A nurse in the emergency department is caring for a client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
The client reports symptoms of vomiting and diarrhea for the past 12 hours. These symptoms are classic indicators of fluid loss from the gastrointestinal tract. Vomiting and diarrhea lead to significant fluid depletion, resulting in a fluid volume deficit. This deficit can lead to dehydration, electrolyte imbalances, and potentially hypotension (low blood pressure), which are consistent with the client's clinical presentation of tachycardia (increased heart rate) and hypotension (blood pressure 102/58 mmHg). The plan for IV fluid replacement upon admission reflects the need to address and correct this fluid deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pain management is important during labor, but in this scenario, the priority is not pain relief but rather addressing potential complications or needs related to the vital signs and labor progress.
B. This position can help improve blood flow to the uterus and placenta, which is crucial given the low maternal blood pressure (92/54 mm Hg). This action can help stabilize the client's condition while further assessments and interventions are planned.
C. Emptying the bladder is often recommended during labor to ensure there is no obstruction to the progress of labor and to reduce the risk of urinary retention. While important, it is not the priority action based on the information provided.
D. The nurse also needs to report the contraction pattern (duration of 1 min, frequency of 3 min) and fetal heart rate (130/min) to ensure appropriate monitoring and management by the healthcare provider. However, this should not delay lifesaving interventions such as positioning.
Correct Answer is A
Explanation
A. The CD4-T-cell count is a critical indicator of immune function in individuals with HIV. CD4 cells are a type of white blood cell that HIV targets and destroys, leading to immune deficiency. A lower CD4 count indicates greater immunosuppression and increased susceptibility to opportunistic infections. Monitoring CD4 counts helps guide decisions regarding antiretroviral therapy (ART) initiation and monitoring response to treatment.
B. White blood cell (WBC) count measures the body's immune response and can fluctuate due to various factors. A WBC count of 5,000/mm3 is within the normal range, but it alone does not provide specific information about the client's HIV status or immune function compared to the CD4 count.
C. Platelets are involved in blood clotting, and a platelet count of 150,000/mm3 is within the normal range. Platelet counts are important for assessing bleeding risk but are not directly related to HIV progression or immune status.
D. A positive Western blot test confirms the presence of HIV antibodies in the blood. It is used for definitive HIV diagnosis after an initial positive screening test (such as ELISA). While important for diagnosis, once HIV is confirmed, ongoing monitoring of CD4 counts and viral load (not directly mentioned in the options) becomes more crucial for managing the disease.
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