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 B
Explanation
Choice A reason: A susceptible host is not an infectious disease, but a factor that influences the transmission of an infectious disease. A susceptible host is a person who is vulnerable to infection due to factors such as age, health status, immunization, or genetic predisposition. A susceptible host may become infected by a communicable disease, but it is not the disease itself.
Choice B reason: A communicable disease is an infectious disease that can be transmitted directly from one person to another. A communicable disease is caused by a pathogen, such as a virus, bacterium, fungus, or parasite, that can spread through contact, droplet, airborne, vector, or vehicle transmission. Examples of communicable diseases are influenza, tuberculosis, measles, malaria, and HIV/AIDS.
Choice C reason: A portal of entry to a host is not an infectious disease, but a factor that influences the transmission of an infectious disease. A portal of entry to a host is a route through which a pathogen can enter the body of a susceptible host and cause infection. A portal of entry to a host may be a break in the skin, a mucous membrane, or a body opening, such as the mouth, nose, eyes, or genitals. A portal of entry to a host may facilitate the transmission of a communicable disease, but it is not the disease itself.
Choice D reason: A portal of exit from the reservoir is not an infectious disease, but a factor that influences the transmission of an infectious disease. A portal of exit from the reservoir is a route through which a pathogen can leave the body of an infected person or animal and reach another susceptible host. A portal of exit from the reservoir may be a body fluid, such as blood, saliva, urine, or feces, or a body part, such as the skin, hair, or nails. A portal of exit from the reservoir may enable the transmission of a communicable disease, but it is not the disease itself.
Correct Answer is A
Explanation
Choice A reason: Administering topical hydrocortisone is the appropriate nursing intervention, because it can help reduce the inflammation and itching of the skin lesions that are common in SLE. SLE is a chronic autoimmune disease that causes the immune system to attack various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Hydrocortisone is a type of corticosteroid that can suppress the immune response and relieve the symptoms of SLE.
Choice B reason: Applying cold therapy to the extremities is not the appropriate nursing intervention, because it can worsen the circulation and sensation of the fingers and toes that are affected by Raynaud's phenomenon, which is a complication of SLE. Raynaud's phenomenon is a condition that causes the blood vessels in the extremities to narrow and spasm in response to cold or stress, resulting in numbness, pain, and color changes. Cold therapy can trigger or aggravate Raynaud's phenomenon.
Choice C reason: Administering antibiotics is not the appropriate nursing intervention, because it is not indicated for SLE, unless there is a secondary infection. SLE is not caused by bacteria, but by the abnormal activity of the immune system. Antibiotics are drugs that can kill or inhibit the growth of bacteria, but they have no effect on the underlying cause of SLE. Antibiotics can also have side effects, such as allergic reactions, gastrointestinal disturbances, or resistance.
Choice D reason: Encouraging ultraviolet (UV) light exposure is not the appropriate nursing intervention, because it can trigger or worsen the skin lesions and the disease activity of SLE. UV light is a type of radiation that can damage the DNA and the cells of the skin, causing inflammation, redness, and blistering. UV light can also stimulate the production of antibodies and cytokines that can attack the organs and tissues of the body.
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