A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct?

“It’s like a transfusion reaction because no perfect matches exist."

“The patient’s cells are fighting donor cells for dominance.”

“The donor's cells are actually attacking the patient's cells."

“Because of immunosuppression, the donor cells take over"

Answer and Explanation

The Correct Answer is C

Graft-versus-host disease (GVHD) is a complex immunological phenomenon occurring after allogeneic hematopoietic stem cell transplantation. It occurs when immunocompetent donor T-lymphocytes recognize the recipient’s HLA antigens as foreign. This leads to a systemic cytotoxic immune response directed against the host's tissues, primarily affecting the skin, liver, and gastrointestinal tract, causing significant morbidity and potential mortality.

Rationale:

A. Comparing GVHD to a transfusion reaction is scientifically imprecise. A transfusion reaction typically involves the recipient's antibodies attacking the donor's red blood cells. In contrast, GVHD involves a cellular immune response where the graft itself becomes the aggressor against the host. This fundamental difference in the "attacker" and the "target" is a crucial distinction.

B. Stating that the patient's cells are fighting donor cells describes a classic transplant rejection. In rejection, the host's immune system identifies the graft as foreign and attempts to destroy it. GVHD is the functional opposite, where the donor’s immune cells survive the conditioning regimen and mount an attack against the immunocompromised recipient.

C. The nurse correctly explains that the donor's cells are attacking the patient's cells. This is the hallmark of GVHD, where donor T-cells initiate an inflammatory cascade against host tissues. This explanation accurately conveys the unique "upside-down" nature of this immune complication, where the transplanted tissue perceives the host's body as the foreign invader.

D. Stating that donor cells "take over" due to immunosuppression is a vague and misleading simplification. While donor cells are intended to engraft and produce new blood cells, the term "taking over" does not explain the pathological destruction of host organs. The issue is not the presence of donor cells, but their aggressive, inappropriate immune activation.

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Correct Answer is B

Explanation

Acute gastritisinvolves sudden inflammation of the gastric mucosa, often triggered by chemical irritants or medications. Prostaglandinsare essential for maintaining the protective mucus barrier of the stomach. Agents that inhibit these protective lipids, particularly NSAIDs, leave the epithelium vulnerable to auto-digestion by hydrochloric acid, leading to erosions, hemorrhage, and severe epigastric pain.

Rationale:

A.Smoking cigarettes is a known risk factor that impairs gastric mucosal healing and increases acid secretion. Nicotine reduces the secretion of pancreatic bicarbonate and slows the healing process of gastric erosions. While this habit is harmful, the client's statement about NSAID use represents a more direct and acute physiological threat to the integrity of the gastric lining in this specific diagnosis.

B.The statement about taking ibuprofen indicates a need for further teaching because NSAIDs are a primary cause of acute gastritis. Ibuprofen inhibits the cyclooxygenase-1 enzyme, which is responsible for synthesizing protective prostaglandins in the stomach. Even occasional use can disrupt the mucosal barrier, leading to further inflammation, ulceration, or life-threatening gastric hemorrhage in a patient already diagnosed with gastritis.

C.Decreasing caffeinated drinks is an appropriate action for a patient with acute gastritis. Caffeine stimulates the parietal cells to increase the production of gastric acid, which can worsen inflammation and pain. The client’s understanding of this dietary restriction shows that the previous teaching regarding gastric irritants was successful and does not require further correction by the nurse.

D.Cutting down on alcohol is a correct self-care measure as ethanol is a direct mucosal toxin. Alcohol causes acute damage to the gastric epithelium and increases the risk of erosive gastritis and bleeding. The client’s recognition that nightly martinis are problematic demonstrates an accurate understanding of the lifestyle changes needed to allow the gastric mucosa to recover and heal.

A. Establishing large-bore intravenous (IV) access. B. Placing the patient in a low, side-lying position. C. Initiating a low-sodium diet to manage ascites. D. Collecting a fecal occult blood test.

Correct Answer is A

Explanation

Esophageal varicesare dilated submucosal veins in the lower esophagus caused by portal hypertension. When these fragile vessels rupture, they cause massive, life-threatening upper gastrointestinal hemorrhage. This leads to a rapid reduction in intravascular volumeand can result in hemorrhagic shock. Immediate stabilization requires the ability to infuse large volumes of fluids and blood productsto maintain vital organ perfusion and systemic blood pressure.

Rationale:

A.Establishing large-bore IV accessis the highest priority to prepare for rapid fluid resuscitation and blood transfusions. Hematemesis and melena indicate significant active bleeding, which can lead to hypovolemic shockand death within minutes. Having two large-bore catheters (18 gauge or larger) allows the nurse to administer the volume necessary to maintain the patient's hemodynamic stability.

B.While positioning can help prevent aspiration, the immediate life-threatening problem is the loss of blood volume. A side-lying position may protect the airway, but without circulatory support, the patient will still succumb to shock. The physiological priority in an active hemorrhage is always the restoration of volume and oxygen-carrying capacity via intravenous access.

C.Initiating a low-sodium diet is a long-term management strategy for chronic ascites, but it is completely irrelevant in an acute emergency. The patient is currently experiencing a vascular crisisthat requires emergency intervention. Focusing on dietary sodium while the patient is actively vomiting blood would be a gross failure to prioritize the most urgent life-saving actions.

D.Collecting a fecal occult blood test (FOBT) is unnecessary because the patient is already presenting with gross signs of bleeding (hematemesis and melena). FOBT is used to find microscopic blood in stable patients. In an emergency hemorrhage, the diagnosis is clear through clinical observation, and the nurse must prioritize hemodynamic stabilizationover redundant diagnostic tests.

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A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a client who has been diagnosed with acute gastritis. What statement by the client indicates a need for further teaching?

Correct Answer is B

Explanation

A client with a history of cirrhosis due to hepatitis C presents to the emergency department with hematemesis and melena. The client is diagnosed with esophageal varices secondary to pulmonary hypertension. Which nursing intervention is the highest priority?

Correct Answer is A

Explanation

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