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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 correct answer is C because in the humoral immune response, B cells are stimulated by T helper cells or macrophages to differentiate into plasma cells that produce antibodies or memory cells. This process involves the production of specific antibodies that target the foreign antigen.
Choice A is incorrect because B cells do not phagocytize antigens; instead, they produce antibodies.
Choice B is incorrect because T cells do not turn into plasma cells. It is the B cells that differentiate into plasma cells in the humoral immune response.
Choice D is incorrect because T cells do not produce antibodies. T cells are involved in cell-mediated immunity, not the humoral immune response.
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A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation.
Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
- A. Fluid intake of less than 2,500mL in 24 hours
- B. Urine output of more than 200mL/hour
- C. Blood pressure of 90/50mmHg
- D. Pulse rate of 126 beats/min
Correct Answer: A
Rationale: The correct answer is A because successful treatment of diabetes insipidus aims to reduce excessive urine output and dehydration. A fluid intake of less than 2,500mL in 24 hours indicates proper control of fluid balance.
Choice B is incorrect because urine output of more than 200mL/hour suggests ongoing excessive fluid loss, which is not indicative of successful treatment.
Choice C is incorrect as a blood pressure of 90/50mmHg is low and may indicate hypotension, which is not a specific indicator of successful diabetes insipidus treatment.
Choice D is incorrect because a pulse rate of 126 beats/min is not a direct marker of diabetes insipidus treatment success.
In summary, the correct indicator of successful treatment of diabetes insipidus is a reduction in fluid intake, option A, as it signifies improved fluid balance and hydration status.
A client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer?
- A. Persistent nausea
- B. Indigestion
- C. Rash
- D. Chronic ache or pain
Correct Answer: D
Rationale: The correct answer is D: Chronic ache or pain. Persistent cough and chronic ache or pain are both common warning signs of cancer. Chronic pain can be a symptom of various types of cancer, signaling the presence of a tumor or cancerous growth. It is important for the client to seek medical evaluation to rule out any underlying serious condition.
A: Persistent nausea is not typically considered a common warning sign of cancer. While it can be a symptom in certain types of cancer or due to treatment side effects, it is not as prominent as chronic ache or pain.
B: Indigestion is a common symptom that can be caused by various non-cancer-related issues such as dietary habits, stress, or gastrointestinal disorders. It is not typically considered a direct warning sign of cancer.
C: Rash is generally not a common warning sign of cancer. Rashes are more commonly associated with skin conditions, allergic reactions, or infections rather than being an indicator of cancer.
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: Objective data in nursing refers to measurable and observable information. Respirations at 16 per minute are a specific, quantifiable measurement that the nurse can directly observe, making it objective data. This information is vital for assessing the patient's respiratory status accurately.
Choice A is incorrect because stating "doesn't feel good" is a subjective statement based on the patient's perception and cannot be directly measured or observed. Choice B, reporting a headache, is also subjective as it relies on the patient's description of their symptoms. Choice D, being nauseated, is subjective as well, as it is a symptom reported by the patient and not a quantifiable measurement.
In summary, choice C is correct as it represents objective data due to its quantifiable and observable nature, while the other choices are subjective and based on the patient's perceptions or feelings.
A 70-year old male diagnosed with BPH (benign prostatic hyperplasia) asks the nurse about his disease. The best response would be:
- A. “It an be caused by chronic infection of the urinary tract.”
- B. “It was caused by your chronic cigarette smoking.”
- C. “As you age, hormonal imbalances are the more likey cause of your disease.”
- D. “Chronic obstruction of the bladder due to stone can cause BPH.”
Correct Answer: C
Rationale: The correct answer is C. Hormonal imbalances are the primary cause of BPH in aging males. As men age, testosterone levels decrease and estrogen levels may increase relative to testosterone, leading to prostate gland growth. This is why hormonal imbalances are more likely the cause of BPH in older males.
Explanation of other choices:
A: Chronic infection of the urinary tract does not directly cause BPH, although it can lead to similar symptoms such as urinary frequency and urgency.
B: Chronic cigarette smoking is not a direct cause of BPH, although it can contribute to overall prostate health and exacerbate symptoms.
D: Chronic obstruction of the bladder due to stone is a separate condition from BPH, although it can cause similar urinary symptoms.