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A nurse in a health clinic is caring for a client.

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing

due to.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for Correct Answers:

  • Infection: HIV targets and depletes CD4+ T cells, impairing immune function. A consistently low WBC count (below the normal range) indicates reduced immune defense, increasing susceptibility to infections.
  • WBC count: The client’s WBC count decreased from 4,500 to 4,100/mm³, both below the normal lower limit. This progressive leukopenia in the context of HIV suggests worsening immunosuppression, which elevates the risk of opportunistic infections.

Rationale for Incorrect Choices:

  • Dysrhythmias: The client’s potassium level is 3.8 mEq/L, within the normal range. Since potassium directly affects cardiac conduction, a normal level does not indicate an increased risk of dysrhythmia.
  • Renal failure: The client’s BUN increased slightly from 16 to 18 mg/dL but remains within the normal range. There are no other signs of renal impairment such as elevated creatinine or abnormal electrolyte levels.
  • Seizures: Sodium is stable at 139 mEq/L, which is within the normal range. Electrolyte imbalance, particularly hyponatremia, is a common trigger for seizures, which is not evident here.
  • Bleeding: The platelet count is slightly decreased but still within the normal range (162,000/mm³). There is no evidence of thrombocytopenia or coagulopathy that would suggest a bleeding risk.


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale for Correct Answers

  • Instruct the client to rise slowly from a sitting position: The client demonstrates orthostatic hypotension (drop in BP with position change). This compensatory instruction reduces fall risk and supports safety while underlying causes are addressed.
  • Evaluate a stool sample for occult blood: The client has signs of iron deficiency anemia (low Hgb, Hct, ferritin), which could result from chronic blood loss, particularly GI bleeding due to long-term NSAID use (naproxen). Occult blood testing identifies hidden bleeding that may be causing anemia.

Rationale for Incorrect Choices

  • Draw a blood sample for arterial blood gases: ABGs are not indicated as the client has no signs of acute respiratory compromise. Oxygen saturation is within normal range, and breath sounds are clear. This test would not yield priority information at this time.
  • Perform a 12-lead ECG: The client has no cardiac-specific symptoms like chest pain or irregular rhythm. A 12-lead ECG is not the immediate priority compared to ruling out chronic blood loss contributing to anemia.
  • Administer an inhaled bronchodilator: The client is not wheezing or showing signs of bronchospasm. Breath sounds are clear, and oxygen saturation is acceptable. A bronchodilator is not relevant to the client’s presenting symptoms or anemia diagnosis.

Correct Answer is ["B","C","G"]

Explanation

A. Temperature: A temperature of 37°C (98.6°F) is within the normal range and does not require follow-up. There are no signs of infection or systemic inflammation.
B. Blood pressure: The client has orthostatic hypotension, shown by a drop from 132/60 mm Hg supine to 102/50 mm Hg standing. This can lead to dizziness or falls and indicates possible anemia-related hypoperfusion.
C. Activity level: The client reports increased fatigue and dyspnea with mild exertion, which is abnormal and consistent with symptomatic anemia. This decline in functional ability warrants further evaluation.
D. Oxygen saturation: An oxygen saturation of 94% on room air is adequate and not critically low. It does not independently indicate a respiratory issue requiring follow-up.
E. Breath sounds: Bilateral breath sounds are clear and present, indicating no airway obstruction or fluid accumulation. Respiratory status appears stable on auscultation.
F. Pain level: The client denies any pain or discomfort, including chest, joint, or abdominal pain. Pain is not a current concern needing follow-up.
G. Hematocrit: A hematocrit of 24% is significantly below normal, indicating moderate to severe anemia. This requires follow-up to determine the cause and initiate appropriate treatment.

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