Foundations and Adult Health Nursing Test Bank

Correct Answer: C

Rationale: Dendritic cells play a critical role in initiating adaptive immune responses by capturing antigens from pathogens, migrating to lymphoid organs, and presenting these antigens to naïve T cells. This activation of naïve T cells by dendritic cells is essential for the adaptive immune system to generate specific immune responses against pathogens. Dendritic cells act as professional antigen-presenting cells, which are specialized to capture, process, and present antigens to T cells, thereby facilitating the activation of T cells and the coordination of adaptive immune responses, such as the production of specific antibodies and the generation of memory T cells.

Correct Answer: B

Rationale: The most effective treatment for addressing the underlying pathophysiology of cystic fibrosis (CF) and preventing disease progression is the use of mucolytic agents, such as dornase alfa. CF is a genetic disorder that leads to the production of thick, sticky mucus in the respiratory tract. This mucus buildup can obstruct airways, lead to recurrent infections, and contribute to pulmonary exacerbations. Mucolytic agents work by reducing the viscosity of the mucus, making it easier to clear from the airways. This helps to improve lung function, reduce the frequency of exacerbations, and slow down disease progression in CF patients. Inhaled corticosteroids may be used for managing airway inflammation, but they do not target the underlying mucus production in CF. Antibiotic therapy is important for treating respiratory infections in CF patients, but it does not address the primary

Correct Answer: B

Rationale: The nurse's best approach to address non-compliance with prescribed medications and treatment plans is to actively listen to the patient's reasons for non-compliance. By acknowledging and addressing any barriers or concerns the patient may have, the nurse can work collaboratively with the patient to find effective solutions. This approach promotes open communication, trust, and a patient-centered care plan that takes into consideration the patient's individual needs and circumstances. Dismissing the patient's reasons (choice A), ignoring the non-compliance (choice C), or resorting to a confrontational approach (choice D) are less effective strategies that may lead to further resistance and hinder the patient's willingness to engage in their treatment.

Correct Answer: D

Rationale: The presentation of sudden-onset severe headache, vomiting, and altered mental status, along with the presence of a berry-shaped aneurysm on imaging, point towards a diagnosis of subarachnoid hemorrhage. The most common cause of a subarachnoid hemorrhage is the rupture of a saccular (berry) aneurysm, which commonly occurs at the junction of the anterior communicating artery and anterior cerebral artery. The sudden headache is often described as the "worst headache of my life" and is typically associated with nausea and vomiting. Altered mental status may be present due to the effects of increased intracranial pressure and possible associated brain injury. It is important to promptly diagnose and manage subarachnoid hemorrhage to prevent complications such as vasospasm, rebleeding, and ischemic deficits.

Correct Answer: A

Rationale: Assessing the infant's latch and feeding effectiveness should be prioritized as the initial nursing intervention to address the client's concerns about inadequate milk supply. Poor latch can lead to ineffective milk removal, which may result in decreased milk production. By ensuring the infant is latching correctly and effectively transferring milk, the client's milk supply can be optimized. Education about techniques to increase milk production can be provided following the assessment of feeding effectiveness. Referring to a lactation consultant may be necessary for further evaluation and support if issues persist despite correcting the latch. Supplemental formula feedings should be recommended as a last resort after all other interventions have been attempted and if there are concerns about inadequate nutrition for the infant.