Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:

Correct Answer: C

Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.

Correct Answer: C

Rationale: The correct answer is C: Non-mobile mass with irregular edges. A non-mobile mass with irregular edges is more likely to be cancerous as it indicates potential infiltration into surrounding tissues. This finding raises suspicion for malignancy as cancerous lumps tend to have irregular shapes due to their invasive nature. In contrast, options A and B describe characteristics of benign masses, such as mobile, soft, and easily delineated. Option D indicates no palpable lymph nodes, which does not directly correlate with the characteristics of the breast lump. Therefore, option C is the most concerning and indicative of a potentially cancerous lesion based on the assessment findings provided.

Correct Answer: C

Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.

Correct Answer: A

Rationale: The correct answer is A: Glucocorticoids and androgens. The adrenal cortex is divided into three layers, with the outer layer responsible for producing mineralocorticoids like aldosterone, the middle layer producing glucocorticoids like cortisol, and the inner layer producing androgens. Glucocorticoids are essential for regulating metabolism and immune response, while androgens are male sex hormones. Choices B, C, and D are incorrect because mineralocorticoids, catecholamines, norepinephrine, and epinephrine are produced by different parts of the adrenal gland, not specifically by the adrenal cortex.

Correct Answer: B

Rationale: The correct answer is B: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. Rationale: 1. Latex condoms create a physical barrier that helps prevent the exchange of bodily fluids containing HIV. 2. Spermicide can further reduce the risk of HIV transmission by killing some viruses and bacteria. 3. Research shows that consistent and correct use of condoms is highly effective in reducing the risk of HIV transmission. 4. Other choices are incorrect: - A: Unprotected sex between HIV-positive individuals can lead to the transmission of drug-resistant strains or different strains of HIV. - C: Contraceptive methods like birth control pills do not protect against HIV transmission. - D: The intrauterine device is not specifically recommended for clients with HIV due to potential risks of infection.

Correct Answer: A

Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances. Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.

Correct Answer: B

Rationale: The correct answer is B: Take the NSAID with meals. Taking NSAIDs with meals helps reduce stomach irritation and risk of developing ulcers. Food acts as a protective barrier and helps in the absorption of the medication. Incorrect Choices: A: Taking NSAID with aspirin can increase the risk of stomach irritation and bleeding due to combined antiplatelet effects. C: Orange juice does not potentiate the effect of NSAIDs and may even worsen stomach irritation due to its acidity. D: NSAIDs do not coat the stomach lining; in fact, they can irritate the stomach lining and increase the risk of ulcers.

Correct Answer: B

Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.

Correct Answer: D

Rationale: The correct answer is D because Buck's extension traction is not used definitively to treat fractures in children due to their growing bones. Instead, it is used temporarily in adults to control muscle spasm and pain. - A: Correct - Buck's extension traction is indeed used temporarily in adults to control muscle spasm and pain. - B: Correct - Buck's extension traction is applied by an orthopedic surgeon under aseptic conditions using wires and pins. - C: Correct - The pulling force in Buck's extension traction is indeed transmitted to the musculoskeletal structures. Therefore, the incorrect option is D as Buck's extension traction is not used definitively to treat fractures in children.