Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 78: Management of Clients with Immune Disorders
MULTIPLE CHOICE
1. The nurse assesses an atopic client with many allergies for the development of a reaction to
medications administered during hospitalization. The nurse recognizes that the most severe
form of a type I hypersensitivity reaction is
a. anaphylaxis.
b. bronchial asthma.
c. dermatitis.
d. cell-mediated sensitivity.
ANS: a
Type I hypersensitivity reactions include anaphylaxis as the most severe form.
DIF: Cognitive Level: Knowledge REF: Text Reference: 2318
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The client receiving a blood transfusion complains of headache and back pain. The most
appropriate initial intervention of the nurse is to
a. evaluate the nature of the headache.
b. call the physician.
c. monitor the client's vital signs.
d. stop the transfusion.
ANS: d
Manifestations of a transfusion reaction result from intravascular hemolysis of red blood cells.
They include headache and back pain (flank), chest pain similar to angina, nausea and vomiting,
tachycardia, hypotension, hematuria, and urticaria. Transfusions of more than 100 ml of
incompatible blood can result in severe permanent renal damage, circulatory shock, and death.
Therefore, if manifestations develop, stop the transfusion at once, maintain an open intravenous
line, check the client's vital signs, and notify the physician immediately.
DIF: Cognitive Level: Analysis REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
3. The nurse caring for a client with allergic rhinitis who is using a decongestant nasal spray
would include in the teaching plan that
a. the spray should be used on a round-the-clock, equally spaced interval basis for
maximal effectiveness.
b. overuse can result in nosebleeds and mucosal ulceration.
c. nasal sprays must be combined with an oral antihistamine to achieve relief.
Chapter 78: Management of Clients with Immune Disorders 2
d. rebound rhinitis (rhinitis medicamentosa) is common with continual use.
ANS: d
Because the prolonged use of topical nasal sprays can cause rhinitis medicamentosa (recurrence
of congestion), it is advisable to limit their use to no more than once a week.
DIF: Cognitive Level: Application
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
4. A nurse conducting an in-service on hypersensitivity disorders uses the term “haptens,”
which refers to
a. routes of transmission.
b. vectors that carry an allergen.
c. molecules that combine with proteins to form antibodies.
d. the type of hypersensitivity response.
ANS: c
Molecules that combine with proteins to produce antibodies are called haptens.
DIF: Cognitive Level: Knowledge REF: Text Reference: 2316
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
5. The home health care nurse who is assessing the environment of a client reminds the client
that most allergens are
a. inhaled.
b. ingested.
c. transmitted by direct contact.
d. injected.
ANS: a
Most allergens are inhaled.
DIF: Cognitive Level: Knowledge REF: Text Reference: 2316
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
6. A client develops a positive reaction to an injection of purified protein derivative, a screening
measure for exposure to tuberculosis. The nurse records this reaction as a
a. Type I reaction.
b. Type II reaction.
c. Type III reaction.
d. Type IV reaction.
ANS: d
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Chapter 78: Management of Clients with Immune Disorders 3
Type IV reactions occur after the intradermal injection of tuberculosis antigen or purified protein
derivative. If the client has been sensitized to tuberculosis, sensitized T cells react with the
antigen at the injection site.
DIF: Cognitive Level: Knowledge REF: Text Reference: 2318, 2319, Table 78-2;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
7. A nurse would observe the client for how long to determine whether there is an immediate
reaction to a skin test?
a. 1 to 2 minutes
b. 2 to 5 minutes
c. 5 to 10 minutes
d. 10 to 20 minutes
ANS: c
Nurses often administer skin tests and interpret test results. An immediate reaction (i.e.,
appearing within 10 to 20 minutes after the injection), marked by erythema and wheal formation
greater than 3 mm of the positive control (usually histamine) denotes a positive reaction.
DIF: Cognitive Level: Application REF: Text Reference: 2320
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. Which remedy should a client be taught to avoid by a nurse who is counseling a client about
how to manage allergic reactions at a skin testing site?
a. Cool compresses
b. Heating pad
c. Topical steroid
d. Antihistamine cream
ANS: b
Itching and discomfort at the injection site are common and can be relieved by the application of
cool compresses, topical steroid or antihistamine creams, and oral antihistamines such as
diphenhydramine (Benadryl). Heat adds to the vasodilation and may cause a false-positive.
DIF: Cognitive Level: Application REF: Text Reference: 2320
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
9. The nurse warns a client about the drowsiness caused by
a. loratadine (Claritin).
b. fexofenadine (Allegra).
c. diphenhydramine (Benadryl).
d. cetirizine (Zyrtec).
ANS: c
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders 4
Traditional antihistamines such as diphenhydramine cross the blood-brain barrier and can
produce significant drowsiness. Because newer agents (cetirizine, fexofenadine, and loratadine)
do not cross the blood-brain barrier (or do so poorly), they do not cause the drowsiness that
limits the use of older medications.
DIF: Cognitive Level: Application
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
10. The nurse explains that the most effective type of drug for the treatment of rhinitis is a(n)
a. antihistamine.
b. decongestant.
c. corticosteroid.
d. anticholinergic.
ANS: c
Corticosteroids are the most effective drug for the treatment of rhinitis.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
11. The nurse instructs the client who has a new prescription for cromolyn sodium (NasalCrom)
that the most effective administration schedule is
a. at the start of allergy season, with once-a-day dosing.
b. 1 week before allergy season begins, with four to six doses per day.
c. just after manifestations begin, with twice daily dosing.
d. when manifestations peak only, with two or three doses per day.
