A client with acquired immunodeficiency syndrome (AIDS) has Pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?
Capillary refill
Radial pulses
Lung sounds
Skin turgor
The Correct Answer is C
Choice A reason: Capillary refill is not the nurse's priority assessment for this client, because it is not the most relevant and sensitive indicator of the client's condition. Capillary refill is a test that measures the time it takes for the color to return to the nail bed after applying pressure, which reflects the peripheral circulation and tissue perfusion. Capillary refill can be affected by factors such as temperature, hydration, or vasoconstriction. Capillary refill is not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Choice B reason: Radial pulses are not the nurse's priority assessment for this client, because they are not the most relevant and sensitive indicator of the client's condition. Radial pulses are the beats that can be felt at the wrist, which reflect the heart rate and rhythm. Radial pulses can be affected by factors such as activity, emotion, or medication. Radial pulses are not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Choice C reason: Lung sounds are the nurse's priority assessment for this client, because they are the most relevant and sensitive indicator of the client's condition. Lung sounds are the noises that can be heard with a stethoscope over the chest, which reflect the air movement and ventilation in the lungs and airways. Lung sounds can reveal the presence of abnormalities, such as crackles, wheezes, or diminished breath sounds, which indicate fluid, inflammation, or obstruction in the lungs or airways. Lung sounds are a specific and reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Choice D reason: Skin turgor is not the nurse's priority assessment for this client, because it is not the most relevant and sensitive indicator of the client's condition. Skin turgor is a test that measures the elasticity of the skin, which reflects the hydration and fluid status of the body. Skin turgor can be affected by factors such as age, weight loss, or edema. Skin turgor is not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the best intervention because it helps the nurse to understand the client's emotional, social, and practical needs and resources. A new diagnosis of HIV can be a devastating and overwhelming experience for the client, who may face stigma, discrimination, isolation, or rejection from others. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide comfort, guidance, and assistance to the client. The nurse should also encourage the client to seek professional counseling, peer support, or other services as needed.
Choice B reason: This is not the best intervention because it may not respect the client's preferences, beliefs, or values. The nurse should not assume that the client wants or needs spiritual or religious support, unless the client expresses such a desire. The nurse should ask the client about their spiritual or religious beliefs and practices and provide appropriate referrals or resources as requested by the client. The nurse should also respect the client's right to privacy and confidentiality and not disclose the client's diagnosis to anyone without the client's consent.
Choice C reason: This is not the best intervention because it may not be the most urgent or appropriate topic to discuss with the client at this time. The nurse should not focus on the legal or ethical aspects of the client's diagnosis, but rather on the client's emotional and physical wellbeing. The nurse should explain the legal requirement to tell sex partners in a sensitive and respectful manner, but only after the client has accepted and understood their diagnosis and has expressed readiness to disclose their status to others. The nurse should also provide the client with information and resources on how to prevent the transmission of HIV and how to protect themselves and their partners.
Choice D reason: This is not the best intervention because it may not be the client's wish or choice. The nurse should not offer to tell the family for the client, unless the client asks for such help. The nurse should respect the client's autonomy and decisionmaking regarding whom to tell and when to tell about their diagnosis. The nurse should also support the client in preparing for the possible reactions and outcomes of disclosing their status to their family and others.
Correct Answer is B
Explanation
Choice A reason: Providing active range of motion (ROM) is not a treatment that the nurse can perform for a quadriplegic client. Active ROM means that the client moves their own joints without assistance. A quadriplegic client has paralysis of all four limbs and cannot move their joints voluntarily.
Choice B reason: Providing passive range of motion (ROM) is a treatment that the nurse can perform for a quadriplegic client. Passive ROM means that the nurse moves the client's joints through their full range of motion without resistance. This helps prevent joint contracture, which is the loss of joint movement and flexibility due to muscle shortening and stiffness. It also helps maintain joint mobility, which is the ability of the joint to move smoothly and freely.
Choice C reason: Turning the client every 2 hours is not a treatment that the nurse can perform to decrease the risk of joint contracture and promote joint mobility. Turning the client every 2 hours is a preventive measure to avoid pressure ulcers, which are skin injuries caused by prolonged pressure on the skin. It does not directly affect the joint function or movement.
Choice D reason: Administering glucosamine supplements is not a treatment that the nurse can perform to decrease the risk of joint contracture and promote joint mobility. Glucosamine supplements are dietary supplements that may help reduce the pain and inflammation of osteoarthritis, which is a degenerative joint disease that causes the breakdown of the cartilage and bone in the joints. It does not affect the muscle or nerve function or movement.
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