The nurse is caring for a client with an immunodeficiency disorder. Which clinical manifestation should the nurse expect to assess in the client?
Hyperactivity and restlessness
Persistent fever and night sweats
Weight gain and increased appetite
Elevated blood pressure
The Correct Answer is B
Explanation: The correct answer is b. Persistent fever and night sweats. Fever and night sweats are common clinical manifestations of immunodeficiency disorders. The immune system's inability to fight off infections can lead to recurrent fevers and night sweats as the body tries to combat pathogens.
Incorrect choices:
a. Hyperactivity and restlessness are not typical clinical manifestations of immunodeficiency disorders. These symptoms are more commonly associated with conditions affecting the central nervous system.
c. Weight gain and increased appetite are not typical clinical manifestations of immunodeficiency disorders. They may be seen in conditions like hypothyroidism or hormonal imbalances.
d. Elevated blood pressure is not a common clinical manifestation of immunodeficiency disorders. It may be seen in conditions like hypertension or cardiovascular disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation: The correct answer is a. Complete blood count (CBC) with differential. A CBC with differential is a standard diagnostic test used to assess the levels of different blood cells, including white blood cells, which are crucial for the immune system. Abnormalities in the white blood cell count and differential can indicate potential immunodeficiency.
Incorrect choices:
b. A chest X-ray is not a specific diagnostic test for immunodeficiency disorders. It is typically used to assess the condition of the lungs and chest organs.
c. An electrocardiogram (ECG) is a test used to assess the electrical activity of the heart and is not related to the diagnosis of immunodeficiency disorders.
d. A urinalysis is a test used to assess the urine for various abnormalities and is not specific to diagnosing immunodeficiency disorders.
Correct Answer is C
Explanation
Explanation: The correct answer is c. Limit visitors to family members only. Clients with immunodeficiency disorders are at increased risk of infections, and limiting visitors to family members only can help reduce the risk of exposure to infectious agents. It is essential to create a controlled and safe environment for these clients.
Incorrect choices:
a. Encouraging the client to interact with other clients in the unit can increase the risk of exposure to infections and is not appropriate for someone with immunodeficiency.
b. Live vaccines contain weakened pathogens and are contraindicated for clients with immunodeficiency disorders, as they can cause serious infections in this population.
d. Providing the client with a private room with negative pressure is not necessary for every client with immunodeficiency disorder. Negative pressure rooms are used for clients with specific airborne infectious diseases, and the decision to use such rooms is based on the specific circumstances of each client.
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