ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 34 : Caring for Clients With Immune-Mediated Disorders Questions
Question 1 of 5
A client is taking oral corticosteroids after having an exacerbation of asthma. What should the nurse be sure to include when instructing the client how to take the medication?
Correct Answer: D
Rationale: Taking the oral corticosteroids in the morning with food will help reduce the gastrointestinal upset that may be experienced. The medication causes weight gain not weight loss, does not cause drowsiness, and should not be taken on an empty stomach.
Question 2 of 5
A client is taking the immunosuppressant medication, azathioprine (Imuran), for the treatment of Crohn's disease. What statement made by the client demonstrates an understanding of the side effects of this medication?
Correct Answer: A
Rationale: The client should be instructed to be sure to report any signs of infection since this drug suppresses the immune system and makes the client susceptible to infections. It is important for a client to drink 3 L of fluid when taking the immunosuppressant drug cyclosporine to prevent hemorrhagic cystitis, but this is not necessary for azathioprine. It is not necessary to inform the physician if the client is not having a bowel movement daily. The client should not stop taking the medication for any reason unless discussed with the physician.
Question 3 of 5
The nursing instructor is discussing hypersensitivity responses with a clinical group. What allergic reaction(s) would the nursing instructor talk about? Select all that apply.
Correct Answer: C,D,E
Rationale: Once sensitization occurs, one of four types of hypersensitivity responses can occur. These may be immediate or delayed depending on the time it takes for the immune system to mount a response. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly. There are three types of immediate hypersensitivity responses: type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies; type II, cytotoxic, which is mediated by immunoglobulin M or G (IgM or IgG) antibodies; and type III, immune complex, which is mediated by IgG antibodies. The first two types of responses occur within minutes; type III responses reach a peak within 6 hours after exposure to an allergen. The nurse would not discuss atypical and unmediated hypersensitivity responses in this scenario.
Question 4 of 5
The clinic nurse is caring for a client with an allergic disorder who has received the first sensitizing dose of a new drug. What nursing action is most important at this point?
Correct Answer: B
Rationale: Monitoring the client for 30 minutes after desensitization injection is necessary to assess for allergic symptoms. Although it is important to ensure the client's comfort, it is not essential to assess the client for changes in urine output, appetite, or heart rate.
Question 5 of 5
The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?
Correct Answer: A
Rationale: Diseases are considered autoimmune disorders and are characterized by unrelenting, progressive tissue damage without any verifiable etiology. In many autoimmune disorders, there tends to be a triggering event, such as an infection, trauma, or introduction of a drug that integrates itself into the membranes of the host's cells. Although older adults face a greater risk of developing autoimmune disorders, persons belonging to any age-group can be affected. Chronic fatigue syndrome is primarily characterized by profound fatigue with no identifiable cause, and this is not a characteristic of autoimmune disorders.