Exam 3 rnsg 1538 immunity questions
with correct answers
A new mother expresses concern about her baby developing allergies
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and asks what the health care provider meant by passive immunity.
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Which example should the nurse use to explain this type of immunity?
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a. Early immunization
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b. Bone marrow donation
| | |
c. Breastfeeding her infant
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d. Exposure to communicable diseases
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ANS: C |
Colostrum provides passive immunity through antibodies from the
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mother. These antibodies protect the infant for a few months. However,
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memory cells are not retained, so the protection is not permanent.
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Active immunity is acquired by being immunized with vaccinations or
| | | | | | | | | |
having an infection. It requires that the infant has an immune response
| | | | | | | | | | | |
after exposure to an antigen. Cell-mediated immunity is acquired
| | | | | | | | |
through T lymphocytes and is a form of active immunity.
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A patient who collects honey to earn supplemental income has
| | | | | | | | | |
developed a hypersensitivity to bee stings.Which statement, if made by
| | | | | | | | | |
the patient, would indicate a need for additional teaching?
| | | | | | | |
a. I need to find another way to earn extra money.
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b. I will get a prescription for epinephrine and learn to self-inject it.
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c. I will plan to take oral antihistamines daily before going to work
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,d. I should wear a Medic-Alert bracelet indicating my allergy to bee
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stings
ANS: C |
Because the patient is at risk for bee stings and the severity of allergic
| | | | | | | | | | | | | |
reactions tends to increase with added exposure to allergen, taking oral
| | | | | | | | | | |
antihistamines will not adequately control the patients hypersensitivity | | | | | | | |
reaction. The other patient statements indicate a good understanding of
| | | | | | | | |
management of the problem.
| | | |
While obtaining a health history from a patient, the nurse learns that
| | | | | | | | | | | |
the patient has a history of allergic rhinitis and multiple food allergies.
| | | | | | | | | | | |
Which action by the nurse is most appropriate?
| | | | | | |
a. Encourage the patient to carry an epinephrine kit in case a type IV
| | | | | | | | | | | | | |
allergic reaction to latex develops.| | | |
b. Advise the patient to use oil-based hand creams to decrease contact
| | | | | | | | | | | |
with natural proteins in latex gloves.
| | | | |
c. Document the patients allergy history and be alert for any clinical
| | | | | | | | | | | |
manifestations of a type I latex allergy. | | | | | |
d. Recommend that the patient use vinyl gloves instead of latex gloves
| | | | | | | | | | | |
in preventing blood-borne pathogen contact.
| | | |
ANS: C |
The patients allergy history and occupation indicate a risk of developing
| | | | | | | | | | |
a latex allergy. The nurse should be prepared to manage any symptoms
| | | | | | | | | | | |
that may occur. Epinephrine is not an appropriate treatment for contact
| | | | | | | | | | |
dermatitis that is caused by a type IV allergic reaction to latex. Oil-based
| | | | | | | | | | | |
creams will increase the exposure to latex from latex gloves. Vinyl
| | | | | | | | | | | |
gloves are appropriate to use when exposure to body fluids is unlikely.
| | | | | | | | | | |
,Which statement by a patient would alert the nurse to a possible
| | | | | | | | | | | |
immunodeficiency disorder? |
a. I take one baby aspirin every day to prevent stroke.
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b. I usually eat eggs or meat for at least 2 meals a day.
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c. I had my spleen removed many years ago after a car accident.
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d. I had a chest x-ray 6 months ago when I had walking pneumonia.
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ANS: C |
Splenectomy increases the risk for septicemia from bacterial infections. | | | | | | | | |
The patients protein intake is good and should improve immune
| | | | | | | | | |
function. Daily aspirin use does not affect immune function. A chest x-
| | | | | | | | | | |
ray does not have enough radiation to suppress immune function.
| | | | | | | | |
A patient who has received allergen testing using the cutaneous scratch
| | | | | | | | | | |
method has developed itching and swelling at the skin site. Which
| | | | | | | | | | |
action should the nurse take first?
| | | | |
a. Administer epinephrine.
| |
b. Apply topical hydrocortisone.
| | |
c. Monitor the patient for lower extremity edema.
