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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Testing new nurses for exposure to tuberculosis is an example of secondary prevention. Secondary prevention aims to detect and treat diseases early in their course to prevent progression. Testing for tuberculosis exposure helps identify the disease early so that treatment can begin promptly.

Choice B reason: Providing treatment for clients who have chronic obstructive pulmonary disease is an example of tertiary prevention. Tertiary prevention focuses on managing and improving the quality of life for individuals with chronic diseases. It aims to reduce the impact of the disease and prevent complications.

Choice C reason: Performing screening for sexually transmitted infections is an example of secondary prevention. Screening helps detect infections early, allowing for timely treatment and reducing the spread of the disease.

Choice D reason: Administering influenza immunizations at a local health fair is an example of primary prevention. Primary prevention aims to prevent diseases before they occur by reducing risk factors and promoting health. Immunizations help prevent the onset of influenza.

A. Monitor the client’s calf for edema. B. Palpate the femoral pulse. C. Measure the circumference of the thigh. D. Instruct the client to wiggle his toes.

Correct Answer is B

Explanation

Choice A reason:

Monitoring the client’s calf for edema is important in assessing for complications such as deep vein thrombosis (DVT) or compartment syndrome, but it is not the primary technique for assessing neurovascular status. Edema can indicate fluid accumulation and potential vascular issues, but it does not directly assess the nerve function or blood flow to the extremity.

Choice B reason:

Palpating the femoral pulse is crucial in assessing the neurovascular status of a client with a femur fracture. The femoral pulse provides information about the blood flow to the lower extremity. A strong, palpable pulse indicates good arterial blood flow, while a weak or absent pulse may suggest vascular compromise, which requires immediate attention. This assessment helps ensure that the blood supply to the limb is adequate, which is vital for healing and preventing complications.

Choice C reason:

Measuring the circumference of the thigh can help monitor for swelling and changes in muscle mass, but it is not a direct assessment of neurovascular status. While it can provide useful information about the extent of swelling or atrophy, it does not evaluate the nerve function or blood flow directly.

Choice D reason:

Instructing the client to wiggle his toes is a useful technique to assess motor function and nerve integrity. However, it is not sufficient on its own to assess the entire neurovascular status. It should be part of a comprehensive assessment that includes checking pulses, sensation, and capillary refill.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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