The Child with an Immunologic Alteration

MULTIPLE CHOICE

1. A nurse in a well-child clinic is teaching parents about their child’s immune system. Which statement, made by the nurse, is correct?

a.
The immune system distinguishes and actively protects the body’s own cells from foreign substances.
b.
The immune system is fully developed by 1 year of age.
c.
The immune system protects the child against communicable diseases in the first 6 years of life.
d.
The immune system responds to an offending agent by producing antigens.

ANS: A

The immune system responds to foreign substances, or antigens, by producing antibodies and storing information. Intact skin, mucous membranes, and processes such as coughing, sneezing, and tearing help maintain internal homeostasis. Children up to the age of 6 or 7 years have limited antibodies against common bacteria. The immunoglobins reach adult levels at different ages. Immunization is the basis from which the immune system activates protection against some communicable diseases. Antibodies are produced by the immune system against invading agents, or antigens.

DIF: Cognitive Level: Application REF: p. 384

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

2. A nurse is teaching parents about the importance of immunizations for infants because of immaturity of the immune system. The parents demonstrate that they understand the teaching if they make which statement?

a.
“The spleen reaches full size by 1 year of age.”
b.
“IgM, IgE, and IgD levels are high at birth.”
c.
“IgG levels in the newborn infant are low at birth.”
d.
“Absolute lymphocyte counts reach a peak during the first year.”

ANS: D

Absolute lymphocyte counts reach a peak during the first year. The spleen reaches its full size during adulthood. IgM, IgE, and IgD are normally in low concentration at birth. IgM, IgE, IgA, and IgD do not cross the placenta. The term newborn infant receives an adult level of IgG as a result of transplacental transfer from the mother.

DIF: Cognitive Level: Analysis REF: p. 387

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

3. Which statement is true regarding how infants acquire immunity?

a.
The infant acquires humoral and cell-mediated immunity in response to infections and immunizations.
b.
The infant acquires maternal antibodies that ensure immunity up to 12 months of age.
c.
Active immunity is acquired from the mother and lasts 6 to 7 months.
d.
Passive immunity develops in response to immunizations.

ANS: A

Infants acquire long-term active immunity from exposure to antigens and vaccines. Immunity is acquired actively and passively. The term infant’s passive immunity is acquired from the mother and begins to dissipate during the first 6 to 8 months of life. Active immunity develops in response to immunizations.

DIF: Cognitive Level: Comprehension REF: pp. 378-388

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

4. A nurse is teaching parents about transmission of human immunodeficiency virus (HIV) in the pediatric population. The nurse should relate that the most common mode of transmission of HIV virus is:

a.
Perinatal transmission
b.
Sexual abuse
c.
Blood transfusions
d.
Poor hand washing

ANS: A

Perinatal transmission accounts for the highest percentage of HIV infections in children. Infected women can transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breast-feeding. Cases of HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV infections. Although in the past some children became infected with HIV through blood transfusions, improved laboratory screening has significantly reduced the probability of contracting HIV from blood products. Poor hand washing is not an etiology of HIV infection.

DIF: Cognitive Level: Application REF: p. 390

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

5. A nurse is preparing to administer routine immunizations to an infant who is HIV positive. What is the American Academy of Pediatrics recommendation for immunizing infants who are HIV positive?

a.
Follow the routine immunization schedule.
b.
Routine immunizations are administered. Assess CD4+ counts before administering the MMR and varicella vaccinations.
c.
Do not give immunizations because of the infant’s altered immune status.
d.
Eliminate the pertussis vaccination because of the risk of convulsions.

ANS: B

Routine immunizations are appropriate. CD4+ cells are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the child’s CD4+ counts. Only inactivated polio (IPV) should be used for HIV-infected children. Immunizations are given to infants who are HIV positive. The pertussis vaccination is not eliminated for an infant who is HIV positive.

DIF: Cognitive Level: Application REF: p. 396

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

6. Which recommendation by the nurse is appropriate for a mother who has a preschool child who refuses to take the medications for HIV infection?

a.
Mix medications with chocolate syrup or follow with chocolate candy.
b.
Mix the medications with milk or an essential food.
c.
Skip the dose of medication if the child protests too much.
d.
Mix the medication in a syringe, hold the child down firmly, and administer the medication.

