Nokea
The nurse recognizes all of the following as type IV hypersensitivity reactions EXCEPT
- A. allergic contact dermatitis.
- B. Crohn's disease.
- C. graft versus host disease.
- D. penicillin allergy.
Correct Answer: D
Rationale: Type IV hypersensitivity is cell-mediated (e.g., contact dermatitis, Crohn’s, GVHD). Penicillin allergy is typically type I (IgE-mediated).
You may also like to solve these questions
The nurse is preparing to administer the first dose of IV antibiotic to the client. Halfway through the infusion, the nurse realizes that the antibiotic dosage is not the same as ordered by the health care provider. Which action should the nurse take first?
- A. stop the infusion
- B. fill out an incident form
- C. notify the health care provider
- D. only give part of the antibiotic to obtain the correct dose
Correct Answer: A
Rationale: Stopping the infusion is the priority to prevent harm from an incorrect dose, followed by notifying the provider and completing an incident report.
The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
- A. Maintaining the client's systolic blood pressure at 70 mmHg or greater
- B. Maintaining the client's urinary output greater than 300 cc per hour
- C. Maintaining the client's body temperature of greater than 33°F rectal
- D. Maintaining the client's hematocrit at less than 30%
Correct Answer: A
Rationale: Adequate blood pressure ensures organ perfusion for donation.
A non-immune nurse should not be assigned a client who has which of the vaccine-preventable airborne diseases? Select all that apply.
- A. tuberculosis
- B. influenza
- C. smallpox
- D. pertussis
Correct Answer: A,C
Rationale: Tuberculosis and smallpox are airborne, vaccine-preventable diseases posing risks to non-immune nurses. Influenza and pertussis are primarily droplet-transmitted.
A client is being evaluated for carpel tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?
- A. Phalen's maneuver
- B. Tinel's sign
- C. Kernig's sign
- D. Brudzinski's sign
Correct Answer: B
Rationale: Tinel's sign involves tapping over the median nerve to elicit pain or tingling, indicating carpal tunnel syndrome. Phalen's maneuver involves wrist flexion, and the others assess meningitis.
The home health nurse is visiting a 30-year-old with sickle cell disease. Assessment findings include spleenomegaly. What information obtained on the visit would cause the most concern? The client:
- A. Eats fast food daily for lunch
- B. Drinks a beer occasionally
- C. Sometimes feels fatigued
- D. Works as a furniture mover
Correct Answer: D
Rationale: Working as a furniture mover involves heavy physical exertion, which can trigger a sickle cell crisis due to increased oxygen demand and dehydration, posing a significant risk.