A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?
I might experience harmless white patches in my mouth.
I will expect to have a mild, occasional fever.
I will avoid people who have just received a live vaccine.
I will limit the use of skin cream to once a week.
The Correct Answer is C
Choice A reason:
The statement “I might experience harmless white patches in my mouth” could indicate the presence of oral thrush, a common fungal infection in immunocompromised individuals. However, this statement does not directly reflect an understanding of preventive measures or home care instructions for someone with immunodeficiency.
Choice B reason:
Expecting to have a mild, occasional fever is not a typical understanding of immunodeficiency care. While fevers can occur, they should not be considered normal or expected. Any fever in an immunocompromised person should be promptly evaluated by a healthcare provider as it could indicate an infection.
Choice C reason:
Avoiding people who have just received a live vaccine is a crucial preventive measure for individuals with immunodeficiency. Live vaccines contain a weakened form of the virus or bacteria, which can pose a risk to immunocompromised individuals. This statement shows an understanding of the need to avoid potential sources of infection.
Choice D reason:
Limiting the use of skin cream to once a week is not a standard recommendation for immunodeficiency care. Skin care is important, but the frequency of using skin cream should be based on individual needs and the type of cream used. This statement does not reflect a specific understanding of immunodeficiency management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: I am a prophet of the most high king
This statement reflects a delusion, which is a common symptom of schizophrenia. Delusions are false beliefs that are not based in reality. This statement does not indicate concrete thinking but rather a fixed, false belief.
Choice B reason: The voices tell me that I must avoid large crowds
This statement indicates auditory hallucinations, another common symptom of schizophrenia. Hallucinations involve perceiving things that are not present. This statement does not reflect concrete thinking but rather a perceptual disturbance.
Choice C reason: I am sure that each problem has only one solution
This statement reflects concrete thinking, which is characterized by a focus on literal and specific details rather than abstract concepts. Concrete thinking involves a rigid and literal interpretation of information, often seen in individuals with schizophrenia. This statement shows a lack of flexibility in thinking and an inability to consider multiple solutions to a problem.
Choice D reason: I know that you and the other nurses are trying to poison me
This statement reflects paranoia, a type of delusion where the individual believes others are out to harm them. Paranoid delusions are common in schizophrenia but do not indicate concrete thinking.
Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,C"},"E":{"answers":"A"}}
Explanation
Joint Pain
Sickle Cell Disease: Joint pain is a common symptom of sickle cell disease due to vaso-occlusive crises, where sickle- shaped red blood cells block blood flow to the joints, causing pain and inflammation. These episodes can be severe and recurrent, leading to chronic pain and joint damage over time.
Leukemia: Joint pain can also be a symptom of leukemia, particularly in children. This occurs because leukemia cells can infiltrate the bone marrow, causing bone and joint pain. The pain is often due to the expansion of the marrow cavity by the leukemic cells.
Heart Rate at 1000
Sickle Cell Disease: An increased heart rate (tachycardia) can occur in sickle cell disease due to anemia. The body compensates for the reduced oxygen-carrying capacity of the blood by increasing the heart rate.
Iron Deficiency Anemia: Tachycardia is also a common symptom of iron deficiency anemia. The heart works harder to pump more blood to deliver adequate oxygen to tissues, resulting in an increased heart rate.
Leukemia: In leukemia, anemia can develop due to the replacement of normal bone marrow cells with leukemic cells, leading to a reduced number of red blood cells and subsequent tachycardia as the body attempts to compensate.
Respiratory Status
Sickle Cell Disease: Dyspnea (difficulty breathing) and labored breathing can occur in sickle cell disease due to anemia and acute chest syndrome, a severe complication where sickle cells block blood flow in the lungs.
Iron Deficiency Anemia: Respiratory symptoms such as shortness of breath and labored breathing are common in iron deficiency anemia due to the reduced oxygen-carrying capacity of the blood.
Leukemia: Leukemia can cause respiratory symptoms due to anemia and the infiltration of leukemic cells into the lungs, leading to reduced oxygenation and labored breathing.
Jaundice
Sickle Cell Disease: Jaundice is a common symptom of sickle cell disease due to the increased breakdown of red blood cells (hemolysis), leading to elevated bilirubin levels.
Leukemia: Jaundice can also occur in leukemia if the liver is infiltrated by leukemic cells or if there is significant hemolysis.
Ankle Ulcer
Sickle Cell Disease: Ankle ulcers are a common complication of sickle cell disease. They result from poor blood flow and oxygen delivery to the skin, leading to chronic, non-healing ulcers.
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