Nursing Elites

1. When a patient asks the nurse what hypersensitivity is, how should the nurse respond? Hypersensitivity is best defined as:

• A. A reduced immune response found in most pathologic states
• B. A normal immune response to an infectious agent
• C. An excessive or inappropriate response of the immune system to a sensitizing antigen
• D. Antigenic desensitization

Correct answer: C

Rationale: Hypersensitivity is correctly defined as an excessive or inappropriate response of the immune system to a sensitizing antigen. This response leads to tissue damage or other clinical manifestations. Choice A is incorrect as hypersensitivity involves an exaggerated, not a reduced, immune response. Choice B is incorrect because hypersensitivity is not a normal immune response to an infectious agent but rather an exaggerated one. Choice D is incorrect as it refers to desensitization, which is the opposite of hypersensitivity.

2. An MRI scan of a 33-year-old female client with new-onset seizures has revealed a lesion on her frontal lobe. Which of the following signs and symptoms would most likely be a direct result of this lesion?

• A. Changes in sensation or movement in the client's limbs
• B. Fluctuations in blood pressure
• C. Changes in speech and reasoning
• D. Increased intracranial pressure

Correct answer: C

Rationale: The correct answer is C: Changes in speech and reasoning. The frontal lobe is responsible for higher cognitive functions, including speech and reasoning. A lesion in this area can lead to difficulties in speech production, language comprehension, and reasoning abilities. Choices A, B, and D are incorrect. Changes in sensation or movement in the client's limbs are more associated with lesions in the motor or sensory cortices of the brain, not the frontal lobe. Fluctuations in blood pressure are often related to autonomic nervous system dysfunction, which is controlled by other brain regions. Increased intracranial pressure is typically seen in conditions like brain tumors or head trauma, not directly related to a frontal lobe lesion.

3. A tension pneumothorax requires a needle thoracostomy and/or chest tube placement as treatment to which component of the pathophysiology of the condition?

• A. An accumulation of blood in the pleural space, which makes it difficult for the lungs to exchange gases.
• B. Extreme pain caused by a fractured rib
• C. A large accumulation of trapped air in the pleural space affecting both the lungs and heart.
• D. Sudden failure of the respiratory system due to fluid accumulation in the alveoli

Correct answer: C

Rationale: A tension pneumothorax is characterized by a large accumulation of trapped air in the pleural space, creating pressure that affects both the lungs and heart. This condition can lead to life-threatening consequences by shifting mediastinal structures and impairing cardiac function. Treatment involves decompressing the trapped air to relieve the tension. Choices A, B, and D are incorrect as they do not describe the primary pathophysiological mechanism of tension pneumothorax, which is the accumulation of air in the pleural space, not blood, rib fractures, or alveolar fluid accumulation.

4. A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?

• A. Evaluate the client's gag reflex.
• B. Assess the client's bowel sounds.
• C. Check the client's pupil reaction.
• D. Monitor the client's heart rate.

Correct answer: A

Rationale: The correct answer is to evaluate the client's gag reflex. When a client has experienced a stroke resulting in severe hemiparesis, assessing the gag reflex is crucial before allowing them to eat or drink. This assessment helps prevent aspiration, a serious complication that can occur due to impaired swallowing ability. Assessing bowel sounds (Choice B), pupil reaction (Choice C), or heart rate (Choice D) are important assessments but are not the priority in this situation where the risk of aspiration is higher.

5. What action is specific to hormonal contraceptives and should be taught to this woman?

• A. The cervical mucus is altered to prevent sperm penetration.
• B. The release of follicle-stimulating hormone is increased to block fertility.
• C. The maturation of the endometrial lining is activated by the contraceptive.
• D. The pituitary gland increases the synthesis and release of luteinizing hormone.

Correct answer: A

Rationale: The correct action specific to hormonal contraceptives that should be taught to the woman is that they alter cervical mucus to prevent sperm penetration. This mechanism helps in preventing pregnancy by reducing the chances of sperm reaching the egg. Choices B, C, and D are incorrect. Choice B is inaccurate as hormonal contraceptives work by inhibiting ovulation rather than increasing follicle-stimulating hormone release. Choice C is incorrect as hormonal contraceptives do not activate the maturation of the endometrial lining; instead, they modify it to prevent implantation. Choice D is also incorrect as hormonal contraceptives do not stimulate the pituitary gland to increase luteinizing hormone synthesis and release.

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