Nokea
A 34 year old client is diagnosed with AIDS. His pharmacologic management includes zidovudine (AZT). During a home visit, the client states, "I don't understand how this medication works. Will it stop the infection?" What is the nurse's best response?
- A. The medication helps to slow the disease process, but it won't cure or stop it totally
- B. The medication blocks reverse transcriptase, the enzyme required fro HIV replication
- C. Don't you know? There aren't medication to stop or cure HIV
- D. No. it won't stop the infection. In fact, sometimes the HIV can become immune to the drug itself
Correct Answer: B
Rationale: The nurse's best response is, "The medication blocks reverse transcriptase, the enzyme required for HIV replication." This response provides the client with a clear and accurate explanation of how zidovudine (AZT) works. AZT is a nucleoside reverse transcriptase inhibitor (NRTI) that works by blocking the activity of reverse transcriptase, an enzyme needed for HIV replication. By inhibiting this enzyme, AZT helps to slow down the replication of the virus, reducing the viral load in the body and slowing the progression of the disease. It is important for the client to understand that while AZT can help manage HIV/AIDS, it is not a cure and will not completely eliminate the infection.
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Which is an important nursing consideration in preventing the complications of congenital hypothyroidism (CH)?
- A. Assess for family history of CH.
- B. Assess mother for signs of hypothyroidism.
- C. Be certain appropriate screening is done prenatally.
- D. Be certain appropriate screening is done on newborn.
Correct Answer: D
Rationale: Early detection and prompt treatment are crucial in preventing the complications of congenital hypothyroidism (CH). All newborns should undergo newborn screening tests, including a test for CH. This screening helps to identify infants with CH early on, allowing for timely interventions such as thyroid hormone replacement therapy. Failure to conduct appropriate screening on newborns can lead to delayed diagnosis and treatment, which can result in significant developmental delays and other complications associated with CH. Therefore, ensuring that appropriate screening is done on newborns is a key nursing consideration in preventing the complications of congenital hypothyroidism.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
- A. Platelet count, prothrombin time, and partial thromboplastin time
- B. Platelet count, blood glucose levels, and white blood cell (WBC) count
- C. Thrombin time, calcium levels, and potassium levels
- D. Fibrinogen level, WBC, and platelet count
Correct Answer: A
Rationale: When monitoring a client for the development of disseminated intravascular coagulation (DIC), it is important to assess key parameters that can indicate abnormal clotting and bleeding tendencies. The platelet count is essential as DIC can lead to thrombocytopenia (low platelet count). Prothrombin time (PT) and partial thromboplastin time (PTT) are coagulation tests that evaluate the extrinsic and intrinsic pathways of blood clotting, respectively. Prolongation of these times can indicate abnormal coagulation processes seen in DIC. Monitoring these parameters allows healthcare providers to assess and manage DIC promptly to prevent further complications.
The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands?
- A. Organize nursing activities to allow for uninterrupted sleep.
- B. Allow the infant to sleep through feedings during the night.
- C. Wait for the infant to cry to show definite signs of hunger.
- D. Discourage parents from rocking the infant
Correct Answer: A
Rationale: Organizing nursing activities to allow for uninterrupted sleep is the most appropriate intervention to decrease cardiac demands in an infant with congestive heart disease (CHD). Providing a peaceful and quiet environment will help in conserving the infant's energy and reducing stress on the heart, ultimately decreasing cardiac demands. Interrupted sleep or inadequate rest can place additional strain on the infant's heart, leading to increased cardiac demands and potential complications. Prioritizing uninterrupted sleep will benefit the infant's overall cardiac function and well-being.
When taking the blood pressure of a client who has AIDS the nurse must;
- A. Wear a mask and gown
- B. Use barrier techniques
- C. Wash the hands thoroughly
Correct Answer: B
Rationale: When taking the blood pressure of a client with AIDS, it is important for the nurse to use barrier techniques to prevent the potential transmission of infection. This includes wearing gloves to protect against exposure to blood or other bodily fluids, using disposable blood pressure cuffs and stethoscopes, and ensuring proper hand hygiene before and after the procedure. Barrier techniques help minimize the risk of cross-contamination and protect both the healthcare provider and the client from potential infections.
Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: For HIV positive clients, one of the most important nursing interventions is to provide referral to support groups and resources where they can find emotional support, information, and guidance. Support groups can offer a sense of community, a safe space to share experiences, and practical advice on living with HIV. These groups can also provide valuable resources on managing HIV, accessing treatment, and coping with any associated stigma or discrimination. By connecting HIV positive clients to support groups and resources, nurses can help them navigate the challenges of living with HIV and promote their overall well-being and quality of life. This intervention fosters a holistic approach to care that goes beyond just medical treatment to address the social, emotional, and psychological needs of the client.