| | | | | | |
d. Ask the patient about exposure to any new lotions or soaps
| | | | | | | | | | |
ANS: A |
The initial symptoms of anaphylaxis are itching and edema at the site of
| | | | | | | | | | | | |
the exposure. Hypotension,tachycardia, dilated pupils, and wheezes
| | | | | | |
occur later. Rapid administration of epinephrine when excessive itching
| | | | | | | | |
or swelling at the skin site is observed can prevent the progression to
| | | | | | | | | | | | |
anaphylaxis. Topical hydrocortisone would not deter an anaphylactic | | | | | | | |
reaction. Exposure to lotions and soaps does not address the immediate
| | | | | | | | | |
concern of a possible anaphylactic reaction. The nurse should not wait
| | | | | | | | | | | |
, and observe for edema. The nurse should act immediately in order to
| | | | | | | | | | | |
prevent progression to anaphylaxis.
| | |
A patient who is anxious and has difficulty breathing seeks treatment
| | | | | | | | | | |
after being stung by a wasp. What is the nurses priority action?
| | | | | | | | | | |
a. Have the patient lie down.
| | | | |
b. Assess the patients airway.
| | | |
c. Administer high-flow oxygen.
| | |
d. Remove the stinger from the site.
| | | | | |
ANS: B |
The initial action with any patient with difficulty breathing is to assess
| | | | | | | | | | | |
and maintain the airway. The other
| | | | |
actions also are part of the emergency management protocol for
| | | | | | | | | |
anaphylaxis, but the priority is airway | | | | |
maintenance
Immediately after the nurse administers an intracutaneous injection of
| | | | | | | | |
an allergen on the forearm, a patient complains of itching at the site and
| | | | | | | | | | | | |
|of weakness and dizziness. What action should the nurse take first?
| | | | | | | | | |
a. Remind the patient to remain calm.
| | | | | |
b. Administer subcutaneous epinephrine.
| | |
c. Apply a tourniquet above the injection site.
| | | | | | |
d. Rub a local anti-inflammatory cream on the site.
| | | | | | | |
ANS: C |
Application of a tourniquet will decrease systemic circulation of the
| | | | | | | | | |
allergen and should be the first reaction. A local anti-inflammatory
| | | | | | | | | |
cream may be applied to the site of a cutaneous test if the itching
| | | | | | | | | | | | | |
persists. Epinephrine will be needed if the allergic reaction progresses to
| | | | | | | | | |
with correct answers
A new mother expresses concern about her baby developing allergies
| | | | | | | | | |
and asks what the health care provider meant by passive immunity.
| | | | | | | | | | |
Which example should the nurse use to explain this type of immunity?
| | | | | | | | | | |
a. Early immunization
| |
b. Bone marrow donation
| | |
c. Breastfeeding her infant
| | |
d. Exposure to communicable diseases
| | | |
ANS: C |
Colostrum provides passive immunity through antibodies from the
| | | | | | | |
mother. These antibodies protect the infant for a few months. However,
| | | | | | | | | | |
memory cells are not retained, so the protection is not permanent.
| | | | | | | | | | |
Active immunity is acquired by being immunized with vaccinations or
| | | | | | | | | |
having an infection. It requires that the infant has an immune response
| | | | | | | | | | | |
after exposure to an antigen. Cell-mediated immunity is acquired
| | | | | | | | |
through T lymphocytes and is a form of active immunity.
| | | | | | | | |
A patient who collects honey to earn supplemental income has
| | | | | | | | | |
developed a hypersensitivity to bee stings.Which statement, if made by
| | | | | | | | | |
the patient, would indicate a need for additional teaching?
| | | | | | | |
a. I need to find another way to earn extra money.
| | | | | | | | | |
b. I will get a prescription for epinephrine and learn to self-inject it.
| | | | | | | | | | | |
c. I will plan to take oral antihistamines daily before going to work
| | | | | | | | | | | |
,d. I should wear a Medic-Alert bracelet indicating my allergy to bee
| | | | | | | | | | | |
stings
ANS: C |
Because the patient is at risk for bee stings and the severity of allergic
| | | | | | | | | | | | | |
reactions tends to increase with added exposure to allergen, taking oral
| | | | | | | | | | |
antihistamines will not adequately control the patients hypersensitivity | | | | | | | |
reaction. The other patient statements indicate a good understanding of
| | | | | | | | |
management of the problem.
| | | |
While obtaining a health history from a patient, the nurse learns that
| | | | | | | | | | | |
the patient has a history of allergic rhinitis and multiple food allergies.
| | | | | | | | | | | |
Which action by the nurse is most appropriate?
| | | | | | |
a. Encourage the patient to carry an epinephrine kit in case a type IV
| | | | | | | | | | | | | |
allergic reaction to latex develops.| | | |
b. Advise the patient to use oil-based hand creams to decrease contact
| | | | | | | | | | | |
with natural proteins in latex gloves.
