A client is admitted with the diagnosis of Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

The correct answers are:

• Immunoglobulin administration: Passive – Artificial Immunity
• Antibodies produced by body after exposure to live pathogen: Active – Natural Immunity
• Vaccine administration: Active – Artificial Immunity
• Antibodies passed from mother to fetus: Passive – Natural Immunity
• Antibodies produced by body after exposure to attenuated virus: Active – Artificial Immunity

A. Immunoglobulin administration involves injecting pre-formed antibodies from an external source, such as human or animal serum, to provide immediate but temporary protection. This does not stimulate the recipient’s immune system to produce antibodies or memory cells, aligning with passive – artificial immunity.

B. Exposure to a live pathogen triggers the body’s immune system to produce antibodies and memory cells, conferring long-term protection. This natural process of immune activation matches active – natural immunity, as the body actively responds to the pathogen without artificial intervention.

C. Vaccine administration introduces attenuated or inactivated pathogens, prompting the immune system to produce antibodies and memory cells without causing disease. This artificial induction of immunity aligns with active – artificial immunity, as it mimics natural infection but is deliberately administered.

D. Antibodies passed from mother to fetus, primarily immunoglobulin G (IgG) through the placenta, provide temporary protection to the newborn without active immune response. This natural transfer of antibodies corresponds to passive – natural immunity, as it occurs without medical intervention.

E. Exposure to an attenuated virus via vaccination stimulates the immune system to produce antibodies and memory cells, offering long-term protection. This controlled, artificial exposure aligns with active – artificial immunity, as it involves deliberate administration of a weakened pathogen to induce an immune response.

Choice A reason: Checking blood glucose is important in stroke management to rule out hypoglycemia mimicking stroke symptoms, but it is not the first action. A neurological exam identifies stroke signs like weakness or speech deficits, guiding urgent interventions like thrombolytics. Glucose testing follows to ensure metabolic causes are addressed after confirming neurological deficits.

Choice B reason: Performing a neurological exam is the first priority in suspected stroke to identify focal deficits, such as hemiparesis, aphasia, or altered consciousness. This confirms the diagnosis and determines eligibility for time-sensitive treatments like thrombolytics or thrombectomy. Rapid assessment using tools like the NIH Stroke Scale ensures timely intervention to minimize brain damage.

Choice C reason: Obtaining a CT scan is critical to differentiate ischemic from hemorrhagic stroke but follows a neurological exam. The exam confirms stroke symptoms, ensuring the scan is warranted. CT scans guide treatment decisions but are not the first step, as clinical assessment drives the urgency and direction of diagnostic imaging.

Choice D reason: Monitoring blood pressure is important in stroke, as hypertension can worsen outcomes, but it is not the first action. A neurological exam identifies stroke symptoms, prioritizing rapid diagnosis and treatment. Blood pressure management follows to optimize cerebral perfusion, especially if thrombolytics are considered, but initial assessment takes precedence.