Nokea
A 5-year-old female takes a hike through the woods during a school field trip. Upon returning home, she hugs her father, and he later develops poison ivy. Which of the following immune reactions is he experiencing?
- A. IgE-mediated
- B. Tissue-specific
- C. Immune complex
- D. Cell-mediated
Correct Answer: D
Rationale: The father's immune reaction to poison ivy is an example of cell-mediated immunity, specifically a type IV hypersensitivity reaction. In this type of reaction, sensitized T cells react to antigens, leading to inflammation and tissue damage. IgE-mediated reactions involve antibodies of the IgE class, commonly seen in allergic responses like anaphylaxis. Tissue-specific reactions target specific organs or tissues. Immune complex reactions involve immune complexes formed by antigens and antibodies that can deposit in tissues, leading to inflammation.
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What type of immunity will the hepatitis B series provide a nursing student scheduled to receive it?
- A. Active immunity
- B. Passive immunity
- C. Innate immunity
- D. Natural immunity
Correct Answer: A
Rationale: The correct answer is active immunity. The hepatitis B series immunization will provide active immunity, where the individual's immune system is stimulated to produce antibodies against the hepatitis B virus. This type of immunity is long-lasting and provides protection against future exposures. Passive immunity (choice B) involves the transfer of pre-formed antibodies and is temporary. Innate immunity (choice C) is the body's natural defense mechanisms, present at birth. Natural immunity (choice D) refers to immunity acquired through normal life processes, such as recovering from an infection.
Innate resistance or immunity:
- A. Involves 'memory'
- B. Is a development of an individual's later years
- C. Is a relatively slow and specific process
- D. Depends on physical, mechanical, and biochemical barriers
Correct Answer: D
Rationale: Innate resistance or immunity relies on the body's natural defenses like physical, mechanical, and biochemical barriers. These barriers act as the first line of defense against pathogens and do not involve memory (choice A). Innate immunity is present from birth and does not develop over an individual's later years (choice B). Additionally, innate immunity is a rapid and nonspecific process, not a slow and specific one (choice C). Therefore, the correct answer is D.
A patient is prescribed clomiphene citrate (Clomid) for the treatment of infertility. Which of the following statements should be included in the nurse's teaching?
- A. This drug induces ovulation by stimulating gonadotropins.
- B. This drug induces ovulation by inhibiting gonadotropins.
- C. This drug suppresses ovulation by inhibiting gonadotropins.
- D. This drug increases progesterone levels, which maintains pregnancy.
Correct Answer: A
Rationale: The correct statement to include in the nurse's teaching is that clomiphene induces ovulation by stimulating the release of gonadotropins, which in turn stimulate the ovaries. Choice B is incorrect because clomiphene does not induce ovulation by inhibiting gonadotropins. Choice C is also incorrect as clomiphene does not suppress ovulation by inhibiting gonadotropins. Choice D is inaccurate as clomiphene does not directly increase progesterone levels to maintain pregnancy.
What should the nurse emphasize regarding the risks associated with hormone replacement therapy (HRT) in a patient with a history of cardiovascular disease?
- A. HRT is associated with an increased risk of cardiovascular events, including heart attack and stroke.
- B. HRT may decrease the risk of osteoporosis.
- C. HRT may improve mood and energy levels.
- D. HRT may increase the risk of venous thromboembolism.
Correct Answer: A
Rationale: The correct answer is A because hormone replacement therapy (HRT) is associated with an increased risk of cardiovascular events, including heart attack and stroke, particularly in patients with a history of cardiovascular disease. Choice B is incorrect because HRT does not decrease the risk of osteoporosis; instead, it may have adverse effects on bone health. Choice C is incorrect as the improvement in mood and energy levels is not a significant risk associated with HRT. Choice D is incorrect because while HRT may increase the risk of venous thromboembolism, the question specifically focuses on patients with a history of cardiovascular disease, where the emphasis should be on cardiovascular risks.
A client is admitted with a suspected aortic dissection. What is the priority nursing intervention?
- A. Administer antihypertensive medications as prescribed.
- B. Prepare the client for emergency surgery.
- C. Administer intravenous fluids to maintain blood pressure.
- D. Monitor the client's urine output closely.
Correct Answer: B
Rationale: The correct answer is B: Prepare the client for emergency surgery. Aortic dissection is a life-threatening emergency that often necessitates immediate surgical intervention to prevent rupture and further complications. Administering antihypertensive medications (choice A) may be necessary but is not the priority over surgical intervention. While maintaining blood pressure with intravenous fluids (choice C) is important, the urgent need for surgery takes precedence. Monitoring urine output (choice D) is essential for assessing renal function but is not the priority in this critical situation.