Immune NCLEX questions

the nurse is assisting in administering immunizations at a health care clinic. the nurse understands that immunization provides which?

acquired immunity from disease rationale acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. natural (innate) immunity is present at birth. no immunization protects the client from all diseases

a client with pemphigus is being seen in the clinic regularly. the nurse plans care based on which description of this condition?

an autoimmune disease that causes blistering in the epidermis rationale pemphigus is an autoimmune disease that causes blistering in the epidermis. the client has large flaccid blisters (bullae). because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. on initial examination, clients may have crusting areas instead of intact blisters.

which individual is least at risk for the development of Kaposi's sarcoma

an individual working in an environment where exposure to asbestos exists rationale Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common AIDS indicator. it is seen frequently in men with a history of same-sex partners. although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. the renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. exposure to asbestos is not related to the development of Kaposi's sarcoma.

the home care nurse is prescribing dressing supplies for a client who has an allergy to latex. the nurse asks the medical supply personnel to deliver which?

cotton pads with silk tape rationale cotton pads and plastic or silk tape are latex-free products.

which are risk factors for systemic lupus erythematous

female gender// african-american origin// being in the childbearing years rationale SLE affects females more commonly than males. it is more common in African-American females than in white females. the females are generally in the childbearing years.

the nurse is assisting in preparing a plan of care for a client with AIDS who has nausea. which dietary measure should the nurse include in the plan?

foods that are at room temperature rationale the client with AIDS experiencing nausea should avoid fatty products, such as dairy products and red meat. meals should be small and frequent to lessen the chance of vomiting. spices and odorous foods should be avoided because they aggravate nausea. food are best tolerated at either cold or at room temperature.

the nurse reinforces home care instructions to a client with SLE and tells the client about methods to manage fatigue. which statement by the client indicates a need for further teaching?

i should take hot baths because they are relaxing rationale to help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. the client is instructed to avoid long periods of rest because it promotes joint stiffness

the home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. in determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food items? select all that apply.

kiwi // bananas rationale individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. this is thought to be due to a possible cross-reaction between the food and the latex allergen.

the nurse is explaining about antigens and antibodies when the client asks where antibodies come from. which is an appropriate response? select all that apply.

tears // spleen // blood serum // saliva // lymph nodes rationale antibodies are found in tears, the spleen, saliva, blood and lymph nodes. each antibody is able to attach to the kind of antigen it is made for. the skin does not form antibodies but rather acts as a barrier.

a client is diagnosed with stage 1 lyme disease. in addition to the rash, the nurse should check the client for which manifestation?

flulike symptoms rationale the hallmark of stage 1 is the development of a skin rash at the tick bite site. the rash develops into a concentric ring that has a bulls-eye appearance. the lesion enlarges up to 50 to 60 cm and smaller lesions develop farther away from the original tick bite. in stage 1, most infected persons develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later.

the nurse is assisting in planning care for a client with a diagnosis of immune deficiency. the nurse should incorporate which as a priority in the plan of care

protecting the client from infection rationale the client with immune deficiency has inadequate or absent immune bodies and is at risk for infection. the priority nursing intervention would be to protect the client from infection

a client is suspected of having systemic lupus erythamatosus. the nurse monitors the client, knowing that which is one of the initial characteristic signs/symptoms of SLE?

rash on the face across the nose and on the cheeks rationale skin lesions or a rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of SLE. fever and weight loss may also occur. anemia is most likely to occur later in SLE

the camp nurse prepares to instruct a group of children about Lyme disease. which information should the nurse include in the instructions?

