Author Question: The nurse is working at a state fair in the health screening booth. The nurse determines that which ... (Read 111 times)

karateprodigy · **on:** Jul 22, 2018

The nurse is working at a state fair in the health screening booth. The nurse determines that which client demonstrates the decline in responsiveness of the immune system of an older adult?

1. A 78-year-old client with pneumonia has a temperature of 99.5F
2. A 68-year-old client who complains of redness and itching after developing a rash from contact with poison ivy
3. An 80-year-old client who has swelling and redness around an abdominal incision from an open appendectomy
4. A 66-year-old client who has 8 mm induration at the site of a mumps skin test 72 hours earlier

Question 2

When planning the care for a client with a penetrating eye injury, which of the following should be included?

1. Apply anesthetic drops
2. Remove foreign body
3. Apply eye ointment
4. Stabilize penetrating object

stanleka1 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1. A 78-year-old client with pneumonia has a temperature of 99.5F

Rationale:
The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration.

Answer to Question 2

4. Stabilize penetrating object

Rationale:
For a severe or penetrating injury, promote rest and stabilize the injured eye by applying an eye pad or gauze dressing loosely over both the affected and unaffected eye. Stabilize any penetrating object if possible. These measures reduce eye movement and can help preserve the client's vision. Anesthetic drops would be appropriate prior to the removal of a foreign body from the eye. Removal of the foreign body is appropriate if the client had a foreign body in the eye. Application of eye ointment would be applicable after the removal of a foreign body or for a corneal abrasion.