Nokea
When a patient asks the nurse what hypersensitivity is, how should the nurse respond? Hypersensitivity is best defined as:
- A. A reduced immune response found in most pathologic states
- B. A normal immune response to an infectious agent
- C. An excessive or inappropriate response of the immune system to a sensitizing antigen
- D. Antigenic desensitization
Correct Answer: C
Rationale: Hypersensitivity is correctly defined as an excessive or inappropriate response of the immune system to a sensitizing antigen. This response leads to tissue damage or other clinical manifestations. Choice A is incorrect as hypersensitivity involves an exaggerated, not a reduced, immune response. Choice B is incorrect because hypersensitivity is not a normal immune response to an infectious agent but rather an exaggerated one. Choice D is incorrect as it refers to desensitization, which is the opposite of hypersensitivity.
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What aspect of hormonal contraceptives places a woman at the greatest risk for the development of blood clots?
- A. Hormonal contraceptives increase serum triglyceride and cholesterol levels.
- B. Hormonal contraceptives increase platelet levels.
- C. Hormonal contraceptives increase blood levels of clotting factors.
- D. Hormonal contraceptives cause injury to blood vessel linings.
Correct Answer: C
Rationale: The correct answer is C. Hormonal contraceptives increase blood levels of clotting factors, particularly factors II, VII, IX, and X. This elevation in clotting factors can predispose individuals to thromboembolic events, including blood clots. Choices A, B, and D are incorrect because hormonal contraceptives do not have a significant effect on serum triglycerides and cholesterol, platelet levels, or causing direct injury to blood vessel linings as the primary mechanism for clot formation.
A patient is prescribed sildenafil (Viagra) for erectile dysfunction. What critical contraindication should the nurse review with the patient?
- A. Use of nitrates
- B. Use of antihypertensive medications
- C. History of hypertension
- D. History of peptic ulcer disease
Correct Answer: A
Rationale: The correct answer is A: Use of nitrates. Sildenafil (Viagra) is contraindicated in patients taking nitrates due to the risk of severe hypotension. Nitrates and sildenafil both cause vasodilation, which can lead to a dangerous drop in blood pressure. Choice B (Use of antihypertensive medications) is incorrect because antihypertensive medications are not a critical contraindication for sildenafil use. Choice C (History of hypertension) is incorrect as it is not a contraindication for sildenafil; in fact, sildenafil is sometimes used in patients with hypertension. Choice D (History of peptic ulcer disease) is also incorrect as it is not a critical contraindication for sildenafil use.
When teaching a patient starting on oral contraceptives, what should the nurse include regarding the medication's effectiveness?
- A. Oral contraceptives are 100% effective when taken correctly.
- B. Oral contraceptives are effective immediately after starting.
- C. Oral contraceptives are less effective if taken with certain antibiotics.
- D. Oral contraceptives are less effective if taken with food.
Correct Answer: C
Rationale: The correct answer is C. Oral contraceptives can be less effective when taken with certain antibiotics as they may interfere with the effectiveness of the contraceptive. It is important for patients to be aware of this interaction to consider additional contraceptive methods during antibiotic therapy. Choices A and B are incorrect as no contraceptive method is 100% effective, and oral contraceptives typically require a period of time to reach full effectiveness. Choice D is incorrect as taking oral contraceptives with food does not significantly impact their effectiveness.
When assessing for potential signs and symptoms of cryptococcosis in a patient with HIV being treated with Amphotericin B, the nurse should prioritize what assessment?
- A. Neurological assessment
- B. Functional assessment
- C. Nutritional assessment
- D. Cardiac assessment
Correct Answer: A
Rationale: In a patient with cryptococcosis and HIV, neurological assessment should be prioritized because cryptococcosis commonly affects the central nervous system, leading to symptoms such as headache, confusion, and altered mental status. This assessment is crucial in monitoring for any neurological complications and guiding appropriate interventions. Functional assessment focuses on the patient's ability to perform activities of daily living and is not directly associated with cryptococcosis. Nutritional assessment is important for overall health but is not the priority when assessing for cryptococcosis. Cardiac assessment is not a priority in cryptococcosis as the primary manifestations are related to the central nervous system.
A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?
- A. Evaluate the client's gag reflex.
- B. Assess the client's bowel sounds.
- C. Check the client's pupil reaction.
- D. Monitor the client's heart rate.
Correct Answer: A
Rationale: The correct answer is to evaluate the client's gag reflex. When a client has experienced a stroke resulting in severe hemiparesis, assessing the gag reflex is crucial before allowing them to eat or drink. This assessment helps prevent aspiration, a serious complication that can occur due to impaired swallowing ability. Assessing bowel sounds (Choice B), pupil reaction (Choice C), or heart rate (Choice D) are important assessments but are not the priority in this situation where the risk of aspiration is higher.