Lyme disease is caused by a tick carried by deer rationale Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. persons bitten by Ixodes ticks can be infected with the spirochete borrelia burgdorferi. lyme disease cannot be transmitted from one person to another. toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. histoplasmosis is caused by the inhalation of spores from bat or bird droppings

a client is positively diagnosed with stage 1 lyme disease. the client asks the nurse about the treatment for the disease. the nurse responds to the client, anticipating that which treatment will be included in the care plan?

a 3-to-4 week course of oral antibiotic therapy rationale a 3-to-4 week course of oral antibiotic therapy is recommended during stage 1. later stages of lyme disease may require therapy with IV antibiotics, such as penicillin G. ultraviolet light therapy is not a component of the treatment plan for lyme disease.

a client reports to the health care clinic to obtain testing regarding HIV status after being exposed to an individual who is HIV positive. the test results are reported as negative and the client tells the nurse that he feels so much better knowing that he has not contracted HIV. the nurse explains the test results to the client, providing which information?

a negative HIV test is not considered accurate during the first 6 months after exposure rationale a test done for HIV should be repeated. there might be a lag period after the infection occurs before antibodies appear in the blood. therefore, a negative HIV test is not considered accurate during the first 6 months after exposure

the nurse is assisting in developing a plan of care for a client with AIDS who is experiencing night fever and night sweats. which nursing intervention should the nurse suggest including in the plan of care to manage this symptom?

administer an antipyretic at bedtime rationale for clients with AIDS who experience night fever and night sweats, it is useful to offer an antipyretic at bedtime. it is also helpful to keep a change of bed linens and night clothes nearby for use. the pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. the client should have liquids at the bedside to drink.

the nurse is caring for a client with SLE that is affecting the hematopoietic system. based on this, which signs and symptoms should the nurse anticipate and collect data on. select all that apply

anemia // splenomegaly // lymphadenopathy rationale hematology is the study of blood and blood-forming tissues, which include the bone marrow, blood, spleen, and lymph system. therefore, anemia is a hematologic system issue, and it often occurs with SLE. lymphadenopathy, or enlarged lymph nodes, and splenomegaly, or an enlarged spleen, are also issues of the hematologic system and occur with SLE. alopecia is loss of hair, which is a dermatological condition, as is discoid erythema. raynaud's phenomenon is cardiopulmonary in origin causing pallor and diminished blood flow to fingers

a client calls the ED and tells the nurse that he received a bee sting to the arm while weeding a garden. the client states that he has received bee stings in the past and is not allergic to bees. the client states that the site is painful and asks the nurse for advice to alleviate the pain. which action should the nurse tell the client to take?

apply ice and elevate the site rationale when a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. pain may be alleviated by the application of an ice pack and elevating the site. a heating pad will increase discomfort at the site. acetaminophen may be taken by the client to assist in alleviating discomfort, but this would not treat the injury at a local level. lying down and elevating the arm may have some effect on reducing edema at the site but will not directly assist in alleviating the pain at the site of injury.

a client arrives at the health care clinic requesting to be tested for lyme disease. the client tells the nurse that he removed the tick and flushed it down the toilet. which nursing action is appropriate.

arrange for the client to return in 4 to 6 weeks to be tested rationale there is a blood test available to detect lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite.

a client calls the office of his primary care HCP and tells the nurse that he was just stung by a bumblebee while gardening. the client is afraid of a severe reaction because his neighbor experienced such a reaction just 1 week ago. which is the appropriate nursing action?

ask the client if he ever sustained a bee sting in the past rationale in some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past.

the nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia and photo sensitivity. Systemic lupus erythematosus (SLE) is suspected. the nurse further checks for which manifestation that is also indicative of the presence of SLE?

butterfly rash on the cheeks and bridge of the nose rationale systemic lupus erythematosus is a chronic inflammatory disease that affects multiple body systems. a butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE

the HCP prescribes fuconazole (Diflucan) for a client. when administering this medication the nurse should explain to the client that it is used to treat which opportunistic infection?

