An adolescent boy is admitted to the emergency department following a bee sting. He arrives with a body rash and 30 minutes later 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: Transparent dressings are semi-permeable, suitable for superficial wounds with minimal exudate. Stage 3 pressure injuries, with deeper tissue damage and granulation, require moisture-retentive dressings to support healing. Transparent dressings may not provide the moist environment needed for optimal granulation tissue formation and epithelialization in deeper wounds.

Choice B reason: Hydrocolloid gel dressings maintain a moist wound environment, ideal for stage 3 pressure injuries with granulation tissue. They promote autolytic debridement, support epithelialization, and protect the wound. This is the best choice, as gauze may adhere to granulation tissue, causing trauma during removal, unlike hydrocolloids, which foster healing.

Choice C reason: Leaving the dressing off exposes the wound to infection and drying, which impairs granulation tissue and delays healing. Stage 3 pressure injuries require a moist, protected environment. Consulting the provider may be appropriate for complex cases, but immediate dressing application is standard to maintain optimal wound conditions.

Choice D reason: Increasing dressing change frequency may disrupt granulation tissue and delay healing, especially with gauze, which can adhere to the wound bed. Stage 3 pressure injuries benefit from stable, moist environments provided by advanced dressings like hydrocolloids, not frequent changes that risk trauma and infection.

Choice A reason: Hyperthyroidism increases metabolic rate, causing tachycardia and potential arrhythmias due to elevated thyroid hormone levels stimulating cardiac beta-receptors. Monitoring heart rate and rhythm is critical to detect cardiovascular complications, guiding urgent treatment to prevent heart failure or atrial fibrillation.

Choice B reason: High-calorie snacks address weight loss in hyperthyroidism but are secondary to cardiovascular risks. Tachycardia and arrhythmias pose immediate threats, making heart rate monitoring the priority, as uncontrolled hyperthyroidism can lead to life-threatening cardiac events before nutritional needs are addressed.

Choice C reason: Supplemental oxygen is not routinely needed in hyperthyroidism unless respiratory distress occurs, which is rare. Elevated heart rate and arrhythmias are more immediate concerns, as hyperthyroidism’s cardiac effects are primary, making heart monitoring critical to prevent acute cardiovascular complications.

Choice D reason: Restricting fluid intake is inappropriate, as hyperthyroidism increases metabolism, risking dehydration. Heart rate monitoring is prioritized, as tachycardia and arrhythmias are direct, life-threatening effects of excess thyroid hormone, requiring immediate assessment to guide antithyroid therapy and prevent cardiac crises.