The nurse is caring for a client with immunodeficiency disorder. Which nursing intervention should be included in the care plan?
Encourage the client to engage in vigorous physical activities to strengthen the immune system.
Limit the client's exposure to visitors and restrict contact with other clients in the healthcare setting.
Administer live vaccines to boost the client's immune response.
Encourage the client to eat a diet high in fresh fruits and vegetables to improve immune function.
The Correct Answer is B
Explanation: The correct answer is b. Limit the client's exposure to visitors and restrict contact with other clients in the healthcare setting. Clients with immunodeficiency disorders are at a higher risk of infections due to their weakened immune system. Restricting exposure to potential sources of infection, such as visitors and other sick clients, can help minimize the risk of acquiring infections.
Incorrect choices:
a. Engaging in vigorous physical activities may not be appropriate for clients with immunodeficiency disorders, as it can lead to an increased risk of infections and may not strengthen the immune system in these individuals.
c. Live vaccines are contraindicated for clients with immunodeficiency disorders, as they can cause severe infections in this population. Only inactivated vaccines are recommended to avoid the risk of vaccine-associated infections.
d. While a healthy diet is essential for overall well-being, there is no specific evidence to suggest that a diet high in fresh fruits and vegetables will improve immune function in clients with immunodeficiency disorders. Dietary considerations for these clients may include avoiding certain high-risk foods, but it should be discussed with the healthcare provider based on the specific immunodeficiency disorder.
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 essential for monitoring the client's immune status and treatment response. It provides information about the client's white blood cell count, including different types of white blood cells, such as lymphocytes, which play a crucial role in the immune response.
Incorrect choices:
b. Blood glucose level is not specifically related to monitoring the immune status or treatment response in clients with immunodeficiency disorders.
c. Liver function tests (LFTs) are important for monitoring liver health but are not directly related to the immune status or treatment response in clients with immunodeficiency disorders.
d. An electrolyte panel is used to assess the balance of electrolytes in the body and is not specifically related to monitoring the immune status or treatment response in clients with immunodeficiency disorders.
Correct Answer is C
Explanation
The correct answer is c. Ataxia-telangiectasia. Ataxia-telangiectasia is a rare genetic disorder that affects the cerebellum, causing poor muscle coordination (ataxia) and small, dilated blood vessels (telangiectasias). It also leads to defective T-cell function, making affected individuals more susceptible to infections.
Incorrect choices:
a. X-linked agammaglobulinemia (XLA) is a primary immunodeficiency disorder that primarily affects B-cell function, leading to a lack of mature B cells and low levels of immunoglobulins, but does not involve defective T-cell function.
b. Selective immunoglobulin A (IgA) deficiency is characterized by a deficiency of IgA, but it does not typically lead to defective T-cell function.
d. DiGeorge syndrome is caused by a deletion on chromosome 22 and primarily affects the development of certain organs, including the thymus and parathyroid glands, resulting in T-cell deficiency. While it may lead to some B-cell abnormalities, defective T-cell function is the hallmark of this disorder.
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