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A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
- A. The client’s diet
- B. The client’s family member’s history of
- C. The client’s drug history chronic diseases
- D. The client’s ability to produce antibodies
Correct Answer: D
Rationale: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly.
A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function.
B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system.
C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.
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An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
- A. Risk for increased cardiac output related to fluid volume excess
- B. Disturbed sensory perception related to bleeding into tissues
- C. Alteration in tissue perfusion related to bleeding and diminished blood flow
- D. Risk for aspiration related to constriction of the respiratory musculature
Correct Answer: C
Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues.
Explanation:
1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output.
2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception.
3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body.
In summary, the correct answer is C because DIC can lead to altered tissue perfusion
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale:
1. Safety: Recording vital signs is crucial for patient safety.
2. Accountability: The nurse is ultimately responsible for ensuring vital signs are documented accurately.
3. Communication: It is essential for the nurse to communicate with the NAP to address the missed vital signs.
4. Corrective Action: Asking the NAP to record vital signs before administering medications ensures proper monitoring.
5. Patient-Centered Care: Prioritizing patient well-being by ensuring vital signs are up-to-date.
Summary:
A: Incorrect. Administering medications without vital sign assessment is unsafe.
B: Incorrect. Reviewing vital signs upon return does not address the immediate need for accurate documentation.
D: Incorrect. Omitting vital signs compromises patient safety and violates standard nursing practice.
The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse’s best response?
- A. “Yes, all pregnant women must have the test.”
- B. “If you do not have multiple sex partners or inject drugs, it is not necessary.”
- C. “Governmental guidelines require an HIV test for all pregnant woman.”
- D. “After voluntary pretest counseling, you decide whether HIV testing should be done.”
Correct Answer: A
Rationale: Rationale for Correct Answer (A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby.
Summary of Incorrect Choices:
B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors.
C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby.
D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.
A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client’s history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:
- A. Testosterone therapy during childhood
- B. Early onset of puberty
- C. Sexually transmitted disease
- D. Cryptorchidism
Correct Answer: D
Rationale: The correct answer is D: Cryptorchidism. Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer as the testicle does not descend into the scrotum during fetal development, increasing the risk of cancer development. Testosterone therapy during childhood (A) and early onset of puberty (B) are not directly linked to testicular cancer. Sexually transmitted diseases (C) typically do not increase the risk of testicular cancer. Therefore, choice D is the most relevant risk factor for testicular cancer in this scenario.
Nurse Melanie is teaching an adult class about the different types of hepatitis. Which statement does not pertain to hepatitis A?
- A. “Is caused by an RNA virus of the enterovirus family.”
- B. “It spreads primarily by fecal-oral route, usually through the ingestion of infcetd food or liquids.”
- C. “It may not be spread from sexual contact.”
- D. “Type A hepatitis occurs worldwide, especially in areas with overcrowding and poor sanitation.”
Correct Answer: A
Rationale: The correct answer is A because hepatitis A is caused by a virus from the Picornaviridae family, not the enterovirus family. Hepatitis A spreads through contaminated food or water, not through sexual contact. It is true that hepatitis A occurs worldwide in areas with poor sanitation, but the virus is not from the enterovirus family. Choices B, C, and D are incorrect because they all pertain to hepatitis A characteristics.