A nurse in a hospital setting is developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?

Impaired skin integrity related to persistent deep skin abscesses

Grieving related to the poor prognosis of the condition

Risk for infection related to altered immune cell function

Anxiety related to an inherited disorder

Answer and Explanation

The Correct Answer is C

A. Impaired skin integrity related to persistent deep skin abscesses: While this is an important concern, the priority for a client with a primary immunodeficiency is to prevent and manage infections, as these are more likely to occur due to the compromised immune system.

B. Grieving related to the poor prognosis of the condition: Grieving is a valid concern, especially in a chronic or life-limiting condition, but the priority is to address the client's immediate physical health needs, such as infection prevention and management.

C. Risk for infection related to altered immune cell function: This is the priority nursing diagnosis for a client with a primary immunodeficiency. The altered immune system significantly increases the client's risk for infections, so preventing and managing infections becomes the primary focus of care.

D. Anxiety related to an inherited disorder: The immediate concern for a client with a primary immunodeficiency is the prevention and management of infections. Anxiety can be addressed as part of emotional and psychological support once the physical health needs are stabilized.

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Correct Answer is A

Explanation

A. "Your body may not have developed antibodies yet, so we need to follow up.": It can take several weeks to months for the body to produce detectable antibodies after HIV exposure. Follow-up testing is essential to ensure the person remains HIV-negative or to detect early infection.

B. "You're one of the lucky ones who are immune to the virus.": There is no immunity to HIV, and this could provide false reassurance to the client. A negative result simply means no infection has been detected at the time of testing.

C. "Congratulations, a negative result means that you're not infected with the virus.": This explanation is premature as a negative test result is not definitive in the early stages of exposure, as it may take time for antibodies to develop. Follow-up testing is necessary to confirm the status.

D. "You might still go on to develop AIDS even with negative results.": AIDS develops only after a person has been infected with HIV. A negative result indicates that the person is not currently infected, but they may need further testing to rule out early infection.

A. The client with painful lymph nodes under the arm. B. The client with enlarged lymph nodes in the neck. C. The client with a painful sore throat. D. The client with painful lymph nodes in the groin.

Correct Answer is B

Explanation

A. The client with painful lymph nodes under the arm: Painful lymph nodes are more likely associated with infections or other benign causes rather than Hodgkin lymphoma. In Hodgkin lymphoma, lymph nodes are typically painless.

B. The client with enlarged lymph nodes in the neck: This is the most likely presentation of Hodgkin lymphoma. It often presents with painless, swollen lymph nodes, particularly in the neck, and can be associated with other systemic symptoms such as fever, night sweats, and weight loss.

C. The client with a painful sore throat: A sore throat is more commonly associated with infections like viral or bacterial throat infections (e.g., streptococcal pharyngitis) and is not a typical symptom of Hodgkin lymphoma.

D. The client with painful lymph nodes in the groin: While Hodgkin lymphoma can cause lymph node enlargement, pain in lymph nodes is commonly related infections. Hodgkins presents with painless lymphadenopathy, particularly in the neck, chest, or armpits.

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A nurse in a hospital setting is developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in a community health setting who has been exposed to the human immunodeficiency virus (HIV), tests negative. Which explanation by the nurse would be most appropriate?

Correct Answer is A

Explanation

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma?

Correct Answer is B

Explanation

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