A nurse develops a delayed hypersensitivity reaction after wearing latex gloves. Which pathophysiologic process is involved in this type of hypersensitive reaction?
Immediate allergic reaction mediated by sensitized mast cells.
Antigen-antibody complexes deposit in tissues activating inflammation.
T-cells sensitization initiates the macrophage release of cytokines causing a delayed reaction.
Antibodies are formed against antigens on cell surfaces.
The Correct Answer is C
A. Immediate allergic reaction mediated by sensitized mast cells. This describes a Type I hypersensitivity reaction, which is an immediate allergic reaction. It involves IgE antibodies and mast cell degranulation, leading to symptoms such as hives, anaphylaxis, and respiratory distress. Latex allergies can involve Type I reactions, but delayed hypersensitivity is a Type IV reaction.
B. Antigen-antibody complexes deposit in tissues activating inflammation. This describes a Type III hypersensitivity reaction, which involves immune complex deposition leading to inflammation, as seen in lupus or serum sickness. Latex allergies do not involve immune complex deposition.
C. T-cells sensitization initiates the macrophage release of cytokines causing a delayed reaction. This describes a Type IV hypersensitivity reaction, which is a delayed-type hypersensitivity (DTH) mediated by T-cells rather than antibodies. In latex-induced delayed hypersensitivity, T-cells recognize latex proteins and release cytokines, leading to localized skin inflammation, rash, and itching, typically 24–48 hours after exposure.
D. Antibodies are formed against antigens on cell surfaces. This describes a Type II hypersensitivity reaction, which involves antibody-mediated destruction of cells, as seen in hemolytic anemia or blood transfusion reactions. Latex allergies do not involve direct antibody attack on cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Remove the ink marks of the portal after each radiation treatment. Ink marks should not be removed, as they help ensure precise radiation targeting during each session. The marks should remain visible until the treatment plan is complete.
B. Apply moisture lotions daily to the radiation portal site. Many lotions and creams contain ingredients that can irritate the skin or interfere with radiation therapy. Only approved, non-irritating, fragrance-free moisturizers should be used, and typically only after consulting the oncology provider.
C. Protect the skin of the radiation portal site from sunlight exposure. Radiation therapy increases skin sensitivity, making it more vulnerable to sunburn and damage. Clients should cover the treated area with loose clothing or use sunscreen (SPF 30 or higher) if sun exposure is unavoidable.
D. Avoid washing the skin inside the radiation portal site. Gentle washing with mild soap and lukewarm water is recommended to keep the area clean and reduce irritation. Harsh scrubbing, hot water, and scented soaps should be avoided.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}
Explanation
Based on the client's history, physical, and laboratory findings, the priority need will be to treat the infection (cellulitis). In addition, the client will need interventions to manage complications, especially deep tissue injury and impaired circulation.
Rationale:
The infection (cellulitis) is the primary concern, as indicated by redness, warmth, swelling, and systemic symptoms like muscle aches. Immediate antibiotic therapy is crucial.
Deep tissue injury is a potential complication due to prolonged inflammation, swelling, and impaired circulation, which can lead to tissue damage.
Impaired circulation is a significant risk in a client with diabetes and peripheral vascular disease, as it can slow healing and increase the likelihood of further complications such as ulcers or necrosis.
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