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: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly. A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function. B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system. C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.

Correct Answer: C

Rationale: The correct answer is C: By suggesting daily food choices. The food pyramid helps guide a client's diet by recommending the types and proportions of food to consume daily, such as fruits, vegetables, grains, protein, and dairy. It does not specify exact servings (A), calculate calories (B), or divide food into only four basic groups (D). The pyramid is a visual representation of a balanced diet, emphasizing variety and moderation.

Correct Answer: A

Rationale: The correct answer is A because thalassemia is a genetic blood disorder that can cause anemia and fatigue. By maintaining the client on bed rest and protecting them from infections, we can help prevent complications such as fatigue and infections due to reduced red blood cell production. Ambulating the client frequently (choice B) may lead to increased fatigue and risk of injury. Advising to drink 3 quarts of fluid per day (choice C) is not specific to thalassemia treatment and could potentially worsen symptoms. Instructing the client to elevate lower extremities (choice D) is not directly related to managing thalassemia and may not provide significant benefits in this context.

Correct Answer: B

Rationale: The correct answer is B: decrease resident intestinal flora. Lactulose is a synthetic sugar that is not absorbed in the intestine and is used to decrease ammonia levels in patients with hepatic encephalopathy by promoting the growth of beneficial gut bacteria that help metabolize ammonia. This action helps reduce the toxic effects of ammonia on the brain. A: prevent constipation - Lactulose may help with constipation, but its primary action in this scenario is to decrease resident intestinal flora. C: increase intestinal peristalsis - Lactulose does not directly increase peristalsis. D: prevent portal hypertension - Lactulose does not have a direct effect on preventing portal hypertension.

Correct Answer: B

Rationale: The correct answer is B: Acute pain. This is the only choice that aligns with NANDA-I approved nursing diagnoses. Acute pain is a common nursing diagnosis that focuses on addressing a patient's immediate discomfort. NANDA-I emphasizes the importance of using standardized nursing diagnoses to improve communication and ensure proper interventions. Sore throat (A) and sleep apnea (C) are symptoms or medical diagnoses, not specific nursing diagnoses. Heart failure (D) is a medical diagnosis and not a NANDA-I approved nursing diagnosis.

Correct Answer: B

Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data. Summary: - A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse. - C: Secondary data are information obtained from other sources, not directly from the client. - D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.

Correct Answer: C

Rationale: The correct answer is C, the 35-year-old with kidney failure. Patients with kidney failure are at high risk for fluid volume overload due to the kidneys' inability to properly regulate fluid balance. This can lead to accumulation of excess fluids in the body, causing edema, hypertension, and heart failure. In contrast, choices A, B, and D are not at as high risk for fluid volume overload as patients with kidney failure, as their conditions do not directly impact fluid regulation in the body.

Correct Answer: A

Rationale: The correct answer is A: Levodopa. Levodopa is the most effective pharmacologic agent for treating Parkinson's disease because it is converted to dopamine in the brain, replenishing the deficient dopamine levels in Parkinson's patients. Selegiline and Symmetrel are also used in treating Parkinson's, but they are typically used as adjunctive therapy rather than the primary treatment. Permax has been withdrawn from the market due to safety concerns, making it an incorrect choice.

Correct Answer: C

Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids and foods that are liquid at room temperature. Jello meets this criteria as it is a clear, easily digestible food. Milk (A) is not allowed on a clear liquid diet due to its opaque nature. Orange juice (B) contains pulp and is not considered clear. Ice cream (D) is a solid food and not permitted on a clear liquid diet. Therefore, Jello is the most suitable option for someone on a clear liquid diet.