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?

Cell-mediated tovity

Autoimmune response

IgE response hypersensitivity

Type II hypersensitivity

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is C

Explanation

Choice A reason: Shouting increases volume but may distort speech, worsening comprehension for an older adult with hearing loss. Age-related presbycusis impairs high-frequency sound perception, and shouting can cause discomfort without improving clarity, making this an ineffective communication strategy for the client.

Choice B reason: Over-enunciating syllables may help slightly but can sound unnatural, confusing the client. It does not address the primary issue of processing speed in age-related hearing loss, where slower speech allows better auditory processing, making this less effective than reducing speaking speed.

Choice C reason: Decreasing speaking speed is best, as presbycusis slows auditory processing in older adults. Slower speech allows the client to process sounds clearly, improving comprehension without distortion, addressing the client’s difficulty hearing questions effectively and enhancing communication during the assessment.

Choice D reason: Exaggerating nonverbal expressions aids visual cues but does not address auditory comprehension. Hearing loss requires auditory adjustments, and nonverbal cues alone are insufficient for understanding spoken questions, making this less effective than slowing speech to improve verbal clarity.

A. Hemoglobin B. Serum creatinine C. Blood glucose D. Liver enzymes

Correct Answer is A

Explanation

Choice A reason: Hemoglobin is critical to review, as diclofenac, an NSAID, can cause gastrointestinal bleeding, leading to anemia. Pale appearance and fatigue suggest blood loss, reducing oxygen-carrying capacity. Low hemoglobin confirms anemia, necessitating intervention to prevent further complications, making this the priority laboratory value.

Choice B reason: Serum creatinine monitors renal function, as diclofenac may cause nephrotoxicity, but pale appearance and fatigue point to anemia from bleeding, not renal issues. Renal effects are less immediate than blood loss, making hemoglobin more urgent to assess in this context.

Choice C reason: Blood glucose is irrelevant, as diclofenac does not significantly affect glucose metabolism. Pale appearance and fatigue are classic anemia symptoms, not hypoglycemia, making hemoglobin the priority over glucose, which does not explain the client’s presentation in rheumatoid arthritis.

Choice D reason: Liver enzymes monitor hepatotoxicity, a diclofenac side effect, but pale appearance and fatigue suggest anemia from gastrointestinal bleeding, not liver dysfunction. Hemoglobin directly addresses the likely cause, making it more critical than liver enzymes for immediate evaluation.

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Naxlex Comprehensive Predictor Exams

An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to “speak up” so that she can hear the questions. Which action is best for the nurse to take?

Correct Answer is C

Explanation

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client’s serum laboratory values is most important for the nurse to review?

Correct Answer is A

Explanation

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with lens implant?

A client with emphysema is reporting a difficulty in breathing and exhibiting an audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

To assess the quality of an adult client’s pain, which approach should the nurse use?

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?

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 with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?