ATI LPN
Immune System Questions Questions
Question 1 of 5
Client with platelet count of 58,000/mm³. Best action?
Correct Answer: D
Rationale: The correct answer is D: Place on safety precautions. With a platelet count of 58,000/mm³, the client is at risk for bleeding due to thrombocytopenia. Safety precautions include measures to prevent injury and bleeding, such as using soft-bristled toothbrushes, avoiding sharp objects, and maintaining a safe environment. Encouraging high-protein foods (choice A) is not directly related to managing low platelet count. Neutropenic precautions (choice B) are for clients with low white blood cell counts, not platelet issues. Limiting visitors (choice C) may reduce infection risk but does not address the bleeding risk associated with low platelet count.
Question 2 of 5
A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ Tlymphocyte cell count drops below what threshold?
Correct Answer: B
Rationale: The correct answer is B: 200 cells/mm3 of blood. This is the threshold at which an HIV-positive individual is considered to have AIDS. When the CD4+ T-lymphocyte cell count drops below 200 cells/mm3, the immune system is significantly compromised, increasing the risk of opportunistic infections. Choices A, C, and D are incorrect because they do not reflect the established CD4+ T-cell count threshold for an AIDS diagnosis.
Question 3 of 5
A client has come into contact with HIV. As a result, HIV glycoproteins have fused with the client's CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle?
Correct Answer: B
Rationale: The correct answer is B: Attachment. This phase in the HIV life cycle involves the fusion of HIV glycoproteins with the client's CD4+ T-cell membranes. This initial step allows the virus to bind to the host cell and gain entry for further infection. Integration (A) refers to the stage where the viral DNA is inserted into the host cell genome. Cleavage (C) involves the processing of viral proteins by host cell enzymes. Budding (D) is the final step where new viral particles are released from the host cell membrane. Thus, the fusion of glycoproteins with the host cell membrane is specifically known as the Attachment phase.
Question 4 of 5
The patient who underwent a bone biopsy yesterday calls the office thinking something is wrong. Which of the following would be cause for concern by the nurse? SATA:
Correct Answer: A
Rationale: The correct answer is A because swelling and redness at the biopsy site can indicate infection, which is a serious concern post-procedure. Red streaks (B) also suggest infection, but swelling and redness are more immediate signs. A low-grade fever (C) is common after a biopsy and may not necessarily indicate a problem. Pain (D) is expected after a biopsy and doesn't necessarily signify a complication. Therefore, choice A is the most concerning symptom that requires prompt attention.
Question 5 of 5
When excessive bleeding occurs, which of the following causes blood pressure to fall?
Correct Answer: A
Rationale: The correct answer is A because when excessive bleeding occurs, the volume of blood in the blood vessels decreases, causing a drop in blood pressure. This is due to the insufficient amount of fluid left in the blood vessels to maintain normal blood pressure. Choice B is incorrect because an increased oxygen supply would not directly cause a drop in blood pressure. Choice C is incorrect because a decrease in iron in the blood would not directly affect blood pressure in the context of excessive bleeding. Choice D is incorrect as an increase in red blood cell production may help compensate for blood loss but would not cause a drop in blood pressure directly.