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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 ["C","D","E","G"]

Explanation

A. Blood glucose level: The blood glucose level is within normal limits (103 mg/dL), so it does not require immediate intervention. However, it should be monitored routinely in clients with diabetes to avoid hypoglycemia or hyperglycemia during acute illness.
B. Bowel sounds: Presence of bowel sounds in all four quadrants is normal and not an urgent concern related to the cardiac event. It is unrelated to the client’s acute presentation of chest pain and cardiac ischemia.
C. Blood pressure: The client’s blood pressure is elevated at 164/80 mm Hg, which increases myocardial workload and oxygen demand. Immediate follow-up is necessary to manage hypertension and reduce the risk of further cardiac ischemia or complications.
D. Pain level: Chest pain rated 7/10 with radiation to the left arm is a classic symptom of acute coronary syndrome. The severity and character of pain require urgent assessment to prevent myocardial damage and guide immediate interventions.
E. Electrocardiogram findings: The ECG shows tachycardia with ST segment elevation and T wave changes, indicative of acute myocardial infarction. This is a critical finding that necessitates rapid medical intervention to restore coronary perfusion and minimize cardiac injury.
F. Lung sounds: Lung sounds are clear, indicating no immediate respiratory compromise or pulmonary edema. This finding does not require urgent follow-up in the context of this client’s presentation.
G. Troponin T level: Elevated troponin T (0.40 ng/mL, normal <0.1) is a highly sensitive and specific marker of myocardial injury. Immediate follow-up is required for diagnosis confirmation, risk stratification, and initiation of treatment for acute coronary syndrome.

Correct Answer is A

Explanation

A. "Place the mouthpiece in your mouth and inhale slowly.": This is the correct technique for using an incentive spirometer. Slow, deep inhalation through the mouthpiece promotes lung expansion and helps prevent atelectasis, especially after surgery or prolonged immobility.
B. "Remove the mouthpiece and exhale quickly.": Exhaling quickly is not part of incentive spirometry use and can negate the benefits of the deep inhalation. The focus should be on slow inhalation to expand the lungs gradually and effectively.
C. "Use the incentive spirometer every 4 hours.": While some protocols may vary, clients are typically instructed to use the incentive spirometer more frequently—often 10 times every hour while awake—to promote optimal lung function and prevent complications like pneumonia.
D. "Avoid coughing during and after the session.": Coughing is encouraged after using the spirometer to help clear secretions that may have mobilized during deep breathing. Suppressing the cough would interfere with respiratory hygiene and lung recovery.

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