The nurse is providing care to a client who is experiencing an allergic reaction. What initial, usual responses of the body to an antigen does the nurse anticipate? (Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Swelling of the larynx
2. Itching with development of hives
3. Release of histamine and mast cells
4. Inflammation production
5. Antibody production
Correct Answer: 2, 3, 4, 5
Rationale 1: Swelling of the larynx is incorrect because as the allergic reaction continues, the client begins to enter anaphylaxis. Tightening of the throat with voice changes and the swelling of the larynx occur, but these are not initial responses.
Rationale 2: Normally, the body responds to an antigen by processes such as inflammation, antibody production, and activation of lymphocytes that rid the body of the foreign agent. Release of histamine and mast cells as well as itching and hives are all responses to the allergen. As the allergic reaction continues and the client begins to enter anaphylaxis, tightening of the throat with voice changes and the swelling of the larynx occur, but these are not initial responses.
Rationale 3: Normally, the body responds to an antigen by processes such as inflammation, antibody production, and activation of lymphocytes that rid the body of the foreign agent. Release of histamine and mast cells as well as itching and hives are all responses to the allergen. As the allergic reaction continues and the client begins to enter anaphylaxis, tightening of the throat with voice changes and the swelling of the larynx occur, but these are not initial responses.
Rationale 4: Normally, the body responds to an antigen by processes such as inflammation, antibody production, and activation of lymphocytes that rid the body of the foreign agent. Release of histamine and mast cells as well as itching and hives are all responses to the allergen. As the allergic reaction continues and the client begins to enter anaphylaxis, tightening of the throat with voice changes and the swelling of the larynx occur, but these are not initial responses.
Rationale 5: Normally, the body responds to an antigen by processes such as inflammation, antibody production, and activation of lymphocytes that rid the body of the foreign agent. Release of histamine and mast cells as well as itching and hives are all responses to the allergen. As the allergic reaction continues and the client begins to enter anaphylaxis, tightening of the throat with voice changes and the swelling of the larynx occur, but these are not initial responses.
Global Rationale: Normally, the body responds to an antigen by processes such as inflammation, antibody production, and activation of lymphocytes that rid of the body of the foreign agent. Release of histamine and mast cells as well as itching and hives are all responses to the allergen. As the allergic reaction continues and the client begins to enter anaphylaxis, tightening of the throat with voice changes and the swelling of the larynx occur, but these are not initial responses. Swelling of the larynx is incorrect because as the allergic reaction continues and the client begins to enter anaphylaxis. Tightening of the throat with voice changes and the swelling of the larynx occur, but these are not initial responses.
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