Nursing Elites

1. Multiple sclerosis manifests as asymmetrical and in different parts of the body because:

• A. Autoreactive lymphocytes are causing diffuse patchy damage to the myelin sheath in the central nervous system.
• B. Acetylcholine receptors are destroyed by immunoglobulin G.
• C. Autoreactive T lymphocytes cause progressive loss of neurons in the substantia nigra.
• D. Cortical motor cells degenerate.

Correct answer: A

Rationale: The correct answer is A. Multiple sclerosis is characterized by the immune system attacking the myelin sheath in the central nervous system. This attack leads to patchy damage on the myelin sheath, resulting in asymmetrical neurological symptoms. Choices B, C, and D are incorrect because they do not accurately describe the pathophysiology of multiple sclerosis. In multiple sclerosis, it is the autoreactive lymphocytes that target and damage the myelin sheath, not acetylcholine receptors, T lymphocytes, or cortical motor cells.

2. A nurse recalls an example of an immune-complex-mediated disease is:

• A. Bronchial asthma
• B. Contact dermatitis
• C. Serum sickness
• D. Rheumatoid arthritis

Correct answer: C

Rationale: The correct answer is C: Serum sickness. Serum sickness is characterized by the formation of immune complexes in response to certain medications or proteins. These immune complexes can deposit in tissues, leading to inflammation and tissue damage. Bronchial asthma (Choice A) is a chronic inflammatory condition of the airways not primarily mediated by immune complexes. Contact dermatitis (Choice B) is a type IV hypersensitivity reaction mediated by T cells, not immune complexes. Rheumatoid arthritis (Choice D) is an autoimmune disease where antibodies target self-antigens, but it is not primarily mediated by immune complexes.

3. A family member expresses concern to a nurse about behavioral changes in an elderly aunt. Which would cause the nurse to suspect a cognitive impairment disorder?

• A. Decreased interest in activities that she once enjoyed
• B. Fear of being alone at night
• C. Increased complaints of physical ailments
• D. Problems with preparing a meal or balancing her checkbook

Correct answer: D

Rationale: The correct answer is D. Problems with tasks like meal preparation and balancing a checkbook can indicate cognitive impairment, as these activities involve cognitive functions such as memory, attention, and executive function. Choices A, B, and C are less indicative of cognitive impairment. Decreased interest in activities and increased complaints of physical ailments may be related to other factors like depression, while fear of being alone at night could be due to anxiety or other psychological issues.

4. When administering azoles in the home setting, the home health nurse should prioritize educational interventions that address what nursing diagnosis?

• A. Risk for injury related to antifungal therapy
• B. Risk for acute confusion related to antifungal therapy
• C. Risk for infection related to antifungal therapy
• D. Risk for falls related to antifungal therapy

Correct answer: A

Rationale: The correct answer is A: Risk for injury related to antifungal therapy. When administering azoles, the priority is to educate patients and caregivers about potential side effects that could lead to injury, such as hepatotoxicity or allergic reactions. Choices B, C, and D are incorrect because acute confusion, infection, and falls are not typically associated with azole therapy.

5. Which of the following is the most appropriate diagnostic method for identifying lung cancer in its early stages?

• A. CT scan
• B. MRI
• C. X-ray
• D. Biopsy

Correct answer: D

Rationale: A biopsy is the most appropriate method for diagnosing lung cancer in its early stages. A biopsy involves taking a small tissue sample from the lung for examination under a microscope. This method provides a definitive diagnosis by identifying cancerous cells. CT scans, MRIs, and X-rays can help detect abnormalities in the lungs, but a biopsy is necessary to confirm the presence of lung cancer. CT scans offer detailed images of the lung's structure, MRIs use magnetic fields for imaging soft tissues, and X-rays provide a basic view of the lungs, but none of these imaging techniques can definitively confirm the presence of cancer without a biopsy.

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