Nokea
ICU patient with DIC from gram-negative infection. Which finding has immediate implications?
- A. No palpable radial/pedal pulse
- B. Complains of chest pain
- C. Oxygen saturation 87%
- D. Mottling of hands and feet
Correct Answer: A
Rationale: The correct answer is A because the absence of palpable radial/pedal pulses indicates poor perfusion, a critical concern in DIC. This finding suggests compromised blood flow, requiring urgent intervention to prevent tissue damage. Choices B, C, and D are not immediate concerns in DIC. Chest pain may indicate cardiac issues, but perfusion is the priority. Oxygen saturation at 87% is low but not as urgent as impaired perfusion. Mottling of hands and feet is a sign of poor perfusion but not as immediate as the absence of palpable pulses.
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The nurse has identified Ineffective Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC). What intervention would be appropriate for the client?
- A. Carefully repositioning the client every 2 hours
- B. Administering oxygen
- C. Monitoring oxygen saturation
- D. Encouraging deep breathing and coughing
Correct Answer: C
Rationale: The correct answer is C: Monitoring oxygen saturation. In DIC, there is impaired blood flow leading to inadequate perfusion of tissues. Monitoring oxygen saturation is crucial to assess tissue perfusion and ensure adequate oxygen delivery. This intervention directly addresses the underlying problem of ineffective tissue perfusion by evaluating the effectiveness of oxygenation. Repositioning the client every 2 hours (choice A) may help prevent pressure ulcers but does not directly address tissue perfusion. Administering oxygen (choice B) and encouraging deep breathing and coughing (choice D) may be beneficial but do not specifically target monitoring the client's oxygen saturation to evaluate tissue perfusion.
A client has come into the free clinic asking to be tested for human immunodeficiency virus (HIV)infection. The client asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the acquired immunodeficiency syndrome (AIDS) virus are present in the blood, this indicates that the client has which of the following?
- A. Immunity to HIV
- B. An intact immune system
- C. An AIDS-related complication
- D. An HIV infection
Correct Answer: D
Rationale: The correct answer is D: An HIV infection. The presence of antibodies to the AIDS virus in the blood indicates that the client has been exposed to HIV and their immune system has produced antibodies against it. This does not mean the client is immune to HIV (choice A) as HIV infection can still occur. It also does not necessarily mean the immune system is intact (choice B) as the presence of antibodies can indicate exposure to the virus. Additionally, the presence of antibodies does not indicate the client has an AIDS-related complication (choice C) as AIDS is a later stage of HIV infection.
During the maturation of a B lymphocyte, the first immunoglobulin heavy chain synthesized is the
- A. Mu chain
- B. gamma chain
- C. epsilon chain
- D. alpha chain
Correct Answer: A
Rationale: The correct answer is A: Mu chain. During B lymphocyte maturation, the first immunoglobulin heavy chain synthesized is the Mu chain. This is because the Mu chain is the first heavy chain isotype expressed during early B cell development. The Mu chain combines with the surrogate light chain to form the pre-B cell receptor, which is essential for signaling in pre-B cells. The Mu chain is later replaced by other heavy chain isotypes such as gamma, epsilon, and alpha during B cell differentiation. Therefore, the Mu chain is the correct answer as it is the initial heavy chain produced in B cell maturation. Choices B, C, and D are incorrect because they represent heavy chain isotypes that are expressed at later stages of B cell development and differentiation.
Scientific studies have indicated that there is a higher percentage of allergies in babies fed formula containing cow's milk than in breast-fed babies. Which statement represents a valid inference made from these studies?
- A. Milk from cows causes allergic reactions in all infants.
- B. Breast feeding prevents all allergies from occurring.
- C. There is no relationship between drinking cow's milk and having allergies.
- D. Breast milk most likely contains fewer substances that trigger allergies.
Correct Answer: D
Rationale: Rationale for Answer D:
1. Scientific studies show higher allergies in cow's milk-fed babies.
2. Breast milk is the alternative in this scenario.
3. Breast milk is generally considered hypoallergenic.
4. Breast milk contains fewer potential allergens.
5. Thus, breast milk most likely contains fewer allergy triggers.
Summary:
A: Overgeneralization, not all infants react to cow's milk.
B: Absolute statement, breast milk is not 100% effective against all allergies.
C: Contradicts scientific findings, relationship exists between cow's milk and allergies.
Which medication is a corticosteroid?
- A. Prednisone
- B. Methotrexate
- C. Hydroxychloroquine
- D. Leflunomide
Correct Answer: A
Rationale: Prednisone is a corticosteroid because it belongs to the class of medications that mimic the actions of corticosteroid hormones produced by the adrenal glands. Corticosteroids have anti-inflammatory and immunosuppressive properties, making them effective for treating various conditions like asthma, arthritis, and autoimmune diseases. Methotrexate, Hydroxychloroquine, and Leflunomide are not corticosteroids; they belong to different classes of medications used for managing conditions like rheumatoid arthritis but work through different mechanisms of action.