Nursing Elites

1. A patient has developed a decubitus ulcer on the coccyx. What defense mechanism is most affected by this homeostatic change?

• A. The mucous membrane is affected.
• B. The respiratory tract is affected.
• C. The skin is affected.
• D. The gastrointestinal tract is affected.

Correct answer: C

Rationale: In this scenario, a decubitus ulcer on the coccyx indicates a breakdown of the skin's integrity due to prolonged pressure. The skin is the primary defense mechanism of the body against external pathogens. When the skin is compromised, it can lead to infections and other complications. The mucous membrane (Choice A) plays a role in protecting internal surfaces, not the skin. The respiratory tract (Choice B) is involved in breathing and not directly related to the skin's defense. The gastrointestinal tract (Choice D) is responsible for digestion and absorption of nutrients, not the primary defense mechanism against external threats like the skin.

2. A client with a history of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which complication should the nurse monitor for?

• A. Pulmonary embolism
• B. Gastrointestinal bleeding
• C. Hemorrhagic stroke
• D. Renal insufficiency

Correct answer: A

Rationale: The correct answer is A, pulmonary embolism. In a client with a history of deep vein thrombosis (DVT) receiving anticoagulant therapy, the nurse should monitor for pulmonary embolism, as it is a serious complication. Pulmonary embolism occurs when a blood clot dislodges from the veins and travels to the lungs, potentially causing life-threatening consequences. Choices B, gastrointestinal bleeding, C, hemorrhagic stroke, and D, renal insufficiency, are not directly associated with deep vein thrombosis or anticoagulant therapy. While these complications may occur in other situations, they are not the primary concern when managing a client with a history of DVT.

3. A 30-year-old male was diagnosed with HIV. Which of the following treatments would be most effective?

• A. Reverse transcriptase inhibitors
• B. Protease inhibitors
• C. Entrance inhibitors
• D. Highly active antiretroviral therapy

Correct answer: D

Rationale: The correct answer is D: Highly active antiretroviral therapy (HAART). HAART involves a combination of different classes of antiretroviral drugs, which can effectively suppress the HIV virus, reduce the viral load, and improve the immune function. While choices A, B, and C are also used in HIV treatment, the most effective approach is a combination therapy like HAART due to its ability to target the virus at different stages of its life cycle, reducing the risk of drug resistance and improving treatment outcomes.

4. When caring for a patient with systemic lupus erythematosus (SLE), the disease the nurse is dealing with is an example of:

• A. Autoimmunity
• B. Alloimmunity
• C. Homoimmunity
• D. Alleimmunity

Correct answer: A

Rationale: When a nurse cares for a patient with systemic lupus erythematosus (SLE), the nurse is dealing with an autoimmune disease. In autoimmune diseases like SLE, the immune system mistakenly attacks the body's own tissues. Choice A, 'Autoimmunity,' is the correct answer because SLE is an example of the immune system attacking self-antigens, leading to tissue damage and inflammation. Choices B, C, and D are incorrect. Alloimmunity refers to the immune response against foreign antigens from members of the same species, homoimmunity is not a recognized term in immunology, and alleimmunity is not a valid term in this context.

5. Which of the following steps occurs first during hemostasis?

• A. Vascular spasm
• B. Platelet plug
• C. Coagulation
• D. Dissolution of the clot

Correct answer: A

Rationale: Vascular spasm is the initial step in hemostasis, where blood vessels constrict to reduce blood flow to the injured area. This constriction helps limit blood loss until further steps like platelet plug formation and coagulation can take place. Platelet plug formation and coagulation occur after the vascular spasm, making them incorrect choices. Dissolution of the clot happens much later in the healing process, after the injury has sufficiently healed.

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