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Chapter 19.

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Chapter 19: Coordinating Care for Patients with Immune Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. The nurse is providing care for a patient diagnosed with agammaglobulinemia and correlates management of this disorder includes which medication? Which is the anticipated treatment for this patient? 1. Oral diphenhydramine 2. Topical corticosteroids 3. Subcutaneous epinephrine 4. Intravenous immunoglobulin (IVIG) ____ 2. The nurse is providing care to a patient diagnosed with X-linked agammaglobulinemia (XLA). Which information does the nurse include in the patient’s plan of care? 1. Immunization with inactivated polio vaccine (IPV) 2. Administration of intravenous immunoglobulin every 6 months 3. Education regarding the use of high-dose prophylactic antibiotics 4. Periodic magnetic resonance imagery (MRI) to monitor for respiratory complications ____ 3. The nurse provides education to the parents of a pediatric patient who is diagnosed with X-linked agammaglobulinemia (XLA). Which statement indicates a need for additional teaching? 1. “I will take my child to the pediatrician if he begins to pull at his ear.” 2. “My other children can receive the live attenuated oral polio vaccine.” 3. “I will clean all vegetables and fruits before giving them to my child.” 4. “My child will likely require intravenous antibiotics for respiratory infections.” ____ 4. The nurse monitors for which clinical manifestations in the patient diagnosed with X-linked agammaglobulinemia (XLA)? 1. Wheezes 2. Stridor 3. Tachypnea 4. Hyper-resonant breath sounds ____ 5. What is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia (XLA)? 1. Risk for Infection 2. Decreased Cardiac Output 3. Body Image Disturbance 4. Fatigue ____ 6. The nurse monitors for which clinical manifestation in the patient diagnosed with DiGeorge’s syndrome? 1. Muscle stiffness 2. Weight gain 3. Shortness of breath 4. Aphasia ____ 7. The nurse correlates which laboratory value as a complication in the patient diagnosed with DiGeorge’s syndrome? 1. Sodium 150 mEq/L 2. Calcium 6.5 mg/dL 3. Potassium 3.0 mEq/L 4. Magnesium 2.5 mg/dL ____ 8. The nursing diagnosis Potential for Ineffective Airway Clearance is most relevant to a patient with which immune disorder? 1. B-cell deficiency 2. T-cell deficiency 3. Type I hypersensitivity reaction 4. X-linked agammaglobulinemia ____ 9. Which is the priority nursing action to decrease the risk for infection for a patient diagnosed with DiGeorge’s syndrome? 1. Hand hygiene 2. Reverse isolation 3. Prokinetic agents 4. Droplet precautions ____ 10. Which immune disorder does the nurse include in the plan of care for a patient who is receiving chemotherapeutic agents for the treatment of cancer? 1. B-cell deficiency 2. T-cell deficiency 3. Excessive immune response 4. Secondary immune deficiency

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Chapter 19: Coordinating Care for Patients with Immune Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is providing care for a patient diagnosed with agammaglobulinemia
and correlates management of this disorder includes which medication? Which is the
anticipated treatment for this patient?
1. Oral diphenhydramine
2. Topical corticosteroids
3. Subcutaneous epinephrine
4. Intravenous immunoglobulin (IVIG)
____ 2. The nurse is providing care to a patient diagnosed with X-linked
agammaglobulinemia (XLA). Which information does the nurse include in the
patient’s plan of care?
1. Immunization with inactivated polio vaccine (IPV)
2. Administration of intravenous immunoglobulin every 6 months
3. Education regarding the use of high-dose prophylactic antibiotics
4. Periodic magnetic resonance imagery (MRI) to monitor for respiratory complications
____ 3. The nurse provides education to the parents of a pediatric patient who is
diagnosed with X-linked agammaglobulinemia (XLA). Which statement indicates a
need for additional teaching?
1. “I will take my child to the pediatrician if he begins to pull at his ear.”
2. “My other children can receive the live attenuated oral polio vaccine.”
3. “I will clean all vegetables and fruits before giving them to my child.”
4. “My child will likely require intravenous antibiotics for respiratory infections.”
____ 4. The nurse monitors for which clinical manifestations in the patient diagnosed
with X-linked agammaglobulinemia (XLA)?
1. Wheezes
2. Stridor
3. Tachypnea
4. Hyper-resonant breath sounds
____ 5. What is the priority nursing diagnosis for a patient diagnosed with X-linked
agammaglobulinemia (XLA)?
1. Risk for Infection

,2. Decreased Cardiac Output
3. Body Image Disturbance
4. Fatigue
____ 6. The nurse monitors for which clinical manifestation in the patient diagnosed
with DiGeorge’s syndrome?
1. Muscle stiffness
2. Weight gain
3. Shortness of breath
4. Aphasia
____ 7. The nurse correlates which laboratory value as a complication in the patient
diagnosed with DiGeorge’s syndrome?
1. Sodium 150 mEq/L
2. Calcium 6.5 mg/dL
3. Potassium 3.0 mEq/L
4. Magnesium 2.5 mg/dL
____ 8. The nursing diagnosis Potential for Ineffective Airway Clearance is most
relevant to a patient with which immune disorder?
1. B-cell deficiency
2. T-cell deficiency
3. Type I hypersensitivity reaction
4. X-linked agammaglobulinemia
____ 9. Which is the priority nursing action to decrease the risk for infection for a
patient diagnosed with DiGeorge’s syndrome?
1. Hand hygiene
2. Reverse isolation
3. Prokinetic agents
4. Droplet precautions
____ 10. Which immune disorder does the nurse include in the plan of care for a
patient who is receiving chemotherapeutic agents for the treatment of cancer?
1. B-cell deficiency
2. T-cell deficiency
3. Excessive immune response

, 4. Secondary immune deficiency
____ 11. The nurse educates a patient who is diagnosed with therapy-induced immune
dysfunction. Which patient statement indicates the need for additional teaching?
1. “My husband cleans the cat's litter box.”
2. “We are planning to get our son an iguana for his birthday.”
3. “I ensure that my steak is well done when I eat out at a restaurant.”
4. “When I need to go shopping, I will go early in the morning to avoid crowds.”
____ 12. The nurse is assessing a patient who is receiving intravenous (IV)
antibiotics. Which item in the patient’s health history increases the risk for
experiencing a hypersensitivity reaction?
1. 26 years of age
2. Caucasian race
3. Previous antibiotic therapy
4. Concurrent chronic illness
____ 13. The nurse provides care to several patients with a history of hypersensitivity
reactions. Which patient requires education regarding a type I reaction?
1. The patient with allergic rhinitis
2. The patient with myasthenia gravis
3. The patient with rheumatoid arthritis
4. The patient with a suspected latex allergy
____ 14. The nurse recognizes which immunoglobulin (Ig) as the mediator for a type I
hypersensitivity reaction?
1. IgA
2. IgE
3. IgG
4. IgM
____ 15. The nurse correlates systemic hypotension to which hypersensitivity
mediator?
1. Kinins
2. Leukotrienes
3. Platelet-activating factor
4. Prostaglandin
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