Chapter 19. Nursing Care of Patients With Immune Disorders
MULTIPLE CHOICE
1. The nurse is contributing to a group of patients care plans. Which patient should the
nurse identify as being at risk for developing serum sickness?
1. A patient who receives IV penicillin for an infection
2. A patient who has a transfusion with packed red blood cells (RBCs)
3. A patient who is given cryoprecipitate and factor IX after an abdominal injury
4. A patient given steroids and immunosuppressant therapy after organ
transplantation
ANS: 1
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
Objective: 2. Explain the pathophysiology of disorders of the immune system.
Page: 304
Heading: Pathophysiology and Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: PHYS–Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
Feedback
1 Serum sickness is seen occasionally after administration of penicillin and
sulfonamide.
2 Serum sickness is not associated with blood transfusions, cryoprecipitate, factor
IX, steroids, or immunosuppressant therapy.
3 Serum sickness is not associated with blood transfusions, cryoprecipitate, factor
IX, steroids, or immunosuppressant therapy.
4 Serum sickness is not associated with blood transfusions, cryoprecipitate, factor
IX, steroids, or immunosuppressant therapy.
PTS: 1 CON: Immunity
2. The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia.
Which action should the nurse include in the plan of care for this patient?
1. Assist with ambulation
2. Teach good hand hygiene.
3. Avoid intramuscular injections.
4. Obtain manual blood pressures.
ANS: 1
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
Objective: 8. Plan nursing care for patients with disorders of the immune system.
Page: 308
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: PHYS—Basic Care and Comfort
, Cognitive Level: Application (Applying)
Concept: Safety
Difficulty: Moderate
Feedback
1 With anemia, the patient will be fatigued and may have activity intolerance and
be a fall risk. Assistance with ambulation should be done for safety.
2 This action would be appropriate if the patient had neutropenia.
3 This action would be appropriate if the patient had thrombocytopenia.
4 This action would be appropriate if the patient had thrombocytopenia.
PTS: 1 CON: Safety
3. The nurse is reviewing orders for a patient with systemic lupus erythematosus (SLE).
For which medication should the nurse request clarification?
1. Levothyroxine (Synthroid)
2. Phenytoin (Dilantin)
3. Promethazine (Phenergan)
4. Pantoprazole (Protonix)
ANS: 2
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
Objective: 8. Plan nursing care for patients with disorders of the immune system.
Page: 309
Heading: Medications Associated With Triggering Lupus Erythematosus (Box 19.1)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: PHYS—Pharmacological Therapies
Cognitive Level: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
Feedback
1 Levothyroxine does not trigger SLE.
2 Phenytoin is known to trigger SLE and should be avoided.
3 Promethazine does not trigger SLE.
4 Promethazine does not trigger SLE.
PTS: 1 CON: Safety
4. The nurse is caring for a patient who is stung by a wasp. Which manifestation should
the nurse expect if an allergic reaction develops?
1. Hives
2. Retinal hemorrhage
3. Jugular vein distention
4. Pallor around the sting sites
ANS: 1
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
Objective: 3. Identify the etiologies, signs, and symptoms of immune system disorders.
Page: 297
, Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: PHYS—Basic Care and Comfort
Cognitive Level: Application (Applying)
Concept: Immunity
Difficulty: Moderate
Feedback
1 Hives is one of several symptoms of an allergic reaction.
2 This manifestation is not associated with an allergic reaction.
3 This manifestation is not associated with an allergic reaction.
4 This manifestation is not associated with an allergic reaction.
PTS: 1 CON: Immunity
5. A patient with type O blood is scheduled to undergo open heart surgery. Which blood
type would this patient receive?
1. A
2. B
3. AB
4. O
ANS: 4
Chapter: Chapter 19. Nursing Care of Patients with Immune Disorders
Objective: 8. Plan nursing care for patients With disorders of the immune
system. Page: 303
Heading: Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Application (Applying)
Concept: Safety
Difficulty: Moderate
Feedback
1 Patients with type O blood can only receive type O blood.
2 Patients with type O blood can only receive type O blood.
3 Patients with type O blood can only receive type O blood.
4 Patients with type O blood can only receive type O blood.
PTS: 1 CON: Safety
6. A patient is stabilized after having an allergic reaction. Which preventive instructions should
the nurse reinforce with the patient?
