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Why would it be important for the nurse to question the client about sexual practices, history of substance use disorder, and lifestyle during the interview process?
- A. To find out if the client will be compliant with therapeutic treatments
- B. To determine if the client has practices that are risk factors for acquired immunodeficiency syndrome (AIDS)
- C. To determine if the client needs a referral to counseling services
- D. To determine what type of personality the client has
Correct Answer: B
Rationale: The nurse investigates the client's allergy history and asks about practices that put the client at risk for AIDS. The interview will not determine the client's ability to be compliant. The physician would make the determination if a counseling referral should be made. It is irrelevant to determine the personality traits in the initial interview.
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The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?
- A. Toxins of invading antigens are neutralized.
- B. The invading antigens link together (agglutination).
- C. The invading antigens precipitate.
- D. T-cell lymphocytes survey proteins in the body and attack the invading antigens.
Correct Answer: D
Rationale: During a cell-mediated response, T-cell lymphocytes survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. For example, a cell-mediated response occurs when an organ is transplanted. Immunoglobulins hinder the antigens physically by neutralizing their toxins through agglutination or by causing them to precipitate.
What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction?
- A. IgG
- B. IgA
- C. IgM
- D. IgE
Correct Answer: D
Rationale: IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reactions. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.
The nurse is beginning the physical examination of a client who has reported fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
- A. The client appears mildly ill, listless, and disheveled.
- B. The client has a blood pressure of 120/72 mm Hg.
- C. The client is alert and oriented to all spheres.
- D. The client has palpable peripheral pulses in the upper extremities.
Correct Answer: A
Rationale: The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then perform a more comprehensive examination.
What is the function of the thymus gland?
- A. Produces stem cells
- B. Programs B lymphocytes to become regulator or effector B cells
- C. Develops the lymphatic system
- D. Programs T lymphocytes to become regulator or effector T cells
Correct Answer: D
Rationale: The thymus gland is located in the neck below the thyroid gland. It extends into the thorax behind the top of the sternum. The thymus gland produces lymphocytes during fetal development. It may be the embryonic origin of other lymphoid structures such as the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to become regulator or effector T cells. The thymus gland becomes smaller during adolescence but retains some activity throughout the life cycle. The other options are incorrect.
An older adult client, who leads a sedentary lifestyle, and a younger client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. The nurse knows that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?
- A. The older client because of age
- B. The older client because of lifestyle
- C. The younger client because of age
- D. The younger client because of lifestyle
Correct Answer: A
Rationale: Vaccines are less effective in an older adult than in a younger adult because the activity of the immune system declines with the aging process. The lifestyle of the client does not have great implications on the effectiveness of a vaccine.