The nurse understands that an anaphylactic reaction is considered which of the following types of hypersensitivity reactions?

Correct Answer: A

Rationale: The correct answer is A: Type I hypersensitivity reaction. In Type I hypersensitivity, anaphylactic reactions involve immediate IgE-mediated responses to allergens, leading to histamine release and potentially life-threatening symptoms. This type of reaction is characterized by rapid onset and systemic involvement. Choices B, C, and D are incorrect because Type III reactions involve immune complex deposition leading to inflammation (B), Type II reactions involve cytotoxic antibodies targeting cells (C), and Type IV reactions involve delayed cell-mediated responses (D).

Correct Answer: B

Rationale: The primary purpose of using measurable client outcomes during the nursing process is to evaluate the effectiveness of nursing interventions. This is crucial in determining whether the care provided has led to the desired outcomes for the client's health. By measuring outcomes, nurses can assess if the interventions are successful, make any necessary adjustments to the care plan, and ensure optimal patient outcomes. Choice A is incorrect because diagnosing client conditions accurately is not the primary purpose of using measurable client outcomes; it is more related to the initial assessment phase. Choice C is incorrect because prioritizing nursing diagnoses effectively is an important aspect of the nursing process, but it is not the primary purpose of using measurable client outcomes. Choice D is incorrect because while documentation in the client's health record is important, it is not the primary purpose of using measurable client outcomes.

Correct Answer: A

Rationale: The correct answer is A: Phagocytosis. Macrophages and neutrophils are both types of phagocytes responsible for engulfing and digesting pathogens such as bacteria. This process helps in clearing infections and maintaining immune homeostasis. Summary: - Choice B (Complement fixation) is incorrect as it refers to a process where complement proteins bind to pathogens to enhance their removal by phagocytes. - Choice C (Antibody production) is incorrect as macrophages and neutrophils do not produce antibodies. They mainly rely on phagocytosis for pathogen clearance. - Choice D (Suppression of autoimmunity) is incorrect as these cells are involved in innate immunity and do not play a direct role in regulating autoimmunity.

Correct Answer: D

Rationale: The correct answer is D because it involves collaboration with the client to validate their experience. It shows respect for the client's perspective and promotes open communication. Choice A is incorrect as it lacks client involvement. Choice B is incorrect as it focuses on the nurse's interpretation rather than the client's experience. Choice C is incorrect as it may come off as accusatory or judgmental, lacking empathy.

Correct Answer: A

Rationale: The correct answer is A: Pregnancy. During pregnancy, the need for iron increases significantly to support the growth of the fetus and to prevent maternal anemia. Iron is essential for the production of hemoglobin and for oxygen transport in the blood. In contrast, infants require iron for rapid growth and development, making choice B partially correct. Choice C (Old age) and choice D (Male reproductive years) are incorrect as the need for iron typically decreases in old age and remains relatively stable during male reproductive years.

Correct Answer: D

Rationale: The correct answer is D because systemic lupus erythematosus can lead to inflammation in the lungs, causing abnormal lung sounds. Dysphagia (choice A) is not typically associated with lupus. Dryness or itching of genitalia (choice B) is more characteristic of conditions like yeast infections or dermatitis. Decreased visual acuity or blindness (choice C) is not a common manifestation of lupus. Abnormal lung sounds (choice D) are commonly seen in lupus patients due to inflammation and possible lung involvement.

Correct Answer: B

Rationale: The correct answer is B: helicobacter pylori infection. This bacterium is a major cause of peptic ulcers by weakening the protective mucous layer of the stomach and duodenum. Research has shown a strong association between H. pylori infection and peptic ulcer development. Genetic defects in the gastric mucosa (choice A) are not a proven cause of peptic ulcers. While a high-fat diet (choice C) can exacerbate symptoms, it is not the primary cause. Work-related stress (choice D) may exacerbate symptoms but is not a direct cause of peptic ulcers. Therefore, choice B is the most supported and logical answer based on current research findings.

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.

Correct Answer: A

Rationale: Step 1: Regular aerobic exercise helps lower blood pressure by improving heart health and circulation. Step 2: Exercise reduces stress and promotes weight loss, factors that contribute to hypertension control. Step 3: Alcohol consumption can raise blood pressure and should be limited or avoided. Step 4: Smoking and using low-tar cigarettes can still raise blood pressure and have other negative health effects. Step 5: Daily multivitamin supplements do not directly impact blood pressure control.