10.12: Reading- Overview of the New-Product Development Process
Introduction
There are probably as many varieties of new-product development systems as there are types of companies, but most of them share the same basic steps or stages—they are just executed in different ways. Below, we have divided the process into eight stages, grouped into three phases; subsequent readings will discuss these phases in greater detail. Many of the activities are performed repeatedly throughout the process, but they become more concrete as the product idea is refined and additional data are gathered. For example, at each stage of the process the product team is asking, “Is this a viable product concept?” but the answers change as the product is refined and more market perspectives can be added to the evaluation.
| Phase I: Generating and Screening Ideas | Phase II: Developing New Products | Phase III: Commercializing New Products |
|---|---|---|
| Stage 1: Generating New Product Ideas | Stage 4: Business Case Analysis | Stage 6: Test Marketing |
| Stage 2: Screening Product Ideas | Stage 5: Technical and Marketing Development | Stage 7: Launch |
| Stage 3: Concept Development and Testing | Stage 8: Evaluation |
Stage 1: Generating New Product Ideas
Generating new product ideas is a creative task that requires a particular way of thinking. Coming up with ideas is easy, but generating good ideas is another story. Companies use a range of internal and external sources to identify new product ideas. A SWOT analysis might suggest strengths in existing products that could be the basis for new products or market opportunities. Research might identify market and customer trends. A competitive analysis might expose a hole in the company’s product portfolio. Customer focus groups or the sales team might identify unmet customer needs. Many amazing products are also the result of lucky mistakes—product experiments that don’t meet the intended goal but have an unintended and interesting application. For example, 3M scientist Dr. Spencer Silver invented Post-It Notes in a failed experiment to create a super-strong adhesive. [1]
The key to the idea generation stage is to explore possibilities, knowing that most will not result in products that go to market.
Stage 2: Screening Product Ideas
The second stage of the product development process is idea screening. This is the first of many screening points. At this early stage much is not known about the product and its market opportunity. Still, product ideas that do not meet the organization’s objectives should be rejected at this stage. If a poor product idea is allowed to pass the screening stage, it wastes effort and money in later stages until it is abandoned. Even more serious is the possibility of screening out a worthwhile idea and missing a significant market opportunity. For this reason, this early screening stage allows many ideas to move forward that may not eventually go to market.
At this early stage, product ideas may simply be screened through some sort of internal rating process. Employees might rate the product ideas according to a set of criteria, for example; those with low scores are dropped and only the highest ranked products move forward.
Stage 3: Concept Development and Testing
Today, it is increasingly common for companies to run some small concept test in a real marketing setting. The product concept is a synthesis or a description of a product idea that reflects the core element of the proposed product. Marketing tries to have the most accurate and detailed product concept possible in order to get accurate reactions from target buyers. Those reactions can then be used to inform the final product, the marketing mix, and the business analysis.
New tools for technology and product development are available that support the rapid development of prototypes which can be tested with potential buyers. When concept testing can include an actual product prototype, the early test results are much more reliable. Concept testing helps companies avoid investing in bad ideas and at the same time helps them catch and keep outstanding product ideas.
Stage 4: Business Case Analysis
Before companies make a significant investment in a product’s development, they need to be sure that it will bring a sufficient return.
The company seeks to answer such questions as the following:
- What is the market opportunity for this product?
- What are the costs to bring the product to market?
- What are the costs through the stages of the product life cycle?
- Where does the product fit in the product portfolio and how will it impact existing product sales?
- How does this product impact the brand?
- How does this product impact other corporate objectives such as social responsibility?
The marketing budget and costs are one element of the business analysis, but the full scope of the analysis includes all revenues, costs, and other business impacts of the product.
Stage 5: Technical and Marketing Development
A product that has passed the screening and business analysis stages is ready for technical and marketing development. Technical development processes vary greatly according to the type of product. For a product with a complex manufacturing process, there is a lab phase to create specifications and an equally complex phase to develop the manufacturing process. For a service offering, there may be new processes requiring new employee skills or the delivery of new equipment. These are only two of many possible examples, but in every case the company must define both what the product is and how it will be delivered to many buyers.
While the technical development is under way, the marketing department is testing the early product with target customers to find the best possible marketing mix. Ideally, marketing uses product prototypes or early production models to understand and capture customer responses and to identify how best to present the product to the market. Through this process, product marketing must prepare a complete marketing plan—one that starts with a statement of objectives and ends with a coherent picture of product distribution, promotion, and pricing integrated into a plan of marketing action.
Stage 6: Test Marketing and Validation
Test marketing is the final stage before commercialization; the objective is to test all the variables in the marketing plan including elements of the product. Test marketing represents an actual launching of the total marketing program. However, it is done on a limited basis.
Initial product testing and test marketing are not the same. Product testing is totally initiated by the producer: he or she selects the sample of people, provides the consumer with the test product, and offers the consumer some sort of incentive to participate.
Test marketing , on the other hand, is distinguished by the fact that the test group represents the full market, the consumer must make a purchase decision and pay for the product, and the test product must compete with the existing products in the actual marketing environment. For these and other reasons, a market test is an accurate simulation of the broader market and serves as a method for reducing risk. It should enhance the new product’s probability of success and allow for final adjustment in the marketing mix before the product is introduced on a large scale.
Stage 7: Launch
Finally, the product arrives at the commercial launch stage. The marketing mix comes together to introduce the product to the market. This stage marks the beginning of the product life cycle.
Stage 8: Evaluation
The launch does not in any way signal the end of the marketing role for the product. To the contrary, after launch the marketer finally has real market data about how the product performs in the wild, outside the test environment. These market data initiate a new cycle of idea generation about improvements and adjustments that can be made to all elements of the marketing mix.
Contributors and Attributions
- Revision and Adaptation. Provided by : Lumen Learning. License : CC BY: Attribution
- Chapter 7: Introducing and Managing the Product, from Introducing Marketing. Authored by : John Burnett. Provided by : Global Text. Located at : http://solr.bccampus.ca:8001/bcc/file/ddbe3343-9796-4801-a0cb-7af7b02e3191/1/Core%20Concepts%20of%20Marketing.pdf . License : CC BY: Attribution
- Design Sketching. Authored by : Jordanhill School D&T Dept. Located at : https://www.flickr.com/photos/designandtechnologydepartment/3968172841/ . License : CC BY: Attribution
- Circuit Sticker Prototypes. Authored by : Jie Qi. Located at : https://www.flickr.com/photos/jieq/9002249677/ . License : CC BY: Attribution
- Open Ideas. Provided by : opensource.com. Located at : https://www.flickr.com/photos/opensourceway/7496802920/ . License : CC BY-NC: Attribution-NonCommercial
- Science!. Authored by : Quinn Dombrowski. Located at : https://www.flickr.com/photos/quinnanya/8042323280/ . License : CC BY-SA: Attribution-ShareAlike


14: Biomolecules - Nucleic Acids
When you have completed Chapter 14, you should be able to
- fulfill all of the detailed objectives listed under each individual section.
- draw the structure of a given nucleotide.
- discuss the structure of DNA and RNA.
- describe the processes involved in DNA replication, transcription, translation, and protein synthesis.
- define, and use in context, the key terms introduced in this chapter.
Two types of nucleic acids are found in cells—deoxyribonucleic acid (DNA) and ribonucleic acid (RNA). These highly complex substances are built up from a number of simpler units, called nucleotides. Each nucleotide consists of three parts: a phosphoric acid residue, a sugar and a nitrogen‑containing heterocyclic base. Thus, in order to understand the biochemistry of the nucleic acids, you must first study the chemistry of the sugars (see Chapter 25) and simple heterocyclic systems. We have already discussed certain aspects of the structure of heterocyclic ring systems during our study of aromaticity (Sections 15.5–15.6). You may find it helpful to review this chapter.
Chapter 14 examines the structure and replication of DNA and then describes the structure and synthesis of RNA. The chapter closes with a brief study of the role played by RNA in the biosynthesis of proteins.
-
- 14.1: Chapter Objectives
- Nucleic acids are indispensable molecules that underpin the central dogma of molecular biology, governing the storage, transmission, and expression of genetic information in all living organisms. Understanding their structure, function, and interactions is fundamental to unraveling the complexities of life and advancing fields such as medicine, biotechnology, and genetics.
-
- 14.5: Transcription of DNA
- Three types of RNA are formed during transcription: messenger RNA (mRNA), ribosomal RNA (rRNA), and transfer RNA (tRNA). These three types of RNA differ in function, size, and percentage of the total cell RNA. mRNA makes up only a small percent of the total amount of RNA within the cell, primarily because each molecule of mRNA exists for a relatively short time; it is continuously being degraded and resynthesized.


10.8: The McNemar Test
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Suppose you’ve been hired to work for the Australian Generic Political Party (AGPP), and part of your job is to find out how effective the AGPP political advertisements are. So, what you do, is you put together a sample of N=100 people, and ask them to watch the AGPP ads. Before they see anything, you ask them if they intend to vote for the AGPP; and then after showing the ads, you ask them again, to see if anyone has changed their minds. Obviously, if you’re any good at your job, you’d also do a whole lot of other things too, but let’s consider just this one simple experiment. One way to describe your data is via the following contingency table:
| Before | After | Total | |
|---|---|---|---|
| Yes | 30 | 10 | 40 |
| No | 70 | 90 | 160 |
| Total | 100 | 100 | 200 |
At first pass, you might think that this situation lends itself to the Pearson χ2 test of independence (as per Section 12.2). However, a little bit of thought reveals that we’ve got a problem: we have 100 participants, but 200 observations. This is because each person has provided us with an answer in both the before column and the after column. What this means is that the 200 observations aren’t independent of each other: if voter A says “yes” the first time and voter B says “no”, then you’d expect that voter A is more likely to say “yes” the second time than voter B! The consequence of this is that the usual χ2 test won’t give trustworthy answers due to the violation of the independence assumption. Now, if this were a really uncommon situation, I wouldn’t be bothering to waste your time talking about it. But it’s not uncommon at all: this is a standard repeated measures design, and none of the tests we’ve considered so far can handle it. Eek.
