1. Your client is about to have a skin test for an allergic disorder. What critical
instruction should the nurse give this client?
A) Avoid red meat for 48 to 72 hours before the test.
B) Avoid strenuous physical activity for 24 hours before the test.
C) Avoid antihistamines and cold preparations for 48 to 72 hours before the test.
D) Avoid sunlight for 48 to 72 hours before the
test. Ans: C
Feedback:
The nurse should instruct the client to avoid taking prescribed or over-the-counter
antihistamine or cold preparations for at least 48 to 72 hours before a skin test because
this reduces the potential for false-negative test results. The nurse should not ask the
client to avoid red meat, strenuous physical activity, or sunlight because these do not
affect the test results.
2. 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?
A) Assess the client for reduced urine output.
B) Monitor the client for reactions.
C) Assess the client for reduced appetite.
D) Monitor the client for increased heart
rate. Ans: B
Feedback:
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.
3. You are caring for a client with an autoimmune disease. What is a characteristic
of autoimmune disorders?
A) Progressive tissue damage without any verifiable etiology
B) Absence of a triggering event
C) Profound fatigue with no identifiable cause
D) Affects only older adults and infants less than 3
months Ans: A
Feedback:
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.
Page 1
, 4. You are caring for a client with chronic fatigue syndrome. What is a realistic
nursing intervention when taking care of a client with this diagnosis?
A) Educate the client about the disease process.
B) Advise the client to avoid moderate exertion.
C) Instruct the client to reduce the intake of potassium-rich foods.
D) Advise the client to avoid being in crowds.
Ans: A
Feedback:
The nurse should educate the client about the disease process and the limitations that it
requires because nothing, as yet, holds promise for a complete cure. The client need not
be advised to avoid moderate exertion because the physician may prescribe a modest
exercise program to treat chronic fatigue syndrome. A client who experiences
hypotension may be advised to increase salt and water intake but need not reduce the
intake of potassium-rich foods or avoid being in crowds.
5. A client presents at the clinic with an allergic disorder. The client asks the nurse what an
“allergic disorder” means. What would be the nurse's best response?
A) “It means you are very sensitive to something inside of yourself.”
B) “It is a hyperimmune response to something in the environment that is
usually harmless.”
C) “It is a muted response to something in the environment.”
D) “It is a harmless reaction to something in the
environment.” Ans: B
Feedback:
An allergic disorder is characterized by a hyperimmune response to weak antigens that
usually are harmless. The antigens that can cause an allergic response are called
allergens.
6. The nursing instructor is discussing allergic reactions with her clinical group.
What allergic reactions would the nursing instructor talk about? Select all that
apply.
A) Atypical
B) Unmediated
C) Cytotoxic
D) Atopic
E) Immune complex
Ans: C, D, E
Feedback:
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
Page 2
instruction should the nurse give this client?
A) Avoid red meat for 48 to 72 hours before the test.
B) Avoid strenuous physical activity for 24 hours before the test.
C) Avoid antihistamines and cold preparations for 48 to 72 hours before the test.
D) Avoid sunlight for 48 to 72 hours before the
test. Ans: C
Feedback:
The nurse should instruct the client to avoid taking prescribed or over-the-counter
antihistamine or cold preparations for at least 48 to 72 hours before a skin test because
this reduces the potential for false-negative test results. The nurse should not ask the
client to avoid red meat, strenuous physical activity, or sunlight because these do not
affect the test results.
2. 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?
A) Assess the client for reduced urine output.
B) Monitor the client for reactions.
C) Assess the client for reduced appetite.
D) Monitor the client for increased heart
rate. Ans: B
Feedback:
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.
3. You are caring for a client with an autoimmune disease. What is a characteristic
of autoimmune disorders?
A) Progressive tissue damage without any verifiable etiology
B) Absence of a triggering event
C) Profound fatigue with no identifiable cause
D) Affects only older adults and infants less than 3
months Ans: A
Feedback:
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.
Page 1
, 4. You are caring for a client with chronic fatigue syndrome. What is a realistic
nursing intervention when taking care of a client with this diagnosis?
A) Educate the client about the disease process.
B) Advise the client to avoid moderate exertion.
C) Instruct the client to reduce the intake of potassium-rich foods.
D) Advise the client to avoid being in crowds.
Ans: A
Feedback:
The nurse should educate the client about the disease process and the limitations that it
requires because nothing, as yet, holds promise for a complete cure. The client need not
be advised to avoid moderate exertion because the physician may prescribe a modest
exercise program to treat chronic fatigue syndrome. A client who experiences
hypotension may be advised to increase salt and water intake but need not reduce the
intake of potassium-rich foods or avoid being in crowds.
5. A client presents at the clinic with an allergic disorder. The client asks the nurse what an
“allergic disorder” means. What would be the nurse's best response?
A) “It means you are very sensitive to something inside of yourself.”
B) “It is a hyperimmune response to something in the environment that is
usually harmless.”
C) “It is a muted response to something in the environment.”
D) “It is a harmless reaction to something in the
environment.” Ans: B
Feedback:
An allergic disorder is characterized by a hyperimmune response to weak antigens that
usually are harmless. The antigens that can cause an allergic response are called
allergens.
6. The nursing instructor is discussing allergic reactions with her clinical group.
What allergic reactions would the nursing instructor talk about? Select all that
apply.
A) Atypical
B) Unmediated
C) Cytotoxic
D) Atopic
E) Immune complex
Ans: C, D, E
Feedback:
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
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