A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestations?

Serum sickness

Bronchospasm

Tissue damage at the site

Excessive mucus secretion

Answer and Explanation

The Correct Answer is C

A.   Serum sickness is a systemic reaction and not characteristic of delayed hypersensitivity.
B.   Bronchospasm is more indicative of immediate hypersensitivity reactions.
C.   Tissue damage at the site occurs in delayed hypersensitivity reactions, such as those seen in contact dermatitis.
D.   Excessive mucus secretion is also more typical of immediate reactions rather than delayed ones.

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Correct Answer is D

Explanation

A. A pill-rolling tremor is associated with Parkinson's disease, not myasthenia gravis.
B. Electrical charge in a muscle increasing is not relevant to this test.
C. Muscle strength showing no change indicates a negative test result.
D. Muscle contractions becoming progressively stronger after administration of Tensilon indicates a positive test for myasthenia gravis.

A. Administer warfarin. B. Administer furosemide. C. Measure the client's abdominal girth. D. Encourage weight lifting during physical therapy. E. Implement a low-sodium diet.

Correct Answer is ["B","C","E"]

Explanation

A. Administering warfarin is contraindicated due to liver impairment affecting coagulation.
B. Administering furosemide helps manage fluid retention in cirrhosis.
C. Measuring abdominal girth is important to assess for ascites and fluid retention.
D. Encouraging weight lifting is not appropriate due to the risk of increased abdominal pressure.
E. Implementing a low-sodium diet is important to manage fluid retention.

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A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Correct Answer is D

Explanation

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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