Nokea
The student nurse learns that the most important function of inflammation and immunity is which purpose?
- A. The majority has bacteria of damage vaccines.
- B. Preventing any entry of foreign material
- C. Providing protection against invading organisms
- D. Regulating the process of self-tolerance
Correct Answer: C
Rationale: The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents.
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A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?
- A. Noticeable rubor
- B. Puniform learning
- C. Swelling and pain
- D. Warmth in the site
Correct Answer: B
Rationale: During the second phase of the inflammatory response, neutrophilia occurs, producing pus, which is assessed as purulent drainage or 'puniform learning' in the context of the question.
A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?
- A. Assessing vaccination records for booster shot needs
- B. Encouraging the client to eat a nutritious diet
- C. Instructing the client to wash minor wounds carefully
- D. Teaching hand hygiene to prevent the spread of microbes
Correct Answer: A
Rationale: Older adults may have insufficient antibodies against microbes to which they have been exposed. Assessing vaccination records ensures they receive necessary booster shots to maintain immunity.
Which are steps in the process of making an antigen-specific antibody?
- A. Antibody-antigen binding
- B. Invasion
- C. Opsonization
- D. Recognition
- E. Sensitization
Correct Answer: A,B,D,E
Rationale: The process of making antigen-specific antibodies includes exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is a separate process where antibodies mark antigens for destruction.
The student nurse is learning about the functions of different antibodies. Which principles does the student learn?
- A. IgD is found in high concentrations in secretions from mucous membranes
- B. IgD is present in the highest concentrations in mucous membranes
- C. IgE is associated with antibody-mediated hypersensitivity reactions
- D. IgE is present in the majority of the antibody-mediated population
- E. IgE is present in the majority of the antibody-mediated population
- F. IgE is present in the majority of the antibody-mediated population
- G. IgE is present in the majority of the antibody-mediated population
Correct Answer: C
Rationale: IgE is associated with antibody-mediated hypersensitivity reactions, such as allergic responses, due to its role in triggering mast cell degranulation.
An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best?
- A. Administer pneumonia vaccination
- B. Recognize the client may have a false negative TB test
- C. Teach the client about viral infections
- D. Treat the client as if he or she has tuberculosis (TB)
- E. Tell the client to rest and drink plenty of fluids
Correct Answer: D
Rationale: Due to age-related decreases in T lymphocytes, older adults may have a falsely negative TB test. Given symptoms suggestive of TB, the nurse should treat the client as if they have TB.