candidiasis rationale fluconazole is a broad-spectrum antifungal medication. candidiasis is a fungal infection that causes thrush and vaginal yeast infections, so fluconazole would be an appropriate medication to treat this. cytomegalovirus and herpes simplex 1 are viral disease and mycobacterium tuberculosis is classified in the bacterial/mycobacterial category. thus, fluconazole, an antifungal medication, would not be appropriate treatment

a HCP aspirates synovial fluid from a knee joint of a client with rheumatoid arthritis. the nurse reviews the laboratory analysis of the specimen and should expect the results to indicate which finding?

cloudy synovial fluid rationale cloudy synovial fluid is diagnostic of rheumatoid arthritis. organisms present in the synovial fluid are characteristic of a septic joint condition. bloody synovial fluid is seen with trauma. urate crystals are found in gout.

a client with AIDS reports nausea, vomiting and abdominal pain after beginning didanosine (Videx) therapy. the clinic nurse reinforces which instruction to this client?

come to the health care clinic to be seen by the HCP rationale pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine (Videx). the client should be seen by the HCP and be monitored for indications of developing pancreatitis. the reported symptoms are not the primary subject. the nurse should not encourage the client to alter the medication dose without first notifying the HCP.

the nurse reads the chart of a client who has been diagnosed with stage 3 lyme disease. which sign/symptom supports this diagnosis?

complaints of joint pain rationale stage 3 develops within a month to several months after initial infection. it is characterized by arthritic symptoms such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. cardiac and neurological dysfunction occurs in stage 2. a rash occurs in stage 1. paralysis of the extremity where the tick bite occurred is not a characterized of lyme disease.

the nurse is assisting in the care of a client diagnosed with SLE. the nurse should administer which prescribed medication that is needed to manage the condition?

corticosteriod rationale treatment of SLE is based on the systems involved and symptoms. treatment normally consists of anti-inflammatory medications, corticosteroids, and immunosuppressants.

a clinic nurse periodically cares for a client diagnosed with AIDS. the nurse assesses for an early manifestation of pneumocystits jiroveci infection by monitoring for which sign/symptom at each client visit?

cough rationale the client with P. jiroveci infection usually has a cough as a first symptom which begins as nonproductive and then progresses to productive. later signs include fever, dyspnea on exertion, and finally dyspnea at rest.

the home care nurse is assigned to care for a client who returned home from the ED following treatment for a sprained ankle. the nurse notes that the client was sent home with crutches that have rubber axillary pads and needs to reinforce instructions regarding crutch walking. on data collection, the nurse discovers that the client has an allergy to latex. before providing instruction regarding crutch walking, the nurse should do which?

cover the crutch pads with cloth. rationale the rubber pads used on crutches may contain latex. if the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. telling the client that the crutches must be immediately removed from the house is inappropriate and may alarm the client. the nurse cannot prescribe a cane for a client. in addition, this type of assistive device may not be appropriate considering the client's injury. no reason exists to contact the HCP at this time.

the nurse is assisting in developing a plan of care for a pregnant client with AIDS. the nurse determines that which concern is the priority for this client?

development of an infection rationale AIDS decreases the body's immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes which are vital to the body's defense system. opportunistic infections are a primary cause of death in people affected with AIDS. therefore, preventing infection is a priority of nursing care.

the nurse is assessing a client who has small groups of vesicles over his chest and upper abdominal area. they are located only over the right side of his body. the client states his pain level is 8/10 and describes the pain as burning in nature. which question is most appropriate to include in the data collection

did you have chicken pox as a child rationale the client has the symptoms of herpes zoster or shingles which is caused by the same organism as chicken pox. asking about sexual partners is inappropriate for this disorder. use of an electric blanket does not cause this type of lesions. abreva is used on herpes simplex 1 (cold sores)

a client with acquired immunodeficiency syndrome (AIDS) is taking zidovudine (Retrovir) 200 mg orally three times daily. the client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. which should the nurse anticipate to be prescribed for the client?

discontinuation of the medication rationale hematological monitoring should be done every 2 weeks in the client taking zidovudine. if severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. if anemia or neutropenia is mild, a reduction in dosage may be sufficient. the administration of prednisone may further alter the immune function. epoetin alfa is given to clients experiencing anemia.

a client with AIDS is taking zidovudine (retrovir) 200 mg orally three times daily. the client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. which should the nurse anticipate to be prescribed for the client?

discontinuation of the medication rationale hematological monitoring should be done every 2 weeks in the client taking zidovudine. if severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. if anemia or neutropenia is mild, a reduction in dosage may be sufficient. the administration of prednisone may further alter the immune function. epoetin alfa is given to clients experiencing anemia.

