Nokea
A baby is born temporarily immune to the diseases to which the mother is immune. The nurse understands that this is an example of which of the following types of immunity?
- A. Naturally acquired passive immunity
- B. Naturally acquired active immunity
- C. Artificially acquired passive immunity
- D. Artificially acquired active immunity
Correct Answer: A
Rationale: In the scenario described, the baby is born with temporary immunity to diseases that the mother is immune to. This is an example of naturally acquired passive immunity, where the baby receives preformed antibodies from the mother, providing immediate protection against certain diseases. This type of immunity is passive because the baby did not produce the antibodies themselves, and it is naturally acquired as it occurs through the transfer of antibodies from the mother to the baby during pregnancy.
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Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: B
Rationale: Following laryngectomy surgery, the larynx (voice box) is removed, making it impossible for the patient to produce sound for speech. The options listed are alternative communication methods for patients post-surgery, except for using a picture board. Placing a finger over the stoma can help redirect air for speech, using a special valve can help divert air for speech as well, and learning esophageal speech involves speaking by swallowing air into the esophagus and then releasing it to create sound. Picture boards are not a common method of communication for patients following laryngectomy surgery.
An adult has been treated for pulmonary tuberculosis and is being discharged home with his wife and two young children. His wife asks how TB is passed from one person to another so she can prevent anyone from catching it. How should the nurse respond?
- A. You should wear gloves when handling his linen and bedding
- B. You should keep the windows and doors closed so as not to spread the droplets
- C. He must be careful to cough into a handkerchief that is washed in hot water or discarded
- D. Make sure to boil all water before drinking or using it
Correct Answer: C
Rationale: Tuberculosis is primarily spread through the air when an infected person coughs, sneezes, speaks, or sings, releasing bacteria-containing droplets into the air. Therefore, it is important for the individual with TB to cover their mouth and nose when coughing or sneezing to prevent the spread of the bacteria. By coughing into a disposable tissue or a handkerchief that can be washed in hot water, the risk of spreading the infection to others is significantly reduced. This measure helps minimize the transmission of the disease within the household and community.
In planning an educational session for a patient with HIV, the nurse would include which of the following as a method of transmission for HIV? i.Saliva iv.Semen ii.Tears v.Blood iii.Breast milk
- A. 1, 4, 2005
- B. 1, 2, 4, 5
- C. 3, 4, 2005
- D. All of the above
Correct Answer: C
Rationale: HIV can be transmitted through specific body fluids that contain the virus. Saliva, tears, and semen do not typically contain enough HIV to transmit the virus, so they are not considered significant modes of transmission. However, blood, breast milk, and genital fluids (such as semen) are known to contain higher levels of HIV and can lead to transmission of the virus. Therefore, the nurse would include blood, breast milk, and semen as methods of transmission for HIV during the educational session.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. "Client will lose 2lb per week on a calorie-restricted diet."
- B. "Client will exhibit no signs or symptoms of aspiration."
- C. "Client will exhibit bowel and bladder continence."
- D. "Client will exhibit alertness and orientation to person, place, and time."
Correct Answer: B
Rationale: Polymyositis is a condition that involves inflammation of the muscles, including the muscles involved in swallowing (dysphagia) and breathing. This can lead to a higher risk of aspiration, where food or fluids go into the airway instead of the esophagus. Therefore, monitoring for signs and symptoms of aspiration and ensuring the client exhibits no signs of aspiration are crucial in the care of a client with polymyositis. The other options are not directly related to the potential problems associated with polymyositis and are more general aspects of nursing care.
A nurse is formulating a clinical question for evidence-based practice. Place in order the steps the nurse should use to clarify the scope of the problem and clinical topic of interest. Begin with the first step of the process and proceed ordering the steps ending with the final step of the process. Provide answer as lowercase letters separated by commas (e.g., a, b, c, d, e).
- A. Intervention
- B. Outcome
- C. Population
- D. Time
Correct Answer: c
Rationale: Population : The first step is to clearly define the population of interest for the clinical question. Identifying the specific population will help in formulating a focused and relevant question.