Which patient is most at risk for fluid volume overload?

Correct Answer: C

Rationale: The patient with kidney failure is most at risk for fluid volume overload because the kidneys are responsible for regulating fluid balance in the body. In kidney failure, the kidneys are unable to effectively filter and excrete excess fluids, leading to an accumulation of fluid in the body. This can result in fluid volume overload, which can be dangerous and lead to complications such as pulmonary edema, congestive heart failure, and hypertension. It is important to monitor this patient closely for signs and symptoms of fluid overload and manage their fluid intake carefully.

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: C

Rationale: When caring for a client with influenza, immediate recognition of respiratory distress is crucial. Influenza can lead to respiratory complications such as pneumonia, which may result in respiratory distress. Early detection of symptoms such as increased respiratory rate, shortness of breath, and chest pain can help in providing prompt intervention and preventing further complications. Therefore, the nursing intervention involved in caring for a client with influenza is to closely monitor the respiratory status and quickly recognize any signs of respiratory distress. This proactive approach can potentially save the client's life and improve outcomes.

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.