ANS: A

Liquid forms of HIV medications may be foul tasting or have a gritty texture. Chocolate would help to make these foods more palatable and is liked by most children. Medications should be mixed with nonessential foods. Doses of medication should never be skipped. Fighting with the child or using force should be avoided. A nonessential food that will make the taste of the medication more palatable for the child should be the correct action. The administration of medications for the child with HIV becomes part of the family’s everyday routine for years.

DIF: Cognitive Level: Application REF: p. 396

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

7. What is the primary nursing concern for a hospitalized child with HIV infection?

a.
Maintaining growth and development
b.
Eating foods that the family brings to the child
c.
Consideration of parental limitations and weaknesses
d.
Resting for 2 to 3 hours twice a day

ANS: A

Maintaining growth and development is a major concern for the child with HIV infection. Frequent monitoring for failure to thrive, neurological deterioration, or developmental delay is important for HIV-infected infants and children. Nutrition, which contributes to a child’s growth, is a nursing concern; however, it is unnecessary for family members to bring food to the child. Although an assessment of parental strengths and weaknesses is important, it will be imperative for healthcare providers to focus on the parental strengths not weaknesses. This is not as important as the frequent assessment of the child’s growth and development. Rest is a nursing concern, but it is not as high a priority as maintaining growth and development. Rest periods twice a day for 2 to 3 hours may not be appropriate.

DIF: Cognitive Level: Comprehension REF: p. 392|p. 406

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

8. What should the nurse include in a teaching plan for a mother of a toddler who will be taking prednisone for several months?

a.
The medication should be taken between meals.
b.
The medication needs to be discontinued because of the risks associated with long-term usage.
c.
The medication should not be stopped abruptly.
d.
The medication may lower blood glucose so the mother needs to observe the child for signs of hypoglycemia.

ANS: C

The dosage must be tapered before the drug is discontinued to allow the gradual return of function in the pituitary-adrenal axis. Prednisone should be taken with food to minimize or prevent gastrointestinal bleeding. Although there are adverse effects from long-term steroid use, the medication must not be discontinued without consulting a physician. Acute adrenal insufficiency can occur if the medication is withdrawn abruptly. The dosage needs to be tapered. The medication puts the child at risk for hyperglycemia, not hypoglycemia.

DIF: Cognitive Level: Application REF: p. 400

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

9. A nurse assesses a child on long-term systemic corticosteroid therapy for which condition?

a.
Hypotension
b.
Dilation of blood vessels in the cheeks
c.
Growth delays
d.
Decreased appetite and weight loss

ANS: C

Growth delay is associated with long-term steroid use related to protein catabolism and decreased growth hormone. Hypertension is a clinical manifestation of long-term systemic steroid administration. Dilation of blood vessels in the cheeks is associated with an excess of topically administered steroids. Increased appetite and weight gain are clinical manifestations of excess systemic corticosteroid therapy.

DIF: Cognitive Level: Analysis REF: p. 400

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

10. Which statement by the parent of a 5-year-old child with acquired immunodeficiency syndrome (AIDS) regarding prescribed antiretroviral agents indicates that she has a good understanding of disease management?

a.
“When my child’s pain increases, I double the recommended dosage of antiretroviral medication.”
b.
“Addiction is a risk, so I use the medication only as ordered.”
c.
“Doses of the antiretroviral medication are selected on the basis of my child’s age and growth.”
d.
“By the time my child is an adolescent, she will not need her antiretroviral medications any longer.”

ANS: C

Doses of antiretroviral medication to treat HIV infection for infants and children are based on individualized age and growth considerations. Antiretroviral medications are not administered for pain relief. Doubling the recommended dosage of any medication is not appropriate without an order from the physician. Addiction is not a realistic concern with antiretroviral medications. Antiretroviral medications are still needed during adolescence. Doses for adolescents are based on pubertal status by Tanner staging.

DIF: Cognitive Level: Analysis REF: p. 393

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

11. A mother of a child in the terminal stages of AIDS tells the nurse that her child wants to celebrate his birthday early because he won’t be here on his birthday. Which is the best response the nurse can make to this mother?

a.
“What does your husband think about giving the party for the child?”
b.
“How does the family feel about your giving in to the child?”
c.
“Ill children can be very manipulative.”
d.
“Is this the first time he has spoken about death?”

ANS: D

Dying children know they are dying. Disclosure of awareness of death comes in various ways and needs to be identified by the family and the nurse. The major concern is the child’s disclosure of awareness of death, not the husband’s reaction. Making statements such as “giving in” is inappropriate when seeking information. Manipulation is not a major concern during the terminal stage of disease.

