(Osborn) Chapter 60: Learning Outcome 1 Learning Outcome 2 Learning Outcome 3

[Osborn] chapter 60
Learning Outcomes [Number and Title ]

Learning Outcome 1
Differentiate the nursing management for patients with immune
hypersensitivity responses and immune deficiencies.
Learning Outcome 2
Compare and contrast the immune hypersensitivity response
related to allergy, autoimmune, and alloimmune disorders.
Learning Outcome 3
Compare and contrast the pathophysiology, clinical
manifestations, and laboratory data for the human
immunodeficiency virus (HIV) and acquired immune
deficiency syndrome (AIDS).
Learning Outcome 4
Prioritize the nursing management of the patient with
HIV/AIDS to decrease the incidence of opportunistic
infections.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
Which statement made by the client taking an immunosuppressive agent to manage

rheumatoid arthritis would require further teaching by the nurse?
1.
1.
2.
3.
4.
I should drink a lot of fluids like grapefruit juice.

I know Ill have to cope with having my blood drawn regularly.
This medication may cause damage to my kidneys.
If I experience any joint pain, I can take ibuprofen as needed every 4 hours.
Correct Answer: I should drink a lot of fluids like grapefruit juice.

Rationale: Fluids should be increased to maintain good hydration and urinary output, but
the client should avoid grapefruit juice, which can raise cyclosporine levels by 50% to
200% and increase the risk of toxicity. Immunosuppressive agents inhibit T cell
development and activation. Nursing responsibilities would include monitoring BUN and
creatinine for evidence of nephrotoxicity that would require frequent blood draws.
Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with
cytotoxic agents.
Cognitive Level: Application
Nursing Process: Evaluation
Client Needs: Physiological Integrity
LO: 1
2. A client with a history of latex allergies has developed itching and hives after being
admitted for a fractured left femur. The initial nursing intervention is to:
1.
2.
3.
4.
Ask if the client is experiencing any difficulty breathing.

Collect a detailed history from the client regarding the allergies.
Survey the clients room for possible latex-containing items.
Alert the clients health care provider concerning the clients symptoms.
Correct Answer: Ask if the client is experiencing any difficulty breathing.

Rationale: A history of latex allergies in combination with the clients symptoms would
alert the nurse to the possibility of an allergic reaction. Such reactions can result in
respiratory distress, so assessment of the airway is the nursing priority. The health care
provider should be alerted if there is reason to believe the clients condition warrants it, but
not before assessing the airway. Conducting a nursing history and attempting to locate
latex-containing items do not have priority over airway maintenance.
Nursing Process: Implementation
LO: 1
3. A client is suspected of having an allergic reaction to certain laundry detergents. The

nurse recognizes that the diagnostic test result that would best confirm a hypersensitivity
reaction would be:
1.
2.
3.
4.
Patch test with a 1-inch area of erythema.

Eosinophils of 2% of the total WBC.
Indirect Coombs showing no agglutination.
Rh antigen with negative results.
Correct Answer: Patch test with a 1-inch area of erythema.

Rationale: A patch test assesses a 1-inch area impregnated with the allergen. Positive
responses are graded from mild (erythema in the exposed area) to severe (papules, vesicles,
or ulcerations) and reflect the presence of an allergic reaction to the allergen. The indirect
Coombs test detects the presence of circulating antibodies against RBCs. The eosinophil
count is 1% to 4%, which is within normal range. Rh antigen results that are negative
reflect the absence of the Rh factor in a clients blood.
Nursing Process: Assessment
LO: 1
4. A client asks the nurse what a hypersensitivity response is. The nurse best answers the
clients question by responding:
1. Its why some people sneeze and have itchy, watery eyes when theyre around cats
and some people dont.
2. Its the reaction your body shows when it overreacts to a substance it isnt familiar
with.
3. Are you familiar with the term allergy or being allergic?
4. Are you interested because you feel you may have the problem?
Correct Answer: Its why some people sneeze and have itchy, watery eyes when theyre
around cats and some people dont.
Rationale: While an immune hypersensitivity response occurs when the immune system
does not maintain self-tolerance, in other words when it overreacts to the presence of a
foreign antigen, the nurses best response is an example that the client is most likely able to
understand. Asking whether the client is familiar with related terms or has a suspicion of
being affected is not directly addressing the clients question. Hypersensitivity response is
not a reaction to an unfamiliar substance.
Cognitive Level: Analysis
LO: 2
5. A client who believes he has a peanut allergy presents at the emergency department
concerned about the possibility that he has ingested a small amount of commercially
prepared food that may have contained peanut oil. The nurse best addresses the clients risk
for injury by asking:
1.
2.
3.
4.
Have you ever experienced an allergic reaction to peanuts before?

