Exhibits

The nurse reviews the electronic health record.

Highlight the finding(s) that require the nurse's attention. Select all that apply.

Heart rate 88 beats/minute

Blood pressure 122/72 mm Hg

Temperature 100.5° F (38° C)

Reports of pain with ambulation

Respirations 20 breaths/minute

Left lower leg with erythema, warm, and swollen

Blood glucose 252 mg/dL (13.9 mm

A. Has hyperemia at the site of an acute local infection. Hyperemia (increased blood flow) is a sign of the body's normal immune response to infection. While the client has an infection, their immune system is still active, making them less vulnerable to new healthcare-associated infections (HAIs) compared to an immunosuppressed individual.
B. Recently received a series of adult immunizations. Vaccinations enhance the immune system and help protect against infections. This does not increase the risk of developing an HAI.
C. Lost ten pounds adhering to a low carbohydrate diet. Dietary changes alone do not significantly impact infection risk unless they lead to malnutrition. A 10-pound weight loss does not necessarily indicate a compromised immune system.
D. Receiving immune suppressant therapy for cancer. Immunosuppressive therapy weakens the immune system, making the client highly susceptible to HAIs. Cancer treatments, such as chemotherapy, radiation, or corticosteroids, reduce the body's ability to fight infections, increasing the risk of hospital-acquired infections like pneumonia, bloodstream infections, and surgical site infections.

A. Brown, rough, greasy, wart-like papules on the face. These describe seborrheic keratosis, a benign skin growth, which is unrelated to overexposure from PUVA therapy.
B. Requires sunglasses because sunlight hurts eyes. PUVA therapy increases sensitivity to light, and clients are advised to wear sunglasses. However, light sensitivity alone does not indicate overexposure. Severe overexposure could cause ocular damage or photokeratitis, but this symptom alone is not diagnostic of excessive treatment.
C. Tenderness upon palpation and generalized erythema. Overexposure to PUVA therapy can cause phototoxic reactions, including skin tenderness, erythema (similar to a sunburn), and blistering. These signs indicate that the client has received too much ultraviolet A (UVA) exposure, requiring treatment adjustments to prevent further skin damage.
D. Thick skin plaques topped by silvery white scales. These are classic symptoms of psoriasis vulgaris and do not indicate overexposure. In fact, PUVA therapy is used to reduce these plaques, not cause them.