The nurse is caring for a client with immunodeficiency disorder. Which nursing intervention should be included in the care plan?
Encourage the client to engage in vigorous physical activities to strengthen the immune system.
Limit the client's exposure to visitors and restrict contact with other clients in the healthcare setting.
Administer live vaccines to boost the client's immune response.
Encourage the client to eat a diet high in fresh fruits and vegetables to improve immune function.
The Correct Answer is B
Explanation: The correct answer is b. Limit the client's exposure to visitors and restrict contact with other clients in the healthcare setting. Clients with immunodeficiency disorders are at a higher risk of infections due to their weakened immune system. Restricting exposure to potential sources of infection, such as visitors and other sick clients, can help minimize the risk of acquiring infections.
Incorrect choices:
a. Engaging in vigorous physical activities may not be appropriate for clients with immunodeficiency disorders, as it can lead to an increased risk of infections and may not strengthen the immune system in these individuals.
c. Live vaccines are contraindicated for clients with immunodeficiency disorders, as they can cause severe infections in this population. Only inactivated vaccines are recommended to avoid the risk of vaccine-associated infections.
d. While a healthy diet is essential for overall well-being, there is no specific evidence to suggest that a diet high in fresh fruits and vegetables will improve immune function in clients with immunodeficiency disorders. Dietary considerations for these clients may include avoiding certain high-risk foods, but it should be discussed with the healthcare provider based on the specific immunodeficiency disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation: The correct answer is c. Failure to thrive. SCID is a severe form of immunodeficiency that affects multiple components of the immune system, leading to recurrent and severe infections and failure to thrive in affected infants.
Incorrect choices:
a. Recurrent ear infections are more commonly seen in other types of immunodeficiency disorders, such as selective IgA deficiency.
b. Chronic fatigue and lethargy may be seen in various medical conditions but are not specific to SCID.
d. Persistent joint pain is not a characteristic symptom of SCID. It may be associated with other autoimmune or inflammatory conditions.
Correct Answer is C
Explanation
Explanation: The correct answer is c. Allergic reactions and skin rashes are not typically associated with immunodeficiency disorders. Immunodeficiency disorders primarily result in an increased susceptibility to infections and recurrent, severe infections.
Incorrect choices:
a. Frequent, severe infections are a common symptom of immunodeficiency disorders due to the weakened immune response, making individuals more susceptible to infections.
b. Fatigue and weakness can occur in individuals with immunodeficiency disorders due to the impact of chronic infections on the body's energy reserves.
d. Delayed wound healing may occur in individuals with immunodeficiency disorders due to the impaired immune response and decreased ability to fight infections at the site of a wound.
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