The solution to the problem was published by McNemar (1947). The trick is to start by tabulating your data in a slightly different way:
| Before: Yes | Before: No | Total | |
|---|---|---|---|
| After: Yes | 5 | 5 | 10 |
| After: No | 25 | 65 | 90 |
| Total | 30 | 70 | 100 |
This is exactly the same data, but it’s been rewritten so that each of our 100 participants appears in only one cell. Because we’ve written our data this way, the independence assumption is now satisfied, and this is a contingency table that we can use to construct an X 2 goodness of fit statistic. However, as we’ll see, we need to do it in a slightly nonstandard way. To see what’s going on, it helps to label the entries in our table a little differently:
| Before: Yes | Before: No | Total | |
|---|---|---|---|
| After: Yes | a | b | a+b |
| After: No | c | d | c+d |
| Total | a+c | b+d | n |
Next, let’s think about what our null hypothesis is: it’s that the “before” test and the “after” test have the same proportion of people saying “Yes, I will vote for AGPP”. Because of the way that we have rewritten the data, it means that we’re now testing the hypothesis that the row totals and column totals come from the same distribution. Thus, the null hypothesis in McNemar’s test is that we have “marginal homogeneity”. That is, the row totals and column totals have the same distribution: P a +P b =P a +P c , and similarly that P c +P d =P b +P d . Notice that this means that the null hypothesis actually simplifies to P b =P c . In other words, as far as the McNemar test is concerned, it’s only the off-diagonal entries in this table (i.e., b and c) that matter! After noticing this, the McNemar test of marginal homogeneity is no different to a usual χ2 test. After applying the Yates correction, our test statistic becomes:
\(X^{2}=\dfrac{(|b-c|-0.5)^{2}}{b+c}\)
or, to revert to the notation that we used earlier in this chapter:
\(X^{2}=\dfrac{\left(\left|O_{12}-O_{21}\right|-0.5\right)^{2}}{O_{12}+O_{21}}\)
and this statistic has an (approximately) χ2 distribution with df=1. However, remember that – just like the other χ2 tests – it’s only an approximation, so you need to have reasonably large expected cell counts for it to work.
Doing the McNemar test in R
Now that you know what the McNemar test is all about, lets actually run one. The
agpp.Rdata
file contains the raw data that I discussed previously, so let’s have a look at it:
load("./rbook-master/data/agpp.Rdata")
str(agpp)
## 'data.frame': 100 obs. of 3 variables:
## $ id : Factor w/ 100 levels "subj.1","subj.10",..: 1 13 24 35 46 57 68 79 90 2 ...
## $ response_before: Factor w/ 2 levels "no","yes": 1 2 2 2 1 1 1 1 1 1 ...
## $ response_after : Factor w/ 2 levels "no","yes": 2 1 1 1 1 1 1 2 1 1 ...
The
agpp
data frame contains three variables, an
id
variable that labels each participant in the data set (we’ll see why that’s useful in a moment), a
response_before
variable that records the person’s answer when they were asked the question the first time, and a
response_after
variable that shows the answer that they gave when asked the same question a second time. As usual, here’s the first 6 entries:
head(agpp)
## id response_before response_after
## 1 subj.1 no yes
## 2 subj.2 yes no
## 3 subj.3 yes no
## 4 subj.4 yes no
## 5 subj.5 no no
## 6 subj.6 no no
and here’s a summary:
summary(agpp)
## id response_before response_after
## subj.1 : 1 no :70 no :90
## subj.10 : 1 yes:30 yes:10
## subj.100: 1
## subj.11 : 1
## subj.12 : 1
## subj.13 : 1
## (Other) :94
Notice that each participant appears only once in this data frame. When we tabulate this data frame using
xtabs()
, we get the appropriate table:
right.table <- xtabs( ~ response_before + response_after, data = agpp)
print( right.table )
## response_after
## response_before no yes
## no 65 5
## yes 25 5
and from there, we can run the McNemar test by using the
mcnemar.test()
function:
mcnemar.test( right.table )
##
## McNemar's Chi-squared test with continuity correction
##
## data: right.table
## McNemar's chi-squared = 12.033, df = 1, p-value = 0.0005226
And we’re done. We’ve just run a McNemar’s test to determine if people were just as likely to vote AGPP after the ads as they were before hand. The test was significant (χ2(1)=12.04,p<.001), suggesting that they were not. And in fact, it looks like the ads had a negative effect: people were less likely to vote AGPP after seeing the ads. Which makes a lot of sense when you consider the quality of a typical political advertisement.


14.9: Impact of Sexual Violence and Some Statistics
The impact of SV is not solely left with the survivors, but can be felt in society as a whole (About Sexual Assault, n.d.). Consequences from sexual violence can be felt by survivors themselves to loved ones, communities, and society (About Sexual Assault, n.d.). The section below highlights some additional statistics gathered from RAINN (Rape, Abuse & Incest National Network).
The impact of SV is not solely left with the survivors, but can be felt in society as a whole (About Sexual Assault, n.d.). Consequences from sexual violence can be felt by survivors themselves to loved ones, communities, and society (About Sexual Assault, n.d.). The section below highlights some additional statistics gathered from RAINN (Rape, Abuse & Incest National Network).
“Number of people victimized per year”
- 80,600 inmates sexually assaulted or raped
- 60,000 children were victims of “substantiated or indicated” sexual abuse
- 433,648 Americans 12 and older were sexually assaulted or raped
- 18,900 military personnel experienced unwanted sexual contact
- Every 68 seconds an American is sexually assaulted
- 1 out of every 6 American women has been the victim of an attempted or completed rape in her lifetime (14.8% completed, 2.8% attempted)
- About 3% of American men (or 1 in 33) have experienced attempted or completed rape in their lifetime
- A majority of child victims are 12-17. Of victims under the age of 18: 34% of victims of sexual assault and rape are under age 12, and 66% of victims of sexual assault and rape are age 12-17
“Locations where sexual assault occurs”
- 55% at or near the victim’s home
- 15% in an open public place
- 12% at or near a relative’s home
- 10% in an enclosed but public area, such as a parking lot or garage
- 8% on school property
“What was the survivor doing when the crime occurred?”
- 48% were sleeping, or performing another activity at home
- 29% were traveling to and from work or school, or traveling to shop or run errands
- 12% were working
- 7% were attending school
- 5% were doing an unknown or other activity
Reference: Scope of the problem: Statistics. RAINN. (n.d.). Retrieved February 26, 2022, from https://www.rainn.org/statistics/scope-problem .


8.10: Hypothesis Testing (4 of 5)
Learning Objectives
- Recognize the logic behind a hypothesis test and how it relates to the P-value.
Hypothesis testing appears in all upcoming modules. The process and the logic of the hypothesis test will always be the same, but the details will differ somewhat.
Every hypothesis test will use a P-value to make a decision about the population(s). The P-value is the connection between probability and decision-making in inference. Now we discuss the P-value in more depth and relate it to our work in Linking Probability to Statistical Inference . Later we use both simulations and statistical software to find the P-value.
To develop a better understanding of the P-value, we need to return to the idea of a sampling distribution and a normal probability model. These are ideas from Linking Probability to Statistical Inference .
Example
What Is a P-value?
Let’s return to the familiar example of the 2008 presidential election. In that election, newspapers reported that Obama received 40% of the white male vote. We wonder if a smaller percentage of white males will support Obama in the 2012 election. We define the following hypotheses and conduct a hypothesis test.
- H 0 : The proportion of white males voting for Obama in 2012 is 0.40.
- H a : The proportion of white males voting for Obama in 2012 is less than 0.40.
We select a random sample of 200 white male voters and find that 35% plan to vote for Obama in 2012. Clearly 35% is less than 40%. But is the difference statistically significant or due to chance? If the population proportion is 0.40, we expect to see sample proportions vary from this. But will sample proportions as small as or smaller than 0.35 occur very often? What’s the probability?
The probability (P-value) is about 0.078.
The P-value is the chance that a random sample of 200 white males will have, at most, 35% supporting Obama if 40% of this population supports Obama. This is quite a mouthful. We find that visualizing the sampling distribution helps us understand the P-value. Here is a diagram that may be helpful in interpreting the P-value.
In general, the P-value is the probability that sample results are as extreme as or more extreme than the result observed in the data if the null hypothesis is true. The phrase “as extreme as or more extreme than” means further from the center of the sampling distribution in the direction of the alternative hypothesis.
Note: You may recall the concept of a conditional probability from Relationships in Categorical Data with Intro to Probability . The P-value is a conditional probability. The condition is “the null hypothesis is true.”
Note: We can also look at the P-value in terms of error in the sample proportion. If 40% of this population support Obama, then our sample with 35% supporting Obama has a 5% error. From this perspective, the P-value is the chance that sample proportions supporting the alternative hypothesis have as much as or more error than the data. For this example, the P-value describes sample proportions less than 0.40 that deviate 0.05 or more from 0.40. This describes sample proportions at or below 0.35.
Comment
Recall in Linking Probability to Statistical Inference when we investigated the conditions that make a normal model a good fit for the sampling distribution. When a normal model is a good fit, we use it to find probabilities. In the Obama example, we can see that a normal model is a good fit for the sampling distribution, so we can find the P-value by calculating the z -score and using a simulation. Below we created a diagram to remind you how the sampling distribution relates to the standard normal model of z -scores. We will find P-values in this way in “Hypothesis Test for a Population Proportion,” but for now, we focus on what the P-value is and how to use it to make decisions.
Notice that for our example , the P-value from the standard normal curve (0.074) is not exactly equal to the relative frequency in the simulated sampling distribution (0.078), but it is close. Both of these values represent estimates of the probability we want.
In hypothesis testing you use the standard normal curve (or a similar model) to find P-values. For this reason, you will frequently see the P-value defined in terms of the “test statistic,” which is the z -score in our example. Here is a common definition: The P-value is the probability of obtaining a test statistic at least as extreme as the one that was actually observed, assuming the null hypothesis is true.
Comment
The purpose of the hypothesis test is to describe the degree of evidence that the sample provides against the null hypothesis. The P-value does this job. In the next two activities, we do not give a P-value. We want you to practice visualizing the sampling distribution to identify the most convincing evidence against the null hypothesis. This type of visualization is important to understanding the ideas we discuss on this page.
Example
More on Using the P-Value to Make a Decision
Let’s finish the hypothesis test about white male support for Obama.
- H 0 : The proportion of white males voting for Obama in 2012 is 0.40.
