Deck 47: Nursing Care of the Child With an Alteration in Immunity or Immunologic Disorder

Question 1

While providing care to a 5-month-old girl whose family has a history of food allergies, the nurse instructs the parents about foods to be avoided in the first year of life. Which response by the parents indicates a need for further teaching?

A) "She cannot have any cow's milk."
B) "I should continue breastfeeding until at least 6 months."
C) "Peanuts in any form should be avoided."
D) "Any kind of fruit is acceptable."

Answer 1

"Any kind of fruit is acceptable."

Question 2

A nurse is caring for a 12-year-old girl with a severe peanut allergy. The girl's parents are upset because the school does not permit her to carry her EpiPen with her. It must remain in the school's office per school regulations. Which response by the nurse would be most appropriate?

A) "She is allowed by law to carry her EpiPen with her; I will talk to school authorities."
B) "Let's file an action plan and keep it in the school office in the event of anaphylaxis."
C) "Make sure she wears a medical alert bracelet so that school staff know she has allergies."
D) "I will be happy to train school authorities and staff to recognize anaphylaxis."

Answer 2

"She is allowed by law to carry her EpiPen with her; I will talk to school authorities."

Question 3

The nurse is caring for a child who is having an anaphylactic reaction with bronchospasm. The nurse would expect to administer which of the following for bronchospasm as ordered?

A) Epinephrine
B) Corticosteroid
C) Albuterol
D) Diphenhydramine

Answer 3

Albuterol

Question 4

The nurse is caring for a child undergoing highly active antiretroviral therapy (HAART) for HIV infection. The nurse is preparing to administer the prescribed medication. In addition to the nucleoside analog reverse transcriptase inhibitors (NRTIs) and the nonnucleoside analog reverse transcriptase inhibitors (NNRTIs), the nurse is cognizant that the child will be taking which additional medication as part of the three-drug regimen?

A) Protease inhibitors
B) Corticosteroids
C) Cytotoxic drugs
D) Disease-modifying antirheumatic drugs (DMARDs)

Question 5

The nurse is providing home care instructions for a 13-year-old girl recently diagnosed with systemic lupus erythematosus. Which response by the girl indicates a need for further teaching?

A) "I need to wear sunscreen in the summer to prevent rashes."
B) "I need to eat a healthy diet, exercise, and get plenty of sleep."
C) "I need an eye examination every year."
D) "I need to be careful when it is cold; I should always wear gloves."

Question 6

The nurse is caring for a child who is taking corticosteroids for systemic lupus erythematosus. The nurse closely monitors the child based on the understanding that corticosteroids exert which major action?

A) They increase liver enzymes.
B) They can mask signs of infection.
C) They cause bone marrow suppression.
D) They decrease renal function.

Question 7

The school nurse is walking through the lunchroom when one of the children says she feels strange after switching her lunch with her friend. Which assessment would be most important?

A) Asking if she has a rash anywhere
B) Checking if she has any nausea
C) Determining if her throat itches
D) Asking if she has abdominal pain

Question 8

The nurse is caring for a child who has undergone stem cell transplantation for severe combined immune deficiency. Which of the following would the nurse interpret as indicative of graft-versus-host disease?

A) Presence of wheezing
B) Splenomegaly
C) Maculopapular rash
D) Chronic or recurrent diarrhea

Question 9

The nurse is administering intravenous immune globulin (IVIG). The nurse assesses vital signs and for adverse reactions every 15 minutes for the first hour of administration. After the first hour, the nurse most likely would continue to assess the child at which frequency?

A) Every 30 minutes
B) Every 45 minutes
C) Every 60 minutes
D) Every 2 hours

Question 10

When reviewing the history of a child with suspected primary immunodeficiency, which of the following would the nurse be least likely to find?

A) Weight appropriate for height
B) Antibiotic therapy for the past 3 months without effect
C) 10 episodes of otitis media in the last year
D) Three bouts of sinusitis within a year's time

Question 11

Which of the following would the nurse expect to find in a male infant with Wiskott- Aldrich syndrome?

