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exam 4

Nursing

QuestionAnswer
a nurse is caring for a pt. who had a kidney transplant. what should be included in the care of the patient with a suppressed immune system? meticulous aseptic technique
Humoral immunity is mediated by? B cells
cellular immunity develops when which cells are mediated by an anitgen T cells
Desenization is another word for? immunotherapy
5. The patient tells the nurse he is overwhelmed. There is so much he must do to keep his new kidney functioning, and then rejection may still occur. Which nursing diagnosis is appropriate? Ineffective coping
6. The patient comes to the clinic for his weekly allergy injection. He missed his appointment the week before because of a family emergency. Which action is appropriate in administering the patient’s injections? Consult with the physician about decreasing the dosage for this injection
7. A patient is undergoing plasmapheresis for treatment of systemic lupus erythematous. The nurse explains that plasmapheresis is used to: Exchange her plasma that contains antinuclear antibodies with a substitute fluid
Type I allergic reaction to latex is a response to? Natural rubber latex protein
Which illnesses are believed to be an autoimmune disorder? Rheumatoid arthritis Systemic lupus erythematous Gillian barre syndrome
A pt. is brought to the emergency room department and is experiencing an anaphylactic reaction from eating shellfish. The nurse implements which immediate reaction? Maintain a patent airway.
The pt. with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by? Punch biopsy of the cutaneous lesions.
Describe how natural and aquired immunity work within the body Natural immunity: provides a barrier against invaders and nonspecific immunity to the individual Aquired immunity: Provides a specific reaction to invaders and remembers the antigen that caused the attack.
How is cell-mediated immunity achieved? By activation of T cells.
What happens to sensitized T cells They are released into the blood and body tissues
What is the significance of cell-mediated immmunity? To distinquish between self and foreign antigens
What type of cells initate antibody production? B-cells.
What is active immunity? Provide an example Antibodies produced by ones own body Vaccination against Rubeola
What is passive immunity? Include an example Antibodies that are formed by one person in response to a specific antigen and administered to another person. Hepatitis B immune globulin administered after exposure to Hep B. virus in a non-immune person.
Which cells mediate humoral immunity? The B cells
What is released in an antigen-antibody reaction? Histamine
To what type of antigens does humoral immunity respond? Bacteria foreign tissue
The pt. has asked the nurse to explain the difference between immunocompetency, immunodeficiency & autoimmunity. How will the nurse explain the difference in terms she will understand? Immunocompetency means the body is healthy enough to fight off an infection without help Immunodeficiency: THe body is unstable and cannot fight off an infection Autoimmunity: The body turns on itself and begins to fight off normal bacteria in the body
Describe how immunization and immunotherapy can be used to help the body develop immunity Immunizations control exposure to a disease to produce antigens while preventing the actual disease. Immunotherapy: Desensitizing the body to the allergen (allergy shots)
Identify common substances that can initiate a hypersensitity disorder Pollens/spores/dust insect vemon's Dander's Foods chemicals
Discuss the manner in which exposure to substances occur Inhalation ingestion injection touch
What is thought to be the primary cause of hypersensitivity disorder? a genetic defect that allows increased production of immunoglobulin E (IgE, a humoral antibody)
How is hypersensitivity disorders diagnosed? Through pt. History and physical examination.
What are common clinical manifestations of hypersensitity disorders? sneezing/excessive nasal secretions/inflammed nasal membranes skin rash/areas of raised inflammation Lacrimation diarrhea Cough/weezes/inpaired breathing Hypotension
List factors that can increase the symptoms of hypersensitivity Host response to allergen Exposure amount route of allergen entry repeated exposure
List three nursing diagnoses applicable to a pt. experencinga hypersensitivity reaction risk for injury related to exposure to allergen Activity intolerance related to malaise Risk for infection related to inflammation of protective mucus membranes
List the body system & sign/symptoms that indicate an anaphylactic response. Upper respiratory: Edema of the lips, tounge, and larynx Gastrointestional: dysphagia, involentary stools Cardiovasular: Tachycardia, Hypotension Treatment: 0.2-0.5 mL of epinephrine Sub-Q q 20minutes
Describe the difference between type IV allergic contact dermititis and type I allergic reaction Type IV: caused by chemicals used in the manufactoring of latex gloves Type I: a response to the natural rubber latex proteins
Eight recommendations from NIOSH that can be used to prevent allergic reactions to latex in the workplace Non-latex, powder free gloves No hand creams/oil Wash hands after wearing gloves Clean work areas Know the signs/symptoms of a latex allergy Avoid direct contact with latex gloves Wear a medical alert bracelet/carry epipen
List all of the ways that transfusion reaction can be prevented careful selection of blood donors & crossmatching Proper storage Verify donor/recipient numbers Administer all products throug microaggregrate filters
What is the best method for preventing transfusion reactions? autologous transfusion, use of ones own blod for replacement therapy
Created by: MPettypiece
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