Medical and Nursing Management
A patient has been brought to the emergency department in apparent anaphylaxis. The priority aspect of care is:
What is ensuring a patent airway
Rationale:
The immediate priority in all care situations is protection of the patient’s airway. Anaphylaxis involves a direct threat to the patency of the patient’s airway.
A client has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the client will present with what alteration in laboratory values?
A. Increased eosinophils
B. Increased neutrophils
C. Increased serum albumin
D. Decreased blood glucose
What is A- Higher percentages of eosinophils are considered moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and is found in clients with allergic disorders. Hypersensitivity does not result in hypoglycemia or increased albumin and neutrophil counts.
A patient is experiencing anaphylaxis after eating shellfish. What type of reaction is the patient experiencing?
Type I, II, III, IV
What is type I hypersensitivity reaction. The most severe form of hypersensitivity reaction is anaphylaxis or type I hypersensitivity. Type II, or cytotoxic hypersensitivity, occurs when the system mistakenly identifies a normal constituent of the body as foreign. Type III, or immune complex, hypersensitivity involves immune complexes that are formed when antigens bind to antibodies. Type IV, or delayed-type hypersensitivity, also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen. An example of this reaction is the effect of an intradermal injection of tuberculin antigen or purified protein derivative (PPD).
A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?
A. IgA
B. Igb
C. IgE
D. IgG
What is C-IgE
Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates complement. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.
Lymphocytes are the primary cellular participants in the immune system?
What is true. Lymphocytes, which are either T-cell or B-cell lymphocytes, comprise 20% to 30% of all leukocytes. T-cell and B-cell lymphocytes are the primary participants in the immune response.
A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the patient be instructed to do?
What is keeping hands clean and well moisturized
Guidelines for treatment include decreasing itching and scratching by wearing cotton fabrics, washing with a mild detergent, humidifying dry heat in the winter, maintaining a moderate room temperature, using antihistamines such as diphenhydramine, and avoiding animals, dust, sprays, and perfumes. Keeping the skin moisturized with daily baths to hydrate the skin and topical skin moisturizers is encouraged.
The nurse is administering intravenous vancomycin. What is a priority nursing assessment if the client begins to experience a possible allergic reaction?
What is airway assessment, monitoring, and management.
What is the initial nursing assessment and intervention needs to be directed toward evaluating breathing and maintaining an open airway, so the initial assessment will be for dyspnea, bronchospasm, and laryngeal edema. Hypotension, pruritis, and flushing may occur, but the airway is most important.
In which stage of the immune response does the antibody of the humoral response or the cytotoxic killer T-cell of the cellular response reach and connect with the antigen on the surface of the foreign pathogen?
What is the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign pathogen.
Recognition of antigens as foreign, or nonself, by the immune system is the initiating event in any immune response. The body accomplishes recognition using lymph nodes and lymphocytes for surveillance. During the proliferation stage, the circulating lymphocyte containing the antigenic message returns to the nearest lymph node. Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. The production of antibodies by the B lymphocytes in response to a specific antigen begins the humoral response. Most immune responses to antigens involve both humoral and cellular responses, although one usually predominates.
The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?
A. Percussion of client's abdomen
B. Palpation of client's liver
C. Auscultation of client's apical HR
D. Palpation of the client's lymph nodes
What is D, palpation of the lymph nodes
During the assessment of immune function, the anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement. If palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Because of the central role of lymph nodes in the immune system, they are prioritized over the heart, liver, and abdomen, even though these would be assessed.
What organ is considered lymphoid tissue?
Lymphoid tissues, such as the thymus gland, tonsils and adenoids, spleen, and lymph nodes, play a role in the immune response and prevention of infection.
FYI- The pancreas, intestines, and liver are not lymphoid tissue.
A patient is being seen in the dermatology clinic for urticaria. The nurse would expect which medication to be prescribed for the patient?
Pseudoephedrine (Sudafed)?
Diphenhydramine?
Dexamethasone?
Cromolyn Sodium?
What is Diphenhydramine
Oral antihistamines are given to patients with hay fever, vasomotor rhinitis, urticaria (hives), and mild asthma. Benadryl is an oral antihistamine. Sudafed is an adrenergic agent used for nasal congestion. Decadron is used in the treatment of allergic rhinitis and perennial rhinitis. NasalCrom is a mast cell stabilizer used in the treatment of chronic allergic rhinitis.
What teaching point should the nurse prioritize when providing health education to the family of a child with a newly diagnosed food allergy?
A.Managing the GI symptoms of a food allergy
B.Strategies for avoiding the offending food
C.Techniques for ensuring adequate nutrition
B. Strategies for avoiding the offending food
Rationale: It is imperative that patients with food allergies and their families be aware of hidden sources of food allergens and know how to avoid locations and facilities where those allergens are likely to be present. This holds priority over GI management and nutritional interventions.
A 25-year-old female is admitted to the ER in anaphylactic shock due to a bee sting. According to the patient's mother, the patient is severely allergic to bees and was recently stung by one. This type of anaphylactic reaction is known as a?
A. Type I Hypersensitivity Reaction
B. Type II Hypersensivity Reaction
C. Type III Hypersensivity Reaction
D. Type IV Hypersensivity Reaction
The answer is A.
