On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate 125 beats/minute, respiratory rate 36 breaths/minute, and blood pressure 166/88 mm Hg. Which nursing intervention(s) should the nurse implement? (Select all that apply.)

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.

Choice A reason: This is incorrect because performing a complete mental status exam is not a relevant or appropriate action for the nurse to implement. A mental status exam is used to evaluate the client's cognitive, emotional, and behavioral functioning, but it does not address the client's physical pain or its underlying cause.

Choice B reason: This is incorrect because determining if the client has had a shingles vaccination is not a priority or helpful action for the nurse to implement. A shingles vaccination is recommended for people who are 50 years or older to prevent or reduce the severity of shingles, but it does not affect the occurrence or treatment of postherpetic neuralgia, which is a chronic pain condition that can develop after shingles.

Choice C reason: This is incorrect because teaching the client about phantom pain symptoms is not an accurate or useful action for the nurse to implement. Phantom pain is a type of neuropathic pain that occurs when a person feels pain in a body part that has been amputated or removed. However, this is not the case for the client who has pain in the area where the shingles rash occurred.

Choice D reason: This is correct because completing an assessment of the client's pain is the most important action for the nurse to implement. Pain assessment involves collecting information about the location, intensity, quality, duration, frequency, and aggravating or relieving factors of the pain, as well as its impact on the client's daily activities and quality of life. This can help the nurse identify the cause and severity of the pain, as well as plan and evaluate appropriate interventions.