Correct Answer: D

Rationale: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly. A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function. B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system. C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.

Correct Answer: A

Rationale: Rationale for Correct Answer (A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby. Summary of Incorrect Choices: B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors. C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby. D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.

Correct Answer: A

Rationale: The correct answer is A: Medulla. The medulla is located in the brainstem and plays a crucial role in controlling involuntary functions like breathing. It contains the respiratory center, which regulates the rate and depth of breathing. The medulla sends signals to the diaphragm and intercostal muscles to control breathing. The cerebrum (B) is responsible for higher brain functions, not breathing control. The cerebellum (C) coordinates movement and balance, not breathing. The thalamus (D) relays sensory information to the cerebral cortex, not involved in breathing regulation.

Correct Answer: B

Rationale: The correct answer is B because inserting a mouth gag during a convulsive seizure can obstruct the airway and pose a choking hazard. Step-by-step rationale: A: Loosening clothing helps improve ventilation. C: Positioning on the side with head flexed forward prevents aspiration. D: Providing privacy is important for patient dignity and confidentiality. B is incorrect as it can be harmful.

Correct Answer: B

Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data. Summary: - A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse. - C: Secondary data are information obtained from other sources, not directly from the client. - D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.