Deck 22: Alterations in Immune Function

Question 1

The nurse is providing care to a school-age client with a documented immunodeficiency who is admitted to the general pediatric unit for intravenous medication administration. Which interventions are appropriate for this client? Select all that apply.
1) Institute droplet precautions.
2) Place in a positive-pressure room.
3) Avoid live vaccines.
4) Perform frequent handwashing.
5) Recommend fresh fruits brought in by the family.

Answer 1

2, 3, 4

Question 2

An HIV-positive mother states she is relieved after the birth of her child to hear that the child is HIV-negative. Which response by the nurse is the most appropriate?
1) "Symptoms could still appear over the next 2 years."
2) "You took good care of yourself, so your child did not get HIV."
3) "We will assess for signs of pneumonia to be sure."
4) "The test will be repeated in 1 week to verify the negative status."

Answer 2

1

Question 3

Parents of a child who experienced a moderately severe allergic reaction after eating peanuts ask the nurse what they can do to help if it happens again. Which response by the nurse is the most appropriate?
1) "If it happens again, I will teach you what to do."
2) "You should have an antihistamine like Benadryl with you at all times."
3) "We can start a desensitization process to take the allergy away."
4) "I will teach you how to use an Epi-Pen."

Answer 3

4

Question 4

A nurse begins an infusion of intravenous immune globulin (IVIG) to a child who has combined immunodeficiency disease. Which assessment finding indicates that the nurse should stop the infusion?
1) A mild headache
2) Clear yellow urine
3) Severe shaking, chills, and fever
4) Complaints of being "thirsty"

Question 5

A preschool-age child has just had a moderate reaction to latex. When teaching the parents about latex allergy, the nurse should inform the parents of what common household items that contain latex? Select all that apply.
1) Rubber bands
2) Sneakers
3) Toothbrushes
4) Big Wheel^® tricycle
5) Water toys

Question 6

A child with human immunodeficiency virus is started on sulfamethoxazole and trimethoprim (Bactrim) for Pneumocystis carinii pneumonia (PCP) prophylaxis. The recommended dose is based on the trimethoprim (TMP) component and is 15 to 20 mg TMP/kg/day in divided doses every 6 to 8 hours. The child weighs
6.8 kg. The highest dose of TMP the child can receive a day is ________.
Round your answer to the nearest whole number.

Question 7

The nurse is providing care to an adolescent client diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of body changes associated with SLE?
1) She refuses to attend school.
2) She doesn't want to attend any social functions.
3) She discusses the body changes with a peer.
4) She discusses the body changes with healthcare personnel only.

Question 8

A child is prescribed Didanosine (Videx), a nucleoside reverse transcriptase inhibitor, for human immunodeficiency virus (HIV). Which lab value will the nurse monitor closely for this child?
1) Potassium
2) Sodium
3) RBC count
4) Glucose

Question 9

The nurse is providing care to a preschool-age client who is diagnosed with acquired immune deficiency syndrome (AIDS). In planning the client's care, which vaccine is inappropriate for the client to receive?
1) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)
2) Haemophilus influenzae type B (HIB conjugate vaccine)
3) Varicella vaccine
4) Hepatitis B vaccine (Hep B)

Question 10

A child with the diagnosis of Wiskott-Aldrich syndrome has been ordered an IV infusion of gamma globulin. The child weighs 20 pounds. The healthcare provider orders: gamma globulin 2 g/kg IV over 12 hours.
Calculate how many grams of gamma globulin will be given IV.

Question 11

A nurse is administering an intramuscular vaccination to an infant diagnosed with Wiskott-Aldrich syndrome (WAS). Which reaction is the infant more at risk for due to the diagnosis of WAS?
1) Pain at injection site
2) Bleeding at injection site
3) Redness and swelling at injection site
4) Mild rash at injection site

Question 12

The nurse is providing discharge teaching to a school-age client who was recently diagnosed with a latex allergy. Which product will the nurse educate the client and family to avoid?
1) Plastic bottles
2) Footballs
3) Chewing gum
4) Paper bags

Question 13

The nurse is caring for an adolescent client diagnosed with rheumatoid arthritis. Which nonpharmacological measure to reduce joint pain is most appropriate for the nurse to recommend to this client?
1) Moist heat
2) Elevation of extremity
3) Massage
4) Immobilization

Question 14

The nurse is caring for the adolescent with systemic lupus erythematosus (SLE). What nursing diagnoses would the nurse address? Select all that apply.
1) Activity intolerance
2) Risk for impaired skin integrity
3) Body image disturbed
4) Ineffective breathing pattern
5) Risk for infection

Question 15

A child with human immunodeficiency virus (HIV) also has oral candidiasis. Which type of mouth care solution will the nurse teach the child to use?
1) Normal saline
2) Listerine
3) Scope
4) Viscous lidocaine

Question 16

A school-age child diagnosed with rheumatoid arthritis asks the nurse to recommend an exercise activity. Which activity is most appropriate for this child?
1) Softball
2) Football
3) Swimming
4) Basketball

Question 17

A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child?
1) Risk for Infection
2) Risk for Fluid-Volume Deficit
3) Ineffective Thermoregulation
4) Ineffective Tissue Perfusion, Peripheral

Question 18

A child comes to the clinic for an assessment 20 days post-bone marrow transplant. Which system should receive the highest priority during the nursing assessment?
1) Integumentary
2) Gastrointestinal
3) Respiratory
4) Cardiovascular