- H a : The proportion of white males voting for Obama in 2012 is less than 0.40.
Recall our random sample of 200 white male voters with 35% planning to vote for Obama in 2012. Clearly 35% is less than 40%, but is the difference statistically significant or due to chance?
The probability (P-value) is about 0.078. What can we conclude? A small P-value indicates that the data are unlikely to occur in random sampling from a population in which the null hypothesis is true. So the smaller the P-value, the stronger the evidence is against the null hypothesis.
Do you view something that happens 7.8% of the time as “unlikely”? This is a judgment call. There is no right or wrong answer. Because this is a judgment call, we will often agree to a definition of “unlikely” before we run the test. This is the significance level, α. The significance level is a benchmark for how small the P-value must be in order for us to say results are statistically significant. It gives us a cutoff point for rejecting the null hypothesis. Here are the decision-making rules that we gave earlier.
If the P-value ≤ α, we reject the null hypothesis in favor of the alternative hypothesis.
If the P-value > α, we fail to reject the null hypothesis.
Why do these “rules” make sense? Again, we think that visualizing a simulation of the sampling distribution is helpful.
Keep in mind that all of the sample proportions in the simulation did actually occur when we selected random samples from a population with P = 0.40. Results less than 0.40 support the alternative hypothesis but to varying degrees. To provide enough evidence to reject the null hypothesis and accept the alternative hypothesis, results have to be smaller than 0.40 and “rare.” When we set the significance level at 5% (α = 0.05), we agree to view results that occur less than 5% of the time as “rare enough” to question whether the sample came from the population described by the null. So we reject the null hypothesis and accept the alternative. If we set the significance level at 10% (α = 0.10), we have changed the definition of rare. As you can see, different significance levels can lead to different conclusions.
Here are our conclusions for the two different levels of significance.
At the 5% level, our poll results are not statistically significant (P-value = 0.078). We conclude that white male support for Obama will not be less than 40% in 2012. (Note: This statement says we do not have enough evidence to accept H a . Because H a is related to the claim or hunch that motivated our investigation, we state our conclusion in terms of H a .)
At the 10% level, our poll results are statistically significant (P-value = 0.078). We conclude that white male support for Obama will be less than 40% in 2012. (Note: This statement says we have enough evidence to accept H a . Again, the conclusion is stated in terms of H a .)
How Do You Choose a Level of Significance?
Remember that the purpose of the hypothesis test is to describe the degree of evidence that the sample provides against the null hypothesis. The P-value does this. How small a P-value is convincing evidence? It depends on the situation and the opinions of the people who use the hypothesis test to make a decision. If rejecting the null hypothesis will be controversial or expensive, then the users of the test results may want to use a smaller level of significance than we did. For this reason, we always report the P-value with our conclusions so that the people who use the results of the test can determine if the P-value is strong enough evidence for their purpose.
Later we discuss other considerations for choosing a level of significance.
Contributors and Attributions
- Concepts in Statistics. Provided by : Open Learning Initiative. Located at : http://oli.cmu.edu . License : CC BY: Attribution


6: Reports Last updated Save as PDF Page ID 46034 Nina Burokas Lumen Learning Learning Objectives Discuss the different types of reports and their purposes Create an informal report Create formal reports and proposals 6.1: Formal Reports 6.2: Sections of Formal Reports 6.3: Front Sections of a Report 6.4: Body Sections of a Report 6.5: Back Matter 6.6: Organization of Formal Reports 6.7: How to Write a Formal Report 6.8: Putting It Together- Reports 6.9: Assignment- Reports 6.10: Why It Matters- Reports 6.11: Introduction to Business Reports 6.12: Types of Reports 6.13: Stakeholders 6.14: Introduction to Informal Reports 6.15: Using Informal Reports 6.16: Organizing an Informal Report 6.17: How to Write an Informal Report 6.18: Introduction to Formal Reports


41.3.5: Chapter 6
Review Questions
1.
d.
Cell-mediated immunity is primarily responsible for recognizing and attacking infected cells, including viral cells.
2.
c.
When treating RA, hydroxychloroquine is used to modify the disease progression by reducing joint inflammation and preventing joint damage.
3.
a.
Biologic drugs, particularly tumor necrosis factor-alpha (TNF-alpha) inhibitors, can increase the risk of reactivating latent tuberculosis.
4.
c.
The five cardinal signs of inflammation are redness (rubor), swelling (tumor), warmth (calor), pain (dolor), and loss of function (functio laesa).
5.
c.
6.
d.
A vaccine is a medication containing weakened or killed pathogens or antigens, given to prevent future infections, while an immunization is the process of administering a vaccine.
7.
c.
NSAIDs can cause irritation and damage to the gastrointestinal lining, resulting in gastrointestinal bleeding.
8.
a.
Red meat is high in purines, which can increase uric acid levels and exacerbate gout symptoms.
9.
c.
In active immunity, the body's immune system actively responds to the presence of an antigen, such as a vaccine, and produces its own antibodies. The client receives long-lasting protection from future infections due to the development of memory cells. On the other hand, passive immunity involves the transfer of pre-formed antibodies from an external source, such as immune globulin or maternal antibodies, providing immediate but temporary protection.
10.
d.
Divide the prescribed dose (40 mg) by the concentration of the adalimumab solution (40 mg/0.8 mL);
.


2.11: Why It Matters- Retail Environmental Analysis
Why evaluate different types of retail institutions?
Think about your local grocery store or supermarket. You probably enter into the produce section or perhaps the deli or bakery departments. The milk, butter, and meat sections are probably located at the back of the store, while the center of the store is filled with several rows of packaged items like soup, cereal, and peanut butter. There might be displays of chips, cake mixes, or seasonal items at the end of each aisle. The frozen foods are probably relegated to one or two aisles, either in open freezer chests or behind closed freezer doors. The cash registers are at the front of the store, along with displays of soft drinks, candy, and magazines.
Regardless of where you live and where you shop, it’s likely that the store you imagine is very similar to the one described and those imagined by others throughout the country. That’s because the retail grocery industry has not changed much since the 1950s when the supermarket concept first flourished in growing suburban America. There have been innovations in technology, like UPC scanners and self-checkout kiosks, and there have been a few changes to product assortment and services, like the addition of florists, coffee bars, and banks. But, in most ways, the grocery stores of your parents and grandparents are not unlike the the grocery stores of today.
However, your local grocery store might not be the only place you shop for food. Are there some stores you like best for quick trips, like convenience stores? Do you ever go to a club store like Costco to buy food in bulk?
While the typical supermarket hasn’t changed much in over sixty years, what has changed is the number of places and number of ways you can get your groceries. And because more changes to food retailing are on the horizon, it’s important to understand the differences in retail formats, including how they compete with each other.
Contributors and Attributions
- Why It Matters: Retail Environmental Analysis. Authored by : Patrick Williams. Provided by : Lumen Learning. License : CC BY: Attribution
- Grocery Aisle. Authored by : Joey Fernandez. License : Public Domain: No Known Copyright


2.5: "Not Both" and "Neither Nor"
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Two common English phrases that can sometimes cause confusion are “not both” and “neither nor.” These two phrases have different meanings and thus are translated with different symbolic logic sentences. Let’s look at an example of each.
Carla will not have both cake and ice cream.
Carla will have neither cake nor ice cream.
The first sentence uses the phrase “not both” and the second “neither nor.” One way of figuring out what a sentence means (and thus how to translate it) is by asking the question: What scenarios does this sentence rule out? Let’s apply this to the “not both” statement (which we first saw back in the beginning of section 2.4). There are four possible scenarios, and the statement would be true in every one except the first scenario:
| Carla has cake | Carla has ice cream | False |
| Carla has cake | Carla does not have ice cream | True |
| Carla does not have cake | Carla has ice cream | True |
| Carla does not have cake | Carla does not have ice cream | True |
To say that Carla will not have both cake and ice cream allows that she can have one or the other (just not both). It also allows that she can have neither (as in the fourth scenario). So the way to think about the “not both” locution is as a negation of a conjunction, since the conjunction is the only scenario that cannot be true if the statement is true. If we use the constant “C” to represent the atomic sentence, “Carla has cake,” and “I” to represent “Carla has ice cream,” then the resulting symbolic translation would be:
~(C ⋅ I)
Thus, in general, statements of the form “not both p and q” will be translated as the negation of a conjunction:
~(p ⋅ q)
Note that the main operator of the statement is the negation. The negation applies to everything inside the parentheses—i.e., to the conjunction. This is very different from the following sentence (without parentheses):
~p ⋅ q
The main operator of this statement is the conjunction and the left conjunct of the conjunction is a negation. In contrast with the “not both” form, this statement asserts that p is not true, while q is true. For example, using our previous example of Carla and the cake, the sentence
~C ⋅ I
would assert that Carla will not have cake and will have ice cream. This is a very different statement from ~(C ⋅ I) which, as we have seen, allows the possibility that Carla will have cake but not ice cream. Thus, again we see the importance of parentheses in our symbolic language.
Earlier (in section 2.3) we made the distinction between what I called an “exclusive or” and an “inclusive or” and I claimed that although we interpret the wedge (v) as an inclusive or, we can represent the exclusive or symbolically as well. Since we now know how to translate the “not both,” I can show you how to translate a statement that contains an exclusive or. Recall our example:
Bob placed either first or second in the race.
As we saw, this disjunction contains the two disjuncts, “Bob placed first in the race” (F) and “Bob placed second in the race” (S). Using the wedge, we get:
F v S
However, since the wedge is interpreted as an inclusive or, this statement would allow that Bob got both first and second in the race, which is not possible. So we need to be able to say that although Bob placed either first or second, he did not place both first and second. But that is just the “not both” locution. So, to be absolutely clear, we are asserting two things:
Bob placed either first or second.
and
Bob did not place both first and second.
We have already seen that the first sentence is translated: “F v S.” The second sentence is simply a “not both F and S” statement:
~(F ⋅ S)
Now all we have to do is conjoin the two sentences using the dot:
(F v S) ⋅ ~(F ⋅ S)
That is the correct translation of an exclusive or. Notice that when conjoining the “F v S” to the “~(F ⋅ S)” I needed to put parentheses around the “F v S” to show that it was grouped together. Thus, it would have been incorrect to write:
F v S ⋅ ~(F ⋅ S)
since that is not a well-formed formula. The problem, as before, is that this sentence is ambiguous between two sentences that have different meanings:
F v (S ⋅ ~(F ⋅ S))
(F v S) ⋅ ~(F ⋅ S)
While both of these sentences are well-formed, only the latter is the correct translation of the exclusive or.
