A mother brings her children into the clinic and they are diagnosed with chickenpox. The mother had chickenpox as a child and is not concerned with contracting the disease when caring for her children. what type of immunity does this mother have?
- A. Active natural immunity
- B. Passive artificial immunity
- C. Passive natural immunity
- D. Active artificial immunity
Correct Answer: A
Rationale: The correct answer is A: Active natural immunity. The mother had chickenpox as a child, which triggered her immune system to produce antibodies, providing long-lasting protection. This is an example of active immunity because her immune system actively responded to the pathogen.
Summary:
B: Passive artificial immunity - This involves receiving pre-made antibodies, not produced by the individual's immune system.
C: Passive natural immunity - This is acquired through placental transfer or breastfeeding, not through prior exposure to the pathogen.
D: Active artificial immunity - This is acquired through vaccination, not through natural exposure to the pathogen.
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A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is supported by the subjective data provided. Choice A is incorrect because fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming all previous medications is not related to the patient's fear of going home. Choice D is incorrect as the subjective data does not provide any information about the success of the surgery.
A patient is being given Digoxin to treat heart failure. Which of the ff. is a usual adult daily dosage of digoxin (Lanoxin)?
- A. 0.005 mg
- B. 0.025 mg
- C. 0.25 mg
- D. 2.5 mg
Correct Answer: C
Rationale: Rationale:
C: 0.25 mg is the correct daily dosage of Digoxin for adults with heart failure. This dosage is within the usual range of 0.125-0.25 mg. It helps improve heart function and manage heart failure symptoms.
A: 0.005 mg is too low and ineffective.
B: 0.025 mg is also too low for therapeutic effect.
D: 2.5 mg is too high and may lead to toxicity in most adult patients.
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
- A. An example of inappropriate euphoria characteristic of the disease process f. A reflection of coping mechanisms used to deal with the exacerbation of her illness g. Indicative of the remission phase of her chronic illness h. Realistic for her current level of physical functioning
Correct Answer: B
Rationale: Step 1: The scenario describes Toni minimizing her visual problems, planning advanced degrees, seeking full-time jobs, and wanting more children.
Step 2: Choice B is correct because it recognizes Toni's behavior as a coping mechanism to deal with her illness.
Step 3: Minimizing visual problems and focusing on future goals can be a way for Toni to maintain a positive outlook and cope with her challenges.
Step 4: Choices A, C, and D are incorrect because they do not address Toni's behavior as a coping mechanism. Choice A mentions euphoria, which is not supported by the scenario. Choice C and D do not acknowledge Toni's coping mechanism but instead focus on different aspects like disease process and physical functioning.
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.
Before administering a food feeding the nurse knows to perform which of the following assessments/
- A. The GI tract, including bowel sounds, last BM, and distention
- B. The client’s neurologic status, especially the gag reflex
- C. The amount of air in the stomach
- D. That the formula is used directly from the refrigerator
Correct Answer: A
Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.
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