A 45-year-old patient presents to the trauma unit after a gunshot wound (GSW) to the abdomen. The patient has a temperature of 92 degrees Fahrenheit, is restless and confused, and has large amount of blood noted from the nasogastric (NG) tube as well as from the indwelling urinary catheter. Which additional assessment finding likely causes death within the first 24 hours following this injury?

Heart rate of 130 beats per minute

PH of 7.21 (normal 7.35-7.45)

Serum potassium 5.7 mEq/L (normal 3,5-5.3)

Platelet count 200,000 (normal 150,000-450,000)

Answer and Explanation

The Correct Answer is B

A) Heart rate of 130 beats per minute
A heart rate of 130 beats per minute is tachycardia, which is often a compensatory response to injury, particularly in cases of trauma, blood loss, or shock. It is common in the initial phase after trauma as the body attempts to compensate for decreased blood volume or oxygen delivery. However, tachycardia alone is not typically fatal in the immediate post-injury period and can often be managed.

B) pH of 7.21 (normal 7.35–7.45)
A pH of 7.21 indicates acidosis, which is life-threatening and typically arises from shock, blood loss, or severe trauma. Acidosis occurs when the body is unable to compensate for lactic acid or other metabolic byproducts that accumulate due to insufficient oxygen delivery to tissues. In the case of a gunshot wound to the abdomen, there is a high risk of internal bleeding, hypoperfusion, and hypoxia, all of which can lead to metabolic acidosis. Severe acidosis can cause organ failure, particularly affecting the heart, kidneys, and brain.

C) Serum potassium 5.7 mEq/L (normal 3.5–5.3)
A serum potassium of 5.7 mEq/L is elevated, but it is moderately high and not typically life-threatening unless it reaches much higher levels (e.g., >6.0 mEq/L), which can cause cardiac arrhythmias. Elevated potassium can occur due to cellular injury (e.g., muscle trauma or rhabdomyolysis), but it would need to be corrected to prevent complications like arrhythmias.

D) Platelet count 200,000 (normal 150,000–450,000)
A platelet count of 200,000 is within the normal range (150,000–450,000) and does not indicate a problem with coagulation. The blood loss and the NG tube hemorrhage mentioned in the scenario suggest that the patient may be at risk for bleeding, but a platelet count in the normal range suggests that the body’s ability to form clots is likely intact.

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Correct Answer is D

Explanation

A) Ice packs may be applied to the site for 30 minutes every hour for comfort:
This is not an appropriate recommendation for skin care related to radiation therapy. Applying ice packs to the skin can cause vasoconstriction and might worsen skin irritation or damage from radiation. Instead, the patient should be advised to avoid extreme temperatures, including hot or cold compresses, which could exacerbate skin issues in the radiation field.

B) Incorporate rest periods throughout the day:
While rest is important for overall well-being during radiation therapy, this instruction does not directly address the skin care needs associated with radiation. The primary concern with radiation therapy is protecting the skin from further irritation and damage, so specific skin care measures are more crucial in this context than general rest periods.

C) Do not share bathrooms/toilets with others for 48 hours after treatment:
This instruction is not necessary for most patients undergoing radiation therapy, especially for lung cancer. The concern about not sharing bathrooms or toilets generally applies to patients receiving brachytherapy or radioactive implants, where radiation is placed inside the body. For external radiation, there is no risk of contamination through shared bathroom use.

D) Wear loose, soft clothing over the treated area:
This is the most appropriate instruction for skin care during radiation therapy. Radiation therapy can cause the skin to become tender, red, and irritated, so wearing loose, soft clothing will help minimize friction and pressure on the skin. Tight or rough clothing can irritate the radiation site, increasing the risk of skin breakdown. Loose, breathable fabrics like cotton can help keep the skin comfortable and allow it to heal while protecting it from further damage.

A. CD4 count of less than 200 cells/uL, (ranges 500-1800) and new diagnosis of pneumocystis pneumonia B. CD4 count of 1200 cells/uL (ranges 500-1800) and a new diagnosis hepatitis A C. low grade fever with the diagnosis of influenza A D. New atopic dermatitis and a White Blood count 11 million/mm3

Correct Answer is A

Explanation

A) CD4 count of less than 200 cells/uL, and new diagnosis of pneumocystis pneumonia:
A CD4 count of less than 200 cells/uL and the diagnosis of a severe opportunistic infection, such as pneumocystis pneumonia (PCP), are major criteria for the diagnosis of acquired immunodeficiency syndrome (AIDS). AIDS is the final stage of HIV infection, where the immune system is severely compromised, and the individual is highly susceptible to opportunistic infections like PCP, tuberculosis, and others. The CD4 count, which measures the number of immune system cells (specifically T-helper cells), is used to monitor disease progression, with values below 200 cells/uL indicating a diagnosis of AIDS.

B) CD4 count of 1200 cells/uL and a new diagnosis of hepatitis A:
While hepatitis A is an important condition that should be managed, it is not an opportunistic infection associated with AIDS. A CD4 count of 1200 cells/uL is within the normal range (500-1800 cells/uL), indicating that the immune system is not severely compromised.

C) Low grade fever with the diagnosis of influenza A:
A low-grade fever and a diagnosis of influenza A do not indicate AIDS. Influenza is a viral infection that can affect both individuals with and without HIV. It is common to experience flu-like symptoms in the early stages of HIV infection, but the presence of a fever and influenza does not confirm AIDS. A low-grade fever is also not specific to AIDS or opportunistic infections.

D) New atopic dermatitis and a white blood count of 11 million/mm³:
Atopic dermatitis is a chronic inflammatory skin condition that is not specifically associated with HIV or AIDS. The white blood cell (WBC) count of 11 million/mm³ is elevated, but this alone does not confirm a diagnosis of AIDS. Elevated WBC counts can occur with various conditions, including infections and allergic reactions, but they are not a diagnostic feature of AIDS.

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Naxlex Comprehensive Predictor Exams

Which instruction is most important for the nurse to provide a client who is receiving radiation therapy for lung cancer when teaching about skin care?

Correct Answer is D

Explanation

The nurse is providing care for a client who has tested positive for human immunodeficiency virus (HIV). Which of the following findings would confirm the diagnosis of acquired immunodeficiency syndrome (AIDS) in this client?

Correct Answer is A

Explanation

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