A client with acquired immunodeficiency syndrome (AIDS) has Pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?
Capillary refill
Radial pulses
Lung sounds
Skin turgor
The Correct Answer is C
Choice A reason: Capillary refill is not the nurse's priority assessment for this client, because it is not the most relevant and sensitive indicator of the client's condition. Capillary refill is a test that measures the time it takes for the color to return to the nail bed after applying pressure, which reflects the peripheral circulation and tissue perfusion. Capillary refill can be affected by factors such as temperature, hydration, or vasoconstriction. Capillary refill is not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Choice B reason: Radial pulses are not the nurse's priority assessment for this client, because they are not the most relevant and sensitive indicator of the client's condition. Radial pulses are the beats that can be felt at the wrist, which reflect the heart rate and rhythm. Radial pulses can be affected by factors such as activity, emotion, or medication. Radial pulses are not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Choice C reason: Lung sounds are the nurse's priority assessment for this client, because they are the most relevant and sensitive indicator of the client's condition. Lung sounds are the noises that can be heard with a stethoscope over the chest, which reflect the air movement and ventilation in the lungs and airways. Lung sounds can reveal the presence of abnormalities, such as crackles, wheezes, or diminished breath sounds, which indicate fluid, inflammation, or obstruction in the lungs or airways. Lung sounds are a specific and reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Choice D reason: Skin turgor is not the nurse's priority assessment for this client, because it is not the most relevant and sensitive indicator of the client's condition. Skin turgor is a test that measures the elasticity of the skin, which reflects the hydration and fluid status of the body. Skin turgor can be affected by factors such as age, weight loss, or edema. Skin turgor is not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "Tell me about what medications you are taking." is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Medications are part of the physical or pharmacological assessment, which focuses on the type, dose, frequency, and effectiveness of the drugs that the client is taking for rheumatoid arthritis. Medications may have some psychosocial implications, such as side effects, costs, or adherence, but they are not the main focus of the psychosocial assessment.
Choice B reason: "What physical limitations are you experiencing?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Physical limitations are part of the functional or mobility assessment, which focuses on the range of motion, strength, endurance, and coordination of the joints and muscles that are affected by rheumatoid arthritis. Physical limitations may have some psychosocial implications, such as pain, disability, or dependence, but they are not the main focus of the psychosocial assessment.
Choice C reason: "How does this impact your role in your family?" is the most appropriate statement by the nurse, because it is related to the psychosocial assessment. Role in the family is part of the social or relational assessment, which focuses on the interactions, responsibilities, and expectations of the client and their family members in relation to rheumatoid arthritis. Role in the family may have significant psychosocial implications, such as role changes, role conflicts, role strain, or role loss, which can affect the client's selfesteem, identity, and coping.
Choice D reason: "What therapies are you using to reduce swelling?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Therapies are part of the physical or nonpharmacological assessment, which focuses on the modalities, techniques, or devices that the client is using to manage the symptoms of rheumatoid arthritis. Therapies may have some psychosocial implications, such as availability, accessibility, or preference, but they are not the main focus of the psychosocial assessment.
Correct Answer is C
Explanation
Choice A reason: An event that can cause serious injury to a client that should never happen in a hospital is not the best description of a sentinel event, because it is too vague and broad. It does not specify the degree of injury or the nature of the event. It also implies that some events that cause serious injury are acceptable in a hospital, which is not true.
Choice B reason: Specific events that enable a hospital to maximize reimbursement is not a description of a sentinel event, but rather a description of quality indicators or performance measures. These are criteria that reflect the quality of care provided by a hospital and affect its payment from payers. They are not related to sentinel events, which are adverse events that require immediate investigation and response.
Choice C reason: An unexpected event involving death or serious physical or psychological injury is the best description of a sentinel event, because it captures the essence and severity of the event. According to the Joint Commission, a sentinel event is "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" . Examples of sentinel events include wrongsite surgery, medication error, suicide, or abduction.
Choice D reason: Operating room event involving the use of unsafe equipment is not a description of a sentinel event, but rather an example of a potential sentinel event. It is not a general definition that applies to all sentinel events, but a specific scenario that may or may not result in death or serious injury. It also does not indicate the unexpectedness of the event, which is a key characteristic of a sentinel event.
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