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 A

Explanation

Choice A reason: Escorting the client with Huntington’s disease is best, as chorea and cognitive decline impair navigation and memory. Physical guidance ensures safety, preventing falls or disorientation in unfamiliar hospital settings, directly addressing the disease’s motor and cognitive deficits for effective cafeteria access.

Choice B reason: Orienting to a color-coding system is impractical, as Huntington’s cognitive impairments, like executive dysfunction, hinder processing complex visual cues. This approach overwhelms the client, increasing confusion, and is less effective than physical escorting to ensure safe and direct cafeteria navigation.

Choice C reason: Using a hospital map relies on spatial reasoning, which is impaired in Huntington’s due to basal ganglia degeneration. The client’s cognitive and motor deficits make map-based navigation challenging, increasing disorientation risk, making this less effective than escorting for cafeteria access.

Choice D reason: Step-by-step verbal directions require intact memory and processing, compromised in Huntington’s due to cortical and striatal atrophy. Verbal instructions may confuse the client, leading to navigation errors, making physical escorting a more reliable method to ensure safe cafeteria arrival.

A. Heart rate 120 beats/minute B. Respiratory rate 28 breaths/minute C. Oxygen saturation 90% D. Peak expiratory flow 60% of predicted

Correct Answer is A

Explanation

Choice A reason: A heart rate of 120 beats/minute requires immediate intervention, as albuterol, a beta-agonist, stimulates cardiac beta-1 receptors, causing tachycardia. In emphysema, repeated dosing increases cardiovascular stress, risking arrhythmias or ischemia, necessitating evaluation to adjust therapy or address potential overdose effects.

Choice B reason: Respiratory rate of 28 breaths/minute is elevated but expected in emphysema with dyspnea. Albuterol aims to reduce bronchospasm, and this rate does not indicate immediate danger compared to tachycardia, which poses a cardiovascular risk, making it less urgent.

Choice C reason: Oxygen saturation of 90% is low but common in emphysema exacerbations. Albuterol improves airflow, and supplemental oxygen may address hypoxia. While concerning, this is less immediately life-threatening than tachycardia, which indicates potential albuterol toxicity, requiring urgent intervention.

Choice D reason: Peak expiratory flow at 60% reflects airflow limitation in emphysema, improved by albuterol. While low, it is not as urgent as tachycardia, which signals cardiovascular strain from repeated albuterol doses, posing a greater immediate risk to the client’s stability.

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Naxlex Comprehensive Predictor Exams

Which approach is best for the nurse to use when directing a client with Huntington’s disease to the hospital cafeteria?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

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 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?

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow-up action by the nurse?

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?

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?