Exhibits
The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?
The client's age
The client's facial droop
The client's garbled speech
The client's alcohol consumption
The client's seafood intake
The Correct Answer is B
a) The client's age: The client is 70 years old, which puts her at a higher risk of having a stroke or other cardiovascular problems. Stroke is a medical emergency that requires prompt treatment to prevent brain damage and disability.
b) The client's facial droop: The client has a noticeable facial droop, which is a sign of facial nerve weakness or paralysis. This can be caused by a stroke, Bell's palsy, or other neurological conditions. Facial droop can affect the client's ability to speak, eat, and express emotions.
c) The client's garbled speech: The client has garbled speech, which means she has difficulty producing or understanding words. This can be caused by a stroke, brain injury, or other disorders that affect the language areas of the brain. Garbled speech can impair the client's communication and cognition.
d) The client's alcohol consumption: The client had a few drinks at a seafood restaurant, which may have interacted with her medications or medical conditions. Alcohol can increase the risk of bleeding, lower blood pressure, and worsen dehydration. Alcohol can also impair the client's judgment and coordination.
e) The client's seafood intake: The client ate seafood at a restaurant, which may have triggered an allergic reaction or food poisoning. Seafood allergies can cause symptoms such as hives, swelling, breathing difficulties, and anaphylaxis. Food poisoning can cause symptoms such as nausea, vomiting, diarrhea, and dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Rocky Mountain spotted fever is not the most likely condition for the client who has a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. Rocky Mountain spotted fever is a bacterial infection transmitted by ticks that causes a distinctive rash that usually begins on the wrists and ankles and spreads to the rest of the body. The rash is not limited to the arms and legs, and the client may also have other symptoms such as nausea, vomiting, abdominal pain, and muscle aches.
Choice B reason: Intracerebral hemorrhage is not the most likely condition for the client who has a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. Intracerebral hemorrhage is a type of stroke that occurs when a blood vessel bursts inside the brain, causing bleeding and swelling. The rash is not a typical sign of intracerebral hemorrhage, and the client may also have other symptoms such as weakness, numbness, vision loss, confusion, and loss of consciousness.
Choice C reason: Cerebrovascular accident (CVA) is not the most likely condition for the client who has a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. CVA is another term for stroke, which occurs when the blood supply to a part of the brain is interrupted, causing brain tissue damage. The rash is not a common sign of CVA, and the client may also have other symptoms such as facial drooping, slurred speech, difficulty swallowing, paralysis, and cognitive impairment.
Choice D reason: Meningococcal meningitis is the most likely condition for the client who has a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. Meningococcal meningitis is a bacterial infection that causes inflammation of the membranes that cover the brain and spinal cord. The rash is a characteristic sign of meningococcal meningitis, which can appear as small red or purple spots that do not fade when pressed. The client may also have other symptoms such as nausea, vomiting, sensitivity to light, confusion, and seizures.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because the humoral immune response involves B cells that produce antibodies against specific antigens. However, AIDS affects the cellular immune response, which involves T cells that activate other immune cells and directly kill infected cells.
Choice B reason: This is correct because AIDS is caused by human immunodeficiency virus (HIV), which infects and destroys CD4+ T cells, also known as helper T cells. These cells are essential for initiating and regulating both humoral and cellular immunity. Without enough CD4+ T cells, the body cannot mount an effective response against pathogens, especially opportunistic infections that take advantage of a weakened immune system.
Choice C reason: This is incorrect because bone marrow suppression of white blood cells is not a direct consequence of AIDS. However, some drugs used to treat AIDS, such as zidovudine, may cause bone marrow suppression as a side effect.
Choice D reason: This is incorrect because exposure to multiple environmental infectious agents does not cause AIDS. However, people with AIDS are more susceptible to infections from various sources due to their impaired immune system.
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