What makes you think you are allergic to peanuts?
Have you every undergone testing for a peanut allergy?
Did you self-administer epinephrine?
Correct Answer: Have you ever experienced an allergic reaction to peanuts before?
Rationale: The priority is to determine whether the client is allergic to peanuts and at risk
for injury in the form of an allergic reaction. Confirming a past reaction to ingestion of
peanuts is the best way to determine that possibility for this client at this particular time.
Asking why the client believes he is allergic or whether he has undergone allergy testing
may result in the needed information, but does not directly address the information needed.
Self-administration of epinephrine is directed more toward management of a reaction than
confirming the possibility of a reaction.
LO: 2
6. The nurse is providing discharge education for a client who experienced an anaphylactic
reaction as a result of a bee sting. In order to best assure the client will receive prompt,
appropriate medical care in the event of another bee sting, the nurse encourages the client
to:
Select al that apply.
1.
2.
3.
4.
5.
Wear a medical alert bracelet that identifies his allergy to bee venom.
Always have quick access to an epinephrine pen.
Be aware of how quickly the symptoms occur and exacerbate.
Minimize the amount of time spent out of doors.
Apply insect repellant before spending time outside.
Correct Answer:
1. Wear a medical alert bracelet that identifies his allergy to bee venom.
2. Always have quick access to an epinephrine pen.
3. Be aware of how quickly the symptoms occur and exacerbate.
Rationale: Wear a medical alert bracelet that identifies his allergy to bee venom. The
nurse can further promote patient health and safety by encouraging patients with a history
of anaphylactic reactions to wear a medical alert bracelet or other form of medical
identification tag that identifies allergies. Always have quick assess to an epinephrine
pen. Carrying a self-administered epinephrine kit to use in the event of an anaphylactic
reaction is essential. Be aware of how quickly the symptoms occur and exacerbate.
Being aware of symptom and the speed with which anaphylactic shock can occur will be
vital to the client receiving appropriate, prompt medical care. Minimize the amount of
time spent out of doors. Minimizing the time spent outdoors may decrease the potential of
being stung, but does not affect prompt, appropriate care in the event of a sting. Apply
insect repellant before spending time outside. Wearing insect repellant may decrease the
potential of being stung, but does not affect prompt, appropriate care in the event of a sting.
LO: 2
7. The home health nurse is discussing nutritional needs with a client diagnosed with HIV.
The nurse stresses the importance of daily vitamin and mineral supplements based on the
knowledge that:
Select all that apply.
1. Research has shown that such supplements have an impact on retarding the progress
of the disease.
2. Vitamins A, C, and E assist the bodys immune system to combat infections.
3. Being vitamin and mineral deficient contributes to increasing HIV replication.
4. Multivitamin supplements contribute to the decreased risk of mouth ulcers in HIV
clients.
5. The use of megavitamin supplementation has resulted in the long-term
improvement of T-cell counts in some HIV clients.
Correct Answer:
1. Research has shown that such supplements have an impact on retarding the progress
of the disease.
2. Vitamins A, C, and E assist the bodys immune system to combat infections.
3. Being vitamin and mineral deficient contributes to increasing HIV replication.
4. Multivitamin supplements contribute to the decreased risk of mouth ulcers in HIV
clients.
Rationale: Research has shown that such supplements have an impact on retarding
the progress of the disease. There is indication from research studies that clearly indicates
the efficacy of vitamin supplements for HIV patients for retarding the progress of the
disease. Vitamins A, C, and E assist the bodys immune system to combat infections.
Vitamins and minerals needed for the immune system to fight infections include A, Bcomplex, C, and E, and selenium and zinc. Being vitamin and mineral deficient
contributes to increasing HIV replication. In addition, deficiencies of antioxidant
vitamins and minerals contribute to oxidative stress, which may accelerate immune cell
death and increase the rate of HIV replication. Multivitamin supplements contribute to
the decreased risk of mouth ulcers in HIV clients. Research has found that
supplementation with multivitamins reduces the incidence of complications, including oral
ulcers. The use of megavitamin supplementation has resulted in the long-term
improvement of T-cell counts in some HIV clients. There is no research to support the
positive affect of megavitamin supplementation on the long-term improvement of T-cell
counts of HIV clientssuch results remain anecdotal.
LO: 3
8. Which of the following statements by the client who has HIV would require further
teaching by the health care professional?
1.
2.
3.
4.
I will use an oil-based lubricant when I use condoms.

