Author Question: The nurse determines that a client has adequate physiological barriers to defend the body against ... (Read 33 times)

joesmith1212 · **on:** Jul 23, 2018

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client?

1. Intact and dry skin
2. Intact oral mucous membranes
3. Bowel sounds present in all four quadrants
4. Nasal congestion
5. Urinary retention

Question 2

A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client?

1. Social Isolation
2. Anxiety
3. Acute Pain
4. Imbalanced Nutrition: Less Than Body Requirements

asware1 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1, 2, 3
Rationale 1: Intact skin is the body's first line of defense against microorganisms.
Rationale 2: Intact mucous membranes are the body's first line of defense against microorganisms.
Rationale 3: Peristalsis tends to move microbes out of the body.
Rationale 4: Nasal congestion would mean that the nasal passages would be ineffective in filtering microorganisms from inspired air.
Rationale 5: Urinary retention would cause the urine to remain in the body, possibly leading to an infection.

Answer to Question 2

Correct Answer: 1
Rationale 1: Social Isolation would be appropriate for the client who needs to be separated from others during a contagious episode.
Rationale 2: Anxiety would be appropriate if the client were demonstrating apprehension regarding a change in life activities because of the communicable disease.
Rationale 3: Acute Pain would be appropriate if the client were experiencing discomfort.
Rationale 4: Imbalanced Nutrition: Less Than Body Requirements would be appropriate if the client were too ill to eat adequately.