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The nurse is caring for a patient who just returned from surgical decompression of the carpal tunnel. Which finding requires the nurse's immediate action?
- A. The patient's fingers swollen and warm.
- B. The patient complains of generalized pain 5/10.
- C. The capillary refill time is 8 seconds.
- D. The patient's fingers are pink and cool bilaterally.
Correct Answer: C
Rationale: The correct answer is C because a capillary refill time of 8 seconds indicates poor perfusion, which could be a sign of compromised blood flow to the fingers post-surgical decompression. This finding requires immediate action to prevent complications such as ischemia or impaired wound healing.
A: Swollen and warm fingers are expected after surgery due to inflammation.
B: Generalized pain can be managed with appropriate pain relief measures and is not an immediate concern post-surgery.
D: Pink and cool fingers indicate adequate perfusion and are normal findings post-surgery.
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In a patient with a CD4 count less than 200, the most important nursing assessment would include:
- A. Bowel movements.
- B. Urinary output.
- C. Fever.
- D. Blood pressure.
Correct Answer: C
Rationale: A CD4 count below 200 indicates advanced HIV infection (AIDS), making the patient highly susceptible to opportunistic infections. Fever is a key sign of infection and requires immediate attention. Bowel movements and urinary output are less urgent priorities in this context.
Match the immunoglobulins with their primary functions:
- A. 1-C, 2-A, 3-B, 4-D
- B. 1-B, 2-C, 3-D, 4-A
- C. 1-D, 2-B, 3-C, 4-A
- D. 1-A, 2-D, 3-B, 4-C
Correct Answer: A
Rationale: The correct answer is A: 1-C, 2-A, 3-B, 4-D. Immunoglobulins are antibodies with different functions:
1. IgG (C) - Main antibody in secondary immune response.
2. IgA (A) - Found in mucosal areas, neutralizes pathogens.
3. IgM (B) - First antibody produced in primary immune response.
4. IgE (D) - Involved in allergic reactions and defense against parasites. Other choices are incorrect as they mismatch the immunoglobulins with their functions.
Which of the following is NOT a function of the immune system?
- A. Promoting wound healing
- B. Fighting cancer
- C. Increasing pathogen reproduction
- D. Eliminating cell debris
Correct Answer: C
Rationale: The correct answer is C: Increasing pathogen reproduction. The immune system's main function is to protect the body from pathogens and foreign invaders, not to promote their reproduction. A: Promoting wound healing is correct as the immune system helps in tissue repair. B: Fighting cancer is correct as the immune system plays a role in recognizing and destroying cancerous cells. D: Eliminating cell debris is correct as the immune system helps in clearing out dead or damaged cells to maintain tissue health.
Which of the following is NOT true with respect to T cell development?
- A. It establishes MHC restriction of the T cell repertoire
- B. It takes place in the thymus
- C. Thymic dendritic cells are involved
- D. It only occurs after the naïve T cell has been activated by antigen
Correct Answer: D
Rationale: The correct answer is D because T cell development starts in the thymus while the naïve T cell activation by antigen occurs outside of the thymus. T cell development involves positive and negative selection, establishing MHC restriction, and interaction with thymic dendritic cells for maturation. Naïve T cells are activated by antigens in the periphery, not during T cell development in the thymus. Therefore, D is the correct answer as it does not align with the process of T cell development.
A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?
- A. Antihistamines do not help poison ivy.
- B. There are different antihistamines to try.
- C. You should be seen in the clinic right away.
- D. You will need to take some IV steroids.
Correct Answer: C
Rationale: The correct answer is C: "You should be seen in the clinic right away." This response is appropriate because poison ivy rashes can worsen and may require prescription medications like corticosteroids. Seeing a healthcare provider ensures proper diagnosis and treatment.
A: "Antihistamines do not help poison ivy." - Incorrect, as antihistamines may provide some relief for itching but are not the primary treatment for poison ivy rashes.
B: "There are different antihistamines to try." - Incorrect, as trying different antihistamines may not address the underlying issue of poison ivy exposure.
D: "You will need to take some IV steroids." - Incorrect, as IV steroids are typically reserved for severe cases and should be prescribed by a healthcare provider after evaluation.