DIF: Cognitive Level: Application REF: pp. 394-395

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

12. Which intervention is appropriate for a child receiving high doses of steroids?

a.
Limit activity and receive home schooling.
b.
Decrease the amount of potassium in the diet.
c.
Administer a killed virus vaccine.
d.
Monitor for seizure activity.

ANS: C

The child on high doses of steroids should not receive live virus vaccines because of immunosuppression. Limiting activity and home schooling are not routine for a child receiving high doses of steroids. The child receiving steroids is at risk for hypokalemia and needs potassium in the diet. Children on steroids are not typically at risk for seizures.

DIF: Cognitive Level: Application REF: p. 400

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

13. The nurse observes a red rash that spreads across the child’s cheeks and nose. This assessment finding is characteristic of which of the following conditions?

a.
Systemic lupus erythematosus (SLE)
b.
Rheumatic fever
c.
Kawasaki disease
d.
Anaphylactic reaction

ANS: A

A red, flat, or raised malar “butterfly” rash over the cheeks and bridge of the nose is a clinical manifestation of SLE. A major manifestation of rheumatic fever is erythema marginatum, which appears as red skin lesions spread peripherally over the trunk. An erythematous rash, induration of the hands and feet, and erythema of the palms and soles are manifestations of Kawasaki disease. Initial symptoms of anaphylaxis include severe itching and rapid development of erythema.

DIF: Cognitive Level: Knowledge REF: p. 402

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

14. What is the major nursing concern for a child having an anaphylactic reaction?

a.
Identifying the offending allergen
b.
Ineffective breathing pattern
c.
Increased cardiac output
d.
Positioning to facilitate comfort

ANS: B

Laryngospasms resulting in ineffective breathing patterns are a life-threatening manifestation of anaphylaxis. The primary action is to assess airway patency, respiratory rate and effort, level of consciousness, oxygen saturation, and urine output. Determining the cause of an anaphylactic reaction is important to implement the appropriate treatment, but the primary concern is the airway. During anaphylaxis, the cardiac output is decreased. During the acute period of anaphylaxis, the nurse’s primary concern is the child’s breathing. Positioning for comfort is not a primary concern during a crisis.

DIF: Cognitive Level: Comprehension REF: p. 404

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

15. What is the drug of choice the nurse would administer in the acute treatment of anaphylaxis?

a.
Diphenhydramine (Benadryl)
b.
Cimetidine (Tagamet)
c.
Epinephrine (Adrenaline)
d.
Albuterol (Ventolin)

ANS: C

Epinephrine is the first drug of choice in the immediate treatment of anaphylaxis. Treatment must be initiated immediately because it may only be a matter of minutes before shock occurs. Although diphenhydramine and a histamine inhibitor such as cimetidine may be indicated, epinephrine is the first drug of choice in the immediate treatment of anaphylaxis. Albuterol is not usually indicated for the treatment of anaphylaxis.

DIF: Cognitive Level: Application REF: p. 404

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

MULTIPLE RESPONSE

1. Which home care instructions should the nurse provide to the parents of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

a.
Give supplemental vitamins as prescribed.
b.
Avoid yearly influenza vaccination.
c.
Administer trimethoprim-sulfamethoxazole (Bactrim) as prescribed.
d.
Notify the physician if child develops a cough or congestion.
e.
Missed doses of antiretroviral medication do not need to be recorded.

ANS: A, C, D

The parents should be taught that supplemental vitamins will be prescribed to aid in nutritional status. Bactrim is administered to prevent the opportunistic infection of Pneumocystis pneumonia. The physician should be notified if the child with AIDS develops a cough and congestion. The yearly influenza vaccination is recommended and any missed doses of antiretroviral medication need to be recorded and reported.

DIF: Cognitive Level: Application REF: p. 397

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

OTHER

1. A child is having an anaphylactic response. Place in order the interventions a nurse should perform beginning with the initial (highest priority) intervention and ending with the lowest priority intervention. Use the following format for your answers: A, B, C, D

a. Administer steroids and antihistamines as prescribed.

b. Ensure an adequate airway.

c. Administer epinephrine as prescribed.

d. Administer oxygen.

e. Determine the cause of the reaction.

ANS:

B, C, D, A, E

The airway should be stabilized first and then the epinephrine administered. Oxygen would be given next and the steroids and antihistamines given after the airway, epinephrine, and oxygen are initiated. Determining the cause of the reaction should be done last.

DIF: Cognitive Level: Application REF: pp. 404-405

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity