Chapter 54: Care of the Patient with an Immune Disorder

1.Which of the following is an example of immunocompetence? a. A child that is immune to measles because of an inoculation b. A person who has seasonal allergies every fall c. When the symptoms of a common cold disappear in 1 day d. A neonate having a natural immunity from maternal antibodies ANS: C Immunocompetence is demonstrated by the immune system responding appropriately to a foreign stimulus and the body’s integrity is maintained as with cold symptoms that resolve with residual illness. PTS: 1 DIF: Cognitive Level: Application REF: Page 1962 OBJ:1TOP:Immunocompetence KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2.An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurse’s first intervention? a. Apply cool compresses to urticaria b. Provide oxygen per non-rebreathing mask c. Cover patient with a warm blanket d. Prepare for venipuncture for the delivery of IV medication ANS: B Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the patient may have to be intubated. Covering the patient with a warm blanket is not wrong, but not an initial intervention.