Ch. 13 Altered Immune Response------5

Question 1

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient?

a. Screening for allergies
b. Screening for malignancies
c. Screening for antibody deficiencies
d. Screening for autoimmune disorders

Answer 1

ANS: B
Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune
disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity

Question 2

Which example should the nurse use to explain an infant’s “passive immunity” to a new mother?

a. Vaccinations
b. Breastfeeding
c. Stem cells in peripheral blood
d. Exposure to communicable diseases

Answer 2

ANS: B
Colostrum in breast milk 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. Active immunity is acquired by being
immunized with vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a person’s bone marrow
after high-dose chemotherapy

Question 3

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value?

a. IgE c. Basophils
b. IgA
c. Basophils
d. Neutrophils

Answer 3

ANS: A
Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than
neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has
symptoms of atopic dermatitis.

Question 4

An older adult patient who is having an annual check-up tells the nurse, “I feel fine, and I don’t want to pay for all these unnecessary cancer screening tests!” Which information should the nurse plan to teach this patient?

a. Consequences of aging on cell-mediated immunity
b. Decrease in antibody production associated with aging
c. Impact of poor nutrition on immune function in older people
d. Incidence of cancer-associated infections in older individuals

Answer 4

ANS: A
The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity.
Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no
evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this
patient does not have an active infection.

Question 5

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching?

a. “I need to find a different way to earn extra money.”
b. “I will take oral antihistamines before going to work.”
c. “I will get a prescription for epinephrine and learn to self-inject it.”
d. “I should wear a Medic-Alert bracelet indicating my allergy to bee stings.”

Answer 5

ANS: B
Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen,
taking oral antihistamines will not adequately control the patient’s hypersensitivity reaction. The other patient statements indicate a
good understanding of management of the problem.

Question 6

Which information about intradermal skin testing should the nurse teach to a patient with possible allergies?

a. “Do not eat anything for about 6 hours before the testing.”
b. “Take an oral antihistamine about an hour before the testing.”
c. “Plan to wait in the clinic for 20 to 30 minutes after the testing.”
d. “Reaction to the testing will take about 48 to 72 hours to occur.”

Answer 6

ANS: C
Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20
minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be
avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

Question 7

The nurse reviewing a clinic patient’s medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate?

a. Schedule an additional dose the following week.
b. Administer the scheduled dosage of the allergen.
c. Consult with the health care provider about giving a lower allergen dose.
d. Re-evaluate the patient’s sensitivity to the allergen with a repeat skin test

Answer 7

ANS: C
Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check
with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be
used at this time. An additional dose for the week may increase the risk for a reaction.

Question 8

The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct?

a. Recommend that the patient use latex gloves in preventing blood-borne pathogen
contact.
b. Document the patient’s history and teach about clinical manifestations of a type I
latex allergy.
c. Encourage the patient to carry an epinephrine kit in case a type IV allergic
reaction to latex develops.
d. Advise the patient to use oil-based hand creams to decrease contact with natural
proteins in latex gloves.

Answer 8

ANS: B
The patient’s allergy history and occupation indicate a risk of developing a latex allergy. The patient should be taught about
symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic
reaction to latex. Using latex gloves increases the chance of developing latex sensitivity. Oil-based creams will increase the
exposure to latex from latex gloves.

Question 9

What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)?

a. Plasmapheresis eliminates eosinophils and basophils from blood.
b. Plasmapheresis decreases the damage to organs from T lymphocytes.
c. Plasmapheresis removes antibody-antigen complexes from circulation.
d. Plasmapheresis prevents foreign antibodies from damaging various body tissues

Answer 9

ANS: C
Plasmapheresis is used in SLE to remove antibodies, antibody–antigen complexes, and complement from blood. T lymphocytes,
foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.

Question 10

The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation?

a. Shortness of breath
b. High blood pressure
c. Transfusion reaction
d. Extremity numbness

Answer 10

ANS: D
Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other
clinical manifestations are not associated with plasmapheresis.

Question 11

Which statement by a patient would alert the nurse to a risk for decreased immune function?

a. “I had a chest x-ray 6 months ago.”
b. “I had my spleen removed after a car accident.”
c. “I take one baby aspirin every day to prevent stroke.”
d. “I usually eat eggs or meat for at least two meals a day.”

Answer 11

ANS: B
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 affect immune function. A chest x-ray does not have enough radiation to suppress
immune function.

Question 12

Which patient should the nurse assess first?

a. Patient with urticaria after receiving an IV antibiotic
b. Patient who is sneezing after subcutaneous immunotherapy
c. Patient who has graft-versus-host disease and severe diarrhea
d. Patient with multiple chemical sensitivities who has muscle stiffness

Answer 12

ANS: B
Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should
be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of
life-threatening complications.

