A nurse is assessing a 28-year-old client with HIV who has been admitted with pneumonia. Which of the following observations should the nurse prioritize?
Tachypnea and restlessness
Weight loss of 1 pound since yesterday
Frequent loose stools
Oral temperature of 100°F
The Correct Answer is A
Rationale for Choice A:
Tachypnea and restlessness are common signs of respiratory distress, which is a potential complication of pneumonia. These signs indicate that the client's oxygenation may be compromised and require immediate attention.
Rationale for Choice B:
Weight loss of 1 pound since yesterday is a non-specific finding and could be due to a variety of factors, including poor appetite, dehydration, or muscle wasting. While weight loss can be a symptom of HIV infection, it is not an acute sign that requires immediate prioritization in this case.
Rationale for Choice C:
Frequent loose stools can be a symptom of HIV infection or a side effect of certain medications. However, it is not an acute sign that requires immediate prioritization in this case, especially in the context of the client's respiratory distress.
Rationale for Choice D:
An oral temperature of 100°F is a low-grade fever and is not a specific indicator of any serious condition. While fever can be a symptom of pneumonia, it is not the most concerning finding in this case.
Therefore, based on the client's presenting symptoms, tachypnea and restlessness are the most concerning findings and should be prioritized by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Losing 2 pounds in 2 weeks is not a significant weight loss and may not be a cause for concern in this context. It's important to monitor weight trends over time, but this isolated statement doesn't necessarily require immediate discussion.
Choice B rationale:
Engaging in physical activity like swimming is generally beneficial for individuals with rheumatoid arthritis. It can help improve joint mobility, reduce pain, and enhance overall well-being. The nurse might encourage the client to discuss any specific concerns or limitations with their healthcare provider, but the activity itself is not alarming.
Choice C rationale:
Taking an antibiotic concurrently with naproxen can potentially increase the risk of adverse effects. Some antibiotics, like those in the fluoroquinolone class (e.g., ciprofloxacin, levofloxacin), can interact with naproxen and increase the risk of tendonitis or tendon rupture. This interaction warrants further discussion to ensure the client is aware of potential risks and to explore alternative medications if necessary.
Choice D rationale:
Using applesauce to facilitate medication intake is a common and acceptable practice. It does not affect the absorption or efficacy of naproxen.
Correct Answer is B
Explanation
Choice A rationale:
Acute retroviral syndrome (ARS) is an early stage of HIV infection that often presents with flu-like symptoms. It does not determine AIDS diagnosis.
Choice B rationale:
A CD4+ T lymphocyte level of less than 200 cells/mm is a defining criterion for AIDS diagnosis. This low count indicates a severely weakened immune system, leading to susceptibility to opportunistic infections and other AIDS-defining illnesses.
Choice C rationale:
A person with HIV can transmit the virus to others regardless of their CD4+ T cell count. Transmission risk is not a diagnostic criterion for AIDS.
Choice D rationale:
HIV-specific antibodies are produced by the immune system in response to HIV infection but their presence does not signify AIDS progression.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
