A nurse is assessing a client's immune function by reviewing the laboratory value of the cellular response of the T-cells. The nurse should recognize that which of the following conditions is affected by the T-cells?

Hay fever allergy

Anaphylaxis

Transplant rejection

Bacterial phagocytosis

Answer and Explanation

The Correct Answer is C

Choice A reason:
Hay fever allergy, also known as allergic rhinitis, is primarily associated with the action of Immunoglobulin E (IgE) antibodies and not directly with T-cells. T-cells can contribute to the regulation of the immune response in allergies, but IgE is the main immunoglobulin involved in the typical symptoms of hay fever.

Choice B reason:
Anaphylaxis is a severe, potentially life-threatening allergic reaction that involves the release of large amounts of histamine and other chemicals from mast cells and basophils, often triggered by IgE antibodies. While T-cells can play a role in the sensitization phase of allergy, anaphylaxis itself is not directly caused by T-cells.

Choice C reason:
Transplant rejection is a process in which T-cells play a central role. When a transplant recipient's immune system recognizes the donated organ as foreign, T-cells can mediate the rejection by attacking the transplanted tissue, leading to its failure.

Choice D reason:
Bacterial phagocytosis is primarily the function of phagocytes like neutrophils and macrophages. T-cells are involved in the adaptive immune response and can activate phagocytes, but they do not directly perform phagocytosis.

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Correct Answer is A

Explanation

Choice A reason:
Morphine is an opioid analgesic that can cause a decrease in gastrointestinal motility, leading to constipation and exacerbation of paralytic ileus, a condition where there is a cessation of peristalsis in the intestine. In the case of paralytic ileus, the intestinal contents cannot move, which can lead to bowel distention, pain, and further complications. Therefore, morphine is contraindicated in clients with paralytic ileus due to the risk of worsening the condition..

Choice B reason:
While morphine can suppress cough and provide some relief in respiratory conditions, it is not contraindicated in bronchitis pleurisy unless respiratory depression is present. However, caution is advised as morphine can cause respiratory depression and should be used carefully in patients with underlying respiratory disorders.

Choice C reason:
Morphine is often used in the management of acute myocardial infarction (MI) to relieve chest pain, reduce anxiety, and decrease the workload on the heart by lowering blood pressure and heart rate. It is not contraindicated in MI; in fact, it can be beneficial in managing the symptoms associated with MI.

Choice D reason:
Postoperative pain management following hip arthroplasty often includes opioids like morphine. Morphine is not contraindicated in this situation and can be used to control postoperative pain, provided that the patient's respiratory function is closely monitored

A. Examine the skin for generalized urticaria. B. Monitor the mouth for signs of xerostomia. C. Review laboratory test results for low hemoglobin. D. Observe for signs of infection.

Correct Answer is B

Explanation

Choice A reason:
Generalized urticaria, or hives, is not a common side effect of radiation therapy for lung cancer. While skin reactions can occur, they are usually localized to the area being treated. Urticaria might be a sign of an allergic reaction, which would require immediate attention, but it is not typically associated with radiation therapy¹.

Choice B reason:
Xerostomia, or dry mouth, is a common side effect of radiation therapy, especially when the radiation field includes salivary glands. For lung cancer patients, if the radiation field is near the neck or upper chest, it could potentially affect salivary gland function. Monitoring for xerostomia is important because it can lead to difficulties in speaking, eating, and swallowing, and it increases the risk for dental problems².

Choice C reason:
While reviewing laboratory test results for low hemoglobin is an important part of nursing care, it is not specific to radiation therapy for lung cancer. Low hemoglobin could be related to the cancer itself or a side effect of other treatments like chemotherapy. It is important to monitor, but not the primary action related to radiation therapy³.

Choice D reason:
Observing for signs of infection is a general nursing responsibility for all patients, not specific to those receiving radiation therapy for lung cancer. However, if the patient's immune system is compromised due to the cancer or other treatments, vigilance for infection is heightened.

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A nurse is assessing a client's immune function by reviewing the laboratory value of the cellular response of the T-cells. The nurse should recognize that which of the following conditions is affected by the T-cells?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify as a contraindication to this medication?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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