Immune Responses

Which health promotion action would the nurse include in the teaching plan for a patient who has an immune deficiency involving the T lymphocytes?

Screening for cancers

Which example would the nurse use to explain an infant‘s “passive immunity” to a new mother?

Breastfeeding

Which laboratory value would the nurse expect to be elevated in a patient who has atopic dermatitis?

IgE

A healthy older adult patient who is having an annual checkup tells the nurse, “I feel fine, and I don‘t want to pay for unnecessary cancer screening tests.” Which information would the nurse plan to teach this patient?

Consequences of aging on cell-mediated immunity

A patient who works with bees and collects honey has developed a hypersensitivity to bee stings. Which statement by the patient would indicate a need for additional teaching?

“I will take oral antihistamines before going to work.”

Which information about intradermal skin testing would the nurse teach to a patient with possible allergies?

“Plan to wait in the clinic for about 20 minutes after the testing.”

The nurse reviewing a clinic patient‘s medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action would the nurse take?

Consult with the health care provider about giving a lower allergen dose.

The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action would the nurse take?

Document the patient‘s history and teach about clinical manifestations of a type Iatex allergy.

Which information about plasmapheresis would the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)?

Plasmapheresis prevents inflammatory mediators from injuring tissues.

The nurse would assess the patient undergoing plasmapheresis for which clinical manifestation?

Extremity numbness

Which patient statement would alert the nurse to a risk for decreased immune function?

“I had my spleen removed after a car accident.”

Which patient would the nurse assess first?

Patient who is sneezing after subcutaneous immunotherapy

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. Which process would the nurse suspect is causing the rash?

The patient‘s cells are being attacked by the donor T cell.

A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer?

Gamma globulin

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient indicates a need for further instructions?

“After a couple of years, I will be able to stop taking immunosuppressants.”

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient‘s health history has implications for planning patient teaching about the safe use of cyclosporine?

The patient drinks grapefruit juice every day.

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention would the nurse expect for this patient?

Administration of immunosuppressant medications

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant?

A patient with an anaphylactic reaction

A patient in the health care provider‘s office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action would the nurse plan to take first?

Administer a dose of epinephrine.

A patient in the emergency room is anxious and reports difficulty breathing after being stung by a wasp. Which action would the nurse take first?

Assess the patient‘s airway.

Immediately after the nurse administers an intradermal injection of an allergen on the forearm, the patient reports itching at the site, weakness, and dizziness. Which action would the nurse take first?

Place a tourniquet above the site.

A clinic patient reports experiencing an allergic reaction to an unknown allergen several weeks ago. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)?

Administer a cutaneous scratch skin test.

The health care provider asks the nurse to evaluate whether a patient‘s angioedema has responded to prescribed therapies. Which assessment would the nurse perform?

Observe for swelling of the patient‘s lips and tongue.

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which result should the nurse report to the transplant surgeon?

The patient–donor crossmatch is positive.

A patient who is receiving immunotherapy has just received an allergen injection. Which finding is most important to communicate to the health care provider?

There is a 2-cm wheal at the site of the injection.