A nurse is planning the care of a client with acquired immunodeficiency syndrome (AIDS) who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this client?

Correct Answer: A

Rationale: The correct answer is A: Ineffective airway clearance. This is the highest priority for a client with AIDS and PCP as it can lead to respiratory distress and compromise oxygenation. Priority setting involves addressing life-threatening issues first. Impaired airway clearance can lead to respiratory failure, so it must be addressed immediately. Choices B, C, and D are important but not as critical as ensuring adequate airway clearance in a client with PCP. Impaired oral mucous membranes, imbalanced nutrition, and activity intolerance can be addressed once the airway is secured.

Correct Answer: C

Rationale: The correct answer is C: Fluid overload. In sickle cell disease, excess fluid can lead to increased blood viscosity and further sickling of red blood cells, potentially triggering a pain crisis. In contrast, infection, trauma, and stress are known triggers for pain crisis in sickle cell disease, but they do not necessarily indicate a need for further instructions as the mother may already be aware of these factors. Therefore, identifying fluid overload as a precipitating factor would require additional instructions to avoid exacerbating the child's condition.

Correct Answer: A

Rationale: The correct answer is A. Applying pressure to the biopsy site is the priority post-procedure to prevent bleeding and ensure hemostasis. Inspecting the site for ecchymoses can be done after ensuring hemostasis. Sending the biopsy specimens to the laboratory is important but not as immediate as ensuring the client's safety. Teaching the client about avoiding vigorous activity is important for overall recovery but not as immediate as preventing bleeding post-procedure.

Correct Answer: C

Rationale: The correct answer is C because staying with the patient and focusing on slow deep breathing for relaxation is the most effective response to address the patient's fear and anxiety before the bone marrow aspiration and biopsy. Deep breathing techniques can help the patient calm down, reduce anxiety, and promote relaxation, making the procedure more manageable. This response also shows empathy and support, which can enhance the patient's emotional well-being. The other choices are incorrect because: A: Warning the patient to stay very still may increase her anxiety and fear, leading to more discomfort during the procedure. B: While having family present can provide support, it may not directly address the patient's fear and anxiety or help her relax. D: Delaying the procedure may prolong the patient's distress and uncertainty, whereas addressing the fear and anxiety promptly is crucial for the patient's well-being.

Correct Answer: B

Rationale: The correct answer is B: Platelet (thrombocyte) count. Platelet count typically remains relatively stable with age, so a decreased value in a 76-year-old client would be concerning. Hemoglobin (Hgb) level can decrease with age due to factors like nutritional deficiencies. Red blood cell (RBC) count tends to decrease with age as well. White blood cell (WBC) response can vary with age and immune system activity. Therefore, the decreased platelet count is the most concerning as it is not typically age-related, making it the correct answer.