Nokea
While planning care for an elderly patient, the nurse remembers that increased age is associated with:
- A. Increased T cell function
- B. Increased immune function
- C. Increased production of antibodies
- D. Increased levels of circulating autoantibodies
Correct Answer: D
Rationale: As individuals age, their immune function tends to decrease, making them more susceptible to infections and diseases. Additionally, increased age is associated with higher levels of circulating autoantibodies, which can lead to autoimmune conditions. Choice A is incorrect as aging is not typically associated with increased T cell function. Choice C is also incorrect as aging does not necessarily result in increased production of antibodies. Therefore, the correct answers are B (Decreased immune function) and D (Increased levels of circulating autoantibodies).
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A client with a history of hypertension presents with a severe headache and blurred vision. What is the nurse's priority action?
- A. Administer pain relief medication.
- B. Obtain a stat head CT scan.
- C. Administer antihypertensive medications as prescribed.
- D. Call the healthcare provider immediately.
Correct Answer: C
Rationale: The correct answer is to administer antihypertensive medications as prescribed. In a client with a history of hypertension presenting with severe headache and blurred vision, these symptoms could indicate a hypertensive crisis. The priority action is to lower the blood pressure promptly to prevent complications such as stroke, heart attack, or organ damage. Administering antihypertensive medications is crucial in this situation. Administering pain relief medication (Choice A) may temporarily alleviate symptoms but does not address the underlying issue of elevated blood pressure. Obtaining a stat head CT scan (Choice B) may be necessary to rule out other causes but should not delay the administration of antihypertensive medications. Calling the healthcare provider immediately (Choice D) is important but may not address the immediate need to lower blood pressure in a hypertensive crisis.
A 54-year-old man presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after spending an afternoon building a deck on a very hot, humid day. The physician assessing the man is performing a differential diagnosis as part of her assessment. Which finding would suggest fever rather than hyperthermia as a cause of the elevation in the man's temperature?
- A. Absence of sweating
- B. Shivering
- C. Lack of thirst
- D. Increased heart rate
Correct Answer: B
Rationale: Shivering is a physiological response to fever, as the body attempts to generate heat to increase the internal temperature. Hyperthermia, on the other hand, does not involve shivering. Absence of sweating (choice A) is more indicative of hyperthermia, as the body struggles to cool down without sweating. Lack of thirst (choice C) can be seen in both fever and hyperthermia. Increased heart rate (choice D) can occur in both fever and hyperthermia due to the body's attempt to regulate temperature.
What are the characteristics of the inflammatory process?
- A. Loss of function, coolness
- B. Pain, redness
- C. Heat, pallor
- D. Swelling, pallor
Correct Answer: B
Rationale: The correct answer is B: Pain, redness. Inflammation is characterized by pain and redness as part of the body's response to tissue injury. Choice A, loss of function and coolness, are not primary characteristics of inflammation. Choice C, heat and pallor, may be present in some cases but are not as consistently associated with inflammation as pain and redness. Choice D, swelling and pallor, includes swelling which is common in inflammation but pallor is not a typical characteristic.
A 21-year-old male is being started on zidovudine (AZT) for the treatment of HIV/AIDS. Which of the following statements made by the patient indicates that he has understood the patient teaching?
- A. "AZT inactivates the virus and prevents recurrence of the disease."
- B. "AZT therapy may result in the development of AZT-resistant strains."
- C. "AZT slows the progression of the disease but does not cure it."
- D. "AZT prevents the occurrence of opportunistic infections."
Correct Answer: C
Rationale: The correct answer is C. When the patient states, "AZT slows the progression of the disease but does not cure it," it shows an understanding that zidovudine (AZT) does not provide a cure for HIV/AIDS but helps in slowing down the progression of the disease. Choice A is incorrect because AZT does not inactivate the virus or prevent recurrence. Choice B is incorrect as AZT resistance can develop with therapy. Choice D is incorrect because while AZT can help prevent opportunistic infections by boosting the immune system, its primary action is not the prevention of opportunistic infections.
What physiological reaction occurs in the body with the 'Fight or flight' response?
- A. Increased heart rate
- B. Constricted pupils
- C. Decreased blood pressure
- D. Decreased heart rate
Correct Answer: A
Rationale: The 'fight or flight' response is a primal physiological reaction that prepares the body to respond to a perceived threat or danger. This response triggers an increase in heart rate to pump more blood to the muscles and vital organs, preparing the body for action. Choice B, 'Constricted pupils,' is part of the 'fight or flight' response as well, as it helps improve focus and vision. Choice C, 'Decreased blood pressure,' is incorrect because blood pressure typically increases to ensure adequate circulation during the 'fight or flight' response. Choice D, 'Decreased heart rate,' is incorrect as the heart rate increases to supply more oxygen and nutrients to the body during times of stress.