A teenage client is admitted to the emergency department following a bee sting. The client arrives with a body rash and 30 minutes later becomes short of breath.
The client's vital signs are a heart rate of 130 beats/minute, respirations of 40 breaths/minute, and a blood pressure of 90/52 mm Hg. The client is exhibiting clinical manifestations of which type of immune reaction?

Autoimmune response.

Type II hypersensitivity.

Cell-mediated hypersensitivity.

IgE response hypersensitivity.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Autoimmune responses occur when the immune system mistakenly attacks the body's own tissues. They are not typically triggered by allergens like bee stings.

Autoimmune responses often develop slowly over time and present with symptoms related to the specific tissues being attacked.

The rapid onset of symptoms in this case, along with the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of an autoimmune response.

Choice B rationale:

Type II hypersensitivity reactions involve antibodies that target and destroy cells or tissues. These reactions often take hours or days to develop, rather than minutes.

Examples of type II hypersensitivity reactions include transfusion reactions, hemolytic disease of the newborn, and some autoimmune diseases.

The rapid onset of symptoms in this case is not consistent with a type II hypersensitivity reaction.

Choice C rationale:

Cell-mediated hypersensitivity reactions involve T cells that directly attack cells or tissues. These reactions typically take 1-3 days to develop.

Examples of cell-mediated hypersensitivity reactions include contact dermatitis (e.g., poison ivy), graft-versus-host disease, and some drug reactions.

The rapid onset of symptoms in this case, as well as the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of a cell-mediated hypersensitivity reaction.

Choice D rationale:

IgE response hypersensitivity reactions are the most immediate type of allergic reaction.

They are mediated by immunoglobulin E (IgE) antibodies, which bind to mast cells and basophils.

When an allergen (like bee venom) cross-links IgE antibodies on mast cells, it triggers the release of histamine and other inflammatory mediators.

These mediators cause vasodilation, increased vascular permeability, smooth muscle contraction, and mucus secretion, leading to the characteristic symptoms of an allergic reaction.

The rapid onset of symptoms in this case, including rash, shortness of breath, and low blood pressure, are consistent with an IgE-mediated hypersensitivity reaction.

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Correct Answer is B

Explanation

Choice A rationale:

While ABGs can provide valuable information about a patient's respiratory status, they are not routinely required prior to postural drainage in patients with COPD.

ABGs might be considered if the patient is experiencing acute respiratory distress or if there are concerns about their oxygenation or ventilation status.

However, in the absence of such concerns, obtaining ABGs would not be necessary and could potentially cause discomfort or anxiety for the patient.

Choice C rationale:

Performing postural drainage immediately after meals is not recommended for patients with COPD.

This is because eating can cause a feeling of fullness in the stomach, which can make it difficult for the patient to breathe deeply and effectively during the procedure.

Additionally, there is a risk of aspiration if the patient were to vomit during or after postural drainage.

It is generally recommended to perform postural drainage at least 1-2 hours after meals to reduce these risks.

Choice D rationale:

Instructing the patient to breathe shallow and fast is not appropriate for postural drainage.

The goal of postural drainage is to help the patient mobilize and expectorate secretions from the lungs.

This is best achieved by encouraging the patient to breathe deeply and slowly, which helps to open up the airways and promote mucus clearance.

Shallow, rapid breathing can actually make it more difficult to clear secretions and can lead to increased shortness of breath.

Choice B rationale:

Explaining that the patient may be placed in five positions is the most appropriate approach for postural drainage in a patient with COPD.

This is because different positions help to drain different areas of the lungs. The five positions typically used for postural drainage are:

Head down position (to drain the lower lobes)

Prone position (to drain the posterior segments of the lungs)

Right lateral position (to drain the right middle lobe and right lower lobe) Left lateral position (to drain the left lower lobe)

Sitting upright position (to drain the upper lobes)

By placing the patient in these different positions, the nurse can help to ensure that all areas of the lungs are drained effectively.

A. Hemoccult test on sputum collected from hemoptysis. B. Sputum culture positive for Mycobacterium tuberculosis. C. Positive purified protein derivative (PPD) skin test. D. Chest X-ray or computed tomography (CT).

Correct Answer is B

Explanation

Choice A rationale:

Hemoccult test on sputum collected from hemoptysis is not a diagnostic test for TB. It is a test for blood in the stool, which can be a symptom of TB but is not specific to TB.

Hemoptysis, or coughing up blood, can occur in various conditions, including bronchitis, pneumonia, lung cancer, and TB. The Hemoccult test cannot differentiate between these causes, making it an unreliable test for diagnosing TB.

Choice B rationale:

Sputum culture positive for Mycobacterium tuberculosis is the definitive diagnostic test for TB.

It involves collecting a sample of sputum, which is the mucus coughed up from the lungs, and culturing it in a laboratory to see if Mycobacterium tuberculosis, the bacteria that causes TB, grows.

This test is highly specific for TB, meaning that a positive result is almost always indicative of TB infection. It is also sensitive, meaning that it can detect TB infection even when there are few bacteria present.

Choice C rationale:

Positive purified protein derivative (PPD) skin test indicates exposure to TB but does not confirm active infection.

The PPD skin test involves injecting a small amount of tuberculin, a protein derived from Mycobacterium tuberculosis, into the skin.

If a person has been exposed to TB, their immune system will react to the tuberculin, causing a raised red bump to appear at the injection site.

However, a positive PPD skin test does not necessarily mean that a person has active TB infection.

It could also mean that they have been exposed to TB in the past but have successfully fought off the infection. Further testing, such as a sputum culture, is needed to confirm the diagnosis of TB.

Choice D rationale:

Chest X-ray or computed tomography (CT) can show abnormalities in the lungs that are suggestive of TB, but they cannot definitively diagnose TB.

These imaging tests can reveal changes in the lungs, such as nodules, inflammation, or fluid buildup, which can be caused by TB or other conditions.

Therefore, a chest X-ray or CT scan alone is not sufficient to diagnose TB. A sputum culture is still needed to confirm the diagnosis.

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Naxlex Comprehensive Predictor Exams

When performing postural drainage on a patient with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

Correct Answer is B

Explanation

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results.Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Correct Answer is B

Explanation

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed.Which prescription should the nurse teach the client to use for the skin condition?

The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?

The nurse is preparing to set up the oxygen administration and apply the simple face mask. What should the nurse do before applying the face mask? Select all that apply.

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

A client receives a prescription for ophthalmic ketorolac.Prior to administering the medication, the nurse should review the medical record for which condition?

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?