| | | | |
c. Document the patients allergy history and be alert for any clinical
| | | | | | | | | | | |
manifestations of a type I latex allergy. | | | | | |
d. Recommend that the patient use vinyl gloves instead of latex gloves
| | | | | | | | | | | |
in preventing blood-borne pathogen contact.
| | | |
ANS: C |
The patients allergy history and occupation indicate a risk of developing
| | | | | | | | | | |
a latex allergy. The nurse should be prepared to manage any symptoms
| | | | | | | | | | | |
that may occur. Epinephrine is not an appropriate treatment for contact
| | | | | | | | | | |
dermatitis that is caused by a type IV allergic reaction to latex. Oil-based
| | | | | | | | | | | |
creams will increase the exposure to latex from latex gloves. Vinyl
| | | | | | | | | | | |
gloves are appropriate to use when exposure to body fluids is unlikely.
| | | | | | | | | | |
,Which statement by a patient would alert the nurse to a possible
| | | | | | | | | | | |
immunodeficiency disorder? |
a. I take one baby aspirin every day to prevent stroke.
| | | | | | | | | |
b. I usually eat eggs or meat for at least 2 meals a day.
| | | | | | | | | | | | |
c. I had my spleen removed many years ago after a car accident.
| | | | | | | | | | | |
d. I had a chest x-ray 6 months ago when I had walking pneumonia.
| | | | | | | | | | | | |
ANS: C |
Splenectomy increases the risk for septicemia from bacterial infections. | | | | | | | | |
The patients protein intake is good and should improve immune
| | | | | | | | | |
function. Daily aspirin use does not affect immune function. A chest x-
| | | | | | | | | | |
ray does not have enough radiation to suppress immune function.
| | | | | | | | |
A patient who has received allergen testing using the cutaneous scratch
| | | | | | | | | | |
method has developed itching and swelling at the skin site. Which
| | | | | | | | | | |
action should the nurse take first?
| | | | |
a. Administer epinephrine.
| |
b. Apply topical hydrocortisone.
| | |
c. Monitor the patient for lower extremity edema.
| | | | | | |
d. Ask the patient about exposure to any new lotions or soaps
| | | | | | | | | | |
ANS: A |
The initial symptoms of anaphylaxis are itching and edema at the site of
| | | | | | | | | | | | |
the exposure. Hypotension,tachycardia, dilated pupils, and wheezes
| | | | | | |
occur later. Rapid administration of epinephrine when excessive itching
| | | | | | | | |
or swelling at the skin site is observed can prevent the progression to
| | | | | | | | | | | | |
anaphylaxis. Topical hydrocortisone would not deter an anaphylactic | | | | | | | |
reaction. Exposure to lotions and soaps does not address the immediate
| | | | | | | | | |
concern of a possible anaphylactic reaction. The nurse should not wait
| | | | | | | | | | | |
, and observe for edema. The nurse should act immediately in order to
| | | | | | | | | | | |
prevent progression to anaphylaxis.
| | |
A patient who is anxious and has difficulty breathing seeks treatment
| | | | | | | | | | |
after being stung by a wasp. What is the nurses priority action?
| | | | | | | | | | |
a. Have the patient lie down.
| | | | |
b. Assess the patients airway.
| | | |
c. Administer high-flow oxygen.
| | |
d. Remove the stinger from the site.
| | | | | |
ANS: B |
The initial action with any patient with difficulty breathing is to assess
| | | | | | | | | | | |
and maintain the airway. The other
| | | | |
actions also are part of the emergency management protocol for
| | | | | | | | | |
anaphylaxis, but the priority is airway | | | | |
maintenance
Immediately after the nurse administers an intracutaneous injection of
| | | | | | | | |
an allergen on the forearm, a patient complains of itching at the site and
| | | | | | | | | | | | |
|of weakness and dizziness. What action should the nurse take first?
| | | | | | | | | |
a. Remind the patient to remain calm.
| | | | | |
b. Administer subcutaneous epinephrine.
| | |
c. Apply a tourniquet above the injection site.
| | | | | | |
d. Rub a local anti-inflammatory cream on the site.
| | | | | | | |
ANS: C |
Application of a tourniquet will decrease systemic circulation of the
| | | | | | | | | |
allergen and should be the first reaction. A local anti-inflammatory
| | | | | | | | | |
cream may be applied to the site of a cutaneous test if the itching
| | | | | | | | | | | | | |
persists. Epinephrine will be needed if the allergic reaction progresses to
| | | | | | | | | |
