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:
Delivering meal trays to clients in their rooms is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.
Choice B rationale:
Observing postoperative clients who are confused requires a higher level of skill and knowledge than delivering meal trays. Volunteers are not typically trained to assess and monitor patients for changes in their condition, and they may not be able to recognize and respond to potential emergencies. This task is best assigned to a licensed nurse or other qualified healthcare professional.
Choice C rationale:
Assisting ambulatory clients with meals is another task that can be safely assigned to volunteers. This task involves helping patients with simple activities such as opening food containers and cutting food. Volunteers can be trained to perform these tasks safely and effectively.
Choice D rationale:
Delivering mail is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.
Correct Answer is ["C","D"]
Explanation
Cardiovascular disease (CVD) is a significant risk factor for gout. This is because CVD often coexists with other conditions that can elevate uric acid levels, such as hypertension, obesity, and chronic kidney disease. Additionally, some medications used to treat CVD, such as thiazide diuretics, can also increase uric acid levels.
Research has shown that people with CVD have a 2-3 times higher risk of developing gout compared to those without CVD.
The mechanisms linking CVD and gout are complex and not fully understood, but they likely involve shared pathways of inflammation and endothelial dysfunction.
Choice D rationale:
Diuretic use, particularly thiazide diuretics, is a well-established risk factor for gout. These medications work by increasing the excretion of fluids and electrolytes from the body, which can also lead to a decrease in the excretion of uric acid.
This can result in a buildup of uric acid in the blood, which can then crystallize in joints and cause gout attacks.
The risk of gout associated with diuretic use is dose-dependent, meaning that higher doses of diuretics are associated with a higher risk of gout.
Choice A rationale:
Depression has not been consistently shown to be an independent risk factor for gout. Some studies have suggested a possible link between depression and gout, but others have not found any association. More research is needed to clarify the relationship between these two conditions.
Choice B rationale:
Deep sleep deprivation has not been studied as a risk factor for gout. There is currently no evidence to suggest that it is directly associated with an increased risk of developing the disease.
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