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

Answer and Explanation

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.

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Correct Answer is A

Explanation

a.This is appropriate as regular, moderate exercise can help improve cardiovascular health and functional capacity in clients with heart failure. It is essential to discuss appropriate types and levels of exercise based on the individual’s condition.

b.This is incorrect because clients should be instructed to notify the provider if they gain 1 kg (2.2 lbs) in one day or 2 kg (4.4 lbs) in one week. A weight gain of 0.5 kg is not typically a threshold for concern.

c. Take diuretics early in the morning and before bedtime is wrong because it may disrupt the client's sleep patern and cause nocturia. The nurse should advise the client to take diuretics early in the morning and avoid taking them in the evening or at night, unless prescribed otherwise.

d. Take naproxen for generalized discomfort is wrong because naproxen is a nonsteroidal anti-inﬂammatory drug (NSAID) that can worsen heart failure by causing sodium and water retention, increasing blood pressure, and reducing the eﬀectiveness of diuretics and other heart failure medications. The nurse should advise the client to avoid NSAIDs and use acetaminophen or other alternatives for pain relief, as prescribed by the provider.

A. Adjust the thermostat so that the environment is warm. B. Apply a heating pad on a low setting to help relieve leg pain. C. Wear antiembolic stockings during the day. D. Rest with the legs above heart level.

Correct Answer is A

Explanation

The nurse should instruct the client to adjust the thermostat so that the environment is warm because cold temperatures can cause vasoconstriction and worsen the symptoms of PAD, such as pain, numbness, and poor wound healing. The client should also avoid exposure to cold weather and wear warm clothing.

Apply a heating pad on a low setting to help relieve leg pain is wrong because it can cause burns, vasodilation, and increased blood ﬂow to the legs, which can increase the risk of bleeding and edema in PAD.
Wear antiembolic stockings during the day is wrong because they can impair arterial circulation and cause ischemia and tissue damage in PAD. Antiembolic stockings are used to prevent venous thromboembolism, not arterial disease.

Rest with the legs above heart level is wrong because it can decrease arterial blood ﬂow to the legs and worsen ischemia and pain in PAD. The client should rest with the legs at or below heart level to promote arterial circulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

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