I know I have to assume responsibility when I have sex.
I will not share my toothbrush or razor with my partner.
I know I cant donate blood anymore since I have HIV.
Correct Answer: I will use an oil-based lubricant when I use condoms.

Rationale: The nurse should educate the client regarding the prevention of the spread of
HIV. The client will need further education when he states that he will use an oil-based
lubricant. The client should be educated to use latex condoms for oral, vaginal, or anal
intercourse, and to avoid natural or animal skin condoms, which allow passage of HIV. The
client should use only water-based lubricantsnot oil-based, such as petroleum jelly,
which can result in condom damage. The client is correct in stating that it is not an
acceptable practice to share toothbrushes or razors. The client is also correct in stating that
blood donation is prohibited and in stating his role in engaging only in safe sex.
Client Needs: Health Promotion and Maintenance
LO: 3
9. A client with a diagnosis of AIDS has asked the nurse for information regarding the use
of complementary therapies for the treatment of the disease. The nurses response is based
on the knowledge that:
1. Many HIV/AIDS clients find the complementary treatments helpful.
2. Incorporating such treatments could severely undermine the effectiveness of the
current treatment plan.
3. These treatments will most likely neither help nor hurt the client physically.
4. With a terminal disease, the client deserves to make whatever choices he or she
wants.
Correct Answer: Many HIV/AIDS clients find the complementary treatments helpful
Rationale: There is growing support among HIV-infected patients for the use of
complementary and alternative treatments in symptom management. There is no
compelling evidence that complementary therapies undermine the effectiveness of the
medical treatment clients are already receiving. There is no basis for the statement that the
treatments will neither help or hurt the client physically. All clients, terminal or otherwise,
have the right to make choices regarding their medical treatments.
Client Needs: Health Promotion and Maintenance
LO: 3
10. The home health nurse is revising the care plan of a client diagnosed with HIV who has
developed a vaginal yeast infection. Nursing diagnoses related to this opportunistic
infection include:
1.
2.
3.
4.
5.
Acute/Chronic Pain.
Impaired Skin Integrity.
Deficient Knowledge.
Anxiety.
Infection transmission.
Correct Answer:
1. Acute/Chronic Pain.
2. Impaired Skin Integrity.
3. Deficient Knowledge.
4. Anxiety.
Rationale: Acute/Chronic Pain. The nursing diagnosis of acute/chronic pain is related to
the sensations of irritation and itching created by the infection. Impaired Skin Integrity.
The nursing diagnosis of impaired skin integrity is related to the mucous membranes of the
vaginal walls being affected by the infection. Deficient Knowledge. The nursing diagnosis
of deficient knowledge is related to the vaginal disease process, treatment, and prognosis.
Anxiety. The nursing diagnosis of anxiety is related to anticipatory fear of physical decline
and the dying process. Infection transmission. Infection transmission is not appropriate,
since the vaginal yeast infection is not contagious in nature.
Nursing Process: Planning
LO: 4
11. A nurse is performing an admission assessment on a client with AIDS. To best evaluate
the client for the risk of contracting an opportunistic infection, the nurse asks:
1.
2.
3.
4.
What were the results of your last CD4 and T-cells test?
Can you identify the signs and symptoms of a possible infection?
Are you sexual active with persons who also have AIDS?
Have you had any fever, diarrhea, or chills over the last 48 hours?
Correct Answer: What were the results of your last CD4 and T-cells test?
Rationale: Opportunistic infections occur in HIV-infected individuals as the virus destroys
sufficient numbers of CD4+ T cells and the body is not able to protect itself. As CD4+
counts drop to <200 cells/L, the incidence of opportunistic infection accelerates rapidly.
Being aware of the clients most recent CD4 and T-cells test would provide information
regarding the risk of contracting such a disease. Identifying symptoms of an opportunistic
infection such as fever, diarrhea, or chills is important to the treatment, not to evaluating
the risk of contracting such a disease. The AIDS status of the clients sexual partners has no
bearing on the risk of contracting an opportunistic infection and is not an appropriate
question for the nurse to ask.
Nursing Process: Assessment
LO: 4
12. A client diagnosed with AIDS has developed oral candidiasis. To best manage this
opportunistic infection, the home health nurse educates the clients family to:
1.
2.
3.
4.
5.
Avoid offering the client salty popcorn.