ANS: b
Cromolyn sodium should be administered before allergen exposure. It should be started a week
before allergy season to be most effective in the treatment of seasonal allergic rhinitis. It must be
used on a regular basis and, unfortunately, dosing is required four to six times a day.
DIF: Cognitive Level: Application
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
12. A client is beginning treatment for asthma with an antileukotriene type of drug. The nurse
prepares written instructions for use of
a. zafirlukast (Accolate).
b. albuterol (Ventolin).
c. ipratropium (Atrovent).
d. budesonide (Rhinocort).
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Chapter 78: Management of Clients with Immune Disorders 5
ANS: a
Antileukotrienes are used to treat manifestations of asthma and anaphylaxis. These drugs include
zafirlukast and zileuton (Zyflo).
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
13. A client with a history of type I hypersensitivity reaction is receiving immunotherapy (or
desensitization therapy). The nurse administering the allergen injection at 1:00 PM would ask
the client to remain in the office until
a. 1:10.
b. 1:20.
c. 1:40.
d. 2:15.
ANS: c
Clients are asked to wait at least 30 to 40 minutes after receiving the injections so that immediate
reactions can be treated.
DIF: Cognitive Level: Application REF: Text Reference: 2321
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
14. The nurse teaches the client who will undergo testing for possible food allergy to chocolate,
to eliminate chocolate from the diet prior to the testing for
a. 1 to 2 days.
b. 3 to 5 days.
c. 5 to 10 days.
d. 10 to 14 days.
ANS: d
The suspected food is eliminated from the diet for 10 to 14 days.
DIF: Cognitive Level: Knowledge REF: Text Reference: 2323
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
15. The nurse would teach the client who has atopic dermatitis to avoid the practice of
a. bathing in hot water.
b. using gentle soaps.
c. applying a lubricant after bathing.
d. keeping fingernails trimmed.
ANS: a
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Chapter 78: Management of Clients with Immune Disorders 6
Teach the client general skin care measures, such as how to maintain good skin hydration by
bathing in lukewarm water; to use gentle soaps; apply a lubricant like Alpha Keri, petroleum
jelly, Eucerin, or Aquaphor to the skin immediately after bathing; avoid scratching; and keep
fingernails trimmed to avoid infection.
DIF: Cognitive Level: Application REF: Text Reference: 2324
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
16. The nurse instructs a client diagnosed with urticaria in the use of the most common remedy,
which is
a. warm oatmeal baths.
b. nonsteroidal anti-inflammatory drugs (NSAIDs).
c. antihistamines.
d. corticosteroids.
ANS: c
Antihistamines are the mainstay of therapy for urticaria.
DIF: Cognitive Level: Knowledge
REF: Text Reference: 2322, Integrating Pharmacology Box - Medications for Allergies;
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
17. When assisting in the treatment of a client with anaphylaxis the nurse would avoid using
which measure?
a. Oxygen
b. Reverse Trendelenburg position
c. Normal saline intravenous (IV) infusion
d. Epinephrine
ANS: b
Anaphylaxis is treated by subcutaneous epinephrine injection, removing or discontinuing the
causative agent, administering emergency oxygen, maintaining an open airway, placing the client
in the Trendelenburg position, and giving supportive IV fluids, such as 0.9% normal saline or
lactated Ringer's solution as necessary.
DIF: Cognitive Level: Application REF: Text Reference: 2325
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
18. The nurse explains that in step I (sensitization) of becoming allergic, the body,
upon exposure to an allergen,
a. forms mast cells.
b. reacts with rhinitis, urticaria , asthma, or gastrointestinal (GI) manifestations.
c. develops immunoglobulin E (IgE) antibodies.
d. produces basophils.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders 7
ANS: c
In the first step of a two-step process the body reacts to the exposure to an allergen by the
production of IgE antibodies.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2315
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
19. The nurse reminds a client that a delayed inflammatory response can occur 2 to 8
hours after exposure to an allergen and is governed by
a. T cells.
b. mast cells.
c. eosinophils.
d. basophils.
ANS: a
T cells govern the delayed response that occurs about 2 to 8 hours after mast cells have been
activated by the initial allergen exposure.
DIF: Cognitive Level: Analysis REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
20. The nurse explains that a type II hypersensitivity reaction results in
a. cell destruction.
b. mast cell production.
c. T-cell stimulation.
d. antibody formation.
ANS: a
In the type 2 hypersensitivity reaction the antigen-antibody binding results in activation of the
complement system and destroys the cell on which the antigen is bound.
DIF: Cognitive Level: Analysis REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
21. The nurse closely monitors a client receiving a blood transfusion because permanent damage
can occur with an infusion as small as
a. 50 cc.
b. 100 cc.
c. 300 cc.
d. 500 cc.
ANS: b
Permanent renal damage, circulatory shock, and death can occur with the infusion of as little as
100 cc of incompatible blood.
Elsevier items and derived items © 2005 by Elsevier Inc.
Chapter 78: Management of Clients with Immune Disorders 8
DIF: Cognitive Level: Application REF: Text Reference: 2318
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
22. The nurse instructs a group of allergic clients that a type III hypersensitivity reaction can
result in an Arthus reaction, which is
a. a sudden asthmalike attack.
b. a localized area of necrosis.
c. a severe gastrointestinal (GI) response.
d. a sudden, severe hypotensive episode.
ANS: b
An Arthus reaction is a localized area of tissue necrosis that results from immune complex
hypersensitivity.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2319
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
Elsevier items and derived items © 2005 by Elsevier Inc.
