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A nurse in a health clinic is caring for a client.

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing

due to.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for Correct Answers:

  • Infection: HIV targets and depletes CD4+ T cells, impairing immune function. A consistently low WBC count (below the normal range) indicates reduced immune defense, increasing susceptibility to infections.
  • WBC count: The client’s WBC count decreased from 4,500 to 4,100/mm³, both below the normal lower limit. This progressive leukopenia in the context of HIV suggests worsening immunosuppression, which elevates the risk of opportunistic infections.

Rationale for Incorrect Choices:

  • Dysrhythmias: The client’s potassium level is 3.8 mEq/L, within the normal range. Since potassium directly affects cardiac conduction, a normal level does not indicate an increased risk of dysrhythmia.
  • Renal failure: The client’s BUN increased slightly from 16 to 18 mg/dL but remains within the normal range. There are no other signs of renal impairment such as elevated creatinine or abnormal electrolyte levels.
  • Seizures: Sodium is stable at 139 mEq/L, which is within the normal range. Electrolyte imbalance, particularly hyponatremia, is a common trigger for seizures, which is not evident here.
  • Bleeding: The platelet count is slightly decreased but still within the normal range (162,000/mm³). There is no evidence of thrombocytopenia or coagulopathy that would suggest a bleeding risk.


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Related Questions

Correct Answer is B

Explanation

A. 25-Hydroxyvitamin D 92 ng/mL (25 to 80 ng/mL): This value is slightly above the normal range and may suggest supplementation but does not directly increase the risk of skin breakdown. Vitamin D supports skin health, but a mild elevation is not typically harmful in this context.
B. Albumin 3.1 g/dL (3.5 to 5 g/dL): Low albumin levels indicate poor nutritional status, which impairs wound healing and skin integrity. Clients with hypoalbuminemia are at higher risk for pressure injuries and delayed tissue repair, especially after a stroke with limited mobility.
C. WBC 12,000/mm³ (5,000 to 10,000/mm³): An elevated white blood cell count suggests infection or inflammation but is not a primary factor for skin breakdown. It may reflect a secondary issue but not the direct cause of impaired skin integrity.
D. Hgb 18 g/dL (12 to 16 g/dL): A slightly elevated hemoglobin level may indicate dehydration or high red blood cell concentration but does not contribute to increased skin breakdown risk. It is not a relevant marker for assessing pressure ulcer vulnerability.

Correct Answer is B

Explanation

A. Epistaxis: While radiation can cause mucosal irritation, epistaxis (nosebleeds) is more commonly associated with trauma, anticoagulant use, or nasal cancers, rather than a direct and expected result of radiation therapy to the head and neck.
B. Xerostomia: Radiation to the head and neck often damages salivary glands, leading to xerostomia (dry mouth). This is a common and expected side effect that can affect swallowing, speaking, and increase the risk of oral infections and dental decay.
C. Tinnitus: Tinnitus is associated with ototoxic medications or direct auditory nerve damage, which is less commonly affected by standard radiation fields in head and neck therapy. It is not a typical side effect unless the inner ear is specifically involved.
D. Diplopia: Double vision is usually related to cranial nerve involvement or neurological conditions like stroke or multiple sclerosis. It is not a standard or expected effect of radiation to the head and neck unless adjacent neural structures are compromised.

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