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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

Answer and Explanation

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 D

Explanation

Choice A reason: Intermittent flatus and minor abdominal discomfort are not signs that would prompt the nurse to call the provider immediately. They are common and expected after surgery and anesthesia. They indicate that the client's bowel function is returning to normal.

Choice B reason: A minor headache and taking an overthe counter pain pill at home are not signs that would prompt the nurse to call the provider immediately. They are mild and manageable symptoms that may be related to stress, dehydration, or caffeine withdrawal. They do not indicate a serious complication or adverse reaction.

Choice C reason: Refusing pain medication and doing physical therapy are not signs that would prompt the nurse to call the provider immediately. They are indicators of the client's preference and motivation to recover. They may also suggest that the client's pain is wellcontrolled or tolerable.

Choice D reason: Paresthesia in the fingers and intense increasing pain in the shoulder are signs that would prompt the nurse to call the provider immediately. They are indicators of a possible nerve injury, compression, or ischemia that may result from the surgery, swelling, or hematoma. They may also indicate a worsening of the client's rheumatoid arthritis or a development of a complex regional pain syndrome. They require prompt assessment and intervention to prevent permanent damage or disability.

A. Stage 4 B. Stage 3 C. Stage 5 D. Stage 1

Correct Answer is A

Explanation

Choice A reason: Stage 4 is the remodeling stage of bone healing, which occurs from 6 to 12 weeks after the fracture. In this stage, the callus, which is a mass of fibrous tissue and cartilage that forms around the fracture site, is gradually resorbed and replaced by mature bone. The bone becomes stronger and more compact and regains its original shape and function.

Choice B reason: Stage 3 is the callus formation stage of bone healing, which occurs from 2 to 6 weeks after the fracture. In this stage, the granulation tissue, which is a soft tissue that fills the fracture gap, is replaced by a callus that bridges the fracture ends. The callus is composed of fibroblasts, chondroblasts, and osteoblasts that produce collagen, cartilage, and bone matrix. The callus stabilizes the fracture and prepares it for remodeling.

Choice C reason: Stage 5 is not a valid stage of bone healing. There are only four stages of bone healing: stage 1 is the inflammatory stage, stage 2 is the reparative stage, stage 3 is the callus formation stage, and stage 4 is the remodeling stage.

Choice D reason: Stage 1 is the inflammatory stage of bone healing, which occurs from the time of the fracture to 3 to 5 days after the fracture. In this stage, the blood vessels around the fracture site are ruptured and form a hematoma, which is a blood clot that surrounds the fracture ends. The hematoma triggers an inflammatory response that involves the release of cytokines, growth factors, and inflammatory cells that initiate the healing process. The hematoma also provides a scaffold for the granulation tissue to grow.

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This is the edited text:Which client is at highest risk of compromised immunity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

Correct Answer is D

Explanation

A client is recovering from a fractured radius that occurred 8 weeks ago. In which stage of bone healing is the callus resorbed and transformed into bone?

Correct Answer is A

Explanation

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This is the edited text:

Which client is at highest risk of compromised immunity?