Which of the ff is an assessment finding in a client with bonchiectasis?

Correct Answer: D

Rationale: The correct answer is D. In bronchiectasis, worsening cough with position changes is an assessment finding due to increased sputum production and airway obstruction. This occurs because of the pooling of secretions in the affected bronchi. Choices A, B, and C are incorrect because in bronchiectasis, there is typically increased sputum production over time, productive cough with expectoration of large amounts of sputum, and cough that worsens with activity or physical exertion, rather than with position changes.

Correct Answer: D

Rationale: Step-by-step rationale: 1. A balanced and varied diet provides essential nutrients for immune function. 2. Including a wide range of foods ensures intake of vitamins, minerals, and antioxidants crucial for immune health. 3. Avoiding extremes like excessive immune-enhancing formulas or eliminating polyunsaturated fatty acids maintains balance. 4. Essential fatty acids and omega-3 fatty acids are beneficial but should be part of a well-rounded diet. 5. For clients with immune-mediated disorders, individualized dietary advice may be necessary. Summary: - A: Immune-enhancing formulas may not be necessary and could disrupt balance. - B: Avoiding all polyunsaturated fatty acids is not advisable as some are essential for health. - C: Increasing essential fatty acids is beneficial but should be part of a balanced diet.

Correct Answer: B

Rationale: The correct answer is B: Abnormal sensations such as burning and numbness. In AIDS-related DSP, damage to nerves causes abnormal sensations like burning and numbness. This is due to the progressive nerve damage affecting sensory functions. Staggering gait and muscle incoordination (A) are more common in conditions affecting motor nerves. Delusional thinking (C) is not a symptom of DSP. Incontinence (D) is not typically associated with DSP but may happen in more advanced stages due to loss of sensation.

Correct Answer: C

Rationale: The correct answer is C: Joint abnormalities. In rheumatoid arthritis, joint abnormalities such as swelling, warmth, and tenderness are the hallmark manifestations. Assessing joint abnormalities first is crucial as they are the primary clinical signs of the disease. Muscle weakness (A) is a common symptom but typically occurs later due to joint inflammation and disuse. Painful subcutaneous nodules (B) are present in some cases but are not as common or prominent as joint abnormalities. Gait disturbances (D) may occur as a result of joint damage, but they are secondary to the primary manifestation of joint abnormalities. By prioritizing the assessment of joint abnormalities, the nurse can promptly identify and address the most prevalent disease manifestations in rheumatoid arthritis.

Correct Answer: A

Rationale: The correct answer is A: Removal of the transplanted kidney. Hyperacute rejection is a severe and immediate immune response to the transplanted organ. In this case, the transplanted kidney must be removed promptly to prevent further complications, as it is irreversibly damaged. High-dose IV cyclosporine (B) is used for immunosuppression but is not effective in treating hyperacute rejection. Bone marrow transplant (C) is not indicated for kidney rejection. Intra-abdominal instillation of methylprednisolone sodium succinate (D) is used for acute rejection, not hyperacute rejection.