A nurse is caring for a 45-year-old male client on a medical-surgical unit.

Select 1 condition and 1 client finding to fill in each blank in the following sentence: The client is at highest risk for developing
__
due to their
_
.

Answer and Explanation

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

The client is at highest risk for developing Pneumocystis pneumonia due to their CD4 T-cell count.

Pneumocystis pneumonia (PCP) is an opportunistic infection commonly seen in clients with AIDS, especially when the CD4 T-cell count drops below 200/mm³.
This client’s CD4 count is around 198–200/mm³, placing them at high risk for PCP.
Respiratory findings and oxygen saturation may help identify existing pneumonia but do not explain the risk as directly as CD4 count.
Diarrhea and potassium level relate more to hydration and electrolyte balance, not directly to the risk of PCP.
Impaired gas exchange or cardiac dysrhythmias are possible complications but secondary to infection risk from low immunity.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale

Assessing for increased calcium levels is not directly related to malnutrition in cancer patients. Malnutrition in cancer often involves deficits in various nutrients, and while electrolyte imbalances can occur, increased calcium is not a primary or universal indicator of malnutrition itself. It might be related to cancer processes like bone metastasis, but not the malnutrition specifically.

Choice B rationale

Encouraging mouth care before and after meals is crucial because it promotes oral hygiene and can improve the client's appetite and taste perception. Malnutrition often leads to oral discomfort, stomatitis, or altered taste, making food unappealing. Proper mouth care can alleviate these issues, thereby enhancing the client's willingness to eat and improving nutrient intake.

Choice C rationale

Advising the client to keep a food diary helps in accurately assessing their dietary intake. This objective record allows the nurse and other healthcare providers to identify patterns of consumption, quantify caloric and nutrient deficits, and tailor nutritional interventions more effectively. It provides valuable data for personalized care planning to address malnutrition.

Choice D rationale

Monitoring the client for changes in mental status is important because severe malnutrition, particularly deficiencies in certain vitamins (e.g., thiamine, B12) or significant electrolyte imbalances, can lead to neurological impairments. Altered mental status could indicate worsening nutritional status or complications requiring immediate intervention to prevent further deterioration.

Choice E rationale

Instructing the client to drink extra fluids between meals helps prevent early satiety that can occur if fluids are consumed with meals, which can reduce food intake. By consuming fluids between meals, the client can maintain hydration without compromising their ability to consume sufficient solid food, thus maximizing caloric and nutrient intake for malnutrition.

A. Maintain social distancing in public. B. Adhere to the medication regimen. C. Wear a mask around family members. D. Drink at least two liters of fluid every day.

Correct Answer is B

Explanation

Choice A rationale

While social distancing can help prevent transmission of various pathogens, for active tuberculosis, the primary focus for discharge teaching is adherence to the medication regimen. Social distancing alone is not sufficient to eradicate the mycobacterium from the individual, which requires comprehensive antimicrobial therapy.

Choice B rationale

Adherence to the medication regimen is paramount for clients with active tuberculosis. This ensures the complete eradication of Mycobacterium tuberculosis, preventing drug resistance and recurrence. Non-adherence can lead to treatment failure, prolonged infectivity, and the development of multi-drug resistant strains, making future treatment more challenging.

Choice C rationale

Wearing a mask around family members is a crucial measure to prevent the airborne transmission of Mycobacterium tuberculosis in the home environment. The mask acts as a physical barrier, containing respiratory droplets expelled during coughing, sneezing, or talking, thus reducing the risk of infection for close contacts.

Choice D rationale

While adequate hydration is generally beneficial for overall health, it is not a specific priority for discharge teaching in clients with active tuberculosis compared to medication adherence. Hydration does not directly impact the elimination of the Mycobacterium tuberculosis from the body or prevent its transmission.

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A nurse is caring for a 45-year-old male client on a medical-surgical unit. Select 1 condition and 1 client finding to fill in each blank in the following sentence: The client is at highest risk for developing ______ due to their _____.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is preparing a client diagnosed with active tuberculosis for discharge to home. The nurse should prioritize which of the following discharge teachings for clients with active tuberculosis?

Correct Answer is B

Explanation

A nurse is reviewing the EKG strip of a client who has End Stage Renal Disease (ESRD) and has missed hemodialysis. Which of the following abnormalities on the client’s EKG should the nurse interpret as a sign of hyperkalemia?

A client diagnosed with autoimmune deficiency syndrome (AIDS) expresses to a nurse that they will never permit disclosure of their diagnosis to anyone. The nurse should provide the client with which of the following education? (Select all that apply.)

A nurse is caring for a client with a history of advanced HIV who was admitted with a diagnosis of Pneumocystis jirovecii pneumonia. The nurse should prioritize which nursing care goal?

A nurse is caring for a client who has developed Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) from cancer. Which of the following nursing interventions should be included in the client's plan of care? (Select all that apply.)

A nurse is caring for a client on a mechanical ventilator receiving a neuromuscular blockade agent. The nurse should prioritize which action?

A nurse is caring for a client involved in a motor vehicle accident 4 hours ago and states, "I just can't breathe.”. The nurse assesses that the client is restless, tachycardic, and has an elevated blood pressure. The nurse should anticipate that the client may be experiencing which condition?

The nurse is providing care to a client who sustained burns to 70% of the body 6 hours ago. Which of the following new assessment data requires the nurse to notify the healthcare provider?

A nurse is teaching a client diagnosed with acute renal failure about how the disease progresses. The nurse should recognize that the teaching is effective when the client can accurately identify which phases of renal disease progression? (Select all that apply).

A nurse is caring for a 45-year-old male client on a medical-surgical unit.

Select 1 condition and 1 client finding to fill in each blank in the following sentence: The client is at highest risk for developing
__
due to their
_
.