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 D
Explanation
The nurse should place a towel under the client's head to protect it from injury during the seizure. The nurse should also loosen any tight clothing, remove any objects that could harm the client, and maintain a patent airway.
Place the client in a prone position is wrong because it can compromise the client's breathing and increase the risk of aspiration. The nurse should place the client in a side-lying position after the seizure to facilitate drainage of oral secretions and prevent aspiration.
Holding the client's arms and legs still is wrong because it can cause injury to the client or the nurse. The nurse should not restrain or interfere with the client's movements during the seizure but rather ensure a safe environment and observe the seizure activity.
Leaving the client to get help is wrong because it can endanger the client's safety and well-being. The nurse should stay with the client during the seizure and call for assistance if needed, but not leave the client alone or unattended.
Correct Answer is D
Explanation
Moving objects away from the client is an important action to take during a seizure, as it can prevent injury and protect the client from harm.
"Place the client on his back." is not correct, as it can cause airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
"Restrain the client." is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
"Insert a padded tongue blade into the client's mouth." is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
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