Question 1

Which of the following statements is true with regard to food allergies and children?

Accepted Answer

Many children eventually outgrow egg, milk, and soy allergies. However, it is important to note that peanut allergy has not decreased in the pediatric population and can be life-threatening. Teenagers with food allergies may be at higher risk for allergic reactions due to increased social and environmental exposure to potential allergens. Peanut allergies are most common in children under 5 years of age.

Question 2

A nurse is working in a summer camp for children.One of the children comes to the clinic with several bee stings.Which clinical manifestations would necessitate injecting the child with epinephrine (EpiPen)? Select all that apply.

Accepted Answer

A)General symptoms of shock that would necessitate an epinephrine injection include cold and clammy skin (which is indicative of decreased perfusion), extreme anxiety and agitation, and facial angioedema. Clients who are experiencing shock are unlikely to be hyperverbal due to respiratory symptoms that make breathing and speaking difficult.
B)General symptoms of shock that would necessitate an epinephrine injection include cold and clammy skin (which is indicative of decreased perfusion), extreme anxiety and agitation, and facial angioedema. Clients who are experiencing shock are unlikely to be hyperverbal due to respiratory symptoms that make breathing and speaking difficult.
C)General symptoms of shock that would necessitate an epinephrine injection include cold and clammy skin (which is indicative of decreased perfusion), extreme anxiety and agitation, and facial angioedema. Clients who are experiencing shock are unlikely to be hyperverbal due to respiratory symptoms that make breathing and speaking difficult.
D)General symptoms of shock that would necessitate an epinephrine injection include cold and clammy skin (which is indicative of decreased perfusion), extreme anxiety and agitation, and facial angioedema. Clients who are experiencing shock are unlikely to be hyperverbal due to respiratory symptoms that make breathing and speaking difficult.
E)General symptoms of shock that would necessitate an epinephrine injection include cold and clammy skin (which is indicative of decreased perfusion), extreme anxiety and agitation, and facial angioedema. Clients who are experiencing shock are unlikely to be hyperverbal due to respiratory symptoms that make breathing and speaking difficult.

Question 3

A nurse is caring for a client with HIV who just learned she is several weeks pregnant.The client states that she is concerned about how her HIV diagnosis might affect the health of her child.Which of the following statements should the nurse include in her teaching for this client?

Accepted Answer

Taking HIV medications during pregnancy can reduce the risk of transmitting the virus to the fetus. Vaginal delivery increases the risk of transmitting the virus to the infant, while a cesarean delivery reduces the risk. HIV can cross the placenta during pregnancy and lead to transmission of the virus to the infant. Women with HIV are at higher risk for miscarriage and fetal loss. Therefore, option C is the best teaching for the client.

Question 4

A pediatric client with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen.Which statements are appropriate for the nurse to include in the discharge instructions for this client and family? Select all that apply.

Accepted Answer

A) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.
B) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.
C) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.
D) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.
E) An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The nurse should recommend the client wear a medical alert bracelet. The EpiPen comes pre-filled to ensure a quick delivery when necessary. The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. The client should have multiple EpiPens and they should be kept in multiple areas, not one location. The expiration date should be checked frequently to ensure accurate strength.

Question 5

The nurse is caring for a client with a history of latex allergies.The client develops audible wheezing,pruritus,urticaria,and signs of angioedema.Which of the following is the priority intervention for this client?

Accepted Answer

Administering epinephrine 1:1000 by subcutaneous injection is the priority intervention as it is the only medication that can rapidly reverse an allergic reaction and prevent anaphylaxis. The other interventions can be done after the client's condition stabilizes.

Question 6

A nurse is caring for a pediatric client who is receiving an infusion of intravenous antibiotic at the ambulatory clinic.Which clinical manifestation indicates that the client is experiencing a type I hypersensitivity reaction?

Accepted Answer

A type I hypersensitivity reaction is an immediate reaction that occurs within minutes to hours after exposure to the allergen. Symptoms include urticaria, pruritus, angioedema, rhinitis, bronchospasm, and hypotension. Hypotension is the most severe manifestation of a type I reaction and requires immediate intervention to prevent anaphylaxis. Erythema, fever, and joint pain are not commonly associated with type I reactions.

Question 7

The nurse suspects that the client is experiencing a reaction to a specific antigen.Which laboratory result supports the conclusion made by the nurse?

Accepted Answer

A patch test with a 1-inch area of erythema indicates a delayed hypersensitivity reaction, which is indicative of a specific antigen. The other options are not directly related to antigens or hypersensitivity reactions.

Question 8

The nurse is admitting a pediatric client to the hospital with a ventriculoperitoneal (VP)shunt malfunction.When gathering the history,the nurse learns that the client received the shunt at birth after a meningocele repair.Based on this data,which product should be avoided when providing care to this client?

Accepted Answer

The client's history of meningocele repair and VP shunt insertion indicates a potential for latex allergy. Therefore, latex gloves should be avoided to prevent an allergic reaction. Synthetic rubber gloves and polyethylene gloves are also made from latex and should be avoided. Non-powdered nitrile gloves are a suitable alternative.

Question 9

A nurse is caring for a client with seasonal hypersensitivity reactions.What teachings should the nurse provide to improve this client's comfort? Select all that apply.

Accepted Answer

A)A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include information about taking antihistamine and antileukotriene medications, not leukotriene medications. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.
B)A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include information about taking antihistamine and antileukotriene medications, not leukotriene medications. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.
C)A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include information about taking antihistamine and antileukotriene medications, not leukotriene medications. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.
D)A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include information about taking antihistamine and antileukotriene medications, not leukotriene medications. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.
E)A client with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should instruct the client to keep doors and windows closed on high-allergen days and to remain indoors if possible. The nurse should also include teaching on maintaining a clean, dust-free environment. Medication instruction should include information about taking antihistamine and antileukotriene medications, not leukotriene medications. The client should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them.

