A nurse is caring for a client who has hypernatremia. Which of the following actions should the nurse take? (Select all that apply.)

Restrict fluid intake

Monitor neurological status

Administer hypotonic IV fluids

Encourage foods high in sodium

Provide oral hygiene frequently

Answer and Explanation

Correct Answer : B,C,E

Choice A reason:

Restricting fluid intake is not an action that the nurse should take for a client who has hypernatremia. Fluid restriction can worsen hypernatremia by increasing the concentration of sodium in the blood. Fluid intake should be increased or replaced with isotonic or hypotonic fluids to dilute sodium and correct hypernatremia.

Choice B reason:

Monitoring neurological status is an action that the nurse should take for a client who has hypernatremia. Hypernatremia can cause neurological symptoms such as confusion, agitation, seizures, coma, and death due to cellular dehydration and brain shrinkage. The nurse should assess the client's level of consciousness, orientation, memory, behavior, and reflexes regularly and report any changes or deterioration.

Choice C reason:

Administering hypotonic IV fluids is an action that the nurse should take for a client who has hypernatremia. Hypotonic fluids have a lower concentration of solutes than normal body fluids and can help lower serum sodium levels by moving water into the cells from the blood vessels. The nurse should administer hypotonic fluids slowly and carefully to avoid fluid overload or cerebral edema.

Choice D reason:

Encouraging foods high in sodium is not an action that the nurse should take for a client who has hypernat

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Correct Answer is B

Explanation

Choice A reason:

B cells are not involved in contact dermatitis, as they do not produce antibodies or form immune complexes.

Choice B reason:

T cells are the type of cells that mediate contact dermatitis, which is a type of type IV hypersensitivity. T cells recognize the poison ivy antigens that bind to the skin proteins and release cytokines that recruit macrophages and other inflammatory cells. This leads to a delayed and localized reaction that manifests as erythema, edema, vesicles, and pruritus.

Choice C reason:

T cells are not the same as B cells, as they have different receptors and functions in the immune system.

Choice D reason:

Mast cells are not involved in contact dermatitis, as they do not express IgE antibodies or release histamine.

A. An induration of 5 mm or more B. An induration of 10 mm or more C. An induration of 15 mm or more D. An induration of 20 mm or more E. None F. None

Correct Answer is B

Explanation

Choice A reason:

This is an incorrect answer because an induration of 5 mm or more is considered a positive reaction only for certain high-risk groups, such as people who are HIV-positive, have recent contact with a person with active tuberculosis, or have chest radiograph findings consistent with prior tuberculosis.

Choice B reason:

This is a correct answer because an induration of 10 mm or more is considered a positive reaction for most people, including those who are recent immigrants from high-prevalence countries, injection drug users, residents or employees of high-risk settings, children younger than 4 years old, or people with certain medical conditions that increase the risk of tuberculosis.

Choice C reason:

This is an incorrect answer because an induration of 15 mm or more is considered a positive reaction only for people who have no known risk factors for tuberculosis.

Choice D reason:

This is an incorrect answer because an induration of 20 mm or more is not a criterion for a positive reaction, as it exceeds the maximum threshold for any group.

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A nurse is caring for a client who has hypernatremia. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has contact dermatitis after exposure to poison ivy. The nurse recognizes that this condition is mediated by what type of cells?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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A nurse is caring for a client who has hypernatremia. Which of the following actions should the nurse take? (Select all that apply.)