Rationale: Type I Hypersensitivity Reactions are immediate and cause anaphylaxis. It occurs when an antigen (the allergen….in this case bee venom) attaches to immunoglobulin E (IgE) antibodies. These antibodies are created due to this allergen and attach to the mast cells and basophils. This leads to a system-wide release of inflammatory mediators (histamine and other inflammatory substances). It is important to note a patient must be sensitized (meaning the immune system has seen the allergen before and produced IgE antibodies in response to the allergen). When the person comes into contact with the foreign substance AGAIN (at a later time) the allergen will attach to that previously created IgE antibody on the mast cell. This will lead to a massive release of histamine and other inflammatory substances that will cause anaphylaxis and lead to anaphylactic shock.
The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child?
A."Our first child was born with a cleft lip."
B. "We are very careful not to get sunburns in our family."
C. "My first child sometimes got a diaper rash."
D. "My husband and our daughter are both lactose-intolerant."
D
Rationale:
Environmental exposure to allergens (milk) and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis (D) because milk allergies can contribute to the child's outbreaks. (A) is not a contributing factor. (B) is an environmental factor in other skin diseases but does not have a strong correlation with eczema in children. (C) is not unusual and occurs in the diaper area, whereas atopic dermatitis occurs most often on the face and extensor aspects of the arms and legs.
The nurse practitioner explains to the patient scheduled for the RAST that the test will measure allergen-specific IG( ____)
*Radioallergosorbent Test (RAST) is a blood test that measures the amount of the allergic antibody IgE produced when your blood is exposed to a specific food protein
What is IgE
IgE, although least abundant in the blood, is capable of triggering a powerful reaction. It is measured by the RAST.
A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow?
What is emergency equipment should be readily available.
Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing.
A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client’s eyes, lips, and face begin to swell, and the nurse hears stridor. What priority intervention should the nurse anticipate/prepare to do?
A. Intubate client
B. Obtain an EKG
C. Assess VS
D. Administer Epinephrine
What is D Administer Epinephrine
Anaphylaxis is a rapid and profound type I hypersensitivity response. A massive release of histamine causes vasodilation; increased capillary permeability; angioneurotic edema (acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs); hypotension; and bronchoconstriction. A nurse must administer 0.2 mg of epinephrine subcutaneously to a client experiencing a severe allergic reaction. It is outside of the nurse’s practice to intubate a client. Performing an ECG and assessing the vital signs delays the treatment of the client and can have negative outcomes.
Which reaction would be consistent with a mild reaction to an allergen?
Bronchospasm? warmth? tearing of eyes? cough?
What is tearing of eyes. Mild systemic reactions may include nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes. Moderate systemic reactions may include flushing, warmth, anxiety, and itching in addition to any of the milder symptoms. Severe systemic reactions include bronchospasm and edema of the airways or larynx with dyspnea, cough and wheezing.
The nurse is caring for an older client admitted to the health-care facility with a new onset of confusion and a low-grade fever. Which age-related changes might contribute to decreased functioning of the immune system?
A. Decreased Kidney Function
B. Thickening of Skin
C. Increased Gastric Secretions
D. Increased ciliary action
What is A decreased kidney function
Decreased kidney function, changes in lower urinary tract function (enlargement of the prostate), and altered genitourinary tract flora all contribute to increased urinary tract infections. With age, the skin thins, gastric secretions decrease, and ciliary action decreases.
A client is informed of having a low white blood cell count and that the client is at risk for the development of infections. The client asks, “Where do I make new white blood cells?” What is the best response by the nurse?
A. WBC's are produced in the plasma
B. WBC's are produced in the thymus
C. WBC's are produced in the lymphatic tissue
D. WBC's are produced in the bone marrow
What is D- WBC's are produced in the bone marrow
White blood cells (leukocytes) are produced in the bone marrow. They are not produced in the plasma, thymus gland, or the lymphatic tissue.
A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of allergic rhinitis. What should the nurse educate the patient is a major side effect of antihistamines?
What is drowsiness, fatigue, sedation
Antihistamines are the major class of medications prescribed for the symptomatic relief of allergic rhinitis. The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines.
A patient received epinephrine in response to an anaphylactic reaction at 10:00 AM. The nurse knows to observe the patient for a “rebound” reaction that may occur as early as:
A. 2:00 PM
B. 4:00 PM
C. 6:00 PM
D. 10:00 PM
What is 2:00 pm
Rebound reactions can occur from 4 to 10 hours after an initial allergic reaction. Therefore the patient needs to be assessed from 2:00 PM to 8:00 PM.
When reviewing the chart of a patient diagnosed with allergic rhinitis, the nurse understands that this allergic disorder is caused by which type of hypersensitivity reaction?
What is Type I hypersensitivity reaction.
Allergic rhinitis (hay fever, seasonal allergic rhinitis) is the most common form of chronic respiratory allergic disease presumed to be medicated by an immediate (type I hypersensitivity) immunologic reaction, and is one of the most common reasons for visits to primary care practitioners.
The nurse is caring for a client exposed to peanuts with a known allergy. What assessment is considered the most serious manifestation of angioneurotic edema?
A. Abdominal Pain
B. Conjunctivitis
C. Laryngeal swelling
D. Urticaria
What is C- Laryngeal swelling
Diffuse swelling can affect many regions: lips, eyelids, cheeks, hands, feet, genitalia, tongue, larynx, bronchi, and the gastrointestinal canal. The most serious is the larynx because of the potential for compromised breathing. Abdominal pain, conjunctivitis and urticaria are not the most serious manifestations.
The nurse should recognize a client's risk for impaired immune function if the client has undergone surgical removal of which of the following:
A. Thyroid Gland
B. Spleen
C. Kidney
D. Pancreas
What is B, spleen.
A history of surgical removal of the spleen, lymph nodes, or thymus may place the client at risk for impaired immune function. Removal of the thyroid, kidney, or pancreas would not directly lead to impairment of the immune system.