A nurse is caring for a 43-year-old client who has human immunodeficiency virus (HIV).
Drag words from the choices below 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":"C"}
Sepsis: The client's low CD4 count indicates a weakened immune system, making them susceptible to infections. The presence of fever, cough, and other symptoms suggests a potential infection, which can lead to sepsis if not treated promptly.
Malnutrition: The client's weight loss, diarrhea, anorexia, and difficulty eating are all signs of malnutrition. A compromised immune system can also contribute to malnutrition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Anuria, or the absence of urine output, occurs in later stages of shock when there is significant renal hypoperfusion. It is not an early indicator of shock.
B. Hypotension is a classic sign of shock, but it generally occurs after compensatory mechanisms have failed. It is not the earliest indicator.
C. A decreased level of consciousness occurs later in the progression of shock due to decreased cerebral perfusion. It is not the earliest sign of shock.
D. Increased respiratory rate is often the earliest indicator of shock. As the body attempts to compensate for decreased oxygen delivery and tissue perfusion, the respiratory rate increases to enhance oxygenation and eliminate excess carbon dioxide. This compensatory mechanism is typically one of the first signs that shock is developing.
Correct Answer is B
Explanation
A. Assessing for sources of bleeding is important in clients with neutropenia, but the highest priority is preventing infection, as the client’s absolute neutrophil count is zero, indicating an extremely high risk for infection.
B. Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
C. Administering antiemetics and assessing nutrition and hydration are important for managing symptoms, but they do not address the immediate risk of infection associated with severe neutropenia.
D. Monitoring energy levels and implementing energy-conserving techniques are important for overall care but do not address the urgent need to protect the client from infections due to their neutropenic status.
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