A nurse is providing care to a group of patients with chronic illnesses.
Who among the following patients should the nurse identify as being at the highest risk for sepsis?
The patient with polycystic ovarian syndrome.
The patient with cancer.
The patient with Kallmann’s syndrome.
The patient with Addison’s disease.
The Correct Answer is B
Choice A rationale
Polycystic ovarian syndrome is a hormonal disorder common among women of reproductive age. While it can lead to several complications, it does not significantly increase the risk of sepsis.
Choice B rationale
Cancer and certain treatments for cancer can weaken the immune system, increasing the risk of infections that could lead to sepsis.
Choice C rationale
Kallmann’s syndrome is a genetic condition that affects the production of a hormone involved in sexual development. It does not significantly increase the risk of sepsis.
Choice D rationale
Addison’s disease affects the adrenal glands and can disrupt the balance of hormones in the body, but it does not significantly increase the risk of sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Frothy sputum is a common finding in patients with left-sided heart failure. This is due to fluid accumulation in the lungs (pulmonary edema), which can cause the sputum to become frothy.
Choice B rationale
Dependent edema is more commonly associated with right-sided heart failure. It occurs due to fluid accumulation in the systemic circulation, leading to swelling in the lower extremities.
Choice C rationale
Nocturnal polyuria can occur in heart failure, but it is not a specific sign of left-sided heart failure.
Choice D rationale
Jugular venous distention is a sign of right-sided heart failure, not left-sided heart failure. It occurs due to increased pressure in the right atrium, leading to visible distention of the jugular veins.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The nurse should first: C. Administer additional morphine for pain management, followed by B. Reposition the client for comfort.
The client is reporting a pain level of 6 on a scale from 0 to 10, which indicates moderate to severe pain. As per the medication administration record, the client has an order for Morphine 4 mg IV bolus every 6 hours PRN for pain. Since the client is in pain, it would be appropriate to administer the morphine first to manage the pain.
After addressing the client’s pain, the nurse should then reposition the client for comfort. This can help to alleviate any discomfort or pressure points that may be contributing to the client’s pain. It’s also important to ensure the client’s safety and comfort by making sure the call light is within reach.
The options related to restraints (A and D for Response 1, and A, B, C, D for Response 2) are not relevant in this scenario as there is no indication in the provided information that the client is being restrained or that restraints are necessary. The client is drowsy but arouses easily to verbal stimuli and is able to follow simple commands, suggesting that they are not at risk of harming themselves or others, which would necessitate the use of restraints. Therefore, these options can be ruled out.
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