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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 correct answer is B. The nurse should explain that zidovudine (AZT) works by blocking reverse transcriptase, the enzyme necessary for HIV replication. This is the key mechanism of action for AZT in managing HIV.
Choice A is incorrect because it provides a partial truth - it does slow the disease process but does not provide the mechanism of action. Choice C is incorrect as it provides incorrect information that there are no medications to stop or cure HIV, which is not true. Choice D is incorrect as it provides misleading information about the drug becoming immune to HIV, which is not the primary concern in this context.
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Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?
- A. Fruity odor of the breath
- B. shallow, deep respirations
- C. severe dehydration
- D. profuse sweating
Correct Answer: C
Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect. The anesthesiologist should monitor the client for this adverse reaction. Muscle rigidity and spasms are common with ketamine administration and can affect the client's comfort and safety during the procedure. It is important for the nurse to promptly address any signs of muscle rigidity or spasms to prevent complications.
Summary of why other choices are incorrect:
B: Hiccups - Ketamine can cause hiccups, but it is not the primary side effect to monitor for in this scenario.
C: Extrapyramidal reactions - Ketamine does not typically cause extrapyramidal reactions.
D: Respiratory depression - Ketamine is known for its minimal effect on respiratory depression compared to other anesthetics. Monitoring respiratory depression is still important, but not the primary concern with ketamine administration in this case.
The nurse will assess a loss of ability in which of the following areas?
- A. Balance
- B. Speech
- C. Judgment
- D. Endurance
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate neurological, musculoskeletal, or sensory issues affecting mobility. Speech (B) is related to communication, judgment (C) to decision-making, and endurance (D) to stamina, not specifically to loss of ability. Balance is crucial for mobility and overall function, making it a priority area for assessment in healthcare settings.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is based on the patient's subjective feelings and concerns, which are important to address for a safe discharge. Choices A and B are incorrect as they assume the patient's readiness for independent tasks without considering their emotional state. Choice D is incorrect as there is no objective data provided to support the assumption that the surgery was not successful. It is important for the nurse to acknowledge and address the patient's emotional needs before discharge.
Which assessment action will help the nurse determine if the patient with Bell’s Palsy is receiving adequate nutrition?
- A. Monitor meal trays
- B. Check twice-weekly weights
- C. Measure intake and output
- D. Assess swallowing reflex
Correct Answer: D
Rationale: The correct answer is D: Assess swallowing reflex. This is crucial for a patient with Bell's Palsy as it can affect their ability to swallow properly, leading to inadequate nutrition intake. By assessing the swallowing reflex, the nurse can determine if the patient is at risk of aspiration or difficulty in eating, which directly impacts their nutrition status. Monitoring meal trays (A) may not provide accurate information on actual food intake. Checking weights (B) only gives limited information on nutrition status. Measuring intake and output (C) is important for fluid balance but may not directly reflect adequate nutrition intake.