Let’s move on to the English locution “neither...nor” as in:
Carla will eat neither cake nor ice cream.
This statement might be true if, for example, Carla was on a diet (and was sticking to her diet). Using the same method I introduced earlier, we can ask under what conditions the statement would be true or false. As before, there are only four possibilities, which I represent symbolically this time:
| C | I | False |
| C | ~I | False |
| ~C | I | False |
| ~C | ~I | True |
There is only one circumstance in which this statement is true and that is the one in which it is false that Carla eats cake and false that Carla eats ice cream. That should be obvious from the meaning of the “neither nor” locution. Thus, the correct translation of a “neither nor” statement is as a conjunction of two negations:
~C ⋅ ~I
The main operator of this statement is the dot, which is conjoining the ~C with the ~I. Thus, the form of any “neither nor” statement can always be translated as a conjunction of two negations:
~p ⋅ ~q
As we will see in a later section (where we will prove it), this statement is also equivalent to a negation of a disjunction:
~(p v q)
Thus, the English locution “neither nor” can also be translated using this statement form.
Exercise
For each of the following, write out what atomic proposition each constant stands for. Then translate the sentences using the constants you have defined. Finally, after you have translated the sentence, identify which truth-functional connective is the main operator of the sentence.
1. Coral is not both a plant and an animal. (P, A)
2. Although protozoa and chimpanzees are both eukaryotes, they are not both animals. (There are four atomic propositions here; just use A, B, C, and D for each different proposition.)
3. Neither chimpanzees nor protozoa are prokaryotes. (C, P)
4. China has not signed the Kyoto Protocol and neither has the United States. (C, U)
5. Either Chevrolet or McDonald’s will support the Olympic team, but they won’t both support it. (C, M)
6.  (L, M)
7. Peter Jennings is neither a liar nor has a really bad memory. (L, M)
8.  (L, M)
9.  (L, M)
10. Chevrolet won’t support the Olympic team this year, and McDonald’s won’t either. (C, M)
11. Mother Theresa may be a saint. Even so, she has not been canonized yet by the Catholic Church. (S, C)
12. The best distance runner of the last two decades is either Paul Tergat or Haile Gebrselassie, but it certainly isn’t Jim Ryun. (T, G, R)
13. Jim Ryun was the best high school miler of all time, but he ran a slower time than Alan Webb. (R, W)
14. Neither Paul Tergat nor Haile Gebrselassie knows how to play hockey, but they both know how to play soccer. (A, B, C, D)
15. Ethiopians are neither good bobsledders nor tennis players, but they are excellent distance runners. (B, T, D)
16. Before Helen Keller met Annie Sullivan, she could neither speak, read, nor communicate. (S, R, C)
17. Although Helen Keller learned to communicate, she never learned to play soccer or baseball. (C, S, B)
18. Tom is allowed to play football or soccer, but not both. (F, S)
19. Tom will major in either engineering and physics, or business and sociology. (E, P, B, S)
20. Cartman is both xenophobic and racist, but he isn’t a murderer or a thief. (X, R, M, T)


14.1: Historical Basis of Modern Understanding
Skills to Develop
- Explain transformation of DNA
- Describe the key experiments that helped identify that DNA is the genetic material
- State and explain Chargaff’s rules
Modern understandings of DNA have evolved from the discovery of nucleic acid to the development of the double-helix model. In the 1860s, Friedrich Miescher (Figure \(\PageIndex{1}\)), a physician by profession, was the first person to isolate phosphate-rich chemicals from white blood cells or leukocytes. He named these chemicals (which would eventually be known as RNA and DNA) nuclein because they were isolated from the nuclei of the cells.
Link to Learning
To see Miescher conduct an experiment step-by-step, click through this review of how he discovered the key role of DNA and proteins in the nucleus.
A half century later, British bacteriologist Frederick Griffith was perhaps the first person to show that hereditary information could be transferred from one cell to another “horizontally,” rather than by descent. In 1928, he reported the first demonstration of bacterial transformation , a process in which external DNA is taken up by a cell, thereby changing morphology and physiology. He was working with Streptococcus pneumoniae, the bacterium that causes pneumonia. Griffith worked with two strains, rough (R) and smooth (S). The R strain is non-pathogenic (does not cause disease) and is called rough because its outer surface is a cell wall and lacks a capsule; as a result, the cell surface appears uneven under the microscope. The S strain is pathogenic (disease-causing) and has a capsule outside its cell wall. As a result, it has a smooth appearance under the microscope. Griffith injected the live R strain into mice and they survived. In another experiment, when he injected mice with the heat-killed S strain, they also survived. In a third set of experiments, a mixture of live R strain and heat-killed S strain were injected into mice, and—to his surprise—the mice died. Upon isolating the live bacteria from the dead mouse, only the S strain of bacteria was recovered. When this isolated S strain was injected into fresh mice, the mice died. Griffith concluded that something had passed from the heat-killed S strain into the live R strain and transformed it into the pathogenic S strain, and he called this the transforming principle (Figure \(\PageIndex{2}\)). These experiments are now famously known as Griffith's transformation experiments.
Scientists Oswald Avery, Colin MacLeod, and Maclyn McCarty (1944) were interested in exploring this transforming principle further. They isolated the S strain from the dead mice and isolated the proteins and nucleic acids, namely RNA and DNA, as these were possible candidates for the molecule of heredity. They conducted a systematic elimination study. They used enzymes that specifically degraded each component and then used each mixture separately to transform the R strain. They found that when DNA was degraded, the resulting mixture was no longer able to transform the bacteria, whereas all of the other combinations were able to transform the bacteria. This led them to conclude that DNA was the transforming principle.
Career Connection: Forensic Scientists and DNA Analysis
DNA evidence was used for the first time to solve an immigration case. The story started with a teenage boy returning to London from Ghana to be with his mother. Immigration authorities at the airport were suspicious of him, thinking that he was traveling on a forged passport. After much persuasion, he was allowed to go live with his mother, but the immigration authorities did not drop the case against him. All types of evidence, including photographs, were provided to the authorities, but deportation proceedings were started nevertheless. Around the same time, Dr. Alec Jeffreys of Leicester University in the United Kingdom had invented a technique known as DNA fingerprinting. The immigration authorities approached Dr. Jeffreys for help. He took DNA samples from the mother and three of her children, plus an unrelated mother, and compared the samples with the boy’s DNA. Because the biological father was not in the picture, DNA from the three children was compared with the boy’s DNA. He found a match in the boy’s DNA for both the mother and his three siblings. He concluded that the boy was indeed the mother’s son.
Forensic scientists analyze many items, including documents, handwriting, firearms, and biological samples. They analyze the DNA content of hair, semen, saliva, and blood, and compare it with a database of DNA profiles of known criminals. Analysis includes DNA isolation, sequencing, and sequence analysis; most forensic DNA analysis involves polymerase chain reaction (PCR) amplification of short tandem repeat (STR) loci and electrophoresis to determine the length of the PCR-amplified fragment. Only mitochondrial DNA is sequenced for forensics. Forensic scientists are expected to appear at court hearings to present their findings. They are usually employed in crime labs of city and state government agencies. Geneticists experimenting with DNA techniques also work for scientific and research organizations, pharmaceutical industries, and college and university labs. Students wishing to pursue a career as a forensic scientist should have at least a bachelor's degree in chemistry, biology, or physics, and preferably some experience working in a laboratory.
Experiments conducted by Martha Chase and Alfred Hershey in 1952 provided confirmatory evidence that DNA was the genetic material and not proteins. Chase and Hershey were studying a bacteriophage, which is a virus that infects bacteria. Viruses typically have a simple structure: a protein coat, called the capsid, and a nucleic acid core that contains the genetic material, either DNA or RNA. The bacteriophage infects the host bacterial cell by attaching to its surface, and then it injects its nucleic acids inside the cell. The phage DNA makes multiple copies of itself using the host machinery, and eventually the host cell bursts, releasing a large number of bacteriophages. Hershey and Chase labeled one batch of phage with radioactive sulfur, 35 S, to label the protein coat. Another batch of phage were labeled with radioactive phosphorus, 32 P. Because phosphorous is found in DNA, but not protein, the DNA and not the protein would be tagged with radioactive phosphorus.
Each batch of phage was allowed to infect the cells separately. After infection, the phage bacterial suspension was put in a blender, which caused the phage coat to be detached from the host cell. The phage and bacterial suspension was spun down in a centrifuge. The heavier bacterial cells settled down and formed a pellet, whereas the lighter phage particles stayed in the supernatant. In the tube that contained phage labeled with 35 S, the supernatant contained the radioactively labeled phage, whereas no radioactivity was detected in the pellet. In the tube that contained the phage labeled with 32 P, the radioactivity was detected in the pellet that contained the heavier bacterial cells, and no radioactivity was detected in the supernatant. Hershey and Chase concluded that it was the phage DNA that was injected into the cell and carried information to produce more phage particles, thus providing evidence that DNA was the genetic material and not proteins (Figure \(\PageIndex{3}\)).
Around this same time, Austrian biochemist Erwin Chargaff examined the content of DNA in different species and found that the amounts of adenine, thymine, guanine, and cytosine were not found in equal quantities, and that it varied from species to species, but not between individuals of the same species. He found that the amount of adenine equals the amount of thymine, and the amount of cytosine equals the amount of guanine, or A = T and G = C. This is also known as Chargaff’s rules. This finding proved immensely useful when Watson and Crick were getting ready to propose their DNA double helix model.
Summary
DNA was first isolated from white blood cells by Friedrich Miescher, who called it nuclein because it was isolated from nuclei. Frederick Griffith's experiments with strains of Streptococcus pneumoniae provided the first hint that DNA may be the transforming principle. Avery, MacLeod, and McCarty proved that DNA is required for the transformation of bacteria. Later experiments by Hershey and Chase using bacteriophage T2 proved that DNA is the genetic material. Chargaff found that the ratio of A = T and C = G, and that the percentage content of A, T, G, and C is different for different species.
