The nurse is planning care for a patient with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan?
Protecting the patient from infection.
Encouraging discussion about lifestyle changes.
Identifying factors that decreased the immune function.
Providing emotional support to decrease fear,
The Correct Answer is A
Rationale:
A. Protecting the patient from infection is correct because patients with immunodeficiency have a compromised immune system, making them highly susceptible to infections, which are the leading cause of morbidity and mortality in this population. Priority nursing interventions include strict hand hygiene, use of protective equipment, infection control precautions, and minimizing exposure to pathogens. Preventing infection takes precedence over psychosocial or educational interventions because it addresses an immediate, life-threatening risk.
B. Encouraging discussion about lifestyle changes is important for long-term health promotion but is not the immediate priority. While lifestyle modifications (nutrition, sleep, stress management) can support immune function, they do not address the urgent threat of infection.
C. Identifying factors that decreased the immune function is part of the assessment and overall plan but is secondary to protecting the patient from immediate harm. Recognition of contributing factors helps guide care, but interventions to prevent infection take precedence.
D. Providing emotional support to decrease fear is important for holistic care and patient well-being, but it is not the priority over physical safety. Emotional support should be provided alongside but after implementing measures to prevent infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. Full tonic-clonic seizure activity is correct because status epilepticus often involves generalized tonic-clonic seizures, which are the most recognizable and severe form of seizure activity. Continuous or repeated tonic-clonic activity can cause hypoxia, hypotension, and metabolic disturbances, making rapid intervention critical.
B. Seizure activity that lasts for 2 minutes or longer is incorrect because a seizure lasting 2 minutes is prolonged but does not meet the definition of status epilepticus, which typically requires a longer duration or repeated seizures without recovery.
C. Two or more sequential seizures occur without full recovery of consciousness between seizures is correct because status epilepticus can occur as repeated seizures without regaining consciousness, which is a defining characteristic. This pattern leads to cumulative neuronal injury and systemic complications.
D. Seizure activity that lasts for greater than 60 minutes is incorrect because the formal definition of status epilepticus does not require 60 minutes of continuous seizure activity. Intervention is indicated much earlier, usually after 5 minutes of continuous seizure activity, to prevent long-term neurological damage.
E. Seizure activity that lasts for 30 minutes or longer is correct because prolonged seizures ≥30 minutes are consistent with status epilepticus and pose significant risk for permanent brain injury. Modern definitions often use ≥5 minutes for initiation of treatment, but 30 minutes represents severe ongoing status epilepticus.
Correct Answer is D
Explanation
Rationale:
A. Decreased glomerular filtration is a key underlying mechanism in acute kidney injury (AKI) but alone is not considered a cardinal feature. It contributes to the manifestations but is more of a pathophysiologic change rather than a defining clinical feature.
B. Increase in urine output is incorrect because AKI typically causes oliguria (decreased urine output), although some patients may develop non-oliguric AKI. Increased urine output is not a primary hallmark.
C. Uremia and fatigue are common symptoms of AKI but are consequences of impaired kidney function rather than the cardinal features that define AKI.
D. Azotemia and oliguria are correct because azotemia (elevated blood urea nitrogen and creatinine) and oliguria (reduced urine output, usually <0.5 mL/kg/hr) are the primary clinical and laboratory features that define acute kidney injury. These indicators are used to diagnose and stage AKI and guide management.
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