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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A regular rapid heartbeat (tachycardia) is a common side effect of albuterol, a bronchodilator that relaxes the muscles in the airways to improve breathing. It's often expected after repeated doses. While it warrants monitoring, it doesn't necessarily require immediate intervention unless it becomes significantly elevated or causes other symptoms.
Choice B rationale:
Increased anxiety can also accompany breathing difficulties and albuterol administration. It's crucial to address anxiety, but it's not the most urgent finding in this scenario. Calming techniques and reassurance can often help manage anxiety, while more severe cases might require additional interventions.
Choice C rationale:
Uncontrollable shaking (tremors) is a more serious side effect of albuterol, indicating excessive stimulation of the sympathetic nervous system. It can progress to serious complications like seizures or cardiac events. Immediate intervention is crucial to prevent these risks. Actions might include:
Holding the next albuterol dose Notifying the healthcare provider Monitoring vital signs closely
Administering medications to counteract the tremors, such as beta-blockers, if ordered
Choice D rationale:
Throat irritation is a possible side effect of albuterol, but it's generally mild and self-limiting. It doesn't typically warrant immediate intervention in the absence of other concerning symptoms.
Correct Answer is B
Explanation
Step 1: Identify the desired dose and the available concentration. Desired dose: 500 mg of vancomycin
Available concentration: 500 mg per 100 ml
Step 2: Determine the volume needed to deliver the desired dose.
Since the available concentration is 500 mg per 100 ml, no further calculation is required. The volume needed to deliver 500 mg of vancomycin is already 100 ml.
Step 3: Calculate the infusion rate in mL/hr.
The medication needs to be administered over 1 hour.
Therefore, the infusion pump should be set to deliver the 100 ml of solution over 1 hour. Infusion rate = 100 ml / 1 hour = 100 mL/hr.
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