A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:

Correct Answer: C

Rationale: The correct answer is C: fluid volume deficit. In diabetes insipidus, there is an excessive amount of dilute urine excreted, leading to dehydration and fluid volume deficit. The posterior pituitary tumor causes a deficiency in antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys. As a result, the client experiences polyuria and polydipsia, leading to fluid volume deficit. Choices A, B, and D are incorrect because diabetes insipidus does not cause fluid volume excess, incontinence, or diarrhea. The key is to recognize the pathophysiology of diabetes insipidus and its impact on fluid balance.

Correct Answer: C

Rationale: Correct Answer: C - ACTH Rationale: 1. ACTH (adrenocorticotropic hormone) can help control symptoms and induce remission in multiple sclerosis by reducing inflammation. 2. ACTH stimulates the production of cortisol, a natural anti-inflammatory hormone. 3. By reducing inflammation in the central nervous system, ACTH can help manage symptoms and promote remission. Summary of other choices: A: Acyclovir - Antiviral medication used to treat herpes infections, not effective for multiple sclerosis. B: Thyrotropin - Hormone that stimulates thyroid function, not used in the treatment of multiple sclerosis. D: Benadryl - Antihistamine used for allergies and itching, not indicated for multiple sclerosis management.

Correct Answer: B

Rationale: The correct answer is B: Re-exposure to a specific antigen. Memory cells are formed after initial exposure to an antigen. Upon re-exposure to the same antigen, memory cells quickly recognize and respond, converting into plasma cells to produce antibodies. This process is known as secondary immune response. Incorrect choices: A: An organ transplant - Organ transplant does not involve the conversion of memory cells to plasma cells. C: Release of lymphokines - Lymphokines are signaling molecules secreted by immune cells but do not directly cause memory cells to convert to plasma cells. D: Initial exposure to an antigen - Initial exposure to an antigen leads to the formation of memory cells, not their conversion to plasma cells upon re-exposure.

Correct Answer: C

Rationale: The correct answer is C: Trunk. The thoracic cord supplies nerves to the trunk region of the body. The thoracic spinal nerves innervate the chest, abdomen, and back. They control sensation and movement in these areas. The head (A) is mainly supplied by cranial nerves, the pelvis (B) is innervated by lumbar and sacral nerves, and the coccyx (D) is supplied by the sacral nerves. Therefore, the correct answer is C as it aligns with the anatomical distribution of the thoracic spinal nerves.

Correct Answer: B

Rationale: The correct answer is B - Focus on the patient's presenting situation. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan. Now, let's analyze the other choices: A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific and relevant data.

Correct Answer: B

Rationale: Severe and extensive hemolysis leads to the release of large amounts of hemoglobin into the bloodstream, causing hemoglobinemia. This can result in hemoglobinuria, leading to acute renal failure and ultimately shock. Shock is the correct answer as it is a severe consequence of extensive hemolysis. Leg ulcers (A) may occur in conditions like peripheral arterial disease. Priapism (C) is unrelated to hemolysis. Compromised growth (D) is not a common consequence of hemolysis.

Correct Answer: C

Rationale: Rationale: 1. Abdominal injection sites have a higher blood supply, leading to faster absorption. 2. Insulin absorption is faster in areas with more blood vessels. 3. Rapid absorption at the abdomen results in quicker onset of action. 4. Other sites may have slower absorption due to less blood flow. Summary: A: Incorrect. Absorption is faster at abdominal sites due to increased blood flow. B: Incorrect. Absorption varies based on injection site blood supply. C: Correct. Abdominal injection sites have rapid insulin absorption. D: Incorrect. Insulin absorption is consistent based on blood flow at injection sites.

Correct Answer: A

Rationale: The correct answer is A because a positive diagnosis for HIV infection is confirmed through laboratory testing, specifically the ELISA and Western blot tests. These tests detect the presence of HIV antibodies in the blood, providing definitive evidence of the infection. Choice B is incorrect as weight loss and fever are symptoms but not diagnostic criteria. Choice C is incorrect as opportunistic infections are a consequence of HIV, not the diagnostic criteria. Choice D is incomplete and irrelevant. In summary, the key to diagnosing HIV is through positive laboratory tests, not just based on symptoms or associated infections.

Correct Answer: A

Rationale: The correct answer is A: Pneumocystis carinii pneumonia (PCP). PCP is the most common opportunistic infection in AIDS due to the weakened immune system, making patients vulnerable to this fungal infection. PCP is a leading cause of morbidity and mortality in AIDS patients. Toxoplasmosis (B) is also common but not as prevalent as PCP in AIDS. Candidiasis (C) is a common fungal infection but not the most common in AIDS. Mycoplasma pneumoniae (D) is a bacterial infection and not typically considered an opportunistic infection in AIDS.