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 B
Explanation
Choice A rationale:
Administering the medication without first assessing the pain could lead to inappropriate medication administration and potentially mask underlying issues. It's crucial to gather more information about the pain before providing any medication.
Choice C rationale:
While repositioning might offer some relief in certain cases, it's not the first step in pain management. A thorough assessment to understand the nature, location, and severity of the pain is essential for determining the most appropriate intervention.
Choice D rationale:
Reviewing the effects of previous pain medication is important, but it doesn't take priority over assessing the current pain. Understanding the current pain experience is necessary to make informed decisions about medication administration and other interventions.
Choice B rationale:
Determining the location of the pain is the crucial first step in pain assessment. It helps to: Identify the potential source of the pain, which can guide treatment choices.
Understand the pain's characteristics, such as its quality, intensity, and duration.
Evaluate for any associated symptoms or patterns, which can provide further insights into the underlying cause. Assess for any aggravating or alleviating factors, which can help tailor treatment strategies.
Monitor the effectiveness of interventions by comparing changes in pain location and characteristics.
Correct Answer is A
Explanation
Choice A rationale:
Hydroxychloroquine can cause a rare but serious side effect called bone marrow suppression. This is a decrease in the production of blood cells in the bone marrow.
White blood cells (WBCs) are a key component of the immune system, and a decrease in WBCs can make a patient more susceptible to infections.
Therefore, it's crucial for nurses to monitor the patient's WBC count to detect any potential bone marrow suppression early and take necessary actions to prevent or manage infections.
Choice B rationale:
An increased blood cell count is not a typical side effect of hydroxychloroquine.
Some conditions, like polycythemia vera, can cause an increase in blood cell count, but they are not related to hydroxychloroquine use.
Choice C rationale:
While hydroxychloroquine can sometimes cause a decrease in platelet count, it's less common than bone marrow suppression affecting WBCs.
However, it's still essential for nurses to monitor platelet counts as well, as a significantly low platelet count can impair blood clotting and increase the risk of bleeding.
Choice D rationale:
Hydroxychloroquine does not typically affect red blood cell (RBC) counts.
Conditions that affect RBC counts, such as anemia, are not directly related to hydroxychloroquine use.
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.