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

hairdressers rationale individuals at risk for developing a latex allergy include 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; and individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts and water chestnuts

which signs/symptoms would indicate to the nurse that a client is experiencing an anaphylactic reaction? select all that apply

hives// stridor// dyspnea// urticaria// wheezing rationale hives are one symptom of anaphylaxis. stridor, a high-pitched sound during inspiration, is a symptom. dyspnea occurs as the airway swells. urticaria is an allergic reaction with wheals that causes intense itching. wheezing is a musical sound heard as the respiratory lumen narrows. pallor is not specifically associated with an anaphylactic reaction.

indinavir (crixivan) is prescribed for a client with HIV. the nurse has reinforced instructions to the client regarding ways to maximize absorption of the medication. which statement by the client indicates an adequate understanding of the use of this medication?

i need to take the medication with water but on an empty stomach rationale to maximize absorption, the medication should be administered with water on an empty stomach. the medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal such as cornflakes with skim milk and sugar. it is not to be administered with a large meal. the medication should be stored at room temperature and protected from moisture because moisture can degrade the medication.

the nurse, a cub scout leader, is preparing a group of cub scouts for an overnight camping trip and instructs them about the methods to prevent lyme disease. which statement by one of the cub scouts indicates a need for further teaching?

i should not use insect repellent because it will attract the ticks rationale in the prevention of lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. if possible, one should avoid heavily wooded areas or areas with thick underbrush. socks can be pulled up and over the pan legs to prevent ticks from entering under clothing.

the nurse determines that the neutropenic client needs further teaching if which statement is made by the client?

i will include plenty of fresh fruits in my diet rationale fresh fruits and vegetables are eliminated from the diet to avoid the introduction of pathogens. fever of 100.4 F or greater should be reported immediately. feeding and petting cats and dogs are fine as long as hand washing follows. handling pet excrement must be avoided to avoid exposure to pathogens.

which findings should cause the nurse to postpone administration of an immunization and do further data collection? select all that apply

immune deficiency disease familial history of severe allergic response to the immunization rationale immune deficiency disease or immunosuppressive therapy require postponement of vaccination and checking with primary medical provider. allergic responses to substances by the client or family members should be investigated. being over 60 years of age is not a reason to postpone or cancel immunization. axillary temperature of 99 is not a febrile. a negative tuberculin skin test for tuberculosis is expected and normal. having insulin-dependent diabetes mellitus places a person at risk for some conditions such as pneumonia and influenza, making immunizations more important.

the nurse is assisting in identifying clients in the community at risk for latex allergy. which client population is most at risk for developing this type of allergy?

individuals with spina bifida rationale individuals at risk for developing a latex allergy include health care workers; individuals who work with manufacturing latex products; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers and auto mechanics and individuals allergic to kiwis, bananas, pineapples, passion fruit, avocados, and chestnuts.

a client diagnosed with Lyme disease says to the nurse, I heard this disease can affect the heart. is this true? the nurse should make which response to the client?

it can, but you will be monitored closely for cardiac complications. rationale stage 2 of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. the serious problems that occur in this include cardiac conduction defects and neurological disorders such as Bell's palsy and paralysis.

the nurse is assigned to care for a client with SLE. the nurse plans care considering which factor regarding this diagnosis

it is an inflammatory disease of collagen contained in connective tissue rationale SLE is an inflammatory disease of collagen contained in connective tissue.

