A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?

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Burns Pediatric Primary Care Test Bank Questions

Question 1 of 5

A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?

Correct Answer: D

Rationale: Assessing the client's ability to produce antibodies is a crucial factor in determining immune system function. Antibodies are proteins produced by the immune system to help fight off infections and other harmful substances. In a male client suspected of an immune system disorder, understanding his ability to produce antibodies can provide valuable insights into the functionality of his immune system. This assessment can help healthcare providers identify potential deficiencies or abnormalities in the immune response, leading to appropriate diagnosis and treatment strategies.

Question 2 of 5

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse's analysis are:

Correct Answer: C

Rationale: Following a splenectomy, the client's hemoglobin level of 7.5g/dl indicates anemia, which can contribute to orthostatic hypotension. When the client changes position from lying to standing, the decrease in blood volume may lead to a drop in blood pressure. Additionally, the compensatory mechanism to maintain perfusion to vital organs is to increase the heart rate. Therefore, the vital sign values that would most support the nurse's analysis are a drop in blood pressure (hypotension) and a rise in heart rate (tachycardia).

Question 3 of 5

For a client diagnosed with idiopathic thrombocytopenic purpura (ITP), which nursing intervention is appropriate?

Correct Answer: B

Rationale: The appropriate nursing intervention for a client diagnosed with idiopathic thrombocytopenic purpura (ITP) is administering platelets, as ordered, to maintain an adequate platelet count. ITP is a condition characterized by a decrease in platelet count, which can lead to thrombocytopenia and an increased risk of bleeding. Administering platelets can help prevent excessive bleeding and maintain hemostasis in these patients. Platelet transfusions may be required in severe cases to raise the platelet count to a safe level and prevent bleeding complications. It is crucial for nurses to monitor the platelet count regularly and administer platelets as prescribed to manage ITP effectively.

Question 4 of 5

A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate (Feosol), 300mg PO daily. Before initiating iron therapy, the nurse reviews the client's medical history. Which condition would contraindicate the use of ferrous sulfate?

Correct Answer: D

Rationale: Severely impaired liver function is a contraindication for the use of ferrous sulfate. In patients with liver disease, iron metabolism can be affected, leading to potential toxicity from iron accumulation. Ferrous sulfate is primarily metabolized by the liver, so in cases of severely impaired liver function, the metabolism of the drug may be altered, leading to potential adverse effects. It is important to consider alternative iron therapy options in patients with severe liver impairment to avoid potential complications.

Question 5 of 5

A classic full blown AIDS case is identified by clinical manifestations such as:

Correct Answer: C

Rationale: A classic full-blown AIDS case is characterized by the presence of tumors and opportunistic infections due to the severe immunodeficiency caused by the human immunodeficiency virus (HIV). As the immune system becomes progressively weakened, the individual becomes highly susceptible to various infections and malignancies, which are typically not seen in individuals with a healthy immune system. The presence of tumors and opportunistic infections in an individual signifies the advanced stage of HIV infection and the progression to AIDS. The other options (A, B, D) are more general symptoms that can be seen in various stages of HIV infection and are not specific to a full-blown AIDS case.

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