Nokea
A 28 year-old male has a diagnosis of AIDS. The patient has had a two year history of AIDS. The most likely cognitive deficits include which of the following?
- A. Disorientation
- B. Sensory changes
- C. Inability to produce sound
- D. Hearing deficits
Correct Answer: A
Rationale: Cognitive changes may include confusion and disorientation.
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The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:
- A. elevated blood pressure.
- B. Cheyne-Stokes respiration.
- C. elevated pulse rate.
- D. decreased temperature.
Correct Answer: B
Rationale: Cheyne-Stokes respirations are rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death.
A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?
- A. A 8 year-old boy has been vomiting and appears to have slower movements and has a history of an atrioventricular shunt placement.
- B. A 10 year-old girl feels a dull pain in her abdomen after doing sit-ups in gym class.
- C. A 7 year-old boy has been having a low fever and headache for the past 3 days that has history of an anterior knee wound.
- D. A 7 year-old girl that had a cast on her right ankle is complaining of itching.
Correct Answer: A
Rationale: The shunt may be blocked and require immediate medical attention.
When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?
- A. low-back pain
- B. urinary frequency
- C. GI distress
- D. malaise
Correct Answer: B
Rationale: Urinary frequency is least indicative of UTI during pregnancy because it is a common minor discomfort of pregnancy and is caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are no problems. Frequency returns in the third trimester when the uterus drops into the pelvic cavity. A UTI has the symptoms of frequency, back pain, supra pubic discomfort, and malaise and is diagnosed by laboratory findings.
A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of a cervical implant is:
- A. creamy, pink-tinged vaginal drainage.
- B. stomatitis.
- C. constipation.
- D. xerostomia.
Correct Answer: A
Rationale: Creamy, pink-tinged vaginal drainage persists for 1 to 2 months after removal of a cervical implant.
A man reports his wife is constantly cleaning. The activity has interfered with the family life. Friends have stopped visiting because she makes them uncomfortable. He states he has awakened in the middle of the night and found her cleaning. The nurse should consult with the couple and recommend the husband help with therapy by:
- A. telling his wife to stop cleaning whenever he notices her actions
- B. making a baseline record of the time the wife spends cleaning
- C. decreasing the stimuli in the home
- D. helping his wife with the cleaning
Correct Answer: C
Rationale: Reducing environmental stimuli can decrease anxiety driving obsessive-compulsive cleaning, supporting therapy without confronting or enabling the behavior.