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?

IgE-mediated response

Cell-mediated hypersensitivity

Autoimmune response

Type II hypersensitivity

Answer and Explanation

The Correct Answer is A

Choice A reason: An IgE-mediated (Type I) hypersensitivity reaction, like anaphylaxis, occurs post-bee sting, with rapid onset of rash, shortness of breath, hypotension, and tachycardia. IgE antibodies trigger mast cell degranulation, releasing histamine, causing vasodilation, bronchoconstriction, and systemic symptoms, matching the client’s acute presentation.

Choice B reason: Cell-mediated (Type IV) hypersensitivity involves T-cells, causing delayed reactions like contact dermatitis, not rapid systemic symptoms. Bee sting reactions are immediate, driven by IgE, not T-cells. Rash, hypotension, and respiratory distress indicate anaphylaxis, not a delayed cell-mediated response.

Choice C reason: Autoimmune responses involve self-directed antibodies, as in lupus, not triggered by external allergens like bee stings. The client’s acute rash, hypotension, and respiratory distress suggest an IgE-mediated anaphylactic reaction, not an autoimmune process, which is unrelated to acute allergen exposure.

Choice D reason: Type II hypersensitivity involves antibody-mediated cytotoxicity, as in transfusion reactions, not allergen-induced systemic symptoms. Bee sting reactions are IgE-driven, causing immediate anaphylaxis with rash and hypotension, not cytotoxic damage, making Type II inappropriate for the client’s acute presentation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Administering an antacid relieves epigastric pain but is premature without assessing pain characteristics. Pain in peptic ulcer disease may indicate complications like perforation, requiring urgent evaluation. Assessment guides whether antacids or other interventions are appropriate, prioritizing patient safety.

Choice B reason: Assessing pain characteristics (e.g., location, intensity, radiation) is the first step, as epigastric pain in peptic ulcer disease may signal complications like bleeding or perforation. This data guides interventions, ensuring timely management of potentially life-threatening conditions, making it the priority action.

Choice C reason: Checking NSAID use identifies ulcer triggers but is secondary to pain assessment. Pain characteristics determine urgency, as severe or radiating pain may indicate perforation, requiring immediate action. Assessment provides critical data before investigating contributing factors like medication history.

Choice D reason: Obtaining a stool sample for occult blood detects gastrointestinal bleeding but is not the first step. Assessing pain characteristics identifies urgent complications like perforation, guiding whether diagnostic tests or interventions are needed, making pain assessment the initial priority.

A. Encourage weight-bearing exercises B. Restrict calcium-rich foods C. Limit vitamin D supplementation D. Promote bed rest to prevent fractures

Correct Answer is A

Explanation

Choice A reason: Weight-bearing exercises, like walking, stimulate bone formation by increasing osteoblast activity, improving bone density in osteoporosis. This reduces fracture risk, making it a key intervention to strengthen bones and enhance balance, preventing falls, which is critical for osteoporosis management.

Choice B reason: Restricting calcium-rich foods is inappropriate, as calcium is essential for bone health in osteoporosis. Dietary calcium supports bone mineralization, reducing fracture risk. Weight-bearing exercises are prioritized, as they directly enhance bone strength, unlike dietary restrictions that weaken bones.

Choice C reason: Limiting vitamin D supplementation is incorrect, as vitamin D enhances calcium absorption, supporting bone health in osteoporosis. Weight-bearing exercises are the priority, as they mechanically stimulate bone remodeling, improving density and reducing fracture risk more directly than supplements.

Choice D reason: Promoting bed rest increases bone loss in osteoporosis by reducing mechanical stress, which stimulates bone formation. Weight-bearing exercises are essential, as they enhance bone density and strength, preventing fractures, making bed rest counterproductive to osteoporosis management.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?

Correct Answer is B

Explanation

The nurse is caring for a client with a new diagnosis of osteoporosis. Which intervention should the nurse include in the care plan?

Correct Answer is A

Explanation

The nurse is caring for a client with a history of chronic kidney disease. Which dietary restriction should the nurse emphasize?

The nurse is caring for a client with a new diagnosis of anemia. Which dietary recommendation should the nurse provide?

The nurse is assessing a client with suspected hepatitis. Which finding is most indicative of this condition?

A client with newly diagnosed Crohn’s disease asks the nurse about dietary restrictions. How should the nurse respond?

The nurse is reviewing risk factors for cholelithiasis in a client’s history. Which factor most significantly increases the client’s risk for developing gallstones?

The nurse is caring for a client with a suspected pulmonary embolism. Which diagnostic test should the nurse anticipate?

When performing postural drainage on a client with chronic obstructive pulmonary disease, which approach should the nurse use?

The nurse is caring for a client with a new diagnosis of asthma. Which teaching point should the nurse emphasize for proper inhaler use?