1. Wear medical alert identification.
2. Stay indoor as much as possible.
3. Wear insect repellent when outdoors.
4. Take corticosteroids before going outdoor.
ANS: 1
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
MULTIPLE CHOICE
1. The nurse is contributing to a group of patients care plans. Which patient should the
nurse identify as being at risk for developing serum sickness?
1. A patient who receives IV penicillin for an infection
2. A patient who has a transfusion with packed red blood cells (RBCs)
3. A patient who is given cryoprecipitate and factor IX after an abdominal injury
4. A patient given steroids and immunosuppressant therapy after organ
transplantation
ANS: 1
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
Objective: 2. Explain the pathophysiology of disorders of the immune system.
Page: 304
Heading: Pathophysiology and Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: PHYS–Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
Feedback
1 Serum sickness is seen occasionally after administration of penicillin and
sulfonamide.
2 Serum sickness is not associated with blood transfusions, cryoprecipitate, factor
IX, steroids, or immunosuppressant therapy.
3 Serum sickness is not associated with blood transfusions, cryoprecipitate, factor
IX, steroids, or immunosuppressant therapy.
4 Serum sickness is not associated with blood transfusions, cryoprecipitate, factor
IX, steroids, or immunosuppressant therapy.
PTS: 1 CON: Immunity
2. The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia.
Which action should the nurse include in the plan of care for this patient?
1. Assist with ambulation
2. Teach good hand hygiene.
3. Avoid intramuscular injections.
4. Obtain manual blood pressures.
ANS: 1
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
Objective: 8. Plan nursing care for patients with disorders of the immune system.
Page: 308
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: PHYS—Basic Care and Comfort
, Cognitive Level: Application (Applying)
Concept: Safety
Difficulty: Moderate
Feedback
1 With anemia, the patient will be fatigued and may have activity intolerance and
be a fall risk. Assistance with ambulation should be done for safety.
2 This action would be appropriate if the patient had neutropenia.
3 This action would be appropriate if the patient had thrombocytopenia.
4 This action would be appropriate if the patient had thrombocytopenia.
PTS: 1 CON: Safety
3. The nurse is reviewing orders for a patient with systemic lupus erythematosus (SLE).
For which medication should the nurse request clarification?
1. Levothyroxine (Synthroid)
2. Phenytoin (Dilantin)
3. Promethazine (Phenergan)
4. Pantoprazole (Protonix)
ANS: 2
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
Objective: 8. Plan nursing care for patients with disorders of the immune system.
Page: 309
Heading: Medications Associated With Triggering Lupus Erythematosus (Box 19.1)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: PHYS—Pharmacological Therapies
Cognitive Level: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
Feedback
1 Levothyroxine does not trigger SLE.
2 Phenytoin is known to trigger SLE and should be avoided.
3 Promethazine does not trigger SLE.
4 Promethazine does not trigger SLE.
PTS: 1 CON: Safety
4. The nurse is caring for a patient who is stung by a wasp. Which manifestation should
the nurse expect if an allergic reaction develops?
1. Hives
2. Retinal hemorrhage
3. Jugular vein distention
4. Pallor around the sting sites
ANS: 1
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
Objective: 3. Identify the etiologies, signs, and symptoms of immune system disorders.
Page: 297
, Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: PHYS—Basic Care and Comfort
Cognitive Level: Application (Applying)
Concept: Immunity
Difficulty: Moderate
Feedback
1 Hives is one of several symptoms of an allergic reaction.
2 This manifestation is not associated with an allergic reaction.
3 This manifestation is not associated with an allergic reaction.
4 This manifestation is not associated with an allergic reaction.
PTS: 1 CON: Immunity
5. A patient with type O blood is scheduled to undergo open heart surgery. Which blood
type would this patient receive?
1. A
2. B
3. AB
4. O
ANS: 4
Chapter: Chapter 19. Nursing Care of Patients with Immune Disorders
Objective: 8. Plan nursing care for patients With disorders of the immune
system. Page: 303
Heading: Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Application (Applying)
Concept: Safety
Difficulty: Moderate
Feedback
1 Patients with type O blood can only receive type O blood.
2 Patients with type O blood can only receive type O blood.
3 Patients with type O blood can only receive type O blood.
4 Patients with type O blood can only receive type O blood.
PTS: 1 CON: Safety
6. A patient is stabilized after having an allergic reaction. Which preventive instructions should
the nurse reinforce with the patient?
1. Wear medical alert identification.
2. Stay indoor as much as possible.
3. Wear insect repellent when outdoors.
4. Take corticosteroids before going outdoor.
ANS: 1
Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders
