A patient is diagnosed with a viral infection. The nurse understands that which chemical will act to prevent the spread of the virus to other cells?
1. Interleukin
2. Tissue factor
3. Tumor necrosis factor
4. Interferon
4
Rationale 1: Interleukin enables the cells of the immune system to communicate and coordinate the immune response.
Rationale 2: Tissue factor stimulates platelets to begin clot formation and stop blood loss from injured blood vessels.
Rationale 3: Tumor necrosis factor is a small peptide that is instrumental in the initiation of the inflammatory response.
Rationale 4: Interferons are proteins made and released by T cells when the invading organism is a virus. Interferons protect other cells from viral attack, inhibit the production of the virus within infected cells, prevent the spread of the virus to other cells, and enhance the activity of macrophages to kill the virus.
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Foul-smelling sputum is an abnormal finding and most likely indicates
a. anaerobic infection. c. lung cancer. b. poor oral hygiene. d. viral infection.
When individualizing pain management for a client hospitalized after major surgery, the nurse will: Select all that apply
a. Titrate the prescribed analgesic medication to provide effective pain management b. Assess the client for cultural beliefs that affect individual expression of pain c. Reas-sure the client that pain medication is available whenever they express a need for it d. Antic-ipate the client's need for pain medications e. Im-plement non-pharmacological pain management interventions whenever possible
An older adult patient has fluctuating levels of awareness, anxiety, and appears to be picking things out of the air. The patient says, "I saw my granddaughter standing at the foot of the bed last night." The nurse should suspect
a. delirium. b. dementia. c. schizophrenia. d. bipolar disorder.
A preschool-age client is hospitalized following surgery for a ruptured appendix. During assessment of the child, the nurse notes that the child is sleeping
Vital signs are as follows: temperature 97.8 degrees F axillary, pulse 90, respirations 12, and blood pressure 100/60. Which conclusion by the nurse is appropriate based on the assessment findings? 1. The client is comfortable and the pain is controlled. 2. The client is in shock secondary to blood loss during surgery. 3. The client is experiencing respiratory depression secondary to opioid administration for postoperative pain. 4. The client is sleeping to avoid pain associated with surgery.