A nurse is caring for a client who has Graves' disease. The nurse understands that this condition is caused by what type of hypersensitivity? (Select all that apply.)
Type I hypersensitivity
Type II hypersensitivity
Type III hypersensitivity
Type IV hypersensitivity
Type V hypersensitivity
Correct Answer : B,E
Choice A reason:
Type I hypersensitivity is not involved in Graves' disease, as it does not involve IgE antibodies or mast cells.
Choice B reason:
Type II hypersensitivity is involved in Graves' disease, as it involves IgG antibodies that bind to the thyroid-stimulating hormone (TSH) receptors on the thyroid gland and stimulate the production of thyroid hormones. This leads to hyperthyroidism and manifestations such as goiter, exophthalmos, tachycardia, weight loss, or tremors.
Choice C reason:
Type III hypersensitivity is not involved in Graves' disease, as it does not involve immune complexes or complement activation.
Choice D reason:
Type IV hypersensitivity is not involved in Graves' disease, as it does not involve cytotoxic T cells or helper T cells.
Choice E reason:
Type V hypersensitivity is also involved in Graves' disease, as it involves the stimulation of target cells by antibodies that act as agonists for cell surface receptors. This leads to an increased function of the target organ or tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason:
Applying a moist dressing to the wound provides a moist environment for wound healing and protects the wound from contamination and trauma. Moisture prevents dehydration and necrosis of the wound bed and promotes cell migration and growth.
Choice B reason:
Assessing the wound for signs of infection is important to detect and treat any infection that may impair wound healing or cause systemic complications. Signs of infection include increased redness, warmth, swelling, pain, drainage, odor, fever, or leukocytosis.
Choice C reason:
Debriding necrotic tissue from the wound is essential to remove any dead or devitalized tissue that may interfere with wound healing or serve as a source of infection. Debridement can be done by surgical, mechanical, enzymatic, or autolytic methods.
Choice D reason:
Elevating the affected leg above the heart level reduces edema and improves blood circulation to the wound. Edema can impair wound healing by causing tissue hypoxia, increasing bacterial growth, and delaying granulation tissue formation.
Choice E reason:
Massaging the wound edges gently is not recommended for chronic wounds, as it may cause trauma or bleeding to the wound bed or delay epithelialization. Massaging may be beneficial for preventing hypertrophic scars or contractures in healed wounds.
Correct Answer is A
Explanation
The SOFA score is a tool that assesses the degree of organ dysfunction or failure in septic shock. It is based on six parameters: blood pressure, Glasgow coma scale, PaO2/FiO2 ratio, platelet count, bilirubin level, and creatinine level. Each parameter is assigned a score from 0 to 4 based on the severity of the abnormality. The total SOFA score ranges from 0 to 24, with higher scores indicating worse organ dysfunction or failure.
The client's blood pressure of 80/50 mmHg corresponds to a SOFA score of 1, as it indicates hypotension.
The client's Glasgow coma scale is not given, so it is assumed to be normal (15), which corresponds to a SOFA score of 0.
The client's PaO2/FiO2 ratio is not given, so it is assumed to be normal (>400), which corresponds to a SOFA score of 0.
The client's platelet count is not given, so it is assumed to be normal (>150 x 10^9/L), which corresponds to a SOFA score of 0.
The client's bilirubin level is not given, so it is assumed to be normal (<20 micromol/L), which corresponds to a SOFA score of 0.
The client's creatinine level is not given, so it is assumed to be normal (<110 micromol/L), which corresponds to a SOFA score of 0.
The total SOFA score is the sum of the scores for each parameter: 1 + 0 + 0 + 0 + 0 + 0 = 1. Therefore, the client has a SOFA score of 1.
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