Question 13

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash?

a. The donor T cells are attacking the patient’s skin cells.
b. The patient needs treatment to prevent hyperacute rejection.
c. The patient’s antibodies are rejecting the donor bone marrow.
d. The patient is experiencing a delayed hypersensitivity reaction.

Answer 13

ANS: A
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

Question 14

A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer?

a. Corticosteroids
b. Gamma globulin
c. Hepatitis B vaccine
d. Fresh frozen plasma

Answer 14

ANS: B
The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series
should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B
in the patient.

Question 15

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

a. “I need to be monitored closely for development of malignant tumors.”
b. “After a couple of years I will be able to stop taking the cyclosporine.”
c. “If I develop acute rejection episode, I will need additional types of drugs.”
d. “The drugs are combined to inhibit different ways the kidney can be rejected.”

Answer 15

ANS: B
Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that
no further teaching is necessary about those topics.

Question 16

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient’s health history has implications for planning patient teaching about the medication at this time?

a. The patient restricts salt to 2 grams per day.
b. The patient eats green leafy vegetables daily.
c. The patient drinks grapefruit juice every day.
d. The patient drinks 3 to 4 quarts of fluid each day.

Answer 16

ANS: C
Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and
sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function.

Question 17

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient?

a. Testing for human leukocyte antigen (HLA) match
b. Administration of immunosuppressant medications
c. Insertion of an arteriovenous graft for hemodialysis
d. Placement of the patient on the transplant waiting list

Answer 17

ANS: B
Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute
rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no
indication for repeat HLA testing.

Question 18

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant?

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

Answer 18

ANS: C
There is no increased exposure to infection from a patient who had an anaphylactic reaction. 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.

Question 19

A patient in the health care provider’s office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first?

a. Monitor the patient’s edema.
b. Administer a dose of epinephrine.
c. Provide a prescription for oral antihistamines
d. Ask the patient about the use of new skin products.

Answer 19

ANS: B
Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to
anaphylaxis. The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. The nurse should not wait and
assess for development of additional edema. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Exposure to skin
products does not address the immediate concern of a possible anaphylactic reaction.

Question 20

A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse’s priority action?

a. Provide high-flow oxygen.
b. Administer antihistamines.
c. Assess the patient’s
d. Remove the stinger from the site.

Answer 20

ANS: C
The initial action with any patient with difficulty breathing is to assess and maintain the airway. The patient’s symptoms of anxiety
and difficulty breathing may have other causes than anaphylaxis, so additional assessment is warranted. The other actions are part
of the emergency management protocol for anaphylaxis, but the priority is airway assessment and maintenance

Question 21

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first?

a. Apply antiinflammatory cream.
b. Place a tourniquet above the site.
c. Administer subcutaneous epinephrine.
d. Reschedule the patient’s other allergen tests.

Answer 21

ANS: B
Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. The other actions may
occur, but the tourniquet application slows the allergen progress into the patient’s system, allowing treatment of the anaphylactic
response. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be
needed if the allergic reaction progresses to anaphylaxis. Other testing may be delayed and rescheduled after development of
anaphylaxis.

Question 22

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

a. Perform a focused physical assessment.
b. Obtain the health history from the patient.
c. Teach the patient about the various diagnostic studies.
d. Administer a skin test by the cutaneous scratch method.

Answer 22

ANS: D
LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope
of practice include assessment of health history, focused physical assessment, and patient teaching

Question 23

The health care provider asks the nurse whether a patient’s angioedema has responded to prescribed therapies. Which assessment should the nurse perform?

a. Obtain the patient’s blood pressure and heart rate.
b. Question the patient about any clear nasal discharge.
c. Observe for swelling of the patient’s lips and tongue.
d. Assess the patient’s extremities for wheal and flare lesions.

Answer 23

ANS: C
Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and
hypotension and tachycardia are characteristic of other allergic reactions.

Question 24

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon?

a. Patient is Rh positive and donor is Rh negative
b. Six antigen matches are present in HLA typing
c. Results of patient–donor crossmatching are positive
d. Panel of reactive antibodies (PRA) percentage is low

Answer 24

ANS: C
Positive crossmatching is an absolute contraindication to kidney transplantation because a hyperacute rejection will occur after the
transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable.

Question 25

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider?

a. The patient’s IgG level is increased.
b. The injection site is red and swollen.
c. The patient’s symptoms did not improve in 2 months.
d. There is a 2-cm wheal at the site of the allergen injection

Answer 25

ANS: D
A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates
that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to
achieve an effect, an improvement in the patient’s symptoms is not expected after a few months.

Question 26

A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]).

a. Discontinue the antibiotic.
b. Give diphenhydramine IV.
c. Inject epinephrine IM or IV.
d. Prepare an infusion of dopamine.
e. Provide 100% oxygen using a nonrebreather mask.

Answer 26

ANS:
A, E, C, B, D
The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery
should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine
will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not
have evidence of hypotension, the dopamine infusion can be prepared last.