Glossary
- transformation
- process in which external DNA is taken up by a cell


19.2: Drugs Affecting the Renin-Angiotensin-Aldosterone System
By the end of this section, you should be able to:
- 19.2.1 Identify the characteristics of drugs affecting the renin-angiotensin-aldosterone system that are used to treat heart failure.
- 19.2.2 Explain the indications, actions, adverse reactions, and interactions of drugs affecting the renin-angiotensin-aldosterone system that are used to treat heart failure.
- 19.2.3 Describe nursing implications of drugs affecting the renin-angiotensin-aldosterone system that are used to treat heart failure.
- 19.2.4 Explain the client education related to drugs affecting the renin-angiotensin-aldosterone system that are used to treat heart failure.
Angiotensin-Converting (ACE) Enzyme Inhibitors
As mentioned in Antihypertensive and Antianginal Drugs, Angiotensin-converting enzyme (ACE) inhibitors are a classification of drugs that block the body’s production of angiotensin II. Angiotensin II is one of the products of the renin-angiotensin-aldosterone system (RAAS) (see Figure 19.4), and it stimulates multiple end-organ effects. Two of these effects that are important in heart failure are constriction of arterioles and sodium and water retention of the kidneys. Vasoconstriction causes increased afterload, and sodium and water retention cause increased preload. In heart failure, the heart is already struggling to maintain an adequate cardiac output. Both increased afterload and increased preload will make this task more difficult. ACE inhibitors have been shown to decrease morbidity and mortality in clients with heart failure (Heidenreich et al., 2022).
Special Considerations
ACE Inhibitors
Black clients with hypertension demonstrate a lower response to ACE inhibitor monotherapy. ACE inhibitors interfere with the renin-angiotensin-aldosterone system, which causes high blood pressure when renin levels are high. Black clients often have hypertension but also have lower levels of renin. Therefore, concomitant therapy may be required to increase response to antihypertensive therapies.
(Source: Astra Zeneca, 2012)
Adverse Effects and Contraindications
ACE inhibitors are relatively safe to use and have a low incidence of serious adverse effects. Adverse effects include angioedema, non-productive cough, neutropenia (low neutrophils in the blood), agranulocytosis (low granulocytes in the blood), proteinuria (protein in the urine), and rash. Hypotension may develop. Clients may develop an ACE inhibitor–associated cough (a persistent, dry, itchy cough). Hyperkalemia (elevated potassium level in the blood) may develop.
ACE inhibitors cause fetal toxicity and should be immediately discontinued if pregnancy occurs. Clients with renal impairment should use cautiously. Clients with a previous hypersensitivity reaction to an ACE inhibitor should not be prescribed this classification of drug.
Table 19.4 is a drug prototype table for ACE inhibitors featuring lisinopril. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Angiotensin-converting enzyme (ACE) inhibitor Mechanism of Action Inhibits the enzyme that converts angiotensin I to angiotensin II and thereby suppresses the renin-angiotensin-aldosterone system |
Drug Dosage
2.5–40 mg orally twice daily. |
|
Indications
Hypertension Heart failure Reduction of mortality in acute myocardial infarction Therapeutic Effects Lowers blood pressure Increases blood supply and oxygen to the heart |
Drug Interactions
Aliskiren Lithium Sacubitril Food Interactions Alcohol Tobacco |
|
Adverse Effects
Angioedema Hyperkalemia Fatigue Orthostatic hypotension Asthenia Diarrhea Nausea/vomiting Headache Dizziness/vertigo Cough Rash Abdominal pain Angina |
Contraindications
Hypersensitivity History of angioedema Pregnancy (fetal toxicity) Caution: Aortic stenosis Diabetes Syncope Orthostatic hypotension Impaired renal function Breastfeeding |
Nursing Implications
The nurse should do the following for clients who are taking ACE inhibitors:
- Assess the client’s blood pressure and pulse on an ongoing basis with initial dosing and intermittently during drug therapy.
- Assess and monitor the client for adverse effects, drug and food interactions, and contraindications.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Safety Alert
ACE Inhibitors
Taking ACE inhibitors with potassium-containing salt substitutes or consuming large amounts of high-potassium foods increases the risk of hyperkalemia. Having a blood potassium level above 6.0 mmol/L is considered a medical emergency and can result in cardiac arrest.
Clients of childbearing age should take measures not to become pregnant while taking ivabradine due to teratogenic effects (causing harm to embryo or fetus).
Client Teaching Guidelines
The client taking an ACE inhibitor should:
- Avoid foods high in potassium and salt substitutes (because these are high in potassium) due to the aldosterone release.
- Report side effects such as cough, angioedema, or anaphylactic reactions to their health care provider.
- Notify their health care provider if they experience abdominal pain, joint or muscle aches, muscle weakness, change in the amount of urine produced, or trouble breathing.
- Be aware that a persistent cough may develop when taking ACE inhibitors.
- Notify their health care provider if pregnant, planning on getting pregnant, or breastfeeding prior to starting an ACE inhibitor.
- Report symptoms such as chest pain, slurred speech, hemiparesis, and difficulty speaking or walking to their health care provider immediately because these may be symptoms of a heart attack or stroke.
- Notify their health care provider about symptoms such as dizziness, lightheadedness, or fainting because these could be related to low blood pressure.
Angiotensin II Receptor Blockers
Angiotensin II receptor blockers (ARBs) are a classification of drugs that bind to and inhibit angiotensin II type I receptors. ARBs work directly at the receptor site to block angiotensin II from binding with receptors on the cells (see Figure 19.4). The effect of ARBs is similar to that of ACE inhibitors; however, the side effects are lessened. This means that the potential for angioedema is decreased. Also, there is no side effect of cough.
Angiotensin II receptor blockers decrease blood pressure and therefore decrease afterload. This is beneficial in treating heart failure since decreased afterload means the heart does not have to work as hard to generate stroke volume.
Table 19.5 lists common ARBs used in the management of heart failure and typical routes and dosing for adult clients. A comprehensive list of ARBs can be found in Antihypertensive and Antianginal Drugs.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Candesartan
( Atacand ) |
4 mg orally daily; maximum dose: 32 mg daily. |
|
Losartan
( Cozaar ) |
25–150 orally mg daily. |
|
Valsartan
( Diovan ) |
20–160 orally mg daily. |
Adverse Effects and Contraindications
Adverse effects of ARBs include dizziness, muscle cramps, weakness, heartburn, diarrhea, leg swelling, headaches, and weight loss. Serious adverse effects include angioedema, hypotension, hepatic impairment, and hyperkalemia.
ARBs cause fetal toxicity and should not be taken during pregnancy. Clients with hepatic impairment should use ARBs cautiously. Clients with a previous hypersensitivity reaction or angioedema to an ARB inhibitor should not be prescribed this classification of drug. Clients with a history of mood disturbances or who are at risk for mood disturbances should be monitored closely for suicidal ideation.
Table 19.6 is a drug prototype table for ARBs featuring losartan. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Angiotensin II receptor blocker (ARB) Mechanism of Action Blocks the binding of angiotensin II to the angiotensin I receptor, thereby decreasing vasoconstriction and lowering blood pressure |
Drug Dosage
25–150 mg orally daily. |
|
Indications
Hypertension Heart failure Nephropathy in clients with type 2 diabetes Therapeutic Effects Lowers blood pressure Increases blood supply and oxygen to the heart |
Drug Interactions
Aliskiren Lithium Potassium-sparing diuretics (may increase hyperkalemia) Food Interactions Alcohol Tobacco |
|
Adverse Effects
Hyperkalemia Dizziness Syncope Increased thirst Decreased urinary output Irregular heartbeat Angioedema |
Contraindications
Hypersensitivity Pregnancy (fetal toxicity) Caution: Hepatic impairment Renal impairment Hypotension Hypovolemia Hyperkalemia |
Special Considerations
ARBs
The RAAS has been associated with increased risk of mood disorders. The use of ARBs may be associated with an increased risk of suicide compared with other antihypertensive therapies.
Black clients with hypertension demonstrate a lower response to ARB monotherapy. Concomitant therapy may be required to increase response to antihypertensive therapies.
Older adults and clients with hepatic impairment should start on a low initial dose because the drug is metabolized by the liver.
(Source: Colvin et al., 2020)
Nursing Implications
The nurse should do the following for clients who are taking ARBs:
- Monitor the client’s blood pressure as prescribed.
- Monitor the client for interactions because many medications and herbal supplements interact with ARBs.
- Monitor the client for adverse effects, including electrolyte imbalances and alterations in liver and renal function.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an ARB should:
- Avoid foods high in potassium and salt substitutes (because these substitute potassium for sodium) due to the aldosterone release.
- Report side effects such as cough, angioedema, or anaphylactic reactions to the health care provider.
- Notify their health care provider if they experience abdominal pain, joint or muscle aches, muscle weakness, change in the amount of urine produced, or trouble breathing.
- Notify their health care provider if pregnant, planning on getting pregnant, or breastfeeding prior to starting an ARB.
- Notify their health care provider about symptoms such as dizziness, lightheadedness, or fainting because these could be related to low blood pressure.
Angiotensin Receptor/Neprilysin Inhibitors
Recently, a new classification of heart failure medication was developed, angiotensin receptor/neprilysin inhibitors (ARNIs) . This combination medication is a first-line medication for many classifications of heart failure. It is a combination of an ARB and a new type of medication, a neprilysin inhibitor. There currently is only one medication in the ARNI class: sacubitril/valsartan ( Entresto ).
In heart failure with reduced ejection fraction, there is a lot of stress on the left ventricle as well as left ventricular dilation. This is due to an increased preload. When the ventricle dilates to a point that is no longer helpful to the heart, the myocytes release brain natriuretic peptide (BNP). BNP stimulates a compensatory mechanism that leads to vasodilation and decreased sodium and water absorption. Vasodilation and diuresis decrease afterload and preload, which makes the workload of the heart decrease.
Neprilysin is an enzyme that breaks down BNP. The inhibition of neprilysin means that BNP can stay in the body’s circulatory system longer. If BNP stays in the system longer, then vasodilation and decreased sodium and water reabsorption will last longer, which will decrease afterload and preload. This will decrease the workload of the heart.
Adverse Effects and Contraindications
Adverse effects of ARNIs include angioedema, hypotension, renal impairment, and hyperkalemia.