Allow the clients soup to cool before serving it.
Provide the client with a variety of his favorite beverages.
Offer to quit smoking with the client.
Assist the client with oral care three times a day.
Correct Answer:
1. Avoid offering the client salty popcorn.
2. Allow the clients soup to cool before serving it.
3. Provide the client with a variety of his favorite beverages.
4. Offer to quit smoking with the client.
Rationale: Avoid offering the client salty popcorn. Collaborate with patient and family to
plan a menu that avoids salty, spicy, acidic, or abrasive foods. Allow the clients soup to
cool before serving it. Foods that are extreme in temperature should be avoided in order to
decrease aggravation of oral lesions. Provide the client with a variety of his favorite
beverages. The family should encourage the client to have fluid intake of >2,500 oz/day if
not contraindicated in order to maintain hydration and keep mucous membranes moist.
Offer to quit smoking with the client. By offering to quit smoking with the client, they
are encouraging him to avoid smoking, thus decreasing the drying and irritation to mucous
membranes. Assist the client with oral care three times a day. Assist with oral care every
2 hours by rinsing oral mucosa with saline and dilute hydrogen peroxide solution; this
decreases spread of lesions.
LO: 4

(Osborn) Chapter 60: Learning Outcome 1 Learning Outcome 2 Learning Outcome 3

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[Osborn] chapter 60

Learning Outcomes [Number and Title ]

Which statement made by the client taking an immunosuppressive agent to manage

I should drink a lot of fluids like grapefruit juice.

Correct Answer: I should drink a lot of fluids like grapefruit juice.

Ask if the client is experiencing any difficulty breathing.

Correct Answer: Ask if the client is experiencing any difficulty breathing.

3. A client is suspected of having an allergic reaction to certain laundry detergents. The

Patch test with a 1-inch area of erythema.

Correct Answer: Patch test with a 1-inch area of erythema.

Have you ever experienced an allergic reaction to peanuts before?

I will use an oil-based lubricant when I use condoms.

Correct Answer: I will use an oil-based lubricant when I use condoms.

Avoid offering the client salty popcorn.

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