Question 10

In what ways do type IV hypersensitivity reactions differ from other types of hypersensitivity reactions?

Accepted Answer

Type IV hypersensitivity reactions are different from other types of hypersensitivity reactions because they are cell-mediated responses that take 24 hours or more to develop. Other types of hypersensitivity reactions (types I, II, and III) are antibody-mediated responses that develop much more quickly.

Question 11

A home health nurse is conducting home visits for several clients who are diagnosed with acquired immunodeficiency syndrome (AIDS).Which client would the nurse see first?

Accepted Answer

The client with Pneumocystis jiroveci pneumonia has reported new symptoms and could be experiencing a worsening of their condition. This requires prompt attention from the nurse, as it could indicate a potential respiratory crisis and a need for immediate intervention.

Question 12

The nurse is caring for a client who is newly diagnosed with human immunodeficiency virus (HIV)infection.The client asks the nurse whether there are ways to protect the client's life partner from getting the virus.After the nurse provides the client with teaching related to this topic,which statement on the part of the client would indicate a need for further education?

Accepted Answer

While it is important to use lubricants to prevent tears and abrasions during sexual activity, oil-based lubricants can actually break down latex condoms, making them less effective in preventing the transmission of HIV. Water-based or silicone-based lubricants are recommended instead. The other statements demonstrate a good understanding of ways to protect the partner from getting the virus.

Question 13

The nurse is reviewing the laboratory results of a client who is newly diagnosed with acquired immunodeficiency syndrome (AIDS).Which result would be considered potentially problematic and should be reported to the client's healthcare provider?

Accepted Answer

A CD4 cell count of 195/mm³ is considered low and indicates severe immunosuppression, which is problematic in a client with AIDS and should be reported to the healthcare provider.

Question 14

Which type of precaution should the nurse implement when providing direct care in the intensive care unit (ICU)to a client diagnosed with acquired immunodeficiency syndrome (AIDS)?

Accepted Answer

A)Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, healthcare workers treat all high-risk body fluids as if they are infectious and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.
B)Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, healthcare workers treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.
C)Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, healthcare workers treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.
D)Healthcare workers can prevent most exposures to HIV by using standard precautions. With standard precautions, healthcare workers treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.

Question 15

A nurse working in the pediatric intensive care unit (PICU)is caring for a client with human immunodeficiency virus (HIV).The client is severely symptomatic with the additional diagnoses of lymphoma and wasting syndrome.Based on this data,which clinical stage of HIV does the nurse anticipate for this client?

Accepted Answer

The presence of severe symptoms and comorbid conditions such as lymphoma and wasting syndrome indicates that the client is in clinical stage 3, or category C, of HIV.

Question 16

The nurse is preparing to assess a client when one of the client's family members begins showing symptoms of latex sensitivity.Which action by the nurse is the most appropriate?

Accepted Answer

Obtaining latex-free products for the client's room is the most appropriate action as it addresses the immediate concern of the family member's symptoms while also ensuring that the client can still receive necessary care in their current location. Asking the family member to leave or transferring the client to a different department may not be necessary if latex-free products can be obtained. Waiting until Monday to report the problem to the supervisor could potentially delay the resolution of the issue.

Question 17

The nurse is caring for a client in an allergy clinic.After completing the client history,the nurse selects the nursing diagnosis of Risk for Shock.Which item in the client's history supports the need for this nursing diagnosis?

Accepted Answer

Anaphylaxis is a systemic and severe allergic reaction that can lead to shock and death, therefore a client with a history of an anaphylactic reaction to shellfish is at high risk for shock. The other options do not have a direct correlation with the nursing diagnosis of Risk for Shock.

Question 18

The nurse is assessing a client who is receiving IV antibiotics.Which item in the client's health history increases the risk for experiencing a hypersensitivity reaction?

Accepted Answer

A previous history of antibiotic therapy increases the risk for experiencing a hypersensitivity reaction to antibiotics. Age, race, and chronic illness do not specifically increase this risk.

Question 19

The nurse is planning care for a pediatric client who is infected with the human immunodeficiency virus (HIV).The nurse selects Risk for Infection as a priority nursing diagnosis for this client.Based on this nursing diagnosis,which actions by the nurse are appropriate? Select all that apply.

Accepted Answer

A)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.
B)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.
C)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.
D)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.
E)A client with HIV is at risk for myriad infections because of the virus's effect on the immune system. To help prevent infection, the nurse should teach the family about proper food-handling and hand-washing techniques, as well as the importance of keeping individuals who have symptoms of illness away from the child. Tuberculosis skin tests should be administered annually, not every 6 months. Also, pediatric clients with HIV should be immunized as soon as they reach the age recommended for diphtheria, tetanus, and acellular pertussis; inactivated poliovirus; Haemophilus influenzae type b; hepatitis B; pneumococcal vaccine; and annual influenza vaccine.

Question 20

The nurse is caring for a client who is experiencing anaphylactic shock following the administration of a medication.Based on this data,which position is the most appropriate for the nurse to place the client?

Accepted Answer

The High-Fowler position is the most appropriate position for a client experiencing anaphylactic shock as it helps to improve breathing by opening up the airways and preventing airway obstruction. Trendelenburg position may exacerbate respiratory distress, supine position does not facilitate breathing, and elevating the legs slightly may not be enough to improve breathing.

Quiz 8: Immunity