ARNIs contain ARBs and cause fetal toxicity; they should not be taken during pregnancy. Clients with hepatic impairment should use ARNIs cautiously. Clients with a previous hypersensitivity or angioedema reaction to an ARB inhibitor should not be prescribed this classification of drug. Clients with a history of mood disturbances or who are at risk for mood disturbances should be monitored closely for suicidal ideation.
Clinical Tip
Reviewing Medications
It is important for the nurse to review all of a client’s medications. Clients should not take ACE inhibitors, ARBs, or ARNIs at the same time. Clients should be prescribed only one of these classifications of medication at a time.
Table 19.7 is a drug prototype table for angiotensin receptor/neprilysin inhibitors featuring sacubitril/valsartan. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Angiotensin receptor/neprilysin inhibitor Mechanism of Action Causes angiotensin receptor blockade and inhibition of the enzyme that breaks down BNP |
Drug Dosage
Initial dose: 49 mg/51 mg orally twice daily; maximum dose: 97 mg/103 mg twice daily. |
|
Indications
Heart failure Therapeutic Effects Vasodilation |
Drug Interactions
Potassium-sparing diuretics (may lead to increased serum potassium) Nonsteroidal anti-inflammatory drugs (NSAIDs; may lead to increased risk of renal impairment) Lithium (increased risk of lithium toxicity) ACE inhibitors (increased risk of angioedema) Food Interactions No significant interactions |
|
Adverse Effects
Angioedema Hypotension Hyperkalemia Cough Dizziness Renal failure |
Contraindications
Pregnancy (fetal toxicity) History of angioedema with ACE inhibitor or ARB therapy |
Nursing Implications
The nurse should do the following for clients who are taking ARNIs:
- Monitor the client’s blood pressure as prescribed.
- Monitor the client for medication and herbal supplement interactions.
- Report adverse effects, including electrolyte imbalances and alterations in liver and renal function, to the health care provider.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an ARNI should:
- Avoid foods high in potassium and salt substitutes (because these are high in potassium) due to the aldosterone release.
- Report side effects such as cough, angioedema, and anaphylactic reactions to the health care provider.
- Notify their health care provider if they experience abdominal pain, joint or muscle aches, muscle weakness, change in the amount of urine produced, or trouble breathing.
- Notify their health care provider if pregnant, planning on getting pregnant, or breastfeeding prior to starting an ARNI.
- Notify their health care provider about symptoms such as dizziness, lightheadedness, or fainting because these could be related to low blood pressure.
Mineralocorticoid Receptor Antagonists
Mineralocorticoid receptor antagonists (MRAs) (also known as aldosterone antagonists ) are often categorized as diuretics because they ultimately do cause diuresis. When the RAAS is activated, one of the end results is the stimulation of the adrenal glands to secrete aldosterone. (See Figure 19.4 earlier in the chapter.) Aldosterone binds to receptors on cells in the distal tubule of the nephron, which then causes them to reabsorb sodium and water. During this process, potassium secretion increases. Aldosterone antagonists block the receptor so that aldosterone can’t bind there. The end result is increased sodium and water excretion into the urine, and potassium reabsorption. Aldosterone antagonists are referred to as potassium-sparing diuretics .
MRA medications have been found to reduce the risk of all-cause mortality in clients with heart failure (Heidenreich et al., 2022).
Table 19.8 lists the two MRAs used in heart failure and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Spironolactone
( Aldactone ) |
12.5–25 mg orally daily; maximum dose: 50 mg daily. |
|
Eplerenone
( Inspra ) |
25–50 mg orally daily. |
Adverse Effects and Contraindications
Adverse effects of MRAs include hyperkalemia, hypotension, worsening renal failure, electrolyte abnormalities, and gynecomastia (breast enlargement and/or sensitivity).
MRAs should not be taken during pregnancy. Because MRAs cause potassium retention, they should not be used by clients who have kidney disease. MRAs must be used carefully with other medications, such as ACE inhibitors and ARBs, that may cause hyperkalemia.
Table 19.9 is a drug prototype table for MRAs featuring spironolactone. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Mineralocorticoid receptor antagonist (MRA) Mechanism of Action Binds to receptors in the nephron so that aldosterone is not able to bind, which leads to increased diuresis |
Drug Dosage
12.5–25 mg orally daily; maximum dose: 50 mg daily. |
|
Indications
Heart failure Hypertension Edema associated with hepatic cirrhosis or nephrotic syndrome Therapeutic Effects Diuresis |
Drug Interactions
Agents that increase serum potassium Lithium (increased risk for lithium toxicity) NSAIDs Digoxin Aspirin (may reduce the efficacy of spironolactone) Food Interactions No significant interactions |
|
Adverse Effects
Hyperkalemia Hypotension Worsening renal failure Electrolyte abnormalities Gynecomastia |
Contraindications
Hyperkalemia Addison’s disease Pregnancy Concomitant use of eplerenone |
Safety Alert
MRAs
MRAs can cause significant hyperkalemia. The client should have their serum electrolytes monitored regularly while taking MRAs. If hyperkalemia occurs, the drug may have to be discontinued.
Nursing Implications
The nurse should do the following for clients who are taking MRAs:
- Monitor the client for medication and/or food interactions.
- Monitor the client for adverse effects, including electrolyte imbalances and alteration renal function.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an MRA should:
- Avoid foods high in potassium and salt substitutes (because these are high in potassium) due to the aldosterone release.
- Notify their provider if they are taking an ACE inhibitor, ARB, or other potassium-sparing drugs.
- Notify their health care provider if pregnant, planning on getting pregnant, or breastfeeding prior to starting an MRA.
- Notify their health care provider about breast enlargement and/or tenderness.
- Notify their health care provider about symptoms such as dizziness, lightheadedness, or fainting because these could be related to low blood pressure.
FDA Black Box Warning
Drugs Affecting the Renin-Angiotensin-Aldosterone System
Fetal toxicity can occur when taking ACE inhibitors during the second and third trimesters of pregnancy or when taking ARBs or ARNIs during pregnancy.


5.3: Types of STDs/STIs
What are some types of sexually transmitted diseases or sexually transmitted infections (STDs/STIs)?
Approximately 20 different infections are known to be transmitted through sexual contact. Here are descriptions of some of the most common and well known:
- Chlamydia
- Gonorrhea
- Genital Herpes
- HIV/AIDS
- Human Papillomavirus (HPV)
- Syphilis
- Bacterial Vaginosis
- Trichomoniasis
- Viral Hepatitis
Chlamydia
Chlamydia is a common STD/STI caused by the bacterium Chlamydia trachomatis .  While many individuals will not experience symptoms, chlamydia can cause fever, abdominal pain, and unusual discharge of the penis or vagina.
In women, whether or not they are having symptoms and know about their infection, chlamydia can cause pelvic inflammatory disease ( PID ). In PID, the untreated STD/STI progresses and involves other parts of the woman’s reproductive system, including the uterus and fallopian tubes. This progression can lead to permanent damage to the woman’s reproductive organs. This damage may lead to ectopic pregnancy (in which the fetus develops in abnormal places outside of the womb, a condition that can be life-threatening) and infertility .
Additionally, if the woman is pregnant, her developing fetus is at risk, because chlamydia can be passed on during her pregnancy or delivery and could lead to eye infections or pneumonia in the infant. If chlamydia is detected early, it can be treated easily with an antibiotic taken by mouth.
Gonorrhea
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae, which can grow rapidly and multiply easily in the warm, moist areas of the reproductive tract.
As with chlamydial infection, the most common and serious complications of gonorrhea occur in women and include pelvic inflammatory disease (PID), ectopic pregnancy, infertility, and the potential spread to the developing fetus if acquired during pregnancy. Gonorrhea also can infect the mouth, throat, eyes, and rectum and can spread to the blood and joints, where it can become a life-threatening illness.
In addition, people with gonorrhea can more easily contract HIV, the virus that causes AIDS. HIV-infected people with gonorrhea are also more likely to transmit the virus to someone else.
Genital Herpes
Genital herpes is a contagious infection caused by the herpes simplex virus (HSV). There are two different strains, or types, of HSV: herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2). Both can cause genital herpes, although most cases of genital herpes are caused by HSV-2. When symptomatic, HSV-1 usually appears as fever blisters or cold sores on the lips, but it can also infect the genital region through oral-genital or genital-genital contact. Symptomatic HSV-2 typically causes painful, watery skin blisters on or around the genitals or anus. However, substantial numbers of people who carry these viruses have no or only minimal signs or symptoms.
Neither HSV-1 nor HSV-2 can be cured, and even during times when an infected person has no symptoms, the virus can be found in the body’s nerve cells. Periodically, some people will experience outbreaks in which new blisters form on the skin in the genital area; at those times, the virus is more likely to be passed on to other people.
Pregnant women, especially those who acquire genital herpes for the first time during pregnancy, may pass the infection to their newborns, causing life-threatening neonatal HSV, an infection affecting the infant’s skin, brain, and other organs.
HIV/AIDS
HIV, or the human immunodeficiency virus, is the virus that causes AIDS (acquired immunodeficiency syndrome). HIV destroys the body’s immune system by killing the blood cells that fight infection. Once HIV destroys a substantial proportion of these cells (CD4 cells), the body’s ability to fight off and recover from infections is compromised. This advanced stage of HIV infection is known as AIDS.
The CD4 count is like a snapshot of how well your immune system is functioning. CD4 cells (also known as CD4+ T cells) are white blood cells that fight infection. The more you have, the better. These are the cells that the HIV virus kills. As HIV infection progresses, the number of these cells declines. When the CD4 count drops below 200 due to advanced HIV disease, a person is diagnosed with AIDS. A normal range for CD4 cells is about 500-1,500. Usually, when a person with low CD4 cells starts HIV medicines, the CD4 cell count increases as the HIV virus is controlled. Most, but not all, people will experience an increase in CD4 cells with effective HIV treatment.
People whose HIV has progressed to AIDS are very susceptible to opportunistic infections that do not normally make people sick and to certain forms of cancer.
AIDS can be prevented by early initiation of antiretroviral therapy in those with HIV infection. Transmission of the virus primarily occurs during unprotected sexual activity and by sharing needles used to inject intravenous drugs, although the virus also can spread from mother to infant during pregnancy, delivery, and breastfeeding.
