Adult Health Nursing Test Bank

Correct Answer: A

Rationale: The correct answer is A: Loss of self-tolerance. This is because autoimmune diseases result from a breakdown in the immune system's ability to distinguish between self and non-self antigens, leading to the production of antibodies against self-antigens. When self-tolerance is lost, immune cells mistakenly target the body's own tissues, causing tissue damage and inflammation. Choice B (Failure of innate immunity) is incorrect because autoimmune diseases are primarily driven by adaptive immunity rather than innate immunity. Choice C (Defective T cell activation) is incorrect as T cells play a critical role in the immune response to self-antigens in autoimmune diseases. Choice D (Impaired phagocytosis) is incorrect as phagocytosis is a mechanism primarily involved in the removal of pathogens, not in the development of autoimmune diseases.

Correct Answer: D

Rationale: The correct answer is D: Temporal lobe. Memory and learning are primarily associated with the temporal lobe, specifically the hippocampus. Damage to this area due to stroke can lead to memory loss and impaired learning capacity. Frontal lobe (A) is involved in decision-making and problem-solving. Parietal lobe (B) is responsible for sensory processing. Occipital lobe (C) is related to visual processing. Therefore, the temporal lobe is the most likely site of brain damage in this scenario based on the symptoms presented.

Correct Answer: C

Rationale: Rationale: - ARDS is characterized by severe hypoxemia and respiratory distress. - Tachypnea is a hallmark sign of ARDS due to the body's compensatory mechanism to increase oxygenation. - Hypoxemia refractory to supplemental oxygen signifies the inability to improve oxygen levels despite intervention. - Choices A, B, and D do not align with typical manifestations of ARDS, as they do not directly reflect severe hypoxemia or respiratory distress.

Correct Answer: D

Rationale: The correct answer is D: Trigeminal neuralgia. This condition is characterized by recurrent, severe, stabbing pain in the trigeminal nerve distribution triggered by touch, chewing, or cold exposure. The key feature is the characteristic lancinating pain, which is not typical of migraine (choice A), cluster headache (choice B), or tension-type headache (choice C). Migraine typically presents with pulsating, moderate to severe headache associated with nausea and sensitivity to light and sound. Cluster headache is characterized by severe, unilateral pain around the eye associated with autonomic symptoms. Tension-type headache presents with bilateral, pressing or tightening pain without specific triggers. Therefore, based on the description of the symptoms in the question, trigeminal neuralgia is the most likely diagnosis.

Correct Answer: C

Rationale: The correct answer is C because providing emotional support and offering counseling or therapy sessions address the root cause of the patient's depression in a holistic manner. This intervention allows the patient to express their emotions, process their feelings, and receive guidance on coping strategies. Encouraging social activities (A) may not directly address the underlying emotional issues. Referring to a psychiatrist for medication (B) should be considered if counseling alone is insufficient. Exploring spiritual beliefs (D) is important but may not be the most immediate priority for addressing depression in this context.