The nurse is caring for a patient with an autoimmune disorder. The patient asks, "What might cause my body to do this to itself?"
Which of the following responses by the nurse would be appropriate for factors that alter or influence the self-recognition portion of the immune system? (Select all that apply.)
a. Bacterial infections
b. Viral infections
c. Drugs
d. Hormones
ANS: B, C, D
A number of factors either cause or influence this breakdown of self-recognition, including viral infections, drugs, and cross-reactive antibodies. Hormones have also been found to influence this breakdown of self-recognition.
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The patient has been diagnosed with mitral valve insufficiency and left ventricular hypertrophy. What effect would the nurse expect from the left ventricular hypertrophy?
A) Improved cardiac output from increased left ventricular contractility B) No appreciable signs or symptoms or effects until late in the disease process C) A more obvious and easier-to-auscultate mitral valve regurgitant murmur D) Early onset of pulmonary edema and right-sided congestive heart failure
A client visits the healthcare facility for information on tubal ligation. Which of the following should the nurse inform the client?
A) The client needs only a minor dressing. B) The client can drive home after surgery. C) Only one nonabsorbable stitch is needed. D) It is a temporary sterilization technique.
Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be
A) Independent health problems B) Collaborative health problems C) Physician-developed problems D) Interdisciplinary health problems
Ruby is shocked at the elongated appearance of her new baby's head. The midwife's best response would be:
a. ‘Your baby's head is moulded during birth and will return to normal in a few days.' b. ‘All newborn babies' heads are shaped this way.' c. ‘Your baby's head shape had changed during birth and it will take approximately 6 months for it to return to normal.' d. ‘After the soft spot closes, the head will return to normal.'