the nurse is providing instructions to a client with acquired immunodeficiency syndrome AIDS who is experiencing night fever and night sweats. the nurse advises the client to do which action to increase comfort while minimizing symptoms?

keep liquids on the nightstand at home rationale for clients with AIDS who experience night fever and night sweats; it is useful to keep liquids on the nightstand at home. the client should keep a plastic cover on the pillow and place a towel over the pillowcase if needed also. the client should not decrease fluid intake, and the client should take an antipyretic before going to sleep and before the fever spikes

the nurse interprets that the client who is precribed zalcitabine (Hivid) is experiencing an adverse effect of this medication when which event is reported by teh client

numbness in the legs rationale peripheral neuropathy is an adverse effect associated with the use of zalcitabine, which manifests initially as numbness and burning sensations in the extremities. they may progress to sharp shooting pains or severe continuous burning if the medication is not withdrawn.

which medications should the nurse administer to reduce nasal edema and rhinorrhea (thin watery discharge from the nose) select all that apply.

oxymetazoline (dristan) // pseudoephedrine (sudafed) rationale dristan and sudafed are decongestants that reduce nasal edema and rhinorrhea. corticotropin is an anti-inflammatory agent. isoniazid is used in the treatment of tuberculosis. terbutaline causes bronchodilation. phenazopydridine is a urinary analgesic.

a client is diagnosed with an immune deficiency. the nurse focuses on which nursing responsibility as the highest priority when providing care to this client?

protecting the client from infection rationale the client with immune deficiency has inadequate immune bodies and is at risk for infection. the priority nursing intervention would be to protect the client from infection.

a client with AIDS is experiencing shortness of breath related to pneumocystis jiroveci pneumonia. which measure should the nurse suggest to assist the client in performing ADLs.

provide supportive care with hygiene needs rationale providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing.

a client with AIDS has difficulty swallowing. the nurse has given the client suggestions to minimize the problem. the nurse determines that the client has understood the instructions if the client verbalizes the intent to increase intake of which foods?

puddings rationale the client is instructed to avoid spicy, sticky, or excessively hot or cold foods. the client also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables. the client is encouraged to take in foods that are mild, nonabrasive, and easy to swallow. examples of these include baked fish, noodle dishes, well-cooked eggs, and desserts such as ice creams or puddings. dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating.

the client with AIDS is diagnosed with cutaneous Kaposi's sarcoma. based on this diagnosis, the nurse understands that this has been confirmed by which?

punch biopsy of the cutaneous lesions rationale Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. these large plaques ulcerate or open and drain. the lesions spread by metastasis through the upper body and then to the face and oral mucosa. they can move to the lymphatic system, lungs, and GI tract. late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions

the client with AIDS has raised, dark purplish lesions on the trunk of the body. the nurse anticipates that which procedure will be done to confirm whether these lesions are due to Kaposi's sarcoma?

skin biopsy rationale the skin biopsy is the procedure of choice to diagnose Kaposi's sarcoma which frequently complicates the clinical picture of the client with AIDS. lung biopsy would confirm P. jiroveci infection. the enzyme-linked immunosorbent assay and western blot are tests to diagnose HIV virus status.

a client calls the health care clinic and tells the nurse that he was bitten by a tick. the client is concerned and asks the nurse about the first signs of Lyme disease. which is a characteristic of stage 1 of Lyme disease?

skin rash rationale the hallmark of stage 1 of lyme disease is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. the rash develops into a concentric ring, giving it a bull's eye appearance (although some individuals do not develop a rash) the lesions develop farther away from the original tick bite. it is important to note that in some individuals, a rash does not occur. in stage 1, most infected people develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later.

the nurse is reinforcing dietary instructions to a client with SLE. which dietary items should the nurse instruct the client to avoid?

