Author Question: A type I hypersensitivity to latex is evident if the nurse assesses: A. Localized swelling B. ... (Read 26 times)

Tirant22 · **on:** Jul 24, 2018

A type I hypersensitivity to latex is evident if the nurse assesses:

A. Localized swelling
B. Skin redness and itching
C. Runny eyes and nose and cough
D. Tachycardia, hypotension, and wheezing

Question 2

The patient is a 1-year-old male infant who is admitted with possible sepsis. The patient is irritable and agitates easily. What should the nurse do to assess the patient's temperature?

a. Take an oral temperature before doing anything else.
b. Take an axillary temperature using the upper axilla.
c. Place the child in Sims' position for a rectal temperature.
d. Take a rectal temperature as the last vital sign.

jjorrostieta · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

D
D. Type I allergic reaction is a true latex allergy that can be life-threatening. Reactions vary based on type of latex protein and degree of individual sensitivity, including local and systemic. Symptoms include hives, generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest.
A and C. Type IV hypersensitivity is a cell-mediated allergic reaction to chemicals used in latex processing. Reaction can be delayed up to 48 hours, including redness, itching, and hives. Localized swelling, red and itchy or runny eyes and nose, and coughing may develop.
B. Irritant dermatitis is a nonallergic response characterized by skin redness and itching.

Answer to Question 2

D
Critically ill children sometimes have cool skin but a high core temperature because of poor perfusion to the skin. Children may assume the prone position for rectal temperature measurement. With children who cry or are restless, it is best to take temperature as the last vital sign. Use axillary temperatures for screening purposes only, not to detect fevers in infants and young children. Use the lower axilla to record temperature in side-lying infants.