NCLEX RN Practice Question # 484-486

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy?

1. Hairdressers
2. The homeless
3. Children in day care centers
4. Individuals living in a group home

Latex Allergy ( NCLEX Review)

Description

Latex allergy is a hypersensitivity to latex.
The source of the allergic reaction is thought to be the proteins in the natural rubber latex or the various chemicals used in the manufacturing process of latex gloves.
Symptoms of the allergy can range frommild contact dermatitis to moderately severe symptoms of rhinitis, conjunctivitis, urticaria, and bronchospasm to severe life-threatening anaphylaxis.

Common routes of exposure)

Cutaneous: Natural latex gloves and latex balloons
Percutaneous and parenteral: Intravenous lines and catheters; hemodialysis equipment
Mucosal: Use of latex condoms, catheters, airways, and nipples
Aerosol: Aerosolization of powder from latex gloves can occur when gloves are dispensed from the box or when gloves are removed from the hands.

At-risk individuals

Health care workers
Individuals who work in the rubber industry
Individuals having multiple surgeries
Individuals with spina bifida
Individuals who wear gloves frequently, such as food handlers, hairdressers, and auto mechanics
Individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts

Assessment

Anaphylaxis or type I hypersensitivity is a response to natural rubber latex .
A delayed type IV hypersensitivity reaction can occur; symptoms of contact dermatitis include pruritus, edema, erythema, vesicles, papules, and crusting and thickening of the skin and can occur within 6 to 48 hours following exposure.

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency. The nurse would incorporate which of the following as a priority in the plan of care?

1. Protecting the client from infection
2. Providing emotional support to decrease fear
3. Encouraging discussion about lifestyle changes
4. Identifying factors that decreased the immune function

Immunodeficiency Syndromes (NCLEX Review)

Acquired immunodeficiency syndrome (AIDS)

AIDS is a viral disease caused by human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy.
The syndrome is manifested clinically by opportunistic infection and unusual neoplasms.
AIDS is considered a chronic illness.
The disease has a long incubation period, sometimes 10 years or longer.
Manifestations may not appear until late in the infection.

Diagnosis and monitoring the client with AIDS

See Chapter 11 for diagnostic tests.
Refer to Box 70-4 for tests used to evaluate the progression of HIV infection.

High-risk groups

Heterosexual or homosexual contact with highrisk individuals
Intravenous drug abusers
Persons receiving blood products
Health care workers
Babies born to infected mothers

Assessment

Malaise, fever, anorexia, weight loss, influenzalike symptoms
Lymphadenopathy for at least 3 months
Leukopenia
Diarrhea
Fatigue
Night sweats
Presence of opportunistic infections
Protozoal infections (Pneumocystis jiroveci pneumonia, major source of mortality)
Neoplasms (Kaposi’s sarcoma, purplish-red lesions of internal organs and skin, B-cell non-Hodgkin’s lymphoma, cervical cancer)
Fungal infections (candidiasis, histoplasmosis)
Viral infections (cytomegalovirus, herpes simplex)
Bacterial infections

Interventions

Provide respiratory support.
Administer oxygen and respiratory treatments as prescribed.
Provide psychosocial support as needed.
Maintain fluid and electrolyte balance.
Monitor for signs of infection.
Prevent the spread of infection.
Initiate standard and other necessary precautions.
Provide comfort as necessary.
Provide meticulous skin care.
Provide adequate nutritional support as prescribed.
See Chapters 25 and 47 for additional information on AIDS.
Kaposi’s sarcoma
Description: Skin lesions that occur primarily in individuals with a compromised immune system
Assessment
    Kaposi’s sarcoma is a slow-growing tumor that appears as raised, oblong, purplish, reddish-brown lesions; may be tender or nontender.
    Organ involvement includes the lymph nodes, airways or lungs, or any part of the gastrointestinal tract from the mouth to anus.

Interventions

Maintain standard precautions.
Provide protective isolation if the immune system is depressed.
Prepare the client for radiation therapy or chemotherapy as prescribed.
Administer immunotherapy, as prescribed, to stabilize the immune system.

A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic signs of systemic lupus erythematous?

1. Weight gain
2. Subnormal temperature
3. Elevated red blood cell count
4. Rash on the face across the bridge of the nose and on the cheeks

Autoimmune Disease (NCLEX Review)

Description

Body is unable to recognize its own cells as a part of itself.
Autoimmune disease can affect collagenous tissue.

Systemic lupus erythematosus (SLE)

Description

Chronic, progressive, systemic inflammatory disease that can cause major organs and systems to fail
Connective tissue and fibrin deposits collect in blood vessels on collagen fibers and on organs.
The deposits lead to necrosis and inflammation in blood vessels, lymph nodes, gastrointestinal tract, and pleura.
No cure for the disease is known but remissions are frequently experienced by clients who manage their care well.

Causes

The cause of SLE is unknown, but is believed to be a defect in immunological mechanisms, with a genetic origin.
Precipitating factors include medications, stress, genetic factors, sunlight or ultraviolet light, and pregnancy.
Discoid lupus erythematosus is possible with some medications but totally disappears after the medication is stopped; the only manifestation is the skin rash that occurs in lupus.

Assessment

Assess for precipitating factors.
Erythema butterfly or rash of the face (malar)
Dry, scaly, raised rash on the face or upper body
Fever
Weakness, malaise, and fatigue
Anorexia
Weight loss
Photosensitivity
Joint pain
Erythema of the palms
Anemia
Positive antinuclear antibody (ANA) test and lupus erythematosus (LE) preparation
Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level

Interventions

Monitor skin integrity and provide frequent
Instruct the client to clean the skin with a mild soap, avoiding harsh and perfume substances.
Assist with the use of ointments and creams for the rash as prescribed.
Identify factors contributing to fatigue.
Administer iron, folic acid, or vitamin supplements as prescribed if anemia occurs.
Provide a high-vitamin and high-iron diet.
Provide a high-protein diet if there is no evidence of kidney disease.
Instruct in measures to conserve energy, such as pacing activities and balancing rest with exercise.
Administer topical or systemic corticosteroids, salicylates, and nonsteroidal antiinflammatory drugs as prescribed for pain and inflammation.
Administer medications to decrease the
inflammatory response as prescribed.
Instruct the client to avoid exposure to sunlight and ultraviolet light.
Monitor for proteinuria and red cell casts in the urine.
Monitor for bruising, bleeding, and injury.
Assist with plasmapheresis as prescribed to remove autoantibodies and immune complexes from the blood before organ damage occurs.
Monitor for signs of organ involvement such as pleuritis, nephritis, pericarditis, coronary artery disease, hypertension, neuritis, anemia, and peritonitis.
Note that lupus nephritis occurs early in the disease process.
Provide supportive therapy as major organs become affected.
Provide emotional support and encourage the client to verbalize feelings.
Provide information regarding support groups and encourage the use of community resources. For the client with SLE,