NCLEX RN PEARSON CERTIFICATION
EVALUATION EXAMS WITH WELL
ELABORATED ANSWERS WITH
RATIONALES 100 PERCENT CORRECT FULL
SOLUTION ALREADY PASSED
⩥ A client is noted to have type I (IgE-mediated) hypersensitivity
reaction with a systemic response. Which clinical manifestation should
the nurse anticipate? SATA.
Answer: Wheezing, urticaria, hypotension, stridor
Rationale: Anaphylaxis is a systemic, type I response. Some signs of
anaphylaxis are wheezing, stridor, urticaria, and hypotension. Allergic
rhinitis is a sign of a less serious, local type I response.
⩥ Which hypersensitivity reaction releases enzymes that increase tissue
damage?.
Answer: Type III
Rationale: A type III reaction occurs when neutrophils attempt to
phagocytize the immune complexes, and enzymes are released tat
increase tissue damage. A type I response is triggered when an allergen
interacts with IgE, which is bound to mast cells and basophils. A type II
reaction is a hemolytic transfusion reaction caused by blood in
,capability. A type IV reaction is an exaggerated interaction between an
antigen and the normal cell-mediated mechanism
⩥ Which is the nurse's priority action when managing a client
experiencing a type I hypersensitivity?.
Answer: Airway management
Rationale: Airway management is a priority with a client experiencing a
type I hypersensitivity. A fever is a symptom of a type II, III, and IV
hypersensitivity. Arthralgia is symptom associated with serum sickness,
a type III hypersensitivity. A blood transfusion is the result of a type II
hypersensitivity.
⩥ How are the systemic type I IgE-mediated responses initiated?.
Answer: Allergens are absorbed in the GI mucosa
Rationale: Systemic IgE responses can occur when the GI mucosa is
altered by a local allergic response, then the allergen may be absorbed,
and the resulting reaction may be systemic. IgE is produced by plasma
cells located in lymph. IgE attach to mast cells in body tissues. Contact
of allergens with IgE in the bronchial and conjunctival tissues results in
a localized response
,⩥ The nurse is providing teaching for a client on dietary intake and
anaphylaxis. Which food should the nurse identify that trigger
anaphylaxis in a sensitized individual? SATA.
Answer: Chocolate and Grains
Rationale: The foods that are associated with anaphylaxis in a sensitized
individual include grains and chocolate. Milk, fish, and coconut oil are
not associated with anaphylaxis in a sensitized individual; however,
eggs, seafood, and cottonseed oil are.
⩥ The nurse is teaching a group of clients with allergies to foods and a
history of asthma about the risk factors for the development of
anaphylaxis. The nurse identifies which age group as having the highest
risk for the development and severity of anaphylaxis?.
Answer: Older adult
Rationale: All individuals with allergies to food and asthma may have an
increased risk for the development of an anaphylactic reaction, with
older adults having a greater risk. In the US, food allergies are estimated
to affected approximately 48.5% of children 0-18 years and are the most
common trigger of anaphylaxis in this age group. Teenagers with food
allergies have the highest risk for an allergic reaction because they have
a greater tendency to eat meals outside the home and are less likely to
carry their medication.
, ⩥ The nurse is providing discharge teaching for a teenage who has
experienced anaphylaxis to a food allergy. Which statement by the nurse
addresses the most common risk factor for an allergic reaction in a
teenager?.
Answer: Monitor what you are eating outside the home
Rationale: One of the most common risk factors for a teenager with a
good allergy that contributes to an allergic reaction is the tendency to eat
meals outside the home. The client should avoid foods that are
associated with allergic reactions. The client should be instructed on
how to use an EpiPen as well as the importance of follow-up care after a
reaction has occurred.
⩥ The nurse is caring for a client who requires a course of oral steroids
more than once a year for the treatment of asthma related allergens.
Which alternative therapy should the nurse anticipate being prescribed
for the client to avoid the frequent use of steroids?.
Answer: Immunotherapy
Rationale: Immunotherapy is used primarily for allergic asthma related
to inhaled allergens that have required oral steroids more than once a
year. Omalizumab is approved for use by clients with steroid-dependent
asthma and high IgE values who have not achieved adequate results with
immunotherapy. Plasmapheresis is the removal of harmful components
in the plasma and may be used to treat immune complex responses.
