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Caring for Clients With Immune-Mediated Disorders-Chapter 34

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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. 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? CONTINUED......

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