After performing a head-to-toe assessment for a client with Addison's disease, the nurse reports findings to the healthcare provider. The findings include moist mucous membranes, strong palpable peripheral pulses, and blood pressure 132/88 mm Hg. The client verbalizes understanding of the illness and importance of taking medications every day. Which action should the nurse implement?

Make a referral for social services at home.

Continue to limit daily fluid intake to 500 mL.

Begin preparing the client for discharge home.

Recommend strict intake and output monitoring.

Answer and Explanation

The Correct Answer is C

Choice A reason: A referral for social services at home is not necessary for a client with Addison's disease who has stable vital signs, adequate hydration, and good self-care knowledge.

Choice B reason: Limiting daily fluid intake to 500 mL is not appropriate for a client with Addison's disease, who is at risk of dehydration and hypotension. The client should drink fluids according to thirst and urine output.

Choice C reason: Preparing the client for discharge home is the best action for the nurse to implement, as the client has no signs of complications or deterioration from Addison's disease. The client should be able to manage the condition at home with regular follow-up and medication adherence.

Choice D reason: Strict intake and output monitoring is not required for a client with Addison's disease who has normal blood pressure, moist mucous membranes, and strong peripheral pulses. These indicate adequate fluid balance and renal function.

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Correct Answer is A

Explanation

Choice A reason: Irregular ulcer shapes and severe edema are characteristic of venous ulcers, which are caused by impaired venous return and increased capillary pressure. Venous ulcers are usually located near the medial malleolus and have a shallow depth.

Choice B reason: Hairless lower extremities and cool feet are signs of arterial insufficiency, which reduces blood flow and oxygen delivery to the tissues. Arterial ulcers are usually located on the toes, heels, or lateral malleoli and have a deep, punched-out appearance.

Choice C reason: Black ulcers and dependent rubor are also signs of arterial insufficiency, indicating tissue necrosis and inflammation. Dependent rubor is a reddish-blue color of the lower extremity that occurs when the leg is lowered below the level of the heart.

Choice D reason: Absent pedal pulses and shiny skin are also signs of arterial insufficiency, indicating reduced blood flow and atrophy of the skin. The skin may also be dry, scaly, or cracked.

A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result. B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages. C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms. D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.

Correct Answer is B

Explanation

Choice A reason: This is incorrect because the humoral immune response involves B cells that produce antibodies against specific antigens. However, AIDS affects the cellular immune response, which involves T cells that activate other immune cells and directly kill infected cells.

Choice B reason: This is correct because AIDS is caused by human immunodeficiency virus (HIV), which infects and destroys CD4+ T cells, also known as helper T cells. These cells are essential for initiating and regulating both humoral and cellular immunity. Without enough CD4+ T cells, the body cannot mount an effective response against pathogens, especially opportunistic infections that take advantage of a weakened immune system.

Choice C reason: This is incorrect because bone marrow suppression of white blood cells is not a direct consequence of AIDS. However, some drugs used to treat AIDS, such as zidovudine, may cause bone marrow suppression as a side effect.

Choice D reason: This is incorrect because exposure to multiple environmental infectious agents does not cause AIDS. However, people with AIDS are more susceptible to infections from various sources due to their impaired immune system.

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Naxlex Comprehensive Predictor Exams

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

A client with type 1 diabetes mellitus, hypertension, and chronic kidney disease is to begin hemodialysis treatment. Which statement should the nurse include in client education?

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?