The nurse is explaining defense mechanisms to a client and uses the representative barrier example in the first line of defense known as
a. antigen-antibody reaction.
b. cell-mediated immunity.
c. inflammatory response.
d. pH of vaginal secretions.
D
First-line defenses include physical and chemical barriers and the body's own natural flora. The chemical composition of body secretions such as tears and sweat, together with the pH of saliva, vaginal secretions, urine, and digestive juices, further prevents or inhibits growth of organisms.
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What is the basis for classifying a person as having a mental illness?
a. Behavior exhibited and the context b. Response of society to the behavior c. Ability of the patient to conform d. Patient's history and previous behavior
Which clinical manifestation would the nurse expect when assessing an adult obese patient with bibasilar atelectasis?
A) Diminished chest expansion B) Intercostal retractions on inspiration C) Diminished breath sounds in all lung fields D) Barrel-shaped chest
The nurse performs peritoneal dialysis (PD) on the client with stable chronic renal failure. Which does the nurse determine is an undesirable outcome of therapy? The client:
1. Loses 3 pounds of body weight after dialysis 2. Experiences a persistent irregular heart rhythm 3. Reports feeling full during the dialysate infusion 4. Drains more fluid than dialysate volume instilled
What is the priority nursing intervention for a client during the immediate postoperative period?
a. Monitoring vital signs b. Observing for hemorrhage c. Maintaining a patent airway d. Recording the intake and output