An adolescent boy is admitted to the emergency department (ED) following a bee sting. He arrives with a body rash and 30 minutes later he becomes short of breath. The nurse obtains vital signs with a blood pressure of 90/52 mm Hg, heart rate 130 beats/minute, and respiratory rate 40 breaths/minute. The client is exhibiting clinical manifestations of which type of immune reaction?

Choice A reason: Cell-mediated hypersensitivity (Type IV) involves T-cells, causing delayed reactions like contact dermatitis, not acute symptoms like rash, hypotension, and dyspnea. Bee sting reactions are rapid, driven by IgE-mediated histamine release, making this immune mechanism incorrect for the client’s presentation.

Choice B reason: Autoimmune responses target self-antigens, as in lupus, not external allergens like bee venom. The client’s acute rash, hypotension, and respiratory distress indicate an allergic reaction, not autoimmunity, making this mechanism irrelevant to the anaphylactic response observed.

Choice C reason: IgE response hypersensitivity (Type I) causes anaphylaxis, as bee venom triggers IgE-mediated mast cell degranulation, releasing histamine. This leads to rash, hypotension, and bronchoconstriction, matching the client’s symptoms, making this the correct immune reaction for the acute, life-threatening presentation.

Choice D reason: Type II hypersensitivity involves antibody-mediated cytotoxicity, as in hemolytic anemia, not allergic reactions. Bee sting anaphylaxis results from IgE-driven histamine release, not cell destruction, making this mechanism incorrect for the client’s rapid-onset allergic symptoms.

Choice A reason: Sleeping flat supine is incorrect, as elevating the head post-cataract surgery prevents intraocular pressure spikes, which can disrupt the lens implant. Supine positioning risks fluid accumulation, potentially causing complications like hemorrhage, making this instruction inappropriate for recovery.

Choice B reason: Administering a stool softener is correct, as straining during bowel movements increases intraocular pressure, risking surgical site complications post-cataract extraction. Soft stools reduce Valsalva maneuver effects, protecting the lens implant and promoting healing, making this a key discharge instruction.

Choice C reason: Turning, coughing, and deep breathing prevent pulmonary complications in major surgeries, not cataract extraction, a minor procedure. These actions may increase intraocular pressure, risking implant displacement, making this instruction irrelevant and potentially harmful for eye surgery recovery.

Choice D reason: Observing pupil response of the right eye is irrelevant, as the surgery affects the left eye. Pupil response monitoring is not a standard post-cataract instruction, and patients cannot self-assess this, making it impractical and unrelated to surgical recovery needs.