In 2013, NIH-supported researchers reported that a 2-year-old child who was born with HIV and was treated starting in the first few days of life has had her HIV infection go into remission. This appears to be the first case of functional cure of HIV .
Human Papillomavirus (HPV)
HPV is the most common STD/STI. More than 40 HPV types exist, and all of them can infect both men and women. The types of HPVs vary in their ability to cause genital warts; infect other regions of the body, including the mouth and throat; and cause cancers of the cervix, vulva, penis, and mouth.
Although no cure exists for HPV infection once it occurs, regular screening with a Pap smear test can prevent or detect at an early stage most cases of HPV-caused cervical cancer. (A Pap smear test involves a health care provider taking samples of cells from the cervix during a standard gynecologic exam; these cells are examined under a microscope for signs of developing cancer).
A newly available vaccine protects against most (but not all) HPV types that cause cervical cancer. The American Academy of Pediatrics recommends this vaccine for school-aged boys and girls.
Syphilis
Syphilis infections, caused by the bacterium Treponema pallidum, are passed from person to person during vaginal, anal, or oral sex through direct contact with sores, called chancres. Between 2001 and 2009, the Centers for Disease Control and Prevention (CDC) data show that the syphilis rate increased each year. Those people at highest risk for syphilis include men having sex with both men and women and people residing in the south.  Beyond being the first sign of a syphilis infection, chancres make a person two to five times more likely to contract an HIV infection. If the person is already infected with HIV, chancres also increase the likelihood that the virus will be passed on to a sexual partner. These sores typically resolve on their own, even without treatment. However, the body does not clear the infection on its own, and, over time, syphilis may involve other organs, including the skin, heart, blood vessels, liver, bones, and joints in secondary syphilis. If the illness is still not treated, tertiary syphilis can develop over a period of years and involve the nerves, eyes, and brain and can potentially cause death.
Expectant mothers harboring the bacterium are at an increased risk of miscarriage and stillbirth, and they can pass the infection on to their fetuses during pregnancy and delivery. Infants that acquire congenital syphilis during pregnancy may suffer from skeletal deformity, difficulty with speech and motor development, seizure, anemia, liver disease, and neurologic problems.
Bacterial Vaginosis
Bacterial vaginosis is a common, possibly sexually transmitted, vaginal infection in women of reproductive age. While it is healthy and normal for a vagina to have bacteria, just like the skin, mouth, or gastrointestinal (GI) tract, sometimes changes in the balance of different types of bacteria can cause problems.
Bacterial vaginosis occurs when problematic bacteria that are normally present only in small amounts increase in number, replace normal vaginal lactobacilli bacteria, and upset the usual balance. This situation becomes more likely if a woman douches frequently or has new or multiple sexual partners. The most common sign of a bacterial vaginosis infection is a thin, milky discharge that is often described as having a “fishy” odor. However, some women will have no symptoms at all.
Regardless of symptoms, having bacterial vaginosis increases the risk of getting other STDs/STIs and is also associated with pelvic inflammatory disease (PID), an infection of the female reproductive organs, including the uterus and the fallopian tubes (which carry eggs to the uterus), and postoperative infections. Preterm labor and birth are also possibly more common in women with bacterial vaginosis.
Trichomoniasis
Trichomoniasis infection is caused by the single-celled protozoan parasite Trichomonas vaginalis and is common in young, sexually active women. The parasite also infects men, though less frequently. The parasite can be transmitted between men and women as well as between women whenever physical contact occurs between the genital areas. Although Trichomonas infections do not always cause symptoms, they can cause frequent, painful, or burning urination in men and women as well as vaginal discharge, genital soreness, redness, or itching in women. Because the infection can occur without symptoms, a person may be unaware that he or she is infected and continue to re-infect a sexual partner who is having recurrent signs of infection. As with bacterial STDs/STIs, all sexual partners should be treated at the same time to avoid re-infection.
NICHD-sponsored research has shown that during pregnancy, Trichomonas infection is associated with an increased risk of premature birth and infants with low birth weight. Moreover, infants born to mothers with Trichomonas infection are more than twice as likely as infants born to uninfected women to be stillborn or to die as newborns.
Viral Hepatitis
Viral hepatitis is a serious liver disease that can be caused by several different viruses, which can be transmitted through sexual contact.
- Hepatitis A virus (HAV) causes a short-term or self-limited liver infection that can be quite serious, although it does not result in chronic infection. While there are other ways the virus can be transmitted, HAV can be spread from person to person during sexual activity through oral-rectal contact. Vaccination can prevent HAV infection.
- Hepatitis B virus (HBV) causes a serious liver disease that can result in both immediate illness and lifelong infection leading to permanent liver scarring (cirrhosis), cancer, liver failure, and death. HBV spreads through both heterosexual and homosexual contact as well as through contact with other bodily fluids, such as blood, through shared contaminated needles used for injecting intravenous (IV) drugs, tattooing, and piercing. Pregnant women with HBV can transmit the virus to their infants during delivery. HBV infection is preventable through vaccination.
- Hepatitis C virus (HCV) can cause an immediate illness affecting the liver, but it more commonly becomes a silent, chronic infection that leads to liver scarring (cirrhosis), cancer, liver failure, and death. HCV is most commonly transmitted through sharing needles or exposure to infected blood. However, it can spread through sexual contact or from mother to fetus during pregnancy and delivery. There is no vaccine for HCV, and treatments are not always effective.
- Types of STDs/STIs. Authored by : National Institute of Child Health and Human Development, National Institutes of Health. Provided by : U.S. Department of Health and Human Services. Located at : https://www.nichd.nih.gov/health/topics/stds/conditioninfo/Pages/types.aspx . License : Public Domain: No Known Copyright


8.4.1: How to Save on Food Costs
Food can be expensive. Families on a tight budget may have trouble purchasing food. If Home Health Aides/Personal Care Aides ever observe that a patient does not appear to have enough food in the house, they should discuss this concern with their supervisor.
Here are some tips for Home Health Aides / Personal Care Aides to keep in mind to help cut food costs :
- Use coupons
- Look through weekly store circulars for items on sale
- Avoid convenience foods such as those that are pre-made, pre-packaged, or that come from sections of the grocery store such as the deli, bakery, or salad bar. These items tend to be much more expensive than if you purchased the ingredients and prepared it yourself.
- Check food labels for nutritional value.
- Purchase items such as produce when it is in season. It will be less expensive and fresher.
- Purchase items in bulk, but be aware of storage space. If it can’t be stored or used up before it expires, you will not be saving money.
- Plan meals for a week at a time. Make a grocery list and stick to it.
- Use meat and protein substitutes that tend to be less expensive. Canned tuna, dried beans, yogurt, and eggs are excellent sources of protein.
- When buying meat, check the expiration date to ensure you are buying the freshest meat possible. Spoiled meat is wasted money.
- When possible, buy meat in bulk as costs tend to be lower.
- Always stick within the allowed food budget. Never buy more than you are told or that the patient can afford.
1. Which are ways a HHA/PCA can help reduce food costs for a patient? Select all that apply .
a). Buy salad from the salad bar
b). Check expiration dates of food
c). Purchase bulk items even if they are not needed or there is no storage space
d). Find protein substitutes for fresh meats
e). Use coupons and buy sale items
- Answer
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1. B, D, & E
FEEDBACK :
Purchasing items from a salad bar or other self-service station in a grocery store often leads to higher prices. Whenever possible, purchase fresh fruits and vegetables from the produce aisle. This is a healthier and less expensive option. Regularly checking expiration dates helps to prevent unnecessary waste. Planning meals with items on hand and that have not expired helps the patient and their family save money. Purchasing bulk items can help to save money. However, if they are not needed and there is no storage space for them this can end up costing the patient money as food will more likely have to be thrown away. When coupons are used and sale items are purchased, this can help the patient and their family save money.


13.4: Pollution
13.4.1 Air Pollution
While the technology exists to burn fossil fuels so that the emissions are not particularly significant in terms of air pollution, air quality reduction because of the combustion of fossil fuels is still considerable and is a cause for concern at the international level. Another pollutant that has received worldwide attention is chlorofluorocarbons (CFCs) and their impact on the ozone layer. Water pollution and the disposal problem of solid wastes are also important environmental concerns.
One of the major issues internationally is the suspected anthropogenic, or human-caused, warming of the Earth’s atmosphere because of carbon dioxide in fossil fuel emissions. The issue is complex because “climate change”, as global warming has been dubbed, is affected by both natural and anthropogenic processes. A number of scientists are concerned with warming temperatures in the lower atmosphere because this warming could contribute to rising sea levels, an increase in the frequency of storms and drought, a greater number of heat injuries, and the spread of tropical pests into higher latitudes. Many climatic factors operate to affect global temperatures, so carbon dioxide produced by the burning of coal, oil, and natural gas is not the only important element that dictates temperatures worldwide. Ocean currents, shifts in large warm and cold pools of the Oceans such as El Ǹino/La Ǹina, changes in sunspot activity, photosynthesis from global plant life, the extent of global sea ice, the type and extent of global cloud cover, the natural cycling of carbon, and volcanic activity are but a few of the climate controls of global temperatures.
Despite the complexity of the Earth’s climate system, many scientists attribute the slight warming (degrees C) of the average temperature of the Earth since the Industrial Revolution to increased levels of carbon dioxide, a natural component of the Earth’s atmosphere. Scientists have been measuring atmospheric carbon dioxide in Hawaii since the 1960s, and the trend has been upward for virtually every year on record. The increase in carbon dioxide levels has been linked by many scientists to the burning of fossil fuels. So, how does this increase in carbon dioxide relate to warming temperatures around the globe?
Scientists suspect that a natural phenomenon called the greenhouse effect is related to this warming. The greenhouse effect is the trapping of long wave radiation (heat) by certain greenhouse gases in the lower atmosphere, as these greenhouse gases absorb and reradiate the heat from the Earth, essentially forming a blanket in the Earth’s lower atmosphere. Without the greenhouse effect, the Earth would be over 35 o C cooler, and life on Earth would likely not exist. Global warming is thought to be related to the greenhouse effect because carbon dioxide is one of the many greenhouse gases that traps heat from the Earth, and by humans increasing the concentration of greenhouse gases in the atmosphere, the greenhouse effect is enhanced, leading to increased warming above and beyond the “natural” effect ( Figure 13.4 ).
