A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?

Correct Answer: B

Rationale: A WBC count of 100/µL (normal: 4,500-11,000) indicates severe leukopenia, likely neutropenia, making infection prevention (Choice B) the most important goal. With Hb (14 g/dL, normal: 13.5-17.5) and HCT (40%, normal: 38-50%) within range, anemia or fluid imbalance isn't a concern, ruling out fluid balance (Choice A) and rest (Choice C). Injury prevention (Choice D) is less urgent, as bleeding risk requires low platelets, not specified here. A WBC this lowe.g., post-chemotherapyleaves the client defenseless against pathogens; even minor infections can become septic. Interventions like isolation, hand hygiene, or antibiotics prioritize this risk. For example, a fever in neutropenia is a medical emergency, unlike fatigue or bruising. Survival hinges on infection control, making Choice B the correct and critical goal.

Correct Answer: D

Rationale: Medications impact sleep via physiological or neurological effects. 'Ambien' , or zolpidem, is least likely to harm sleep quality; it's a sedative-hypnotic designed to induce and maintain sleepe.g., shortening sleep latency to 15 minuteswithout altering architecture long-term, per prescribing data. 'Diuretic' disrupts sleep via nocturiae.g., waking 3 times to void after furosemide. 'Steroid' , like prednisone, causes insomniae.g., 20% of users report wakefulness from CNS stimulation. 'Antidepressant' , like SSRIs, alters REMe.g., fluoxetine delays REM onset by 30 minutesdisrupting quality. Ambien's targeted action (GABA enhancement) contrasts with others' side effects, aligning with Taylor's pharmacology. Choice D is correct as it enhances, not impairs, sleep.

Correct Answer: D

Rationale: Sleepwalking (somnambulism), a parasomnia, occurs in NREM stage 3, posing risks. 'Safety' is key; a 10-year-old might wandere.g., downstairs or outsiderisking falls or injury, per sleep disorder texts. 'Sleep deprivation' might exacerbate it but isn't the discussion's focuse.g., it's a trigger, not the issue. 'Privacy' is irrelevant; sleepwalking isn't about exposuree.g., no dignity loss. 'Schoolwork' might reflect fatigue but isn't immediatee.g., a sprained ankle trumps grades. Nurses, per Taylor, advise locks, alarms, or floor paddinge.g., 80% of sleepwalkers injure themselves yearly. Choice D addresses this primary concern correctly.

Correct Answer: A

Rationale: Pain is subjective, per IASP's definition. 'The person who has the pain' best determines ite.g., only they feel 'stabbing' vs. 'dull,' guiding care, per Taylor's patient-centered ethos. 'The person's immediate family' guessese.g., 'He looks bad'but lacks internal insight. 'The nurse caring for the patient' assesses signs (e.g., grimacing) but can't feel ite.g., rating 8 might seem 4 outwardly. 'The physician diagnosing the cause' identifies etiologye.g., fracturebut not sensation. A patient's self-reporte.g., 'It's 10/10'trumps all, making Choice A correct.

Correct Answer: B

Rationale: Post-amputation sensations need validation. 'That is called phantom pain, and it is not unusual' is correct; phantom limb paine.g., cramping in absent toesarises from neural reorganization, per Taylor's neurology, affecting 60-80% of amputees. Choice A, 'all in your mind,' dismisses ite.g., it's real, not imaginary, via spinal/brain misfiring. Choice C, 'really strange,' undermines normalcye.g., it's common, not odd, needing no urgent MD call. Choice D, 'refer to a psychiatrist,' mislabels; it's neuropathic, not psychiatrice.g., managed with meds (gabapentin), not therapy alone. For instance, a patient feels 'toes' because nerves still signal the brain, a known phenomenon. Nurses educate and reassuree.g., 'It'll lessen over time'fostering coping. Choice B is the empathetic, accurate response.