Nokea
Alex Rowe develops hives after having eaten strawberries. He states he has strawberries before, and has never had a problem with them before. This is an example of:
- A. an idiosyncratic response to food.
- B. an autoimmune disorder.
- C. a Type I hypersensitivity response.
- D. an example of immunosuppression.
Correct Answer: C
Rationale: Idiosyncratic response means it occurs because of an unknown reason. This response to something the body has been exposed to before is not unknown. Autoimmune disorders are ones in which the body attacks self-cells. This example is an outside antigen. Type I hypersensitivities are those that occur when the body, previously sensitized to a substance, is then exposed a second time and reacts. Immunossuppression occurs when the immune system is not working. Mr. Rowe's immune system responded to the antigen, so it is not suppressed.
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A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed
occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?
- A. "We can teach you some relaxation techniques to minimize your pain."
- B. "Keep wire cutters with you at all times."
- C. "Use a water pick device to keep your teeth clean."
- D. "Consume a high-protein, liquid diet."
Correct Answer: B
Rationale: The correct answer is B: "Keep wire cutters with you at all times." This is the priority statement because in the event of an emergency, such as airway obstruction or trauma, quick access to wire cutters is crucial to ensure timely removal of the jaw fixation wires. Without immediate access to wire cutters, the client may suffer serious complications.
Incorrect choices:
A: "We can teach you some relaxation techniques to minimize your pain." - While pain management is important, it is not the priority in this situation where the immediate risk is airway compromise.
C: "Use a water pick device to keep your teeth clean." - Oral hygiene is important but not as critical as ensuring access to wire cutters for emergency situations.
D: "Consume a high-protein, liquid diet." - Nutrition is important for healing but is not as time-sensitive as having wire cutters readily available in case of an emergency.
During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow to normal breaths alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A because Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea. This pattern reflects an abnormal breathing cycle that is often seen in end-of-life care or in patients with severe neurological problems.
Choice B is incorrect because it describes a pattern of shallow to normal breaths alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations.
Choice C is incorrect as it describes rapid respirations that are unusually deep and regular, which is not consistent with the pattern of Cheyne-Stokes respirations.
Choice D is also incorrect because it describes an inability to breathe without dyspnea unless sitting upright, which is not a characteristic of Cheyne-Stokes respirations.
Which type of shock has the highest mortality rate?
- A. Neurogenic shock
- B. Anaphylactic shock
- C. Hypovolemic shock
- D. Septic shock
Correct Answer: D
Rationale: Septic shock has a high mortality rate due to systemic inflammation and multiorgan dysfunction.
You are taking histories from several clients who report vertigo. Which client report concerns you the most?
- A. Vertigo with hearing loss
- B. Episodic vertigo
- C. Vertigo without hearing loss
- D. Merry-go-round' vertigo
Correct Answer: A
Rationale: Vertigo accompanied by hearing loss may indicate Meniere's disease or other serious inner ear disorders requiring prompt evaluation.
Which value shows the normal range of plasma pH?
- A. 7.35 to 7.45
- B. 6.35 to 6.45
- C. 7 to 8
- D. 8.35 to 8.45
Correct Answer: A
Rationale: The normal range of plasma pH is 7.35 to 7.45, which indicates a slightly alkaline environment essential for proper cellular function.