International efforts to curb emissions of anthropogenic carbon began in earnest with the Kyoto Protocol in 1997. This agreement, signed and ratified by many countries around the world, sought to establish goals whereby countries would reduce their greenhouse gas emissions. The U.S. never ratified the treaty, particularly because India and China, two of the world’s biggest producers of carbon dioxide, were not required to reduce their emissions. However, the U.S. and other countries have continued their dialogue about lowering emissions, and the recent Paris Climate Summit is 2016, signed by 194 countries (5), is the newest plan for global cooperation in carbon dioxide reductions and with a goal to keep global average temperatures at less than 2o C above preindustrial levels.
Another example of international cooperation to decrease atmospheric pollutants involves the ozone layer. The ozone layer is in the stratosphere or upper atmosphere from 10–50 kilometers above the Earth’s surface. This important layer of ozone gas protects the Earth from harmful ultraviolet radiation that can be harmful to skin by causing sunburn and skin cancer. Scientists believe that chlorofluorocarbons (CFCs), used in refrigeration equipment and aerosols, have damaged the ozone layer and caused it to become dangerously thin over some parts of the globe. This thinning of the ozone layer has been named an “ozone hole”, and is most pronounced around the South Pole during the Antarctic spring ( Figure 13.5 ).
In response to these scientific findings, in 1987, 105 countries signed an international agreement known as the Montreal Protocol. The participating countries agreed to reduce the consumption and production of CFCs and to cease producing CFCs by the year 2000. The Montreal Protocol process continues as countries work to find ever-better substitutes for CFCs. Although CFCs will linger in the upper atmosphere for many years, scientists have already seen some evidence of recovery in the ozone layer.
13.4.2 Water Pollution
While air pollution of the atmospheric global “commons” is an international issue, pollution of water and land areas is likewise problematic. The supply of clean, fresh water for drinking and other uses such as irrigation is under stress as population pressure continues to increase demand. Many regions with water deficits experience periodic droughts that strain available supplies. Unfortunately, both ground and surface waters are being polluted both in the United Statesand abroad. Pollutants such as industrial chemicals, runoff from roadways, and untreated sewage place a heavy toll on water supplies.
Not only is unclean water unsafe to drink and in some cases unfit for irrigation purposes, but pollution can also have a deleterious effect on aquatic life. Large industrial spills, discharge from paper mills, and other types of pollutants can render a lake or stream devoid of life for considerably long periods. Another type of pollutant that is of considerable concern in the United States and abroad is commercial fertilizers used in large-scale agriculture. Although it would seem that fertilizers would encourage plant growth and help aquatic ecosystems thrive, the opposite is, in fact, true in many cases. Rainfall washes commercial fertilizers into surface lakes and streams, and these fertilizers increase the growth of algae. Through a process called eutrophication , the abundant algal blooms die, and in the process of decomposition of the dead plant material, large amounts of oxygen are consumed. The lack of oxygen can result in extensive fish kills. One stark example of the harmful effects of eutrophication can be seen in the Gulf of Mexico. The Mississippi River carries a significant load of commercial fertilizers, and where the river discharges into the Gulf, “dead zones” form at certain times of the year. The bottom and near-bottom portions of the Gulf can become almost devoid of marine life over several thousand square miles. As a result, the Gulf of Mexico has the second largest “dead zone” of depleted oxygen area in the entire world, with the largest being in the Baltic Sea. ( Figure 13.7 ).
13.4.3 Solid Waste
As countries struggle to maintain clean water sources, a related problem with pollution occurs with solid waste and its disposal. Solid waste that is buried beneath the ground can, overtime, begin to pollute the groundwater below it. Water percolating downward through the rubbish can pick up harmful pollutants and deposit them in subsurface water sources. These groundwater reservoirs feed surface streams and are also tapped for well water. In the state of Florida, for example, the pollution of groundwater reservoirs, known as aquifers, is a significant issue because the state relies heavily on groundwater for its water supply.
Three primary solutions to the problem of solid wastes is disposal in landfills, incineration of the trash, or recycling. In the United States, solid waste collectors pick up trash in cities and neighborhoods and transports the waste to landfills where it is buried daily to decrease the pervasive odor and protect it from marauding pests. This is the most common method of dealing with solid waste in the United States, but unfortunately, as urban sprawl expands towards areas where landfills were on the periphery of populated areas, the matter of residents having to live close to landfills is problematic. Moreover, landfills require extensive areas of land, and in some states with heavy population concentrations such as New York City, government officials have resorted to shipping their refuse into adjacent states such as Pennsylvania where space for landfills is more available.
Another less common alternative to landfills is incineration, a process made famous in Disney’s Toy Story 2 ( Figure 13.7 ).  The advantage of incineration is the vast reduction in the amount of trash that must be disposed of in landfills, and these facilities also generate electricity from the combustion of the burning trash. Fortunately, because of advanced technology in the smokestack systems, the emissions from modern incinerators are not particularly harmful in the atmosphere. Because of its enormous output of daily solid waste, New York City takes advantage of incineration through a facility on the Hudson River just north of the city.
The last method to deal with solid waste, recycling, is the most sustainable. Recycling involves the conversion of waste or other unwanted material into something that is reusable. Common wastes that are recycled include paper products, metals, plastics, and glass. In the United States, efforts to improve the percent of waste material that is recycled instead of disposed of in trash disposal units are many. For example, Recyclemania , started in 2001, is a nation-wide competition amongst colleges and universities to promote student knowledge and participation in recycling. Georgia Gwinnett College in Lawrenceville, GA, is one of the many competitors in Recyclemania every spring. Despite efforts such as these, the United States only recycles about 30 percent of solid waste, even though approximately 75 percent of the waste is recyclable. In contrast, Germany recycles about 65 percent of its municipal waste and leads the world, followed closely by South Korea at 59 percent. Germany’s recycling emphasis reflects the generally strong emphasis on recycling in most European countries, thanks to rather strict recycling laws.


15.11: Chapter Review - Review Questions
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- Last updated
- Save as PDF
Review Questions
1 .
Why are collaborative workspaces important?
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They promote teamwork and increase productivity during in-office meetings.
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They enable employees to work independently.
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They enable organizations to meet the diverse needs of their employees through remote work options.
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They make it more efficient for organizations to gather the information and resources needed to complete their work.
2 .
What is one way to convert a PDF file to a .docx file?
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Open the PDF with Word.
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Drag the file from your desktop to your Word document.
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Insert it as a linked object into your Word document.
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Copy and paste the text into your Word document.
3 .
Office’s common user interface fosters integration. What does this mean?
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The common user interface enables collaborative workspaces.
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The common user interface makes remote work possible.
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The common user interface allows users to share files, edit documents, and have virtual meetings in real time.
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The common user interface has a similar format and structure in different applications.
4 .
Which function is similar to cut and paste?
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linking
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embedding
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converting
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integrating
5 .
What happens to the content of an Excel worksheet when it is integrated into a Word document?
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When information in the Excel source file changes, if the file is integrated properly, the information will also be updated in the Word file.
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When information in the Excel source file changes, the information will not be updated in the Word file.
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The Excel data will insert into your Word document as a link.
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The Excel data will insert into your Word document as textual content.
6 .
What steps should you use to integrate a Word document into an Excel file?
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Select the Layout tab and use Page Setup.
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Select the Review tab and use the Changes command.
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Select the Insert Object function and put your cursor where the information should be placed in your Excel document.
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Select the Get Data function and click on the Query Options.
7 .
Where will an Excel table be inserted when embedding it into a Word document?
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at the cursor location
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at the top of the document
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at the bottom of the document
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as an icon in the heading
8 .
How do you embed Access data into Word documents?
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Choose Paste Special options or use classic copy and paste.
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Use Update Link, and the table will be embedded if you click that option.
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Choose References followed by Insert Table of Figures.
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Use Insert followed by SmartArt, and the table will be embedded if you click that option.
9 .
How do you access all of the slides that have been integrated into a Word document?
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from the Review tab
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by double-clicking on the slide image in the document
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by pressing Page down
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by using Ctrl+Click
10 .
When adding Word documents to PowerPoint slides, what happens if you don’t choose the Link box?
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The Word document will be embedded into the slide, rather than linked.
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The Word document will be linked, but you will be unable to make any changes to it.
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The Word document will be embedded, with a picture of the information inserted into the PowerPoint slide.
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The Word document will be linked, but you will have to retype some of the information to make it display properly in PowerPoint.
11 .
__________ makes the PowerPoint file part of the Excel file and increases its file size.
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linking
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embedding
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inserting as a picture
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display as icon
12 .
What approach should you use to link only certain information from an Excel file into a PowerPoint slide?
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Use the Insert tab, Choose Link approach.
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Use the standard copy-and-paste approach.
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Use the Paste Special approach.
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Use the Display as icon approach.
13 .
What is the disadvantage of inserting an Excel chart into a PowerPoint slide as a JPEG or PNG image?
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The image is simply a copy that cannot be moved around once it is inserted into a PowerPoint slide.
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The image is simply a copy that cannot be integrated.
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The image is simply a copy that cannot be duplicated to use on more than one slide.
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The image is simply a copy that cannot be updated.
14 .
To easily export Access data to Excel, what should you do to the database information?
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Format the information.
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Convert the information to a JPEG file.
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Filter the information.
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Drop the information into a table in a Word document.
15 .
What is required to import an Excel file into an Access database?
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header text with appropriate spaces
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a blank database
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a JPEG image that can be double-clicked to edit the Excel file from Access
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a table from a Word document that can integrate the Excel information
16 .
What is one way to insert a chart from Google Sheets into Google Docs?
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You can go to the Insert window menu and use the mouse to choose Chart and then From Sheets.
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You can drag the chart from Google Sheets to Google Docs, as long as they are in separate windows.
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You can use the mouse to select the browser window where Google Sheets is located and then insert the browser window on Google Docs.
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You can use the Print Screen key on the keyboard to copy the chart and then press Ctrl+V at the position where you want to place the chart in Google Docs.
17 .
Which option will preserve much of your formatting in an Excel sheet when bringing it into Sheets?
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Import command
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copy and paste
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copy and paste without formatting
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Preview