During antibiotic therapy, the nurse will monitor closely for signs and symptoms of a hypersensitivity reaction. Which of these assessment findings may be an indication of a hypersensitivity reaction? (Select all that apply.)

Shortness of breath

Black hairy tongue

Itching

Swelling of the tongue

Wheezing

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

Shortness of breath is a common symptom of a hypersensitivity reaction. This occurs because the body’s immune system responds to a foreign substance, known as an antigen, by producing specific antibodies. This immune response can cause inflammation and swelling in various parts of the body, including the airways, leading to shortness of breath.

Choice B rationale:

A black hairy tongue is not typically associated with a hypersensitivity reaction. It is a condition that causes the tongue to appear black and hairy, and it’s usually caused by an overgrowth of bacteria or yeast on the tongue. It’s not related to allergies or hypersensitivity reactions.

Choice C rationale:

Itching is another common symptom of a hypersensitivity reaction. When the body encounters an antigen, it triggers an immune response that releases chemicals like histamine. Histamine can cause itching, among other symptoms.

Choice D rationale:

Swelling of the tongue can be a symptom of a severe hypersensitivity reaction known as anaphylaxis. This is a medical emergency that requires immediate attention. The swelling is caused by inflammation in response to an antigen.

Choice E rationale:

Wheezing is a symptom of a hypersensitivity reaction, specifically type I hypersensitivity. This type of reaction includes allergic disorders, which affect the lungs among other parts of the body. The immune response to an antigen can cause the airways to narrow and produce a wheezing sound.

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Correct Answer is D

Explanation

Choice A rationale:

Rifampin is an antibiotic used to treat or prevent tuberculosis (TB). However, the treatment with this medication typically lasts longer than one month. In fact, TB treatment usually involves taking several drugs for a long time.

Choice B rationale:

While it’s important to take some medications with meals to increase absorption or decrease stomach upset, rifampin should be taken at least 1 hour before or 2 hours after a meal. This helps to ensure optimal absorption of the medication.

Choice C rationale:

Insomnia is not typically listed as a common side effect of rifampin. The medication can cause a number of side effects, but these more commonly include things like upset stomach, loss of appetite, nausea, vomiting, diarrhea, and changes in behavior.

Choice D rationale:

One of the known side effects of rifampin is that it can cause a red-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This can be alarming to patients if they are not forewarned, so it’s important for the nurse to provide this information during discharge instructions.

A. The client refuses breakfast and requests to sleep. B. The client asks the AP to trim his broken toenail. C. The client reports urine that is dark yellow in color. D. The client reports dizziness when standing.

Correct Answer is A

Explanation

Choice A rationale:

Type 1 diabetes mellitus is a chronic medical condition that occurs when the pancreas, an organ in the abdomen, produces very little or no insulin. Insulin is a hormone that helps the body to use glucose for energy. Glucose is a sugar that comes, in large part, from foods we eat. Insulin allows glucose to enter cells in the body. Therefore, if a client with type 1 diabetes refuses breakfast and requests to sleep, it could lead to hypoglycemia, a condition characterized by abnormally low blood glucose levels. Hypoglycemia can cause symptoms such as weakness, sweating, confusion, and in severe cases, unconsciousness or seizures. It is a medical emergency and should be reported immediately.

Choice B rationale:

Trimming a toenail may seem like a simple task, but for a person with diabetes, it can lead to serious complications. Diabetes can cause nerve damage that leads to numbness in the feet, making it difficult for a person to feel a cut, blister, or sore. These injuries can become infected and lead to serious complications, such as the need for amputation. However, this situation is not as immediately life-threatening as hypoglycemia and does not need to be reported immediately.

Choice C rationale:

Dark yellow urine can be a sign of dehydration, which can be a concern for individuals with diabetes. However, it can also be a result of less serious causes such as certain medications, foods, or simply not drinking enough fluids. While it’s important for the AP to encourage the client to drink more fluids, this situation is not as immediately life-threatening as hypoglycemia.

Choice D rationale:

Dizziness when standing, also known as orthostatic hypotension, can be a side effect of some medications used to treat diabetes. It can also be a symptom of dehydration or other conditions. While it’s important for the AP to monitor the client’s symptoms and report any changes, this situation is not as immediately life-threatening as hypoglycemia

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During antibiotic therapy, the nurse will monitor closely for signs and symptoms of a hypersensitivity reaction. Which of these assessment findings may be an indication of a hypersensitivity reaction? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following information should the nurse provide?

Correct Answer is D

Explanation

A nurse is discussing the care of a client who has type 1 diabetes mellitus with an assistive personnel (AP). Which of the following situations should the nurse instruct the AP to report immediately?

Correct Answer is A

Explanation

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