What equipment should the nurse prepare for the primary care provider when a woman says she is concerned about possible Chlamydia infection?
- A. Chlamydia slide
- B. Chlamydia collection kit
- C. Chlamydia swab
- D. Chlamydia wet mount
Correct Answer: B
Rationale: When a woman expresses concerns about a possible Chlamydia infection, the nurse should prepare a Chlamydia collection kit for the primary care provider. This kit typically includes everything needed to collect a specimen for testing, such as a swab for the patient to provide a genital sample. This sample can then be sent to a laboratory for testing to confirm the presence of Chlamydia. Having the appropriate collection kit ready ensures that the primary care provider can promptly gather the necessary information to make an accurate diagnosis and provide appropriate treatment if needed.
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Which of the following is the humoral immune response?
- A. B cells phagocytise the foreign antigen
- B. T cells are stimulated by B cells and turn into plasma cells, which produce antibodies or memory cells.
- C. B cells are stimulated by T helper cells or macrophages and turn into plasma cells, which produce antibodies or memory cells.
- D. T cells produce antibodies.
Correct Answer: C
Rationale: The humoral immune response involves the activation of B cells, which are stimulated by T helper cells or macrophages. When B cells are activated, they differentiate into plasma cells that produce antibodies specific to the foreign antigen. These antibodies can neutralize pathogens, tag them for destruction by other immune cells, or activate the complement system. In addition to producing antibodies, memory B cells are also generated during this process, providing long-lasting immunity upon re-exposure to the same antigen. This coordinated response is an essential part of the adaptive immune system's defense mechanism against foreign invaders.
Which of the ff conditions is evident by persistent hoarseness?
- A. Bacterial infection
- B. Aphonia
- C. Laryngeal cancer
- D. Peritonsillar abscess
Correct Answer: C
Rationale: Persistent hoarseness is often a symptom of laryngeal cancer. Laryngeal cancer affects the voice box, leading to changes in voice quality, such as hoarseness. It is important to seek medical evaluation if hoarseness lasts for more than two weeks, as early detection and treatment of laryngeal cancer can improve outcomes. Bacterial infection, aphonia (loss of voice), and peritonsillar abscess are not typically associated with persistent hoarseness as a primary symptom.
A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She's fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?
- A. Deficient fluid volume related to inability to conserve water
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolic state
- C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
- D. Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency
Correct Answer: C
Rationale: The client's elevated sodium level of 152 mEq/L indicates hypernatremia, which can lead to osmotic diuresis, causing excessive urination and subsequent fluid loss. This fluid loss can result in deficient fluid volume. The client's symptoms of frequent urination, fatigue from lack of sleep, and weight loss are indicative of dehydration due to the osmotic diuresis. Therefore, the most appropriate nursing diagnosis for this client is Deficient fluid volume related to osmotic diuresis induced by hypernatremia.
When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?
- A. A normal finding
- B. An abnormal finding
- C. A normal finding only in the older adult
- D. An abnormal finding only in the older adult
Correct Answer: A
Rationale: A Darwin tubercle is a small, painless, hereditary nodule located on the helix of the ear. It is a normal anatomical variation and is present in varying degrees in the general population, regardless of age. Therefore, it would be documented as a normal finding during the assessment of the external ear.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
- A. Self-care deficient: Bathing/hygiene
- B. Dysfunctional grieving
- C. Ineffective cerebral tissue perfusion
- D. Risk for injury
Correct Answer: C
Rationale: The nursing diagnosis that takes the highest priority for a client in a late stage of AIDS with signs of AIDS-related dementia is Ineffective cerebral tissue perfusion. This diagnosis is prioritized because AIDS-related dementia is associated with changes in brain function due to HIV affecting the brain tissues. Ensuring adequate cerebral perfusion is crucial to maintaining brain function and preventing further deterioration. Monitoring and addressing any factors that could affect cerebral perfusion, such as blood pressure, oxygenation, and circulation, are essential in managing this condition. Other nursing diagnoses are also important, but addressing ineffective cerebral tissue perfusion should be the highest priority in this situation to prevent further complications related to neurological function.