Adult Health Med Surg Nursing Test Banks

Correct Answer: B

Rationale: The assessment of a patient who has ingested poison must include determining the poison ingested and the amount (I), the time from ingestion and the signs and symptoms (II), as well as the weight of the patient (III). These factors are essential in evaluating the severity of the poisoning and determining the appropriate treatment plan. However, the patient's immunization history (IV) is not directly relevant to the assessment of ingested poison and thus is not essential in this context.

Correct Answer: D

Rationale: When a postpartum client exhibits signs of postpartum psychosis such as hallucinations, delusions, and disorganized behavior, it is crucial to involve the healthcare provider immediately. Postpartum psychosis is a psychiatric emergency that requires prompt assessment and intervention by mental health professionals. The healthcare provider can determine the appropriate course of action, which may include hospitalization, medication management, and specialized psychiatric care. Delaying notification can lead to serious consequences for both the client and her infant, so timely intervention is essential in managing postpartum psychosis.

Correct Answer: A

Rationale: The clinical presentation of recurrent episodes of epistaxis, gum bleeding, and easy bruising, along with laboratory findings of prolonged bleeding time, normal platelet count, and normal coagulation studies (PT and aPTT) are highly suggestive of Von Willebrand disease. Von Willebrand disease is the most common inherited bleeding disorder and is characterized by a deficiency or dysfunction of von Willebrand factor (vWF), which plays a key role in platelet adhesion and aggregation. The prolonged bleeding time is due to impaired platelet adhesion to the damaged vessel wall in the absence of functional vWF. Normal platelet count and normal PT/aPTT help differentiate Von Willebrand disease from other bleeding disorders such as hemophilia and platelet function disorders like Glanzmann thrombasthenia and Bernard-Soulier syndrome.

Correct Answer: A

Rationale: Immunological memory is primarily maintained by the clonal expansion of memory B cells. Memory B cells are a type of long-lived immune cell that originates from previously activated B cells during an immune response to a pathogen. When the immune system encounters the same pathogen again, memory B cells can quickly recognize and respond to it by undergoing rapid clonal expansion and differentiation into plasma cells that produce specific antibodies. This quick and robust response leads to the more efficient elimination of the pathogen during secondary exposure, resulting in the faster and stronger immune response characteristic of immunological memory.

Correct Answer: C

Rationale: Tetanus toxoid provides long-lasting active immunity. When a person is vaccinated with tetanus toxoid, their immune system is stimulated to produce antibodies against the tetanus toxin. These antibodies provide protection against tetanus infection by recognizing and neutralizing the toxin if the person is exposed to the bacteria that causes tetanus in the future. This active immune response can last for many years, providing ongoing protection against tetanus. However, booster doses are recommended every 10 years to maintain adequate levels of protection.