A client diagnosed with bowel cancer has recently received a course of chemotherapy and has now developed stomatitis. The nurse provides instructions to the client regarding the condition and determines the need for further teaching if the client makes which statement?
I need to drink room temperature beverages.
I can take a prescribed analgesic to help manage the pain.
I need to be careful not to spread this to my family.
The chemotherapy affected my immune system.
The Correct Answer is C
Choice A rationale
Drinking room temperature beverages can help minimize irritation in the mouth and throat, which is beneficial for clients with stomatitis. Cold or hot beverages can exacerbate the condition by causing discomfort and pain.
Choice B rationale
Taking a prescribed analgesic can help manage the pain associated with stomatitis. Pain management is crucial for maintaining the client’s comfort and ability to eat and drink.
Choice C rationale
Stomatitis is not contagious and cannot be spread to family members. This statement indicates a need for further teaching as it reflects a misunderstanding of the condition.
Choice D rationale
Chemotherapy can affect the immune system, making the client more susceptible to infections and conditions like stomatitis. This statement is accurate and does not indicate a need for further teaching.
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Correct Answer is A
Explanation
Choice A rationale
A CD4-T-cell count of 180 cells/mm³ indicates severe immunosuppression in a client with HIV, making them highly susceptible to opportunistic infections. This is a critical value that requires immediate attention to prevent life-threatening complications.
Choice B rationale
A positive Western blot test confirms the presence of HIV antibodies but does not indicate the current immune status or the urgency of the client’s condition.
Choice C rationale
Platelets at 150,000/mm³ are within the normal range and do not indicate an immediate threat to the client’s health.
Choice D rationale
A WBC count of 5,000/mm³ is within the normal range and does not indicate an immediate threat to the client’s health.
Correct Answer is A
Explanation
Choice A rationale
Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects connective tissue. The immune system mistakenly attacks healthy tissue, leading to inflammation and damage.
Choice B rationale
SLE does not originate in the peripheral vascular system, although it can cause complications in blood vessels.
Choice C rationale
While the lymphatic system is involved in immune responses, SLE primarily targets connective tissue.
Choice D rationale
SLE does not originate in skeletal tissue, though it can cause joint pain and arthritis.