This is the edited text:
Which client is at highest risk of compromised immunity?
A client who has just had surgery
A client with extreme anxiety
A client who is awaiting surgery
A client who just delivered a baby
The Correct Answer is A
Choice A reason: This is the highest risk client because surgery can cause trauma, blood loss, and infection, which can weaken the immune system and increase the susceptibility to complications. The immune system is the body's defense mechanism that protects against foreign invaders, such as bacteria, viruses, or fungi. Surgery can damage the skin and tissues, which are the first line of defense, and cause inflammation, which can impair the function of the white blood cells, which are the second line of defense. The nurse should monitor the client's vital signs, wound healing, and signs of infection and administer antibiotics, fluids, and pain medication as ordered.
Choice B reason: This is not the highest risk client, but it is a moderate risk client because extreme anxiety can cause stress, which can affect the immune system and increase the vulnerability to illness. Stress is the body's response to a perceived threat or challenge, which can activate the sympathetic nervous system and the hypothalamicpituitaryadrenal (HPA) axis. Stress can cause the release of hormones, such as cortisol and adrenaline, which can suppress the immune system and reduce the production and activity of the white blood cells. The nurse should assess the client's anxiety level and provide coping strategies, such as relaxation, breathing, or counseling.
Choice C reason: This is not the highest risk client, but it is a low risk client because awaiting surgery can cause anxiety, which can affect the immune system and increase the vulnerability to illness. However, the client's anxiety level may not be as high as the client with extreme anxiety, and the client's immune system may not be as compromised as the client who has just had surgery. The nurse should assess the client's anxiety level and provide education, reassurance, and support.
Choice D reason: This is not the highest risk client, but it is a low risk client because delivering a baby can cause blood loss, hormonal changes, and fatigue, which can affect the immune system and increase the risk of infection. However, the client's immune system may not be as compromised as the client who has just had surgery, and the client may have some protection from the antibodies that are passed from the mother to the baby through the placenta and breast milk. The nurse should monitor the client's vital signs, lochia, and signs of infection and provide hygiene, nutrition, and rest.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A reason: The main side effect of acetaminophen is gastrointestinal (GI) bleeding is not a teaching that the nurse should include in the education, because it is incorrect and misleading. Acetaminophen is a pain reliever and fever reducer that is commonly used for osteoarthritis, but it does not have antiinflammatory properties. Acetaminophen does not cause GI bleeding, unlike NSAIDs, which can irritate the stomach lining and increase the risk of ulcers and bleeding. The main side effect of acetaminophen is liver damage, which can occur if the dose is exceeded or if the drug is combined with alcohol or other hepatotoxic substances.
Choice B reason: You should not take more than 4000 mg of acetaminophen a day is a teaching that the nurse should include in the education, because it is correct and important. Acetaminophen has a maximum daily dose of 4000 mg for adults, which should not be exceeded to avoid the risk of liver damage or overdose. Acetaminophen can be found in many overthecounter and prescription products, such as cold and flu remedies, cough syrups, or combination analgesics. Therefore, the client should read the labels carefully and keep track of the total amount of acetaminophen they are taking from all sources.
Choice C reason: Nonsteroidal antiinflammatory drugs (NSAIDs) are very safe and have no side effects is not a teaching that the nurse should include in the education, because it is incorrect and misleading. NSAIDs are a group of drugs that have antiinflammatory, analgesic, and antipyretic effects, and that are commonly used for osteoarthritis. However, NSAIDs are not very safe and have many side effects, such as GI bleeding, ulcers, kidney damage, cardiovascular events, allergic reactions, or interactions with other drugs. Therefore, the client should use NSAIDs with caution and under the supervision of the provider.
Choice D reason: The most common adverse effect of nonsteroidal antiinflammatory drugs (NSAIDs) are liver failure and tinnitus is not a teaching that the nurse should include in the education, because it is incorrect and misleading. Liver failure and tinnitus are not the most common adverse effects of NSAIDs, but rather rare and serious ones. Liver failure can occur in some cases of NSAID overdose or hypersensitivity, while tinnitus can occur in some cases of NSAID toxicity or high doses. The most common adverse effects of NSAIDs are GI bleeding, ulcers, or irritation, which can affect up to 15% of the users.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Ischemia is a cause of a pressure ulcer, because it means reduced blood flow to the tissues, which can lead to tissue hypoxia, necrosis, and ulceration. Ischemia can result from factors such as compression, friction, shear, or vascular disease.
Choice B reason: Immobility is a cause of a pressure ulcer, because it means prolonged pressure on the bony prominences, which can impair blood flow and cause ischemia, tissue damage, and ulceration. Immobility can result from factors such as paralysis, injury, illness, or sedation.
Choice C reason: Poor nutrition is a cause of a pressure ulcer, because it means inadequate intake or absorption of nutrients, such as protein, calories, vitamins, and minerals, which are essential for tissue repair and wound healing. Poor nutrition can result from factors such as anorexia, malabsorption, or poverty.
Choice D reason: Moisture is a cause of a pressure ulcer, because it means excessive wetness or dampness of the skin, which can weaken the skin barrier, increase the risk of infection, and delay wound healing. Moisture can result from factors such as incontinence, perspiration, or wound drainage.
Choice E reason: Adequate perfusion is not a cause of a pressure ulcer, but rather a protective factor. Adequate perfusion means sufficient blood flow to the tissues, which can prevent ischemia, tissue damage, and ulceration. Adequate perfusion can be promoted by factors such as regular repositioning, pressure relief, and exercise.
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