A patient, recovering from skin grafts to the arm because of burn injuries, is demonstrating an increase of drainage, bleeding, and edema. The nurse realizes the patient is experiencing which of the following?
1. serum sickness
2. Arthus reaction
3. type I hypersensitivity reaction
4. type IV hypersensitivity reaction
2
Rationale: The arthus reaction is a localized skin reaction in which antigen-antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. The reaction onset is relatively rapid, usually within one hour of exposure, and peaks within 6 to 12 hours. The clinical manifestations are those caused by the inflammatory response and include leaking of fluid causing edema and hemorrhage. Serum sickness is a systemic type III hypersensitivity response. A type I hypersensitivity reaction occurs after repeated exposure to an allergen which causes an allergen-antigen response. A type IV hypersensitivity reaction is a delayed response seen after an insect bite or with poison ivy.
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A client comes to the emergency department complaining of localized pain and swelling of his lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat
Which of the following would the nurse suspect as most likely? A) Fracture B) Contusion C) Sprain D) Strain
A family is planning for discharge following the newborn's surgery. After receiving discharge instructions to keep the baby away from crowds until they are seen at the surgeon's office for a follow-up visit, the mother states, "I can't do that
Who will watch him while I'm at work? If I don't work, we don't eat!" The nurse recognizes this family is under undue stress, and that the priority action would be to: A) teach the mother's 8-year-old child how to care for the baby while the mother is at work. B) call the hospital social worker. C) report the mother for neglect. D) tell the mother she has no choice, and will have to stay home with the child.
Express the dosage using the official symbol/abbreviation: 1 part drug to 5 parts solution
What will be an ideal response?
The nurse at a public health infant immunization clinic is acting as a preceptor for a nursing student
To assess the student's understanding of vaccinations, the nurse asks the student where the hepatitis B vaccine should be administered. The student would be correct to respond that the hepatitis B vaccine should be administered in the a. dorsogluteal muscle in an adult. b. anterolateral thigh in infants. c. ventrogluteal muscle in adolescents. d. deltoid of toddlers.