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 B
Explanation
An exercise stress test is a diagnostic procedure that measures the heart's response to physical activity. The client is instructed to walk on a treadmill or pedal a stationary bike while their heart rate, blood pressure, and electrocardiogram are monitored. The test can help detect coronary artery disease, arrhythmias, or other cardiac problems.
The client should follow certain guidelines before the test, such as:
- Avoiding caffeine, nicotine, alcohol, and stimulants for at least 4 hours before the test, as they can affect the heart rate and blood pressure.
- Fasting for at least 2 hours before the test, as eating can affect the blood flow to the heart.
- Getting adequate rest and sleep the night before the test, as fatigue can affect the performance and results of the test.
- Wearing comfortable clothing and shoes that are suitable for exercise.
- Informing the provider of any medications they are taking, as some medications may need to be withheld or adjusted before the test, such as beta blockers, calcium channel blockers, nitrates, or antiarrhythmics. These medications can affect the heart rate and blood pressure and interfere with the interpretation of the test results.
Therefore, the comment made by the client that indicates a need for further teaching is "I'll take my heart medications the morning of my test." The client should consult with their provider about whether they should take their heart medications or not before the test. The other comments made by the client are appropriate and indicate that they understand the pre-test instructions.
Correct Answer is ["24"]
Explanation
To calculate the infusion rate, use the formula:
(rate in mL/hr) = (desired dose in units/hr) / (available dose in units/mL)
In this case, the desired dose is 1,200 units/hr and the available dose is 25,000 units / 500 mL = 50 units/mL. Therefore,
(rate in mL/hr) = (1,200 units/hr) / (50 units/mL) = 24 mL/hr
Round the answer to the nearest tenth/whole number and use a leading zero if it applies. Do not use a trailing zero because it could be misread as a decimal point. Therefore, the nurse should set the IV pump to deliver 24 mL/hr.
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