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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Lethargy is a sign of increased intracranial pressure (ICP), as it indicates a decreased level of alertness and responsiveness due to brain compression¹².
Choice B reason: Slowed responses to verbal cues are a sign of increased ICP, as they indicate a decreased level of cognitive function and communication ability due to brain compression¹².
Choice C reason: Negative Babinski sign is not a sign of increased ICP, as it indicates a normal reflex response of the toes to stimulation of the sole of the foot³. A positive Babinski sign, where the big toe extends upward and the other toes fan out, is a sign of neurological damage, but not necessarily increased ICP³.
Choice D reason: Altered speech is a sign of increased ICP, as it indicates a decreased level of language function and articulation due to brain compression¹².
Choice E reason: Decreased level of consciousness is a sign of increased ICP, as it indicates a decreased level of awareness and arousal due to brain compression¹².

A. Flexion of the hip causes resistance to extension of the leg. B. Flexion of the neck causes flexion of the hips and knees. C. Flexion of the ankle causes upward fanning of the toes. D. Flexion of the neck causes pain and spasm in the leg muscles.

Correct Answer is B

Explanation

Choice A reason: Flexion of the hip causing resistance to extension of the leg is not a sign of meningitis. It is a sign of hip joint inflammation or injury.

Choice B reason: Flexion of the neck causing flexion of the hips and knees is a positive Brudzinski's sign. It indicates irritation of the meninges, the membranes that cover the brain and spinal cord.

Choice C reason: Flexion of the ankle causing upward fanning of the toes is not a sign of meningitis. It is a sign of an upper motor neuron lesion, such as a stroke or spinal cord injury.

Choice D reason: Flexion of the neck causing pain and spasm in the leg muscles is not a sign of meningitis. It is a sign of muscle strain or nerve compression.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a head injury after a fall from a ladder. The nurse must evaluate the patient for which signs and symptoms of increased intracranial pressure?

Correct Answer is ["A","B","D","E"]

Explanation

The nurse assesses a patient who potentially may have meningitis. The patient demonstrates a positive Brudzinski's sign with which changes in position.

Correct Answer is B

Explanation

An older adult is admitted to the hospital following a closed head injury from a fall that resulted in a 5-minute period of unconsciousness. Which priority nursing assessment indicates neurological deterioration in the patient?

The emergency room nurse notes clear drainage dripping from the nose of a newly admitted patient with a head injury after diving into shallow water. Which initial intervention should the nurse perform?

When teaching the parents and patients newly diagnosed with beta-thalassemia, which statement made by the parents or patients indicates a need for additional teaching?

The nurse is caring for a patient with a new traumatic brain injury and completes a neurologic assessment. The magnetic resonance imaging identifies an intracranial epidural hematoma. The nurse would immediately notify the provider of which assessment finding?

The nurse should complete which essential interventions for a patient who has experienced status epilepticus?

The nurse is preparing a teaching session about Guillain-Barre syndrome. Which statement should be included in the presentation?

A nurse is caring for a client who begins to exhibit seizure activity while in bed. Which of the following actions should the nurse implement to care for the client?

The nurse is explaining early changes with Parkinson disease to the student nurse. Which statement by the nurse is correct regarding the pathophysiology of the disease?