A nurse is caring for a client who has HIV.
Which of the following laboratory values is the nurse's priority?
WBC 5,000/mm³.
Platelets 150,000/mm³.
O Positive Western blot test.
CD4-T-cell count 180 cells/mm.
The Correct Answer is D
Choice A rationale:
A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.
Choice B rationale:
A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.
Choice C rationale:
A positive Western blot test confirms HIV infection, but it is not a priority in this case.
Choice D rationale:
A CD4-T-cell count of 180 cells/mm³ is below the normal range (500 to 1,500 cells/mm³), indicating severe immune system damage in a client with HIV. This is the nurse’s priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
Correct Answer is D
Explanation
Choice A rationale:
Positive Kernig’s sign is a clinical sign of meningitis, not specifically increased ICP12.
Choice B rationale:
Photophobia, or light sensitivity, is a symptom of meningitis but does not specifically indicate increased ICP12.
Choice C rationale:
Nuchal rigidity, or neck stiffness, is another symptom of meningitis, not a specific indicator of increased ICP12.
Choice D rationale:
Restlessness can be a sign of increased ICP as it may indicate changes in mental status, a key symptom of increased ICP12.
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