroids after having an exacerbation of asthma. What should the nurse be sure to include when instructing the client how to take the medication?
- A. The medication will cause weight loss.
- B. The medication will cause drowsiness so do not drive.
- C. Take the medication on an empty stomach to increase absorption.
- D. Take the medication in the morning with food.
Correct Answer: D
Rationale: Taking the oral corticosteroids in the morning with food will help reduce the gastrointestinal upset that may be experienced. The medication causes weight gain not weight loss, does not cause drowsiness, and should not be taken on an empty stomach.
A client is taking the immunosuppressant medication, azathioprine (Imuran), for the treatment of Crohn's disease. What statement made by the client demonstrates an understanding of the side effects of this medication?
- A. I will notify the doctor if I have a fever or any other signs of infection.'
- B. I will drink at least 3 L of fluid per day.'
- C. I will notify the doctor if I am not having a bowel movement daily.'
- D. I will stop taking my medication if I notice any side effects and then notify the doctor.'
Correct Answer: A
Rationale: The client should be instructed to be sure to report any signs of infection since this drug suppresses the immune system and makes the client susceptible to infections. It is important for a client to drink 3 L of fluid when taking the immunosuppressant drug cyclosporine to prevent hemorrhagic cystitis, but this is not necessary for azathioprine. It is not necessary to inform the physician if the client is not having a bowel movement daily. The client should not stop taking the medication for any reason unless discussed with the physician.
A client with rheumatoid arthritis expresses not feeling the need to take medication any longer since being in remission without symptoms. What is the best response by the nurse?
- A. If you don't take your medication, you will become very ill.'
- B. Be sure to let the physician know after you stop your medications.'
- C. It is important that you continue to take your medication to avoid an acute exacerbation.'
- D. As long as you are not having symptoms, you can take a medication vacation.'
Correct Answer: C
Rationale: Even with remission, most people must continue taking prescribed medications to avoid another acute exacerbation. The client should be encouraged to maintain the therapeutic regimen in order to avoid an exacerbation and prolong the period of remission as long as possible. The client should notify the physician if considering discontinuation of the medication. The nurse is not at liberty to allow the client to discontinue medication use. Stating that discontinuing the medication will cause the client to become ill does not provide an adequate explanation to the client.
The nurse is collecting data from a client with the autoimmune disorder endocarditis. What does the nurse recognize as symptom of an acute exacerbation?
- A. Temperature of 100.9?°F
- B. Respiratory rate of 20 breaths/minute
- C. Constipation
- D. Nausea
Correct Answer: A
Rationale: Periods of acute flare-ups (known as exacerbations) are completely unpredictable. During acute exacerbations, clients often experience a low-grade fever, malaise, or fatigue. They also may lose weight. A respiratory rate of 20 breaths/minute is within normal range. Constipation and nausea are not characteristic of a flare-up of endocarditis.
The nurse has four clients who are scheduled to see the physician for 'fatigue' and other general symptom complaints. Which client does the nurse determine is at most risk for having chronic fatigue syndrome?
- A. Male of Hispanic descent, age 28 years
- B. Female of Caucasian descent, age 47 years
- C. Female of African descent, age 42 years
- D. Female of Chinese descent, age 18 years
Correct Answer: B
Rationale: Estimates are that as many as 4 million people in the United States have symptoms corresponding with chronic fatigue syndrome, but fewer than 80% have been diagnosed by a medical provider. Most clients who seek treatment for their symptoms are Caucasian women 40 to 59 years of age. CFS also occurs at lower rates among children, adolescents, and men.