A client is admitted with a suspected aortic dissection. What is the priority nursing intervention?

Correct Answer: B

Rationale: The correct answer is B: Prepare the client for emergency surgery. Aortic dissection is a life-threatening emergency that often necessitates immediate surgical intervention to prevent rupture and further complications. Administering antihypertensive medications (choice A) may be necessary but is not the priority over surgical intervention. While maintaining blood pressure with intravenous fluids (choice C) is important, the urgent need for surgery takes precedence. Monitoring urine output (choice D) is essential for assessing renal function but is not the priority in this critical situation.

Correct Answer: C

Rationale: In Guillain-Barre syndrome, the destruction of myelin leads to axonal damage. If remyelination does not occur, the axon will eventually degenerate and die, impacting nerve function. Choice A is incorrect because the destruction of myelin does not affect Schwann cell production. Choice B is incorrect as the lack of myelin directly affects the conduction of nerve impulses, not the axonal transport system. Choice D is incorrect as a deficit of myelin does not predispose the client to infections by potential pathogens.

Correct Answer: B

Rationale: The correct answer is B because consistent intake of prescribed drugs is crucial for curing tuberculosis. By emphasizing the necessity of following the treatment plan, the patient is more likely to achieve a successful outcome. Choice A is incorrect because it focuses on the risk of adverse effects rather than the primary goal of TB cure. Choice C is incorrect as it does not address the issue of inconsistent drug intake. Choice D is also incorrect as it introduces a different treatment (antiretrovirals) not relevant to latent tuberculosis.

Correct Answer: B

Rationale: In a patient receiving testosterone therapy for androgen deficiency, monitoring weight and blood pressure is crucial. Testosterone therapy can lead to weight gain and hypertension, making regular assessments of these parameters important to detect and manage any adverse effects. Choices A, C, and D are not the priority assessments for a patient on testosterone therapy. Bladder ultrasound and urine testing for glucose and ketones, hearing assessment and abdominal girth measurement, and deep tendon reflexes and random blood glucose testing are not directly related to the common side effects or monitoring requirements of testosterone therapy.

Correct Answer: C

Rationale: Antigens are the correct answer as they are the molecules that trigger the immune response by binding to specific B or T cells. This binding activates these cells, leading to their proliferation and differentiation to fight off the antigen. B cells and T cells are the responders to antigens, not the initiators of clonal selection. Lymphocytes is a broad term encompassing both B and T cells, so it is not the specific factor responsible for initiating clonal selection.

Correct Answer: A

Rationale: The correct statement to include in the nurse's teaching is that clomiphene induces ovulation by stimulating the release of gonadotropins, which in turn stimulate the ovaries. Choice B is incorrect because clomiphene does not induce ovulation by inhibiting gonadotropins. Choice C is also incorrect as clomiphene does not suppress ovulation by inhibiting gonadotropins. Choice D is inaccurate as clomiphene does not directly increase progesterone levels to maintain pregnancy.

Correct Answer: A

Rationale: The correct answer is to administer the first dose of antibiotics immediately after blood cultures are drawn for suspected bacterial meningitis. This is crucial to initiate treatment promptly and improve patient outcomes. Starting an IV line and administering corticosteroids (Choice B) may be part of the treatment plan but administering antibiotics is the priority. Isolating the client (Choice C) is important to prevent the spread of infection but not the priority over initiating antibiotic therapy. Performing a lumbar puncture (Choice D) may confirm the diagnosis, but treatment should not be delayed for this step in suspected cases of bacterial meningitis.

Correct Answer: C

Rationale: In a patient with hyperaldosteronism, the nurse would suspect hyperkalemia. Hyperaldosteronism leads to increased potassium excretion, resulting in low potassium levels in the blood. Therefore, choices A (Hyponatremia), B (Hypernatremia), and D (Hypercalcemia) are incorrect. Hyponatremia refers to low sodium levels, Hypernatremia refers to high sodium levels, and Hypercalcemia refers to high calcium levels, none of which are typically associated with hyperaldosteronism.

Correct Answer: D

Rationale: The father's immune reaction to poison ivy is an example of cell-mediated immunity, specifically a type IV hypersensitivity reaction. In this type of reaction, sensitized T cells react to antigens, leading to inflammation and tissue damage. IgE-mediated reactions involve antibodies of the IgE class, commonly seen in allergic responses like anaphylaxis. Tissue-specific reactions target specific organs or tissues. Immune complex reactions involve immune complexes formed by antigens and antibodies that can deposit in tissues, leading to inflammation.