NCLEX Review about Immune System Disorders
21. The home care nurse is ordering dressing supplies for a client who has an allergy to latex. The nurse asks the medical supply personnel to deliver which of the following?
a) elastic bandages
b) adhesive bandages
c) brown ace bandages
d) cotton pads and silk tape
22. The camp nurse prepares to instruct a group of children about Lyme disease. Which of the following information would the nurse include in the instructions?
a) Lyme disease is caused by tick carried by deer
b) Lyme disease is caused by contamination from cat feces
c) Lyme disease can be contagious through skin contact with an infected individual
d) Lyme disease can be caused by the inhalation of spores from bird droppings
23. The client is diagnosed with stage I Lyme disease. The nurse assesses the client for which characteristic of this stage?
a) arthralgias
b) flu-like symptoms
c) enlarged and inflamed joints
d) signs of neurological disorders
24. Select the interventions that would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply
a) use non-latex gloves
b) use medications from glass ampules
c) place the client in a private room only
d) do not puncture rubber stoppers with needles
e) keep a latex-safe supply cart available in the client's area
f) use a blood pressure cuff from an electronic device only to measure the blood pressure
25. Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the physician immediately if which of the following occurs?
a) nausea
b) lethargy
c) hearing loss
d) muscle aches
NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE
21) D
- Cotton pads and plastic or silk tape are latex-free products. The items identified in options A, B, and C are products that contain latex.
22) A
- Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodesscapularis or I. pacificus tick can become infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces.
23) B
- The hallmark of stage I Lyme disease is the development of a 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. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Neurological deficits occur in stage II. Arthralgias and joint enlargements are most likely to occur in stage III.
24) A, B, D, E
- 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, medications with a rubber stopper that requires puncture with a needle, latex-safe syringes, and latex-safe intravenous tubing. It is not necessary to place the client in a private room.
25) C
Amikacin (Amikin) is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems) confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the physician immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the physician immediately if nausea occurs. If nausea persists or results in vomiting, the physician should be notified.
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