Nokea
What type of immunity occurs when a person has an infectious, communicable disease like the measles?
- A. Adaptive immunity
- B. Passive natural immunity
- C. Active natural immunity
- D. Active artificial immunity
Correct Answer: C
Rationale: Active natural immunity occurs when a person develops immunity after exposure to an infectious disease like measles, producing antibodies through natural infection.
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Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply.
- A. Remove any dentures.
- B. Remove contact lenses.
- C. Provide access to limited food and drink.
- D. Ensure that the informed consent is signed.
- E. Have the client void before transport to endoscopy.
Correct Answer: A,B,D,E
Rationale: If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.
The charge nurse determines that the new nurse understands the concepts associated with suicide and suicide intentions when the new nurse makes which statement?
- A. Only the psychotic individual commits suicide.
- B. Suicidal attempts are attention-seeking behaviors.
- C. Suicide runs in the family, so there is nothing that health care personnel can do about it.
- D. Many individuals who commit suicide have talked about their suicidal intentions to others.
Correct Answer: D
Rationale: Most people who do commit suicide have given definite clues or warnings about their intentions. The individual who is suicidal is not necessarily psychotic. A suicide attempt is not an attention-seeking behavior, and each act should be taken very seriously. Suicide is not an inherited condition. The remaining options are considered myths regarding suicide.
You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: C
Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.
What condition should the nurse assess a client diagnosed with pernicious anemia for? Select all that apply.
- A. Weakness
- B. Constipation
- C. Shortness of breath
- D. Dusky lips and gums
- E. Smooth, sore, red tongue
Correct Answer: A,E
Rationale: Classic clinical indicators of pernicious anemia include weakness; mild diarrhea; and a smooth, sore, red tongue. The client may also have neurological findings, such as paresthesias, confusion, and difficulty with balance. Constipation is not a common finding with pernicious anemia. Pernicious anemia does not affect tissue oxygenation, so the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.
A client at 12 weeks' gestation tells the nurse that she is a vegetarian and eats 'lots of rice.' To help meet the client's need for protein during pregnancy, the nurse suggests that the client combine the rice with which of the following?
- A. Beans.
- B. Soy milk.
- C. Yogurt.
- D. Corn.
Correct Answer: A
Rationale: Combining rice with beans provides a complete protein, meeting the increased protein needs during pregnancy.