A) Eczema
B) Thrombocytosis
C) Lymphadenopathy
D) Pneumonia

Question 12

After teaching a class about humoral and cellular immunity, the nurse recognizes that the additional teaching is needed when the class states which of the following?

A) Humoral immunity crosses the placenta.
B) Cellular immunity involves the T lymphocytes.
C) Cellular immunity recognizes antigens.
D) Humoral immunity does not destroy the foreign cell.

Question 13

A child is diagnosed with juvenile idiopathic arthritis and is receiving several different medications listed in the medication administration record. Which agent would the nurse identify as being used to prevent disease progression?

A) Aspirin
B) Prednisone
C) Ibuprofen
D) Methotrexate

Question 14

A group of nursing students are reviewing information about humoral and cellular immunity. The students demonstrate understanding of this material when they identify which of the following as involved in cellular immunity?

A) B cells
B) Antibodies
C) Antigens
D) T cells

Question 15

A nurse is preparing a plan of care for a child with a primary immunodeficiency. Which nursing diagnosis would the nurse most likely identify as the priority?

A) Imbalanced nutrition, less than body requirements related to poor appetite
B) Ineffective protection related to impaired humoral defenses
C) Acute pain related to inflammatory processes
D) Risk for delayed growth and development related to chronic illness

Question 16

A child with hypogammaglobulinemia is to receive intravenous immunoglobulin (IVIG). Which of the following would be least appropriate for the nurse to do?

A) Shake the vial after reconstituting it
B) Premedicate the child with acetaminophen
C) Obtain preinfusion vital signs
D) Check serum blood urea nitrogen and creatinine levels

Question 17

A nursing student is reviewing information about primary immunodeficiencies. The student demonstrates understanding of the material by identifying which of the following as affecting only males? Select all answers that apply.

A) X-linked agammaglobulinemia
B) Wiskott-Aldrich syndrome
C) Selective IgA deficiency
D) X-linked hyper-IgM syndrome
E) IgG subclass deficiency
F) Severe combined immune deficiency

Question 18

The nurse is reviewing the laboratory test results of a child who is suspected of having systemic lupus erythematosus (SLE). Which of the following would the nurse identify as supporting this diagnosis? Select all answers that apply.

A) Positive antinuclear antibody (ANA)
B) Increased C3 levels
C) Thrombocytopenia
D) Leukopenia
E) Increased hematocrit

Question 19

A child is diagnosed with a food allergy to milk. When teaching the parents about this allergy, which of the following would the nurse suggest as possible substitutions? Select all answers that apply.

A) Fruit juice
B) Rice milk
C) Yogurt
D) Nondairy creamers
E) Soy milk

Question 20

The nurse is talking to the parents of a child who has been diagnosed with severe combined immune deficiency. Which statement by the parents best indicates that they understand their child's condition?

A) "He'll need to receive intravenous immunoglobulin routinely."
B) "We'll need to prepare him and ourselves for a bone marrow transplant.'
C) "He'll need to receive several different types of antiviral medications."
D) "We'll make sure that he has his EpiPen with him at all times."

Question 21

The nurse is assessing a child with pauciarticular-type juvenile idiopathic arthritis. Which of the following would the nurse expect to assess?

A) Fever
B) Rash
C) Eye inflammation
D) Splenomegaly

Question 22

A child with systemic lupus erythematosus is receiving high-dose corticosteroid therapy over the long term. The nurse would instruct the parents and child to report which of the following?

A) Difficulty urinating
B) Visual changes
C) Joint pain
D) Rash

Question 23

A nurse is assessing a child who may have a latex allergy. The nurse asks the child about allergic reactions with certain foods. Which foods if identified by the child as experiencing an allergic reaction would help support the suspected latex allergy? Select all answers that apply.

A) Peaches
B) Plums
C) Carrots
D) Tomatoes
E) Apples
F) Lettuce