The daughter of an older adult asks the nurse why her father seems to have so many respiratory infections despite receiving the annual influenza vaccine. Select the nurse's best response.
After the age of 60, the plasma volume increases and there is a decreased ability to fight infections.
Healthy bone marrow function decreases with aging, which lowers the immune response to infection.
older adults have an overactive antibody response to vaccines.
An older person's blood is more prone to clotting, so infection-fighting cells cannot reach the source of infection quickly.
The Correct Answer is B
Choice A reason: This is incorrect. After the age of 60, the plasma volume decreases and there is a decreased ability to fight infections. The decrease in plasma volume reduces the blood flow and oxygen delivery to the tissues, which impairs the immune function.
Choice B reason: This is correct. Healthy bone marrow function decreases with aging, which lowers the immune response to infection. The bone marrow produces fewer white blood cells, which are essential for fighting infections. The older adult also has a reduced response to vaccines, which makes them more susceptible to infections.
Choice C reason: This is incorrect. Older adults have an underactive antibody response to vaccines. This means that they do not produce enough antibodies to protect themselves from the pathogens that the vaccine is supposed to prevent.
Choice D reason: This is incorrect. An older person's blood is more prone to clotting, but this does not affect the infection-fighting cells. The infection-fighting cells can still travel through the blood vessels and reach the source of infection. However, the increased risk of clotting can lead to other complications such as stroke or heart attack.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct. Monitoring of neurologic status is a priority intervention for a patient with bacterial meningitis, as the infection can cause inflammation and damage to the brain and spinal cord. The nurse should assess the patient's level of consciousness, pupillary response, cranial nerve function, and signs of increased intracranial pressure.
Choice B reason: This is incorrect. Infusion of large volumes of isotonic intravenous fluids is not indicated for a patient with bacterial meningitis, as it can worsen the cerebral edema and increase the intracranial pressure. The patient should receive adequate hydration, but not excessive fluids.
Choice C reason: This is incorrect. Standard precautions are not sufficient for a patient with bacterial meningitis, as the infection can be transmitted through respiratory droplets. The patient should be placed on droplet precautions, which include wearing a mask, gloves, and gown, and limiting the contact with other patients and visitors.
Choice D reason: This is incorrect. Distraction activities to reduce long periods of sleep are not appropriate for a patient with bacterial meningitis, as the patient may need rest and sedation to reduce the agitation and pain. The nurse should provide a quiet and dark environment, and avoid unnecessary stimuli that can increase the intracranial pressure.
Correct Answer is B
Explanation
Choice A reason: Observing the time of onset and end of seizure activity is important, but it is not the priority action. The nurse should first ensure the safety of the client and prevent injury.
Choice B reason: Removing objects within reach of the client's arms and legs is the correct action, as it prevents the client from hitting or injuring themselves during the seizure. The nurse should also lower the bed and raise the side rails.
Choice C reason: Loosening any restrictive clothing around the neck is a good practice, but it is not as urgent as removing objects. The nurse can do this after ensuring the client's safety.
Choice D reason: Placing a padded tongue blade in the client's mouth is a wrong and dangerous action, as it can cause choking, aspiration, or damage to the teeth and oral mucosa. The nurse should never force anything into the client's mouth during a seizure.
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