A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?

Correct Answer: B

Rationale: In caring for a client with AIDS and PCP, the nurse's priority assessment should be lung sounds (Option B). PCP is a type of pneumonia that primarily affects the lungs, causing symptoms like cough, shortness of breath, and chest pain. Monitoring lung sounds is crucial to assess the severity of respiratory distress and the effectiveness of oxygenation. Skin turgor (Option A) is more indicative of hydration status and would be important in other situations like dehydration, but it is not the priority in a client with PCP. Radial pulses (Option C) and capillary refill (Option D) are important assessments for circulatory status, but in this case, respiratory assessment takes precedence due to the nature of PCP affecting the lungs directly. In an educational context, understanding the rationale behind prioritizing assessments helps nurses provide timely and appropriate care to clients with complex conditions. By focusing on the most critical assessment first, nurses can intervene promptly and potentially prevent further complications in clients with AIDS and PCP.

Correct Answer: A

Rationale: The correct answer is A) Mental state, which will NOT be utilized in a Braden Scale Assessment. The Braden Scale is a tool used to assess a patient's risk of developing pressure ulcers. The scale considers six parameters: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. In the context of long-term care, it is crucial to assess a patient's risk of developing pressure ulcers due to their decreased mobility and prolonged periods of immobility. Sensory perception is included in the Braden Scale because patients who have impaired sensation are at a higher risk of developing pressure ulcers as they may not be able to feel discomfort or pain from prolonged pressure on their skin. While mental state is essential for overall patient assessment and care, it is not a specific factor considered in the Braden Scale for assessing pressure ulcer risk. This is because mental state does not directly impact a patient's susceptibility to developing pressure ulcers, unlike the other factors included in the scale. Educationally, understanding the components of assessment tools like the Braden Scale is vital for nurses to provide comprehensive care to patients in long-term care settings. It ensures that nurses can accurately identify patients at risk for pressure ulcers and implement appropriate preventive measures to maintain their skin integrity and overall well-being.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Maintaining the integrity of a portal of entry. By providing measures to reduce skin breakdown, such as keeping the skin clean, dry, and intact, the nurse is effectively preventing pathogens from entering the body through breaks in the skin. This action disrupts the chain of infection at the portal of entry stage, thereby reducing the risk of infection transmission. Option A) Sterilizing the area to reduce the reservoir risk is incorrect because sterilizing the area would target eliminating pathogens at the reservoir stage, not necessarily at the portal of entry. The focus should be on preventing entry rather than reducing reservoir risk. Option C) Creating a reservoir to decrease the risk of infection is incorrect because creating a reservoir would actually increase the risk of infection by providing a source for pathogens to multiply and spread. Option D) Creating a susceptible host is incorrect because the goal is to prevent infection by reducing the opportunity for pathogens to enter the body, not by making the host more susceptible to infection. In an educational context, understanding how infection control measures work to break the chain of infection is crucial for healthcare professionals to provide effective care and prevent the spread of infections in healthcare settings. By emphasizing the importance of maintaining skin integrity and implementing proper infection prevention protocols, nurses can play a significant role in reducing the risk of healthcare-associated infections.

Correct Answer: D

Rationale: In the context of multi-dimensional care, understanding the effects of medication classes on various aspects of health is crucial. The correct answer to the question is D) Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to decrease tissue inflammation by inhibiting cyclooxygenase enzymes, which are responsible for producing inflammation-inducing prostaglandins. However, NSAIDs can delay bone healing by impairing the early stages of bone repair and remodeling. Option A) Opioids are not typically used to decrease tissue inflammation and do not have a direct impact on bone healing. Option B) Anticoagulants are used to prevent blood clotting and do not directly influence tissue inflammation or bone healing. Option C) Narcotics primarily act on the central nervous system to relieve pain and do not have a specific effect on tissue inflammation or bone healing. In an educational context, it is important for healthcare professionals to be aware of the effects of different medication classes on multiple dimensions of patient care. Understanding the mechanisms of action and potential side effects of medications like NSAIDs can help in making informed decisions regarding patient treatment plans, especially when considering factors like tissue inflammation and bone healing. This knowledge is essential in providing comprehensive and effective care to patients across various healthcare settings.

Correct Answer: A

Rationale: The correct answer is option A) A herniated disk in the diseased joint. Crepitus, an audible grating sound, is commonly associated with osteoarthritis due to the roughening of the cartilage surfaces in the affected joints. When the joint moves, the rough surfaces rub together, producing the characteristic sound. Option B) Pieces of bone and cartilage floating is incorrect because while loose bodies in the joint can cause pain and mechanical symptoms, they do not typically produce crepitus. Option C) Popping bursae from standing is incorrect as bursitis, inflammation of the bursae, can cause swelling and pain but not crepitus. Option D) Years of an autoimmune process is incorrect as autoimmune processes like rheumatoid arthritis may cause joint inflammation and damage, but they do not directly lead to crepitus. Understanding the specific sound manifestations in osteoarthritis aids nurses in accurate assessment and diagnosis, enabling appropriate interventions to manage the condition effectively. This knowledge is crucial in providing holistic care to clients with musculoskeletal disorders.