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 D
Explanation
Explanation: The correct answer is d. Educating the client on proper hand hygiene. Educating the client on proper hand hygiene is essential to reduce the risk of infections in individuals with immunodeficiency disorders. Frequent handwashing is a simple yet effective way to prevent the transmission of infectious agents.
Incorrect choices:
a. Administering live vaccines is contraindicated for clients with immunodeficiency disorders, as live vaccines contain weakened pathogens that can cause serious infections in this population.
b. Encouraging the client to perform strenuous physical activities is not appropriate for someone with immunodeficiency, as strenuous activities can put additional strain on the immune system and increase the risk of infections.
c. Limiting the client's intake of fluids is not a necessary intervention for immunodeficiency disorders. Adequate fluid intake is generally important for overall health, but it is not directly related to managing immunodeficiency disorders.
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