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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: Color is an important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the color of the skin, nails, and mucous membranes of the affected and unaffected extremities and look for any signs of pallor, cyanosis, or mottling. These signs can indicate ischemia, hypoxia, or impaired circulation, which can lead to tissue damage or necrosis.
Choice B reason: Temperature is another important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the temperature of the skin of the affected and unaffected extremities by palpating with the back of the hand and look for any signs of warmth or coolness. These signs can indicate inflammation, infection, or reduced perfusion, which can affect the healing process or cause complications.
Choice C reason: Ecchymosis is not an indicator of the neurovascular status of the affected extremity. Ecchymosis is the discoloration of the skin caused by bleeding under the skin, which can result from trauma, surgery, or anticoagulant therapy. Ecchymosis is expected after an ORIF of a femur fracture and does not necessarily indicate a problem with the blood flow or oxygenation to the extremity.
Choice D reason: Skin integrity is not an indicator of the neurovascular status of the affected extremity. Skin integrity is the condition of the skin and its ability to resist damage, infection, or breakdown. Skin integrity can be affected by factors such as pressure, friction, moisture, or foreign bodies. The nurse should assess the skin integrity of the affected extremity and look for any signs of wounds, ulcers, or infections, but these signs do not reflect the neurovascular status of the extremity.
Choice E reason: Sensation is an important indicator of the nerve function and innervation of the affected extremity. The nurse should assess the sensation of the affected extremity by asking the client to report any numbness, tingling, or pain, or by testing the client's response to light touch, pressure, or temperature. These signs can indicate nerve damage, compression, or irritation, which can affect the mobility and function of the extremity.
Correct Answer is B
Explanation
Choice A reason: A susceptible host is not an infectious disease, but a factor that influences the transmission of an infectious disease. A susceptible host is a person who is vulnerable to infection due to factors such as age, health status, immunization, or genetic predisposition. A susceptible host may become infected by a communicable disease, but it is not the disease itself.
Choice B reason: A communicable disease is an infectious disease that can be transmitted directly from one person to another. A communicable disease is caused by a pathogen, such as a virus, bacterium, fungus, or parasite, that can spread through contact, droplet, airborne, vector, or vehicle transmission. Examples of communicable diseases are influenza, tuberculosis, measles, malaria, and HIV/AIDS.
Choice C reason: A portal of entry to a host is not an infectious disease, but a factor that influences the transmission of an infectious disease. A portal of entry to a host is a route through which a pathogen can enter the body of a susceptible host and cause infection. A portal of entry to a host may be a break in the skin, a mucous membrane, or a body opening, such as the mouth, nose, eyes, or genitals. A portal of entry to a host may facilitate the transmission of a communicable disease, but it is not the disease itself.
Choice D reason: A portal of exit from the reservoir is not an infectious disease, but a factor that influences the transmission of an infectious disease. A portal of exit from the reservoir is a route through which a pathogen can leave the body of an infected person or animal and reach another susceptible host. A portal of exit from the reservoir may be a body fluid, such as blood, saliva, urine, or feces, or a body part, such as the skin, hair, or nails. A portal of exit from the reservoir may enable the transmission of a communicable disease, but it is not the disease itself.
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