An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to “speak up so that she can hear.”. Which action is best for the nurse to take?
Decrease speaking speed.
Over-enunciate word syllables.
Raise voice volume to a shout.
Exaggerate nonverbal expressions.
The Correct Answer is B
Choice A rationale
Decreasing speaking speed may help with clarity, but it does not address the issue of hearing loss.
Choice B rationale
Over-enunciating word syllables can help the client understand speech better, especially if they have hearing difficulties. This technique makes it easier for the client to read lips and understand spoken words.
Choice C rationale
Raising voice volume to a shout can be uncomfortable and may not improve understanding. It can also be perceived as rude or aggressive.
Choice D rationale
Exaggerating nonverbal expressions may help with communication, but it is not as effective as over-enunciating word syllables for clients with hearing difficulties.
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Correct Answer is B
Explanation
Choice A rationale
Autoimmune response is not the correct type of immune reaction for a bee sting. Autoimmune responses involve the body’s immune system attacking its own tissues, which is not the case with bee stings.
Choice B rationale
IgE response hypersensitivity is the correct type of immune reaction for a bee sting. Bee stings can trigger an IgE-mediated hypersensitivity reaction, leading to symptoms such as rash, difficulty breathing, and low blood pressure. This type of reaction is also known as anaphylaxis.
Choice C rationale
Cell-mediated hypersensitivity is not the correct type of immune reaction for a bee sting. Cell-mediated hypersensitivity involves T cells and is typically associated with conditions like contact dermatitis, not bee stings.
Choice D rationale
Type II hypersensitivity is not the correct type of immune reaction for a bee sting. Type II hypersensitivity involves antibody-mediated destruction of cells, which is not the case with bee stings.
Correct Answer is D
Explanation
Choice A rationale
A chest X-ray or computed tomography (CT) scan can show abnormalities in the lungs that are suggestive of tuberculosis (TB), but they cannot definitively diagnose TB. These imaging tests can reveal changes in the lungs, such as nodules, inflammation, or fluid buildup, which can be caused by TB or other conditions. Therefore, a chest X-ray or CT scan alone is not sufficient to diagnose TB.
Choice B rationale
A hemoccult test on sputum collected from hemoptysis is not a diagnostic test for TB. It is a test for blood in the stool, which can be a symptom of TB but is not specific to TB. Hemoptysis, or coughing up blood, can occur in various conditions, including bronchitis, pneumonia, lung cancer, and TB. The hemoccult test cannot differentiate between these causes, making it an unreliable test for diagnosing TB.
Choice C rationale
A positive purified protein derivative (PPD) skin test indicates exposure to TB but does not confirm active infection. The PPD skin test involves injecting a small amount of tuberculin, a protein derived from Mycobacterium tuberculosis, into the skin. If a person has been exposed to TB, their immune system will react to the tuberculin, causing a raised red bump to appear at the injection site. However, a positive PPD skin test does not necessarily mean that a person has active TB infection. It could also mean that they have been exposed to TB in the past but have successfully fought off the infection. Further testing, such as a sputum culture, is needed to confirm the diagnosis of TB.
Choice D rationale
A sputum culture positive for Mycobacterium tuberculosis is the definitive diagnostic test for TB. It involves collecting a sample of sputum, which is the mucus coughed up from the lungs, and culturing it in a laboratory to see if Mycobacterium tuberculosis, the bacteria that causes TB, grows. This test is highly specific for TB, meaning that a positive result is almost always indicative of TB infection. It is also sensitive, meaning that it can detect TB infection even when there are few bacteria present.