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A nurse is caring for an adult client in the clinic.

Select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing

and .
Answer and Explanation

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

  1. Sepsis
    • The client’s CD4 count dropped drastically (from 650 to 150 cells/mm³), indicating severe immunosuppression.
    • They already have opportunistic pneumonia caused by Pneumocystis jirovecii, which places them at high risk for systemic infection spreading into the bloodstream.
    • Vital signs show fever, tachycardia, and tachypnea, which are early indicators of systemic inflammatory response that can progress to sepsis.
  2. Malnutrition
    • The client has experienced significant weight loss (15 lb in 3 months).
    • Reports of diarrhea, anorexia, and difficulty eating due to oral ulcers further compromise nutritional intake.
    • Chronic alcohol use, smoking, and HIV infection exacerbate poor nutritional status and increase risk for malnutrition.

Why not the other options?

  • Tuberculosis: While HIV increases TB risk, the diagnostic findings here specifically confirm Pneumocystis jirovecii pneumonia, not TB.
  • Hemorrhage: Platelet count is within normal limits (155,000/mm³), so there is no immediate risk for bleeding disorders.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale

Spinal anesthesia interrupts the sensory and motor pathways of the sacral nerves, which are responsible for the micturition reflex. Therefore, the absence of an urge to void is an expected clinical effect as the anesthesia wears off and the bladder fills. It is not considered a complication but rather a temporary side effect of the blockade. Nurses monitor for urinary retention and typically wait for the sensation to return as the medication is metabolized.

Choice B rationale

Hiccoughs, or diaphragmatic spasms, are not a recognized or typical complication associated with the administration of spinal anesthesia. They are more commonly linked to irritation of the phrenic nerve or certain upper gastrointestinal issues. While they can occur in postoperative patients due to various factors like gastric distension or general anesthesia medications, they do not indicate a failure or a specific adverse physiological reaction related to the spinal block procedure or the subarachnoid injection.

Choice C rationale

Numbness and the inability to move the lower extremities are the primary intended effects of spinal anesthesia, resulting from the chemical interruption of nerve impulse transmission. This state is expected to persist until the local anesthetic agent is naturally redistributed and eliminated from the cerebrospinal fluid. The loss of sensation indicates that the block is working effectively. It only becomes a concern if the numbness persists for an abnormally long time beyond the expected duration.

Choice D rationale

A headache, specifically a post-dural puncture headache, occurs when cerebrospinal fluid leaks through the puncture site in the dura mater. This leak reduces the pressure of the fluid surrounding the brain and spinal cord, leading to severe pain that typically worsens when sitting upright. This is a classic complication of spinal anesthesia. Treatment may include hydration, caffeine, or an epidural blood patch to seal the leakage and restore normal intracranial pressure and comfort.

Correct Answer is ["325"]

Explanation

Step 1 is 5200 mL ÷ 2 = 2600 mL.

Step 2 is 2600 mL ÷ 8 hr = 325 mL/hr. The final calculated answer is 325.

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