Which of the ff symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?

Correct Answer: D

Rationale: When implementing interventions for trauma to the upper airway, it is crucial for the nurse to assess for the presence of laryngospasm. Laryngospasm is a sudden spasm of the vocal cords that may cause difficulty breathing and in severe cases, complete airway obstruction. It is a serious and potentially life-threatening complication that can occur following upper airway trauma. Therefore, prompt recognition and treatment of laryngospasm are essential to ensure adequate oxygenation and ventilation for the client. Pain when talking, increased nasal swelling, and burning in the throat may also be symptoms encountered in upper airway trauma, but the presence of laryngospasm signifies a more critical condition requiring immediate intervention.

Correct Answer: B

Rationale: Anorexia, or loss of appetite, is a common side effect of digoxin. It can lead to weight loss, weakness, and fatigue. Monitoring for anorexia is important because it may indicate digoxin toxicity, which can be serious and require intervention. Skin flushing is not a common side effect of digoxin. Hypertension is also not associated with digoxin use. Constipation is generally not a common side effect of digoxin. Therefore, anorexia is the assessment that indicates a potential side effect of digoxin that requires follow-up.

Correct Answer: D

Rationale: Autoimmunity is a phenomenon in which the immune system mistakenly targets and attacks the body's own cells, tissues, and organs. This occurs due to a breakdown in the immune system's ability to differentiate "self" from "nonself." In a healthy immune system, immune cells recognize and destroy foreign invaders while avoiding attacking the body's own cells. When this self-tolerance is lost, autoimmune diseases can develop, leading to inflammation, tissue damage, and various health problems. Therefore, autoimmunity is defined by the immune system's inability to distinguish between self and nonself.

Correct Answer: E

Rationale: Clients with immune system disorders may receive treatments such as immunoglobulin therapy or biologic agents through infusions. It is essential for the nurse to monitor the client for infusion reactions, which can include symptoms such as fever, chills, nausea, and allergic reactions. Early recognition of infusion reactions is crucial for prompt intervention to prevent complications and ensure the client's safety. By closely monitoring the client during and after the infusion, the nurse can detect and address any adverse reactions promptly.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.