A client has acquired immunodeficiency syndrome (AIDS). Which of these assessment findings indicate possible infection? (Select all that apply.)
Temperature: 101.3 degrees Fahrenheit
Oxygen saturation: 97% on room air
Respirations: 22 breaths per minute
Purulent drainage
Client ambulates 20 feet
Correct Answer : A,D
Choice A reason: A temperature of 101.3 degrees Fahrenheit is a sign of fever, which is a common symptom of infection. Clients with AIDS have a weakened immune system and are more susceptible to opportunistic infections. Fever indicates that the body is trying to fight off an infection.
Choice B reason: An oxygen saturation of 97% on room air is within the normal range and does not indicate infection. Oxygen saturation measures the percentage of hemoglobin that is bound to oxygen in the blood. A low oxygen saturation may indicate respiratory problems, such as pneumonia, which is a common infection in clients with AIDS.
Choice C reason: A respiratory rate of 22 breaths per minute is slightly above the normal range of 12 to 20 breaths per minute, but it does not necessarily indicate infection. Respiratory rate may vary depending on factors such as activity level, stress, pain, or anxiety. A high respiratory rate may indicate respiratory distress, which could be caused by infection or other conditions.
Choice D reason: Purulent drainage is a thick, yellowgreen, or brown pus that indicates infection. It may come from a wound, an abscess, or a body cavity. Purulent drainage is a sign of inflammation and infection and should be reported to the health care provider.
Choice E reason: A client's ability to ambulate 20 feet is not related to infection. Ambulation is a measure of mobility and function and may be affected by factors such as pain, fatigue, or muscle weakness. Ambulation does not reflect the presence or absence of infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Washing your hands thoroughly is an important measure to reduce the risk of infection. Hand washing is one of the most effective ways to prevent the transmission of germs that can cause diseases. Hand washing can remove dirt, bacteria, viruses, and other contaminants from the skin and prevent them from entering the body or spreading to others. The nurse should teach the client with AIDS to wash their hands frequently and properly, especially before and after eating, using the bathroom, touching their face, or handling any objects that may be contaminated.
Choice B reason: Avoiding cleaning your toothbrush with bleach is not a measure to reduce the risk of infection. Cleaning your toothbrush with bleach is not a recommended practice, as bleach is a harsh chemical that can damage the toothbrush and irritate the mouth. However, cleaning your toothbrush with bleach does not increase the risk of infection, as bleach can kill most germs that may be present on the toothbrush. The nurse should teach the client with AIDS to rinse their toothbrush with water after each use and replace it every 3 to 4 months or sooner if the bristles are worn or frayed.
Choice C reason: Avoiding raw fruits and vegetables is a measure to reduce the risk of infection. Raw fruits and vegetables may be contaminated with bacteria, parasites, or pesticides that can cause foodborne illnesses. The client with AIDS has a weakened immune system that cannot fight off these infections effectively and may develop serious complications, such as diarrhea, dehydration, or malnutrition. The nurse should teach the client with AIDS to wash, peel, or cook their fruits and vegetables before eating them and to avoid any that are bruised, moldy, or spoiled.
Choice D reason: Avoiding crowds is a measure to reduce the risk of infection. Crowds are places where many people gather and interact, such as public transportation, shopping malls, schools, or workplaces. Crowds increase the exposure to germs that can cause respiratory, gastrointestinal, or skin infections. The client with AIDS has a lowered resistance to these infections and may contract them more easily and severely. The nurse should teach the client with AIDS to avoid crowds as much as possible and to wear a mask, practice social distancing, and use hand sanitizer if they have to be in a crowded place.
Choice E reason: Not sharing toothpaste with family members is a measure to reduce the risk of infection. Sharing toothpaste with family members can transfer saliva, blood, or other body fluids that may contain germs that can cause oral, dental, or systemic infections. The client with AIDS is more susceptible to these infections and may also transmit the HIV virus to their family members through their body fluids. The nurse should teach the client with AIDS to use their own toothpaste and toothbrush and to store them separately from their family members' ones.
Correct Answer is B
Explanation
Choice A reason: Nociceptive pain is not the type of pain that the client is experiencing. Nociceptive pain is caused by the stimulation of nociceptors, which are sensory receptors that detect tissue damage or potential harm. Nociceptive pain is usually localized, sharp, throbbing, or aching. It is associated with injuries such as cuts, burns, sprains, or fractures. The client's pain is not caused by any tissue damage or harm in the distal part of the amputated limb, as there is no tissue left there.
Choice B reason: Neuropathic pain is the type of pain that the client is experiencing. Neuropathic pain is caused by the damage or dysfunction of the nervous system, such as the peripheral nerves, the spinal cord, or the brain. Neuropathic pain is usually chronic, burning, shooting, or tingling. It is associated with conditions such as diabetes, shingles, stroke, or amputation. The client's pain is caused by the disruption of the nerve signals from the amputated limb, which creates a phantom sensation of pain in the missing part.
Choice C reason: Cutaneous pain is not the type of pain that the client is experiencing. Cutaneous pain is caused by the stimulation of the cutaneous receptors, which are sensory receptors that detect touch, temperature, or pressure on the skin. Cutaneous pain is usually superficial, brief, or pricking. It is associated with stimuli such as pinching, scratching, or cold. The client's pain is not caused by any touch, temperature, or pressure on the skin of the distal part of the amputated limb, as there is no skin left there.
Choice D reason: Visceral pain is not the type of pain that the client is experiencing. Visceral pain is caused by the stimulation of the visceral receptors, which are sensory receptors that detect stretch, inflammation, or ischemia in the internal organs. Visceral pain is usually deep, dull, or cramping. It is associated with conditions such as appendicitis, pancreatitis, or bowel obstruction. The client's pain is not caused by any stretch, inflammation, or ischemia in the internal organs of the distal part of the amputated limb, as there are no organs left there.
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