Nursing Elites

1. What tool is used to determine a client’s level of consciousness?

• A. Magnetic resonance imaging (MRI)
• B. Glasgow Coma Scale (GCS)
• C. Central perfusion pressure (CPP)
• D. Intracranial pressure (ICP) monitoring

Correct answer: B

Rationale: The correct answer is B: Glasgow Coma Scale (GCS). The Glasgow Coma Scale is specifically designed to assess a client's level of consciousness by evaluating verbal, motor, and eye-opening responses. Choice A, Magnetic Resonance Imaging (MRI), is a diagnostic imaging tool that provides detailed images of the body's organs and tissues but is not used to assess consciousness levels. Choice C, Central Perfusion Pressure (CPP), and Choice D, Intracranial Pressure (ICP) monitoring, are related to hemodynamic monitoring and intracranial pressure management, not direct assessment of consciousness.

2. What is the purpose of the inflammatory response?

• A. Prevents blood from entering the injured tissue
• B. Elevates body temperature to prevent spread of infection
• C. Prevents formation of abscess
• D. Minimizes injury and promotes healing

Correct answer: D

Rationale: The inflammatory response is a protective mechanism triggered by tissue damage or infection. It aims to minimize injury by removing harmful stimuli and initiating the healing process. Choice A is incorrect because blood flow to the injured tissue is actually increased to deliver immune cells and nutrients. Choice B is incorrect because while fever is a response to infection, it is not the primary purpose of the inflammatory response. Choice C is incorrect because abscess formation can occur as part of the inflammatory response in an attempt to contain an infection.

3. A 69-year-old female patient has been diagnosed with malignant melanoma. The care team has collaborated with the patient and her family and agreed on a plan of care that includes administration of interferon alfa-2b. After administering interferon alfa-2b, the oncology nurse should anticipate that the patient may develop which of the following adverse effects?

• A. Profound diaphoresis
• B. Decreased level of consciousness
• C. Flu-like symptoms
• D. Cyanosis and pallor

Correct answer: C

Rationale: After the administration of interferon alfa-2b, the patient may develop flu-like symptoms as an adverse effect. Flu-like symptoms are commonly associated with interferon therapy, including fever, chills, fatigue, and muscle aches. These symptoms usually subside over time. Options A, B, and D are not typically associated with interferon alfa-2b administration. Profound diaphoresis is excessive sweating, decreased level of consciousness indicates neurological issues, and cyanosis and pallor suggest circulatory or respiratory problems, none of which are expected adverse effects of interferon alfa-2b.

4. A 5-year-old female takes a hike through the woods during a school field trip. Upon returning home, she hugs her father, and he later develops poison ivy. Which of the following immune reactions is he experiencing?

• A. IgE-mediated
• B. Tissue-specific
• C. Immune complex
• D. Cell-mediated

Correct answer: D

Rationale: The father's immune reaction to poison ivy is an example of cell-mediated immunity, specifically a type IV hypersensitivity reaction. In this type of reaction, sensitized T cells react to antigens, leading to inflammation and tissue damage. IgE-mediated reactions involve antibodies of the IgE class, commonly seen in allergic responses like anaphylaxis. Tissue-specific reactions target specific organs or tissues. Immune complex reactions involve immune complexes formed by antigens and antibodies that can deposit in tissues, leading to inflammation.

5. Which of the following is a sign of hypoglycemia?

• A. Rapid, deep breathing
• B. Increased urination
• C. Weakness and confusion
• D. High blood pressure

Correct answer: C

Rationale: The correct answer is C: Weakness and confusion. Hypoglycemia is characterized by low blood sugar levels, leading to inadequate glucose supply to the brain, resulting in symptoms like weakness and confusion. Choices A, B, and D are incorrect. Rapid, deep breathing is not typically a sign of hypoglycemia but can be seen in other conditions like respiratory issues. Increased urination is more commonly associated with conditions like diabetes mellitus, while high blood pressure is not a typical sign of hypoglycemia.

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