A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?

Correct Answer: D

Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems. Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies. Choice B: HIV weakens the immune system but is not specifically associated with latex allergies. Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.

Correct Answer: A

Rationale: The correct initial action for the school nurse is to assess for signs and symptoms of anaphylaxis (Choice A). This is crucial as anaphylaxis is a severe allergic reaction that can be life-threatening and requires immediate intervention. Assessing for anaphylaxis symptoms such as difficulty breathing, swelling of the face or throat, and a rapid pulse helps the nurse quickly identify the severity of the situation. Administering OTC antihistamines (Choice C) or epinephrine (Choice D) should only be done after confirming the presence of anaphylaxis. Assessing for erythema and urticaria (Choice B) is important but not as immediate as assessing for signs of anaphylaxis in this scenario.

Correct Answer: A

Rationale: The correct answer is A because it shows empathy and offers the patient an opportunity to express their feelings. By acknowledging the patient's frustration and anger, the nurse validates their emotions and creates a safe space for communication. This response promotes trust and understanding, which are crucial in building a therapeutic relationship. Choice B is incorrect because it immediately jumps to teaching coping strategies without addressing the patient's emotional state. Choice C is incorrect as it generalizes the patient's feelings without directly engaging with their specific concerns. Choice D is incorrect as it sounds dismissive and may make the patient feel judged or misunderstood. These responses lack the empathetic approach needed to effectively support the patient in this situation.

Correct Answer: C

Rationale: The correct answer is C: Anaphylaxis due to a latex allergy. Anaphylaxis is a severe allergic reaction that can be triggered by exposure to latex products such as gloves in the operating room. The symptoms of swelling of the eyes and difficulty breathing are classic signs of anaphylaxis. Rationale: 1. Swelling of the eyes and difficulty breathing are hallmark symptoms of anaphylaxis. 2. Latex is a common allergen that can cause severe allergic reactions like anaphylaxis. 3. The student's symptoms are occurring shortly after entering the operating room, suggesting an acute allergic reaction. 4. The other choices (A, B, D) do not align with the symptoms presented and are less likely in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Acyclovir (Zovirax). Acyclovir is an antiviral medication specifically used to treat herpes infections, including genital herpes. It works by inhibiting the replication of the herpes virus, thereby suppressing symptoms and shortening the course of the infection. Clotrimazole (A) is an antifungal medication used to treat yeast infections, not effective against viral infections like herpes. Metronidazole (B) is an antibiotic used to treat bacterial infections, not effective against viruses. Podophyllin (C) is a topical treatment for genital warts caused by the human papillomavirus (HPV), not effective for herpes. Therefore, the correct choice is Acyclovir (D) for treating genital herpes exacerbation.