Nokea
When administering an immunization, which of the following medications should be available?
- A. Diphenhydramine (Benadryl)
- B. Hydroxyzine (Vistaril)
- C. Physostigmine
- D. Epinephrine
Correct Answer: D
Rationale: When administering an immunization, it is essential to have epinephrine available in case of an allergic reaction such as anaphylaxis. Epinephrine is the medication of choice for treating severe allergic reactions due to its ability to reverse the symptoms rapidly. Diphenhydramine and hydroxyzine are antihistamines that can help manage mild allergic reactions but are not the primary medications for severe reactions like anaphylaxis. Physostigmine is not indicated for managing allergic reactions and is used for specific conditions such as anticholinergic toxicity.
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When a patient asks the nurse what hypersensitivity is, how should the nurse respond? Hypersensitivity is best defined as:
- A. A reduced immune response found in most pathologic states
- B. A normal immune response to an infectious agent
- C. An excessive or inappropriate response of the immune system to a sensitizing antigen
- D. Antigenic desensitization
Correct Answer: C
Rationale: Hypersensitivity is correctly defined as an excessive or inappropriate response of the immune system to a sensitizing antigen. This response leads to tissue damage or other clinical manifestations. Choice A is incorrect as hypersensitivity involves an exaggerated, not a reduced, immune response. Choice B is incorrect because hypersensitivity is not a normal immune response to an infectious agent but rather an exaggerated one. Choice D is incorrect as it refers to desensitization, which is the opposite of hypersensitivity.
A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?
- A. Evaluate the client's gag reflex.
- B. Assess the client's bowel sounds.
- C. Check the client's pupil reaction.
- D. Monitor the client's heart rate.
Correct Answer: A
Rationale: The correct answer is to evaluate the client's gag reflex. When a client has experienced a stroke resulting in severe hemiparesis, assessing the gag reflex is crucial before allowing them to eat or drink. This assessment helps prevent aspiration, a serious complication that can occur due to impaired swallowing ability. Assessing bowel sounds (Choice B), pupil reaction (Choice C), or heart rate (Choice D) are important assessments but are not the priority in this situation where the risk of aspiration is higher.
Which immunoglobulin is the first to appear in response to a new antigen?
- A. IgA
- B. IgG
- C. IgE
- D. IgM
Correct Answer: D
Rationale: The correct answer is IgM. IgM is the first immunoglobulin to appear in response to a new antigen. It is produced initially during the primary immune response. IgA is mainly found in mucosal areas and secretions. IgG is produced in a secondary immune response and is the most abundant immunoglobulin in the bloodstream. IgE is involved in allergic reactions and parasitic infections, not the initial response to a new antigen.
A client with a history of smoking presents with a chronic cough and shortness of breath. The nurse should suspect which condition?
- A. Pulmonary fibrosis
- B. Chronic obstructive pulmonary disease (COPD)
- C. Lung cancer
- D. Pulmonary edema
Correct Answer: B
Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). COPD is often associated with a chronic cough and shortness of breath, especially in individuals with a history of smoking. Pulmonary fibrosis (choice A) typically presents with progressive dyspnea and dry cough. Lung cancer (choice C) may present with a chronic cough, shortness of breath, and other symptoms like weight loss and hemoptysis. Pulmonary edema (choice D) presents with symptoms such as acute shortness of breath, orthopnea, and pink, frothy sputum.
When a Tae Kwon Do (TKD) master applies downward pressure just above the elbow joint on an attacker who immediately collapses to the ground, which reflex is applicable to this example?
- A. Golgi tendon reflex
- B. Myotatic reflex
- C. Withdrawal reflex
- D. Crossed-extensor reflex
Correct Answer: A
Rationale: The Golgi tendon reflex is the correct answer. This reflex protects the muscle and tendons from excessive force by causing the muscle to relax. In this scenario, the downward pressure applied just above the elbow joint triggers the Golgi tendon reflex, resulting in the attacker's collapse. The other options are incorrect:
- The myotatic reflex (also known as the stretch reflex) is responsible for contracting a muscle in response to its stretch, not relaxing it.
- The withdrawal reflex is a spinal reflex that moves a body part away from a painful stimulus, not directly related to the scenario described.
- The crossed-extensor reflex is a reflex that occurs on the opposite side of the body in response to a withdrawal reflex, which is not the case in this situation.