A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)

Instruct the client to eat cooked foods only.

Restrict visitors who have active infections.

Dispose of all linen in the trash after use.

Limit the client from bathing daily.

Don a mask, gloves, and gown.

Answer and Explanation

Correct Answer : A,B,E

Choice A reason:
Instructing the client to eat cooked foods only is a necessary precaution for immunosuppressed individuals. Cooking foods thoroughly can help eliminate harmful bacteria and other pathogens that could cause infection in a person with a weakened immune system.

Choice B reason:
Restricting visitors who have active infections is crucial in preventing the transmission of potentially harmful pathogens to the immunosuppressed client. Even minor infections in healthy individuals can be severe for someone with a compromised immune system.

Choice C reason:
Disposing of all linen in the trash after use is not a standard precaution for immunosuppressed clients. Used linens should be handled according to the healthcare facility's infection control policies, which often include laundering and not simply discarding in the trash.

Choice D reason:
Limiting the client from bathing daily is not a necessary precaution for immunosuppression. Maintaining good personal hygiene is important, and there is no need to restrict regular bathing unless there is a specific contraindication.

Choice E reason:
Donning a mask, gloves, and gown when caring for an immunosuppressed client can be part of standard precautions, especially if the client is in a protective environment or if the nurse is performing a procedure that has a high risk of contact with bodily fluids or if the client has a known infection.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason:
Polyuria, or excessive urination, is not typically a direct complication of a cervical spinal cord injury. Polyuria can be related to other conditions such as diabetes or the use of diuretics.

Choice B reason:
A weakened gag reflex can be a complication of a cervical spinal cord injury, especially if the injury affects the nerves that supply the muscles involved in swallowing. This can increase the risk of aspiration and requires careful monitoring.

Choice C reason:
Hypotension, or low blood pressure, is a common complication following a spinal cord injury due to the disruption of the autonomic pathways that control blood pressure. This condition, known as neurogenic shock, can occur in the acute phase following the injury.

Choice D reason:
Hyperthermia, or elevated body temperature, is not a common direct complication of a cervical spinal cord injury. However, the injury can disrupt temperature regulation, leading to difficulty in either staying warm or cooling down, depending on the environment and level of injury.

Choice E reason:
An absence of bowel sounds can indicate a complication of a cervical spinal cord injury, as the injury may disrupt the normal functioning of the bowel. This can lead to ileus or bowel obstruction, which requires prompt medical attention.

A. A client who has an autoimmune disorder. B. A 40-year-old client with hypoglycemia. C. A client who does not get much sleep. D. A 26-year-old female client who has never given birth.

Correct Answer is B

Explanation

Choice A reason:
While autoimmune disorders are associated with type 1 diabetes, where the immune system attacks the pancreas, they are not typically a direct risk factor for type 2 diabetes. Type 2 diabetes is more closely related to lifestyle factors and insulin resistance.

Choice B reason:
A 40-year-old client with hypoglycemia may be at risk for developing type 2 diabetes. Hypoglycemia can be a sign of pre-diabetes or insulin resistance, where the body's response to insulin is not as effective, leading to fluctuations in blood sugar levels. As individuals age, their risk for type 2 diabetes increases, particularly if they have other risk factors such as a sedentary lifestyle, overweight, or a family history of diabetes.

Choice C reason:
Lack of sleep can contribute to the development of type 2 diabetes by affecting the body's ability to regulate glucose and by increasing insulin resistance. However, without additional risk factors, it is not as strong a predictor of type 2 diabetes as the presence of hypoglycemia or other metabolic conditions.

Choice D reason:
Having never given birth is not a recognized risk factor for type 2 diabetes. While gestational diabetes is a risk factor for developing type 2 diabetes later in life, the absence of pregnancy does not increase the risk.

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A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is B

Explanation

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