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Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
- A. Age-related changes
- B. Use of multiple drugs (Polypharmacy)
- C. Poor diet
- D. Reduced activity levels
Correct Answer: A
Rationale: The correct answer is A: Age-related changes. Older clients are more susceptible to immune system disorders due to age-related changes such as a weakened immune response, increased inflammation, and decreased production of immune cells. Providing special care is important to address these specific vulnerabilities.
Incorrect choices:
B: Use of multiple drugs (Polypharmacy) - While polypharmacy can impact the immune system, it is not the primary factor for providing special care to older clients with immune system disorders.
C: Poor diet - While diet plays a role in overall health, it is not the main factor necessitating special care for older clients with immune system disorders.
D: Reduced activity levels - Although physical activity is important for overall health, reduced activity levels are not the primary reason for providing special care to older clients with immune system disorders.
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The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms SLE?
- A. Increased total serum complement levels
- B. An above-normal anti-deoxyribonucleic
- C. Negative antinuclear antibody test acid
- D. Negative lupus erythematosus cell test
Correct Answer: B
Rationale: The correct answer is B: An above-normal anti-deoxyribonucleic acid. In SLE, the body produces antibodies against its own DNA, leading to the presence of anti-dsDNA antibodies. Elevated levels of anti-dsDNA antibodies are specific to SLE, confirming the diagnosis.
A: Increased total serum complement levels are seen in SLE due to complement activation but are not specific to SLE.
C: Negative antinuclear antibody test is not consistent with SLE, as ANA positivity is common in SLE.
D: Negative lupus erythematosus cell test is not specific to SLE as lupus erythematosus cells are not always present.
A 70-year old male diagnosed with BPH (benign prostatic hyperplasia) asks the nurse about his disease. The best response would be:
- A. “It an be caused by chronic infection of the urinary tract.”
- B. “It was caused by your chronic cigarette smoking.”
- C. “As you age, hormonal imbalances are the more likey cause of your disease.”
- D. “Chronic obstruction of the bladder due to stone can cause BPH.”
Correct Answer: C
Rationale: The correct answer is C. Hormonal imbalances are the primary cause of BPH in aging males. As men age, testosterone levels decrease and estrogen levels may increase relative to testosterone, leading to prostate gland growth. This is why hormonal imbalances are more likely the cause of BPH in older males.
Explanation of other choices:
A: Chronic infection of the urinary tract does not directly cause BPH, although it can lead to similar symptoms such as urinary frequency and urgency.
B: Chronic cigarette smoking is not a direct cause of BPH, although it can contribute to overall prostate health and exacerbate symptoms.
D: Chronic obstruction of the bladder due to stone is a separate condition from BPH, although it can cause similar urinary symptoms.
Which information indicates a nurse has a good understanding of a goal? It is a statement describing the patient’s accomplishments without a time
- A. restriction.
- B. It is a realistic statement predicting any negative responses to treatments.
- C. It is a broad statement describing a desired change in a patient’s behavior.
- D. It is a measurable change in a patient’s physical state.
Correct Answer: D
Rationale: Step 1: A goal should be measurable to track progress effectively.
Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome.
Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound.
Step 4: Other choices lack the specificity and measurability required for a clear goal.
Step 5: Choice A talks about restriction, which is not directly related to understanding a goal.
Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal.
Step 7: Choice C is vague and lacks the specificity of a measurable outcome.
Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
- A. Perform dressing changes twice a day as ordered.
- B. Teach the patient about signs and symptoms of infection.
- C. Instruct the family about how to perform dressing changes.
- D. Gently refocus patient from discussing body image changes.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Dressing changes twice a day help maintain a clean wound environment, reducing the risk of infection.
2. Regular dressing changes promote proper wound healing by facilitating moisture balance and removal of dead tissue.
3. It is a direct intervention that addresses the patient's poor wound healing.
4. Teaching the patient about signs of infection (B) is important but does not directly address the wound healing process.
5. Instructing the family on dressing changes (C) is helpful but should not substitute direct patient care.
6. Refocusing the patient from body image changes (D) is not directly related to improving wound healing.
Which of the ff factors predisposes a client to the development of TB?
- A. Exposure to toxic gases
- B. Congenital abnormalities
- C. Obstruction by tumor
- D. Malnutrition
Correct Answer: D
Rationale: The correct answer is D: Malnutrition. Malnutrition weakens the immune system, making individuals more susceptible to contracting tuberculosis. A well-nourished individual has a stronger immune response to fight off TB bacteria. Exposure to toxic gases (A), congenital abnormalities (B), and obstruction by tumor (C) do not directly predispose a client to TB. Malnutrition is the key factor as it impairs the immune system's ability to combat the TB bacteria effectively.