A nurse is caring for a client who has myasthenia gravis. The nurse should recognize that this disease is caused by which of the following types of hypersensitivities?
Delayed
Immediate
Immune complex-mediated
Cytotoxic
The Correct Answer is D
Cytotoxic hypersensitivity is a type of hypersensitivity that involves the production of IgG or IgM antibodies that bind to antigens on the surface of cells, leading to cell destruction by complement activation or antibody-dependent cellular cytotoxicity. Myasthenia gravis is an example of a cytotoxic hypersensitivity, as it is caused by autoantibodies that target the acetylcholine receptors on the muscle cells, impairing neuromuscular transmission and causing muscle weakness.
Delayed hypersensitivity is a type of hypersensitivity that involves the activation of T cells and macrophages, leading to inflammation and tissue damage after several hours or days of exposure to an antigen. Examples of delayed hypersensitivity include contact dermatitis, tuberculin skin test, and transplant rejection.
Immediate hypersensitivity is a type of hypersensitivity that involves the production of IgE antibodies that bind to mast cells or basophils, leading to degranulation and release of histamine and other mediators, causing anaphylaxis, urticaria, or allergic rhinitis within minutes of exposure to an antigen.
Immune complex-mediated hypersensitivity is a type of hypersensitivity that involves the formation of antigen- antibody complexes that deposit in tissues or blood vessels, leading to complement activation and inflammation, causing vasculitis, glomerulonephritis, or serum sickness within hours or days of exposure to an antigen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale for A:
A small hematoma at the catheter insertion site is common after cardiac catheterization due to the puncture of blood vessels. The nurse should inform the client that this may occur but reassure them that it typically resolves on its own.
Rationale for B:
The dressing usually remains intact for 24 to 48 hours post-procedure to prevent infection and promote healing. The client should be instructed to keep the dressing clean and dry until the healthcare provider gives specific instructions.
Rationale for C: Clients are usually advised to avoid strenuous activities and exercise for several days after the procedure, not to resume regular exercise the next day.
Rationale for D: Pain medication may be necessary to manage discomfort post-procedure, and the nurse should encourage the client to take pain relief as needed.
Correct Answer is A
Explanation
The nurse should identify that this client has multiple risk factors for cardiovascular disease, such as hypertension, obesity, and smoking. These factors can increase the risk of atherosclerosis, coronary artery disease, stroke, and peripheral vascular disease.
Depression is wrong because it is not directly related to the client's physical examination findings. Depression may have other risk factors, such as genetics, stress, trauma, or substance abuse.
Thyroid disease is wrong because it is not directly related to the client's physical examination findings. Thyroid disease may have other risk factors, such as autoimmune disorders, iodine deficiency, or radiation exposure.
Testicular cancer is wrong because it is not directly related to the client's physical examination findings. Testicular cancer may have other risk factors, such as cryptorchidism, family
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