A client is noted to have type I hypersensitivity reaction with a systemic response. Which clinical manifestations should the nurse anticipate? (Select all that apply).
Allergic rhinitis
Cough
Hypotension
Wheezing
Urticaria
Correct Answer : A,B,C,D,E
A. Allergic rhinitis: This is a common manifestation of a type I hypersensitivity reaction, often involving nasal congestion, sneezing, and itching.
B. Cough: While a cough can occur, it is not as specific or common in the context of systemic type I hypersensitivity reactions as the other options.
C. Hypotension: Hypotension can occur due to vasodilation and increased vascular permeability, which are hallmarks of systemic anaphylaxis.
D. Wheezing: Wheezing results from bronchoconstriction, a common feature in systemic type I hypersensitivity reactions, such as anaphylaxis.
E. Urticaria: Urticaria (hives) is a common skin manifestation of a type I hypersensitivity reaction, characterized by itchy, raised welts on the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.
B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.
C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.
D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.
Correct Answer is A
Explanation
A. GI intolerance and neutropenia: Antiretroviral therapy can cause gastrointestinal intolerance, including nausea, vomiting, diarrhea, and abdominal pain. Neutropenia, a decrease in neutrophil count, can also occur as a side effect of some antiretroviral medications.
B. T-cell count of 500 and diarrhea: While diarrhea can be a side effect of antiretroviral therapy, a T-cell count of 500 is not necessarily an adverse effect and may indicate effective treatment.
C. Anorexia and constipation: Anorexia and constipation are not commonly associated with antiretroviral therapy. However, gastrointestinal side effects such as diarrhea are more common.
D. Bone demineralization and thrush: Bone demineralization (osteoporosis) can occur as a long- term complication of HIV infection and antiretroviral therapy, but it is not a direct adverse effect of antiretroviral medications. Thrush (oral candidiasis) can occur in HIV-infected individuals, but it is not specifically related to antiretroviral therapy.
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