Chapter 18: Concepts of Care for Patients
with Hypersensitivity (Allergy) and
Autoimmunity
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not
helped with over-the-counter antihistamines. What response by the nurse is most
appropriate?
a. “Antihistamines do not help poison ivy.”
b. “There are different antihistamines to try.”
c. “You should be seen in the clinic right away.”
d. “You will need to take some IV steroids.”
ANS: A
Since histamine is not the mediator of a type IV reaction such as with poison ivy,
antihistamines will not provide relief. The nurse would educate the client about this.
The client does not need to be seen right away. The client may or may not need
steroids; they may be given either IV or orally.
DIF: Understanding TOP: Integrated Process: Communication and
Documentation KEY: Hypersensitivities, Immunity MSC: Client Needs
Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse has educated a client on an epinephrine autoinjector. What statement by the
client indicates additional instruction is needed?
, a. “I don’t need to go to the hospital after using it.”
b. “I must carry two autoinjectors with me at all times.”
c. “I will write the expiration date on my calendar.”
d. “This can be injected right through my clothes.”
ANS: A
Clients would be instructed to call 911 and go to the hospital for monitoring after
using the autoinjector. The medication may wear off before the offending agent has
cleared the client’s system. The other statements show good understanding of this
treatment.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation
KEY: Allergic response, Drug therapy MSC: Client Needs
Category: Health Promotion and Maintenance
3. A nurse has presented an educational program to a community group on Lyme
disease. What statement by a participant indicates the need to review the material?
a. “I should take precautions against ticks, especially in the summer.”
b. “A red rash that looks like a bull’s-eye may be one of the symptoms.”
c. “If Lyme disease is not treated successfully, it is usually fatal.”
d. “For Stage I disease, antibiotics are usually needed for 14 to 21 days.”
ANS: C
Untreated Lyme disease can lead to chronic complications, or Stage III Lyme disease,
such as arthritis, chronic fatigue, memory/thinking problems. It is not usually a fatal
disease so this information would need to be corrected by the nurse. The other
participant statements are correct.
DIF: Analyzing TOP: Integrated Process: Teaching/Learning
KEY: Lyme disease, Health teaching MSC: Client Needs
Category: Health Promotion and Maintenance
with Hypersensitivity (Allergy) and
Autoimmunity
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not
helped with over-the-counter antihistamines. What response by the nurse is most
appropriate?
a. “Antihistamines do not help poison ivy.”
b. “There are different antihistamines to try.”
c. “You should be seen in the clinic right away.”
d. “You will need to take some IV steroids.”
ANS: A
Since histamine is not the mediator of a type IV reaction such as with poison ivy,
antihistamines will not provide relief. The nurse would educate the client about this.
The client does not need to be seen right away. The client may or may not need
steroids; they may be given either IV or orally.
DIF: Understanding TOP: Integrated Process: Communication and
Documentation KEY: Hypersensitivities, Immunity MSC: Client Needs
Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse has educated a client on an epinephrine autoinjector. What statement by the
client indicates additional instruction is needed?
, a. “I don’t need to go to the hospital after using it.”
b. “I must carry two autoinjectors with me at all times.”
c. “I will write the expiration date on my calendar.”
d. “This can be injected right through my clothes.”
ANS: A
Clients would be instructed to call 911 and go to the hospital for monitoring after
using the autoinjector. The medication may wear off before the offending agent has
cleared the client’s system. The other statements show good understanding of this
treatment.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation
KEY: Allergic response, Drug therapy MSC: Client Needs
Category: Health Promotion and Maintenance
3. A nurse has presented an educational program to a community group on Lyme
disease. What statement by a participant indicates the need to review the material?
a. “I should take precautions against ticks, especially in the summer.”
b. “A red rash that looks like a bull’s-eye may be one of the symptoms.”
c. “If Lyme disease is not treated successfully, it is usually fatal.”
d. “For Stage I disease, antibiotics are usually needed for 14 to 21 days.”
ANS: C
Untreated Lyme disease can lead to chronic complications, or Stage III Lyme disease,
such as arthritis, chronic fatigue, memory/thinking problems. It is not usually a fatal
disease so this information would need to be corrected by the nurse. The other
participant statements are correct.
DIF: Analyzing TOP: Integrated Process: Teaching/Learning
KEY: Lyme disease, Health teaching MSC: Client Needs
Category: Health Promotion and Maintenance
