Nokea
Which of the following is the most severe complication among clients with allergies,regardless of type?
- A. Bronchitis
- B. Cardiac arrest
- C. Anaphylactic shock and angioneurotic edema
- D. Asthma and nasal polyps
Correct Answer: C
Rationale: Anaphylactic shock and angioneurotic edema are life-threatening allergic reactions that require immediate medical intervention.
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The patient in a long arm cast (from below the shoulder to the wrist, with a 90-degree elbow flexion) complains of a burning sensation over the elbow. The nurse's initial intervention should be:
- A. Elevate the casted arm on pillows.
- B. Check to see if the cast is properly supported.
- C. Notify the charge nurse of developing pressure ulcer.
- D. Cut a "window" in the cast.
Correct Answer: B
Rationale: The correct answer is B: Check to see if the cast is properly supported. The burning sensation over the elbow could indicate nerve compression due to improper cast positioning. By checking if the cast is properly supported, the nurse can ensure that there is no pressure on the nerves causing the burning sensation. Elevating the casted arm (choice A) may not address the root cause of the burning sensation. Notifying the charge nurse of developing pressure ulcer (choice C) is premature without confirming the cause of the burning sensation. Cutting a "window" in the cast (choice D) should be a last resort after ruling out other issues.
You obtain these assessment data while completing an admission for a patient with a history of a liver transplant who is receiving cyclosporine (Sandimmune),prednisone (Deltasone) and mycophenolate (CellCept) to suppress immune function. Which one will be of most concern?
- A. The patient’s gums appear very pink and swollen.
- B. The patient’s blood glucose is increased to 162 mg/dL.
- C. The patient has a non-tender swelling above the clavicle.
- D. The patient has 1+ pitting edema in the feet and ankles.
Correct Answer: C
Rationale: A non-tender swelling above the clavicle could indicate lymphadenopathy which may be a sign of infection or malignancy. This is particularly concerning in an immunocompromised patient. The other findings while important are less urgent and can be managed with standard nursing interventions.
Which scientist is credited with introducing the germ theory of disease?
- A. Louis Pasteur
- B. Edward Jenner
- C. Elie Metchnikoff
- D. Paul Ehrlich
Correct Answer: A
Rationale: Louis Pasteur is credited with introducing the germ theory of disease. He conducted experiments that demonstrated the role of microorganisms in causing infections. He also developed pasteurization to kill harmful bacteria in food and beverages. Edward Jenner is known for developing the smallpox vaccine, not the germ theory. Elie Metchnikoff studied the immune system and phagocytosis. Paul Ehrlich is known for his work on chemotherapy and the concept of the "magic bullet," targeting specific pathogens.
A client is in the hospital and has received two doses of an angiotensin-converting enzyme for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below: What action by the nurse takes is most appropriate?
- A. Administer epinephrine 1:1000, 0.3 mg IV push immediately.
- B. Apply oxygen by facemask at 100% and a pulse oximeter.
- C. Ensure a patent airway while calling the Rapid Response Team.
- D. Reassure the client that these symptoms will go away.
Correct Answer: C
Rationale: The correct action by the nurse is to ensure a patent airway while calling the Rapid Response Team (Choice C). This is because the client is showing signs of angioedema, a potential adverse reaction to angiotensin-converting enzyme (ACE) inhibitors. Angioedema can lead to airway compromise and respiratory distress, hence ensuring a patent airway is crucial. Additionally, calling the Rapid Response Team will allow for immediate medical intervention and monitoring of the client's condition.
Choice A (Administer epinephrine) is incorrect as epinephrine is not the first-line treatment for angioedema associated with ACE inhibitors. Choice B (Apply oxygen) is not sufficient to address the potential airway compromise. Choice D (Reassure the client) is inappropriate as the client's condition requires immediate action to address the potential airway obstruction.
Recognize the following that would be classified as a delayed hypersensitivity reaction.
- A. Anaphylaxis
- B. Allergic contact dermatitis
- C. Cytotoxic hypersensitivity
- D. Immune complex hypersensitivity
Correct Answer: B
Rationale: The correct answer is B: Allergic contact dermatitis. This is classified as a delayed hypersensitivity reaction because it involves activation of T cells, which takes time to develop. Anaphylaxis (A) is an immediate hypersensitivity reaction mediated by IgE. Cytotoxic hypersensitivity (C) involves antibodies attacking cells directly, not delayed. Immune complex hypersensitivity (D) involves immune complexes depositing in tissues, triggering inflammation, not T cell activation.