Nokea
A client has been newly diagnosed with systemic lupus erythematosus and is reviewing self-care measures with the nurse. Which statement by the client indicates a need to review the material?
- A. I will avoid direct sunlight as much as possible.
- B. Baby powder is good for the constant sweating.
- C. Grouping errands will help prevent fatigue.
- D. Rest time will have to become a priority.
Correct Answer: B
Rationale: The correct answer is B. Baby powder is not recommended for individuals with systemic lupus erythematosus, as it can irritate the skin and worsen symptoms. A: Avoiding direct sunlight is crucial due to photosensitivity. C: Grouping errands helps conserve energy. D: Rest is important to manage fatigue. Summary: A, C, and D are all appropriate self-care measures for a client with systemic lupus erythematosus, while using baby powder is not recommended.
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A cytokine essential for clonal expansion of T cells is
- A. IL-1
- B. IL-2
- C. IL4
- D. IL-5
Correct Answer: B
Rationale: The correct answer is B: IL-2. IL-2 is essential for the clonal expansion of T cells as it promotes T cell proliferation. It is produced by activated T cells themselves and plays a crucial role in regulating immune responses. IL-1 is involved in inflammation, not T cell expansion. IL-4 is important for Th2 cell differentiation, while IL-5 is critical for eosinophil activation. In summary, IL-2 specifically promotes T cell clonal expansion, making it the correct choice in this context.
Class switching of immunoglobulins occurs
- A. Usually with booster immunizations, going from IgM to IgG
- B. binds complement
- C. causes the histamine release
- D. mediates immunoglobulin class switching
Correct Answer: A
Rationale: The correct answer is A because class switching of immunoglobulins typically occurs during an immune response, leading to the production of antibodies of different classes like IgM to IgG. This process helps enhance the immune response and memory. Choice B, binding complement, refers to the function of antibodies in the classical pathway of the complement system, not class switching. Choice C, causing histamine release, is typically associated with IgE antibodies in allergic reactions, not class switching. Choice D, mediating immunoglobulin class switching, is too vague and does not provide a clear explanation compared to choice A.
What is an example of an IV solution that would be appropriate to treat an extracellular fluid volume deficit?
- A. D5W
- B. 3% saline
- C. Lactated Ringer’s solution
- D. D5W in ½ normal saline (0.45%)
Correct Answer: C
Rationale: Lactated Ringer’s solution replenishes extracellular fluids and electrolytes effectively.
How does interferon help the body’s natural defenses?
- A. Directly attacks and destroys virus-infected cells
- B. Augments the immune response by activating phagocytes
- C. Induces production of antiviral proteins in cells that prevent viral replication
- D. Is produced by viral infected cells and prevents the transmission of the virus to adjacent cells
Correct Answer: C
Rationale: Interferons induce the production of antiviral proteins in uninfected cells, preventing viral replication and spread.
The patient is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure ulcer does the nurse expect to see on admission?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: D
Rationale: Stage IV pressure ulcers involve full-thickness tissue loss, exposing muscle, tendon, or bone.