Secondary immunodeficiency involves the loss of a previously functional immune defense system that can be caused by: (Select all that apply.)
a. a single gene defect.
b. AIDS.
c. aging.
d. nutritional deficiencies.
e. immunosuppressive therapies
B, C, D, E
In primary immunodeficiency, the dysfunction exists in the immune system. Most primary immunodeficiencies are congenital disorders related to a single gene defect. Secondary or acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously functional immune defense system. AIDS is the most notable secondary immunodeficiency disorder caused by an infection. Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as diabetes or sickle cell disease are additional examples of conditions that may be associated with acquired immunodeficiencies.
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Which of the following statements about evaluation is false?
a. Evaluation is an end to the nursing process. b. Evaluation is an ongoing mechanism that ensures quality interventions. c. Evaluation is an ongoing part of daily nursing activities. d. Evaluation is planned.
The nurse is caring for a patient on mechanical ventilation. The nurse determines that the endotracheal tube is properly placed by which assessment?
a. Auscultating both lungs and watching the rise and fall of both sides of the chest b. Monitoring and comparing the blood pressure in both arms c. Observing and measuring inspiratory and expiratory rates d. Checking the settings on the ventilator and the low-pressure and high-pressure alarm settings
You are preparing a 2-year-old boy for a physical exam. Which is correct?
a. He voids before the exam. b. His diaper is removed. c. He is undressed. d. His diaper is left on.
A patient with acute pericarditis has a nursing diagnosis of Pain related to the inflammatory process. What nursing action should the nurse recommend?
a. Restrict fluids to 500 mL per day. b. Teach the patient to take shallow, rapid breaths. c. Provide anti-inflammatory medication as ordered. d. Have the patient cough and deep breathe hourly while awake.