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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Correct Answer is C
Explanation
Choice A reason: Calling the provider is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Calling the provider is a communication intervention, not a respiratory intervention. Calling the provider is an important action, but it should be done after raising the head of the bed, and with accurate and complete information.
Choice B reason: Placing the client in the lithotomy position is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Placing the client in the lithotomy position is a positioning intervention, not a respiratory intervention. Placing the client in the lithotomy position is a specific action that is used for pelvic examinations or procedures, not for improving oxygenation.
Choice C reason: Raising the head of the bed is the intervention that the nurse should perform first, because it is the most urgent and relevant action. Raising the head of the bed is a respiratory intervention, not a communication, positioning, or analgesic intervention. Raising the head of the bed is a simple and effective action that can improve the client's breathing, oxygenation, and comfort.
Choice D reason: Obtaining pain medication is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Obtaining pain medication is an analgesic intervention, not a respiratory intervention. Obtaining pain medication is an important action, but it should be done after raising the head of the bed, and with a medical order and a proper route.
Correct Answer is C
Explanation
Choice A reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system. CD4+ Tcells and CD8+ Tcells are types of white blood cells that play a key role in the immune response. CD4+ Tcells are helper cells that activate and coordinate other immune cells, while CD8+ Tcells are cytotoxic cells that kill infected or abnormal cells. Human immunodeficiency virus infects and destroys CD4+ Tcells, which impairs the immune function and increases the risk of opportunistic infections and cancers. CD8+ Tcells are not directly affected by the virus, but they may increase in number as a compensatory mechanism to fight the infection. Therefore, most adults with human immunodeficiency virus will have lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells.
Choice B reason: Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal may indicate a condition that affects both types of Tcells, such as aplastic anemia, chemotherapy, radiation therapy, or immunosuppressive drugs.
Choice C reason: Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells is a laboratory value that most adults with human immunodeficiency virus will exhibit, because it reflects the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells may indicate the progression of the infection and the severity of the immunodeficiency. The normal range of CD4+ Tcells is 500 to 1500 cells per microliter of blood, while the normal range of CD8+ Tcells is 150 to 1000 cells per microliter of blood.
Choice D reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low may indicate a condition that affects CD8+ Tcells, such as leukemia, lymphoma, or corticosteroid therapy.
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