steak rationale the client with SLE is at risk for cardiovascular disorders such as coronary artery disease and hypertension. the client is advised of lifestyle changes to reduce these risk, which include smoking cessation and prevention of obesity and hyperlipidemia. the client is advised to reduce salt, fat and cholesterol intake.

a client with AIDS has a respiratory infection from P. jiroveci and a client problem of impaired gas exchange written in the plan of care. which indicates that the expected outcome of care has not yet been achieved?

the client limits fluid intake rationale the status of the client with a nursing diagnosis of impaired gas exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. these would include that the client breathes easier, coughs up secretions effectively, and has clear breath sounds. the client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration

a client who is prescribed zidovudine (Retrovir) has been diagnosed with severe neutropenia. the nurse anticipates which intervention should be implemented?

the medication will be temporarily discontinued rationale hematological monitoring should be done every 2 weeks in the client taking zidovudine. if severe anemia or neutropenia develops, treatment should be interrupted until there is evidence of bone marrow recovery. if anemia or neutropenia is mild, a reduction in dosage may be sufficient. the administration of prednisone may further alter the immune function. epoetin alfa is given to clients experiencing enemia.

a client who is prescribed zidovudine (retrovir) has been diagnosed with severe neutropenia. the nurse anticipates which intervention should be implemented

the medication will be temporarily discontinued rationale hematological monitoring should be done every 2 weeks in the client taking zidovudine. if severe anemia or neutropenia develops, treatment should be interrupted until there is evidence of bone marrow recovery. if anemia or neutropenia is mild, a reduction in dosage may be sufficient. the administration of prednisone may further alter the immune function. epoetin alfa is given to clients experiencing anemia.

a client just diagnosed with toxoplasmosis asks the nurse, what is toxoplasmosis? how did i get it, and what do i have to do to get rid of it? which information should the nurse include in the reply? select all that apply.

toxoplasmosis is treated with sulfadiazine; pregnant people should not empty litter boxes; toxoplasmosis is an organism found in rare pork; toxoplasmosis may cause a severe inflammatory response rationale treatment for toxoplasmosis includes pyrimethamine, folinic acid, and sulfadiazine for as long as six weeks. the organism is found in undercooked meats such as pork and venison. symptoms range from flulike symptoms to severe inflammatory responses and may cause central nervous system symptoms. pregnant women should not empty litter boxes because cat feces are often sources of toxoplasmosis. toxoplasmosis is caused by a protozoan called toxoplasmosis gondil. spores can remain in the environment for up to a year.

which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy? select all that apply

use nonlatex gloves // use medications from glass ampules // do not puncture rubber stoppers with needles // keep a latex-supply cart available in the client's area rationale if a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. any supplies or materials that contain latex would be avoided. these include blood pressure cuffs and medication bottles with rubber stoppers that require puncture with a needle. it is not necessary to place the client in a private room

the nurse is providing general information to a group of high school students about preventing HIV transmission. the nurse should inform the students that which behavior is unsafe?

use of natural skin condoms rationale the use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through. abstinence is the safest way to avoid HIV infection. the next most reliable method is participation in a mutually monogamous relationship. the use of latex condoms is considered safe because the latex prevent the transmission of the HIV virus as long as the condom is used properly and remains in place and intact.

the nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. the lesions are open and draining a scant amount of serous fluid. which should the nurse incorporate in the plan during the bathing of this client?

wearing a gown and gloves rationale gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. masks are not required unless droplet or airborne precautions are necessary. regardless of the amount of wound drainage, a gown and gloves must be worn.

a client arrives at the ambulatory care center complaining of flulike symptoms. on data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. the client requests a blood test to determine the presence of lyme disease. which question should the nurse ask next?

when were you bitten by the tick? rationale there is a blood test available to detect lyme disease; however it is not a reliable test if performed before 4 to 6 weeks following the tick bite. the appropriate question by the nurse should elicit information related to when the tick bite occurred.