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A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiological mechanism should the nurse describe in response to this client's question?
- A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
- B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.
- C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
- D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
Correct Answer: B
Rationale: Inadequate numbers of CD4+ T cells impair cellular immunity, making the client susceptible to opportunistic infections like Pneumocystis jiroveci pneumonia due to HIV infection.
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Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- C. Report the COVID-19 result to the local health department according to CDC guidelines.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: B
Rationale: Isolating the client from others not wearing proper PPE is the most important action to prevent transmission of COVID-19, given the client's symptoms suggestive of the virus.
A client who received 6 units of packed red blood cells 3 days ago for a lower gastrointestinal (GI) bleed is now displaying signs of shortness of breath with occasional stridor and is reporting muscle cramping. Which serum laboratory value should the nurse immediately report to the healthcare provider?
- A. Potassium 4.7 mEq/L (4.70 mmol/L).
- B. Magnesium 2.1 mEq/L (0.86 mmol/L).
- C. Calcium 6.5 mg/dL (1.63 mmol/L).
- D. Sodium 135 mEq/L (135 mmol/L).
Correct Answer: C
Rationale: Calcium 6.5 mg/dL (1.63 mmol/L) is below the normal reference range and can cause muscle spasms, cramps, tingling, numbness, and stridor. This critical value should be immediately reported to the healthcare provider, as it can indicate a serious condition such as acute pancreatitis, sepsis, or massive blood transfusion.
A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?
- A. Rocky Mountain spotted fever.
- B. Intracerebral hemorrhage.
- C. Cerebrovascular accident (CVA).
- D. Meningococcal meningitis.
Correct Answer: D
Rationale: Meningococcal meningitis is characterized by severe headache, fever, nuchal rigidity, and a petechial rash, which are consistent with the client's symptoms.
The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
- A. Sweet potatoes.
- B. Spinach salad.
- C. Bananas.
- D. Fish.
Correct Answer: B
Rationale: Spinach salad is high in oxalate, which can combine with calcium in the urine to form stones, increasing the risk of recurrence.
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Irregular ulcer shapes and severe edema.
- B. Hairless lower extremities and cool feet.
- C. Black ulcers and dependent rubor.
- D. Absent pedal pulses and shiny skin.
Correct Answer: A
Rationale: Irregular ulcer shapes and severe edema are characteristic of venous ulcers, caused by impaired venous return and increased capillary pressure.