Antihistamines are not effective in relieving asthmatic responses to
EVALUATION EXAMS WITH WELL
ELABORATED ANSWERS WITH
RATIONALES 100 PERCENT CORRECT FULL
SOLUTION ALREADY PASSED
⩥ A client is noted to have type I (IgE-mediated) hypersensitivity
reaction with a systemic response. Which clinical manifestation should
the nurse anticipate? SATA.
Answer: Wheezing, urticaria, hypotension, stridor
Rationale: Anaphylaxis is a systemic, type I response. Some signs of
anaphylaxis are wheezing, stridor, urticaria, and hypotension. Allergic
rhinitis is a sign of a less serious, local type I response.
⩥ Which hypersensitivity reaction releases enzymes that increase tissue
damage?.
Answer: Type III
Rationale: A type III reaction occurs when neutrophils attempt to
phagocytize the immune complexes, and enzymes are released tat
increase tissue damage. A type I response is triggered when an allergen
interacts with IgE, which is bound to mast cells and basophils. A type II
reaction is a hemolytic transfusion reaction caused by blood in
,capability. A type IV reaction is an exaggerated interaction between an
antigen and the normal cell-mediated mechanism
⩥ Which is the nurse's priority action when managing a client
experiencing a type I hypersensitivity?.
Answer: Airway management
Rationale: Airway management is a priority with a client experiencing a
type I hypersensitivity. A fever is a symptom of a type II, III, and IV
hypersensitivity. Arthralgia is symptom associated with serum sickness,
a type III hypersensitivity. A blood transfusion is the result of a type II
hypersensitivity.
⩥ How are the systemic type I IgE-mediated responses initiated?.
Answer: Allergens are absorbed in the GI mucosa
Rationale: Systemic IgE responses can occur when the GI mucosa is
altered by a local allergic response, then the allergen may be absorbed,
and the resulting reaction may be systemic. IgE is produced by plasma
cells located in lymph. IgE attach to mast cells in body tissues. Contact
of allergens with IgE in the bronchial and conjunctival tissues results in
a localized response
,⩥ The nurse is providing teaching for a client on dietary intake and
anaphylaxis. Which food should the nurse identify that trigger
anaphylaxis in a sensitized individual? SATA.
Answer: Chocolate and Grains
Rationale: The foods that are associated with anaphylaxis in a sensitized
individual include grains and chocolate. Milk, fish, and coconut oil are
not associated with anaphylaxis in a sensitized individual; however,
eggs, seafood, and cottonseed oil are.
⩥ The nurse is teaching a group of clients with allergies to foods and a
history of asthma about the risk factors for the development of
anaphylaxis. The nurse identifies which age group as having the highest
risk for the development and severity of anaphylaxis?.
Answer: Older adult
Rationale: All individuals with allergies to food and asthma may have an
increased risk for the development of an anaphylactic reaction, with
older adults having a greater risk. In the US, food allergies are estimated
to affected approximately 48.5% of children 0-18 years and are the most
common trigger of anaphylaxis in this age group. Teenagers with food
allergies have the highest risk for an allergic reaction because they have
a greater tendency to eat meals outside the home and are less likely to
carry their medication.
, ⩥ The nurse is providing discharge teaching for a teenage who has
experienced anaphylaxis to a food allergy. Which statement by the nurse
addresses the most common risk factor for an allergic reaction in a
teenager?.
Answer: Monitor what you are eating outside the home
Rationale: One of the most common risk factors for a teenager with a
good allergy that contributes to an allergic reaction is the tendency to eat
meals outside the home. The client should avoid foods that are
associated with allergic reactions. The client should be instructed on
how to use an EpiPen as well as the importance of follow-up care after a
reaction has occurred.
⩥ The nurse is caring for a client who requires a course of oral steroids
more than once a year for the treatment of asthma related allergens.
Which alternative therapy should the nurse anticipate being prescribed
for the client to avoid the frequent use of steroids?.
Answer: Immunotherapy
Rationale: Immunotherapy is used primarily for allergic asthma related
to inhaled allergens that have required oral steroids more than once a
year. Omalizumab is approved for use by clients with steroid-dependent
asthma and high IgE values who have not achieved adequate results with
immunotherapy. Plasmapheresis is the removal of harmful components
in the plasma and may be used to treat immune complex responses.
Antihistamines are not effective in relieving asthmatic responses to
