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 B
Explanation
A Colloidal oatmeal-based lotion: Colloidal oatmeal can help to reduce itching and swelling, all while hydrating the skin. It is often used to soothe irritated skin and can be incorporated into a skincare routine through oatmeal baths or oatmeal-infused moisturizers. However, it is typically used as a complementary treatment and may not be sufficient to manage psoriasis symptoms on its own.
B Topical corticosteroids: These are an essential tool for treating inflammatory skin conditions such as psoriasis34. They work by reducing inflammation and slowing down the production of skin cells, which helps to alleviate symptoms such as redness, itching, and scaling. Topical corticosteroids are often the first line of treatment for mild to moderate psoriasis.
C. Topical analgesics: These are primarily used to relieve pain. While they may provide some relief from discomfort associated with psoriasis, they do not address the underlying inflammation and rapid skin cell production that characterize this condition.
D Topical antifungal: Antifungal agents are typically used to treat conditions like seborrheic dermatitis and scalp psoriasis, or in areas where psoriasis involves folds in the skin, where there is an increased potential for localized infection. However, they are not typically used as a primary treatment for psoriasis.
Correct Answer is C
Explanation
Choice A rationale:
Deep breathing and coughing exercises are not a priority intervention immediately following eye surgery. They are more commonly used to prevent postoperative pulmonary complications, such as pneumonia or atelectasis, in patients who have undergone general anesthesia or have respiratory conditions.
While deep breathing and coughing exercises can help promote circulation and prevent blood clots, they are not directly relevant to protecting the eye after surgery.
Engaging in deep breathing and coughing exercises too soon after eye surgery could potentially increase intraocular pressure, which could strain the healing eye and potentially lead to complications.
Choice B rationale:
Obtaining vital signs every 2 hours is a standard nursing intervention for monitoring a patient's overall condition, but it is not the most immediate priority following eye surgery.
Vital signs can provide important information about the patient's heart rate, blood pressure, respiratory rate, and temperature, but they do not directly address the protection of the surgically treated eye.
While monitoring vital signs is important, it does not specifically address the prevention of injury or complications to the eye itself.
Choice C rationale:
Providing an eye shield is the most crucial intervention to protect the eye immediately following surgery. The eye shield serves several important purposes:
Protection from accidental injury: It prevents the patient from accidentally rubbing or bumping the eye during sleep, which could cause further damage or disrupt the healing process.
Prevention of infection: It helps to keep the eye clean and free from debris, reducing the risk of infection. Reduction of swelling: It can help to minimize swelling and discomfort by applying gentle pressure to the eye area.
Promotion of healing: By creating a dark and protected environment, the eye shield can promote rest and healing of the tissues.
Choice D rationale:
Teaching a family member to administer eye drops is an important intervention for long-term care, but it is not the most immediate priority following surgery.
The patient may be able to administer eye drops independently, or a nurse may be responsible for administering them in the initial post-operative period.
Focusing on teaching family members about eye drop administration right after surgery could distract from more urgent priorities, such as protecting the eye with an eye shield.
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