What is an example of a client's primary defense to infection?
Inflammation
Fever
Phagocytosis
Intact skin
The Correct Answer is D
Choice A reason: Inflammation is not an example of a client's primary defense to infection. Inflammation is a secondary defense to infection, which is activated after the primary defense has been breached. Inflammation is a complex process that involves the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of exudate. Inflammation aims to contain, neutralize, and eliminate the infectious agent and to repair the damaged tissue.
Choice B reason: Fever is not an example of a client's primary defense to infection. Fever is a secondary defense to infection, which is activated after the primary defense has been breached. Fever is an elevation of the body temperature above the normal range, which is usually 36.5 to 37.5 degrees Celsius or 97.7 to 99.5 degrees Fahrenheit. Fever is a systemic response to infection that is regulated by the hypothalamus, which is the part of the brain that controls the body's thermostat. Fever enhances the immune system's activity and inhibits the growth of some pathogens.
Choice C reason: Phagocytosis is not an example of a client's primary defense to infection. Phagocytosis is a secondary defense to infection, which is activated after the primary defense has been breached. Phagocytosis is a process that involves the engulfment and destruction of foreign particles, such as bacteria, by specialized cells, such as macrophages and neutrophils. Phagocytosis is a type of cellular immunity that eliminates the infectious agent and prevents its spread.
Choice D reason: Intact skin is an example of a client's primary defense to infection. Intact skin is the first and most important line of defense against infection, as it forms a physical barrier that prevents the entry of pathogens into the body. Intact skin also has chemical and biological properties that resist infection, such as the acidic pH, the secretion of sebum and sweat, and the presence of normal flora. Intact skin protects the underlying tissues and organs from infection and injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A 44yearold prescribed antibiotics for pneumonia is not at the greatest risk for pressure injury development, because he or she does not have any major risk factors for pressure injury. Pressure injury is a localized damage to the skin and underlying tissues caused by pressure, shear, friction, or moisture. Antibiotics for pneumonia do not directly affect the skin integrity or blood circulation, nor do they impair the mobility or sensation of the client.
Choice B reason: A 26yearold bedridden client with a fractured leg is at a high risk for pressure injury development, but not the greatest, because he or she has only one major risk factor for pressure injury. Bedridden status is a major risk factor for pressure injury, because it causes prolonged pressure on the bony prominences, such as the sacrum, heels, or hips, which can impair blood flow and oxygen delivery to the skin and tissues. However, the client's age, fracture, and mobility may mitigate some of the risk, as he or she may have better skin elasticity, wound healing, and ability to reposition.
Choice C reason: A 65yearold with hemiparesis and incontinence is at the greatest risk for pressure injury development, because he or she has multiple major risk factors for pressure injury. Age is a risk factor for pressure injury, because it causes decreased skin elasticity, thickness, and vascularity, which can affect the skin's resilience and repair. Hemiparesis is a risk factor for pressure injury, because it causes reduced mobility, sensation, and muscle mass, which can affect the client's ability to reposition, feel pain, and maintain tissue perfusion. Incontinence is a risk factor for pressure injury, because it causes moisture, irritation, and infection of the skin, which can weaken the skin barrier and delay wound healing.
Choice D reason: A 78yearold requiring assistance to ambulate with a walker is at a moderate risk for pressure injury development, but not the greatest, because he or she has only one major risk factor for pressure injury. Age is a risk factor for pressure injury, as explained above. However, the client's ambulation and assistance may reduce some of the risk, as he or she may have less pressure, shear, and friction on the skin and tissues, and more blood circulation and oxygen delivery.
Correct Answer is D
Explanation
Choice A reason: Heberden's nodes are not a symptom of lupus. Heberden's nodes are bony swellings that form on the distal interphalangeal joints of the fingers. They are a sign of osteoarthritis, which is a degenerative joint disease that causes pain, stiffness, and reduced mobility.
Choice B reason: Chvostek's sign is not a symptom of lupus. Chvostek's sign is a facial twitch that occurs when the facial nerve is tapped near the ear. It is a sign of hypocalcemia, which is a low level of calcium in the blood. Hypocalcemia may be caused by various conditions, such as hypoparathyroidism, vitamin D deficiency, or renal failure.
Choice C reason: OsgoodSchlatter's disease is not a symptom of lupus. OsgoodSchlatter's disease is a condition that affects the growth plate of the tibia, which is the shin bone. It causes pain, swelling, and tenderness below the knee. It is common in adolescents who are active in sports that involve running, jumping, or bending the knee.
Choice D reason: Butterfly rash is a classic symptom of lupus. Butterfly rash is a malar rash that appears across the cheeks and the bridge of the nose. It is a common sign of systemic lupus erythematosus (SLE), which is an autoimmune disease that causes inflammation and damage to various organs and tissues. The rash may flare up or fade depending on the disease activity and exposure to sunlight.
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