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 B

Explanation

A. While not using illicit drugs is important, this statement does not directly relate to preventing HIV transmission.
B. Using a condom during sex is crucial for preventing the spread of HIV and demonstrates understanding.
C. Drinking too much when out with friends is not specifically related to HIV management.
D. While maintaining a low viral load is important, the phrasing suggests the client is not fully understanding the implications of safe practices.

A. Administering an IM injection B. Administering an intermittent IV bolus medication C. Talking to the client at the bedside D. Completing a dressing change

Correct Answer is D

Explanation

A. Administering an IM injection does not typically require a gown.
B. Administering an intermittent IV bolus medication also does not usually require gowning.
C. Talking to the client at the bedside does not pose a risk requiring gowning.
D. Completing a dressing change involves exposure to potentially infectious materials, necessitating the use of a gown.

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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

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