Nokea
The nurse is beginning the physical examination of a client who has reported fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
- A. The client appears mildly ill, listless, and disheveled.
- B. The client has a blood pressure of 120/72 mm Hg.
- C. The client is alert and oriented to all spheres.
- D. The client has palpable peripheral pulses in the upper extremities.
Correct Answer: A
Rationale: The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then perform a more comprehensive examination.
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A client's immune system has the ability to protect itself from external invaders. What type of immune function is present when this occurs?
- A. Immunosuppression
- B. Immunocompetence
- C. An immune response
- D. Immune incompatibility
Correct Answer: B
Rationale: The immune system is a collection of specialized white blood cells and lymphoid tissues that maintain immunocompetence, the ability to cooperatively protect a person from external invaders and the body's own altered cells. Immunosuppression is the opposite and the white blood cells and lymphoid tissue are not able to protect a person from external invaders. An immune response, primarily involves the lymphocytes that are located in blood and lymphoid tissue. Immune incompatibility is not relevant in this situation.
The nurse has several clients scheduled for annual wellness examinations throughout the day. For which client should the nurse prepare the shingles vaccine?
- A. A 24-year-old client who is pregnant
- B. A 32-year-old client who has never had chickenpox
- C. A 65-year-old client who had chicken pox at the age of 12
- D. A 17-year-old client who will be attending college and living in a dormitory
Correct Answer: C
Rationale: The Centers for Disease Control and Prevention recommends annual seasonal influenza vaccine and pneumococcal polysaccharide vaccine (PPSV23; Pneumovax) for all adults 65 years or older or those who are at high risk, and the shingles vaccine (Zostavax) for all individuals who are over the age of 50. Based on this information, the nurse prepares to administer the shingles vaccine to the client who is 65 years of age. The other clients are not eligible to receive this vaccine until the age of 50 years.
What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction?
- A. IgG
- B. IgA
- C. IgM
- D. IgE
Correct Answer: D
Rationale: IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reactions. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.
The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?
- A. Toxins of invading antigens are neutralized.
- B. The invading antigens link together (agglutination).
- C. The invading antigens precipitate.
- D. T-cell lymphocytes survey proteins in the body and attack the invading antigens.
Correct Answer: D
Rationale: During a cell-mediated response, T-cell lymphocytes survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. For example, a cell-mediated response occurs when an organ is transplanted. Immunoglobulins hinder the antigens physically by neutralizing their toxins through agglutination or by causing them to precipitate.
What is the function of the thymus gland?
- A. Produces stem cells
- B. Programs B lymphocytes to become regulator or effector B cells
- C. Develops the lymphatic system
- D. Programs T lymphocytes to become regulator or effector T cells
Correct Answer: D
Rationale: The thymus gland is located in the neck below the thyroid gland. It extends into the thorax behind the top of the sternum. The thymus gland produces lymphocytes during fetal development. It may be the embryonic origin of other lymphoid structures such as the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to become regulator or effector T cells. The thymus gland becomes smaller during adolescence but retains some activity throughout the life cycle. The other options are incorrect.