Question 1

While providing care to a 5-month-old girl whose family has a history of food allergies, the nurse instructs the parents about foods to be avoided in the first year of life. Which response by the parents indicates a need for further teaching?

Accepted Answer

Fruits, especially citrus fruits, can sometimes cause allergic reactions or be difficult for infants to digest, so the statement that "any kind of fruit is acceptable" indicates a need for further teaching.

Question 2

A nurse is caring for a 12-year-old girl with a severe peanut allergy. The girl's parents are upset because the school does not permit her to carry her EpiPen with her. It must remain in the school's office per school regulations. Which response by the nurse would be most appropriate?

Accepted Answer

CA) It is important for individuals with severe allergies to have immediate access to an EpiPen. Laws in many places support the right of students to carry their lifesaving medications.C) Wearing a medical alert bracelet is an additional safety measure that ensures anyone who finds the girl in distress is immediately aware of her allergy, potentially speeding up the response time.

Question 3

The nurse is caring for a child who is having an anaphylactic reaction with bronchospasm. The nurse would expect to administer which of the following for bronchospasm as ordered?

Accepted Answer

Albuterol is a bronchodilator that is used to treat bronchospasm.

Question 4

The nurse is caring for a child undergoing highly active antiretroviral therapy (HAART) for HIV infection. The nurse is preparing to administer the prescribed medication. In addition to the nucleoside analog reverse transcriptase inhibitors (NRTIs) and the nonnucleoside analog reverse transcriptase inhibitors (NNRTIs), the nurse is cognizant that the child will be taking which additional medication as part of the three-drug regimen?

Accepted Answer

Protease inhibitors are a key component of highly active antiretroviral therapy (HAART) for HIV infection, often used in combination with nucleoside and nonnucleoside analog reverse transcriptase inhibitors to suppress the virus and improve immune function.

Question 5

The nurse is providing home care instructions for a 13-year-old girl recently diagnosed with systemic lupus erythematosus. Which response by the girl indicates a need for further teaching?

Accepted Answer

The answer of The nurse is providing home care instructions...

Question 6

The nurse is caring for a child who is taking corticosteroids for systemic lupus erythematosus. The nurse closely monitors the child based on the understanding that corticosteroids exert which major action?

Accepted Answer

Corticosteroids can suppress the immune system, making it harder for the body to fight infections. This immunosuppressive effect can mask signs of infection, such as fever and inflammation, because the body's normal response to infection is dampened.

Question 7

The school nurse is walking through the lunchroom when one of the children says she feels strange after switching her lunch with her friend. Which assessment would be most important?

Accepted Answer

Determining if her throat itches is crucial because it could indicate an allergic reaction, which can be life-threatening if not addressed promptly.

Question 8

The nurse is caring for a child who has undergone stem cell transplantation for severe combined immune deficiency. Which of the following would the nurse interpret as indicative of graft-versus-host disease?

Accepted Answer

A maculopapular rash is a common early sign of graft-versus-host disease (GVHD) following stem cell transplantation.

Question 9

The nurse is administering intravenous immune globulin (IVIG). The nurse assesses vital signs and for adverse reactions every 15 minutes for the first hour of administration. After the first hour, the nurse most likely would continue to assess the child at which frequency?

Accepted Answer

After the initial hour of close monitoring, it is common practice to continue assessing the patient receiving IVIG every 60 minutes to ensure safety and identify any adverse reactions as the infusion continues. This frequency balances the need for monitoring with the practical aspects of nursing care.

Question 10

When reviewing the history of a child with suspected primary immunodeficiency, which of the following would the nurse be least likely to find?

Accepted Answer

Children with primary immunodeficiency often present with recurrent infections, failure to respond to antibiotics, and failure to thrive or poor growth, making weight appropriate for height (A) the least likely finding.

Question 11

Which of the following would the nurse expect to find in a male infant with Wiskott- Aldrich syndrome?

Accepted Answer

Wiskott-Aldrich syndrome is characterized by a triad of symptoms: eczema, thrombocytopenia (not thrombocytosis), and recurrent infections. Eczema is a common finding in affected individuals.

Question 12

After teaching a class about humoral and cellular immunity, the nurse recognizes that the additional teaching is needed when the class states which of the following?

Accepted Answer

The answer of After teaching a class about humoral and...

Question 13

A child is diagnosed with juvenile idiopathic arthritis and is receiving several different medications listed in the medication administration record. Which agent would the nurse identify as being used to prevent disease progression?

Accepted Answer

Methotrexate is a disease-modifying antirheumatic drug (DMARD) that is used in the management of juvenile idiopathic arthritis to slow disease progression and prevent joint damage.

Question 14

A group of nursing students are reviewing information about humoral and cellular immunity. The students demonstrate understanding of this material when they identify which of the following as involved in cellular immunity?

Accepted Answer

T cells are a key component of cellular immunity, which involves the direct killing of infected cells or coordination of other parts of the immune system.

Question 15

A nurse is preparing a plan of care for a child with a primary immunodeficiency. Which nursing diagnosis would the nurse most likely identify as the priority?

Accepted Answer

Ineffective protection related to impaired humoral defenses is the priority nursing diagnosis for a child with a primary immunodeficiency because the primary concern is the child's increased susceptibility to infections due to the impaired immune system.

Question 16

A child with hypogammaglobulinemia is to receive intravenous immunoglobulin (IVIG). Which of the following would be least appropriate for the nurse to do?

Accepted Answer

Shaking the vial after reconstituting IVIG can damage the protein structure, making it less effective or potentially harmful. The other options are appropriate steps in administering IVIG.

Question 17

A nursing student is reviewing information about primary immunodeficiencies. The student demonstrates understanding of the material by identifying which of the following as affecting only males? Select all answers that apply.

Accepted Answer

X-linked agammaglobulinemia, Wiskott-Aldrich syndrome, and X-linked hyper-IgM syndrome are conditions that are typically X-linked recessive disorders, primarily affecting males because they have only one X chromosome. Females, having two X chromosomes, are less likely to be affected since they are likely to have at least one normal allele.

Question 18

The nurse is reviewing the laboratory test results of a child who is suspected of having systemic lupus erythematosus (SLE). Which of the following would the nurse identify as supporting this diagnosis? Select all answers that apply.

Accepted Answer

A positive antinuclear antibody (ANA) test is commonly associated with systemic lupus erythematosus (SLE), as it indicates the presence of autoantibodies typical in this condition. Thrombocytopenia (low platelet count) and leukopenia (low white blood cell count) are also findings that can be associated with SLE, reflecting the autoimmune nature of the disease that can lead to decreased levels of these cells.

Question 19

A child is diagnosed with a food allergy to milk. When teaching the parents about this allergy, which of the following would the nurse suggest as possible substitutions? Select all answers that apply.

Accepted Answer

The answer of A child is diagnosed with a food...

Question 20

The nurse is talking to the parents of a child who has been diagnosed with severe combined immune deficiency. Which statement by the parents best indicates that they understand their child's condition?

Accepted Answer

Severe combined immune deficiency (SCID) is a primary immune deficiency that often requires a bone marrow transplant to correct the immune system's function. This treatment can potentially cure the condition by providing the child with a new, functioning immune system. Intravenous immunoglobulin (choice A) is more commonly used for conditions like primary immunodeficiency diseases where patients have trouble making their own antibodies, but it does not cure SCID. Antiviral medications (choice C) may be used to treat specific infections but do not address the underlying immune deficiency. An EpiPen (choice D) is used for immediate response to allergic reactions, not for managing or treating SCID.

Quiz 47: Nursing Care of the Child With an Alteration in Immunity or Immunologic Disorder