This is the edited text:
Which client is at highest risk of compromised immunity?
A client who has just had surgery
A client with extreme anxiety
A client who is awaiting surgery
A client who just delivered a baby
The Correct Answer is A
Choice A reason: This is the highest risk client because surgery can cause trauma, blood loss, and infection, which can weaken the immune system and increase the susceptibility to complications. The immune system is the body's defense mechanism that protects against foreign invaders, such as bacteria, viruses, or fungi. Surgery can damage the skin and tissues, which are the first line of defense, and cause inflammation, which can impair the function of the white blood cells, which are the second line of defense. The nurse should monitor the client's vital signs, wound healing, and signs of infection and administer antibiotics, fluids, and pain medication as ordered.
Choice B reason: This is not the highest risk client, but it is a moderate risk client because extreme anxiety can cause stress, which can affect the immune system and increase the vulnerability to illness. Stress is the body's response to a perceived threat or challenge, which can activate the sympathetic nervous system and the hypothalamicpituitaryadrenal (HPA) axis. Stress can cause the release of hormones, such as cortisol and adrenaline, which can suppress the immune system and reduce the production and activity of the white blood cells. The nurse should assess the client's anxiety level and provide coping strategies, such as relaxation, breathing, or counseling.
Choice C reason: This is not the highest risk client, but it is a low risk client because awaiting surgery can cause anxiety, which can affect the immune system and increase the vulnerability to illness. However, the client's anxiety level may not be as high as the client with extreme anxiety, and the client's immune system may not be as compromised as the client who has just had surgery. The nurse should assess the client's anxiety level and provide education, reassurance, and support.
Choice D reason: This is not the highest risk client, but it is a low risk client because delivering a baby can cause blood loss, hormonal changes, and fatigue, which can affect the immune system and increase the risk of infection. However, the client's immune system may not be as compromised as the client who has just had surgery, and the client may have some protection from the antibodies that are passed from the mother to the baby through the placenta and breast milk. The nurse should monitor the client's vital signs, lochia, and signs of infection and provide hygiene, nutrition, and rest.
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Correct Answer is B
Explanation
Choice A reason: Providing the client with antipyretic therapy is not the nurse's priority. Antipyretic therapy is a treatment that lowers the body temperature and reduces fever. Fever is a common symptom of acute osteomyelitis, which is a bacterial infection of the bone and bone marrow. Antipyretic therapy may help to relieve the discomfort and inflammation caused by fever, but it does not address the underlying cause of the infection.
Choice B reason: Administering antibiotics to the client is the nurse's priority. Antibiotics are medications that kill or inhibit the growth of bacteria. Antibiotics are the main treatment for acute osteomyelitis, as they target the specific type of bacteria that is causing the infection. Antibiotics can prevent the spread of the infection to other bones or organs and reduce the risk of complications, such as chronic osteomyelitis, septic arthritis, or sepsis.
Choice C reason: Increasing the client's protein intake is not the nurse's priority. Protein intake is a nutritional factor that affects the wound healing and immune system. Protein is composed of amino acids, which are the building blocks of cells and tissues. Protein intake can enhance the repair and regeneration of the bone and the soft tissues that are damaged by the infection. Protein intake can also support the immune system's ability to fight off the infection. However, protein intake alone is not sufficient to treat acute osteomyelitis, as it does not eliminate the bacteria that are causing the infection.
Choice D reason: Teaching relaxation breathing to reduce the client's pain is not the nurse's priority. Relaxation breathing is a technique that involves deep and slow breathing that helps to relax the body and mind. Relaxation breathing can help to reduce the pain and stress that are associated with acute osteomyelitis. Pain is a common symptom of acute osteomyelitis, which is caused by the inflammation and pressure on the bone and the surrounding tissues. Relaxation breathing can help to ease the pain and improve the mood and quality of life of the client. However, relaxation breathing alone is not enough to treat acute osteomyelitis, as it does not address the source of the pain.
Correct Answer is B
Explanation
Choice A reason: "You should never go around people after your baby is born." is not a good response, because it is unrealistic, rigid, and dismissive of the mother's concern. It does not acknowledge the benefits of social interaction and support for the mother and the baby, nor the risks of isolation and depression. It also does not provide any evidence or rationale for the advice.
Choice B reason: "Tell me more about that." is the best response, because it is openended, empathetic, and respectful of the mother's concern. It invites the mother to share her feelings and thoughts, and allows the nurse to explore the source and extent of the mother's anxiety. It also creates an opportunity for the nurse to provide education and reassurance based on the mother's needs.
Choice C reason: "I did that, and my kids turned out just fine." is not a good response, because it is personal, irrelevant, and unprofessional. It does not address the mother's concern, but rather shifts the focus to the nurse's own experience, which may not be applicable or helpful to the mother. It also implies that the mother's concern is unfounded or exaggerated, and may make the mother feel judged or defensive.
Choice D reason: "Why do you think that is a bad idea?" is not a good response, because it is closedended, confrontational, and accusatory. It does not show empathy or respect for the mother's concern, but rather challenges or criticizes it. It may make the mother feel defensive or guilty, and may discourage further communication.
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