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

Select 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"}

​​​​​​​Condition Choices

  • Dysrhythmias: Dysrhythmias are often linked to electrolyte imbalances, particularly potassium abnormalities, rather than WBC count changes. The client’s potassium level remains within normal limits, making dysrhythmias unlikely.
  • Infection: A decreasing WBC count below the normal range weakens the immune response, increasing susceptibility to infections. The client’s WBC count has declined from 4,500/mm³ to 4,100/mm³, placing them at higher risk for opportunistic infections, a major concern in HIV.
  • Renal failure: Renal failure is typically assessed through elevated BUN and creatinine levels, along with signs of fluid imbalance. The client’s BUN is slightly elevated but not significantly high, and there are no other indicators of renal failure.
  • Bleeding: Bleeding risk is associated with low platelet levels, which impair clotting ability. The client’s platelet count remains within normal limits, reducing the likelihood of bleeding complications.
  • Seizures: Seizures can result from severe electrolyte imbalances, neurological conditions, or uncontrolled infections. The client does not exhibit signs of neurological dysfunction, and electrolyte levels are stable, making seizures unlikely.

Finding Choices

  • WBC count: A declining WBC count below the normal range weakens the immune response, making the client more susceptible to infections. This is particularly concerning for individuals with HIV, as they are already at an increased risk for opportunistic infections.
  • Potassium level: Potassium levels are crucial for cardiac function and neuromuscular stability. The client’s potassium level remains within normal limits, making it an unlikely contributor to any immediate risk.
  • Platelets: Platelets play a key role in clot formation. The client’s platelet count is within the normal range, so they are not currently at increased risk for bleeding.
  • Sodium level: Sodium is essential for fluid balance and neurological function. The client’s sodium level remains within the normal range, meaning it is not contributing to any immediate concerns.
  • BUN level: Elevated BUN levels can indicate impaired kidney function, dehydration, or increased protein metabolism. The client’s BUN level has increased slightly but is still within the normal range, making renal failure unlikely at this time.


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Related Questions

Correct Answer is B

Explanation

A. "This device delivers heat via electrodes that are attached to the affected area.": A TENS unit does not use heat for pain relief. It works by delivering low-voltage electrical impulses to the skin, stimulating nerve fibers to reduce pain perception.

B. "Adjust the dial until you feel a pins-and-needles sensation.": The intensity of the electrical stimulation should be adjusted to a comfortable level where the client feels a tingling or pins-and-needles sensation. This indicates that the nerves are being stimulated appropriately for pain relief.

C. "You can apply the electrodes directly over sensitive areas of skin.": Electrodes should not be placed on irritated, broken, or sensitive skin, as this can cause discomfort or skin damage. Placement should follow guidelines to ensure effective and safe pain management.

D. "This device requires access to a 220-volt outlet.": TENS units are battery-operated and do not require a high-voltage power source. This makes them portable and convenient for home use.

Correct Answer is A

Explanation

A. Initiate oxygen therapy: Sepsis can lead to tissue hypoxia and organ dysfunction due to impaired perfusion. Oxygen therapy is the priority to ensure adequate oxygenation, prevent respiratory failure, and support vital organ function.

B. Administer antibiotics: Broad-spectrum antibiotics are essential to treat the underlying infection, but they should be given after obtaining blood cultures to ensure accurate pathogen identification and prevent delays in appropriate therapy.

C. Obtain blood cultures: Blood cultures must be collected before antibiotic administration to identify the causative organism, but stabilizing the client's oxygenation and perfusion takes precedence in acute management.

D. Begin an IV crystalloid infusion: Fluid resuscitation is crucial for managing septic shock, but oxygen therapy should be initiated first to immediately improve oxygen delivery and prevent hypoxia-related complications.

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