Nokea
A classic full blown AIDS case is identified by clinical manifestations such as:
- A. Persistent generalized lymphadenopathy
- B. Sudden loss of weight, afternoon fever and general malaise
- C. Tumors and opportunistic infections
- D. Fever, weight loss, night sweats and diarrhea
Correct Answer: C
Rationale: Step 1: Classic full-blown AIDS presents with tumors and opportunistic infections due to severe immune system suppression.
Step 2: These manifestations occur when CD4 cell count drops significantly, leading to inability to fight infections.
Step 3: Persistent generalized lymphadenopathy (Choice A) can be seen in early HIV infection, not necessarily in full-blown AIDS.
Step 4: Sudden weight loss, fever, and malaise (Choice B) are non-specific symptoms seen in various conditions, not specific to AIDS.
Step 5: Fever, weight loss, night sweats, and diarrhea (Choice D) are common symptoms but lack the specificity of tumors and opportunistic infections seen in classic full-blown AIDS.
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A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is important because the patient may not accurately express their pain level verbally. By addressing the discrepancy between the patient's verbal report and non-verbal cues, the nurse can gather more information to assess the patient's pain accurately. By directly communicating with the patient, the nurse can ensure that the appropriate interventions are provided.
Choice A is incorrect because it disregards the need to address the patient's pain assessment. Choice B assumes the patient's preference without further clarification. Choice D jumps to administering pain medication without fully assessing the situation, which could lead to inappropriate treatment.
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
- A. Obtain his oral temperature
- B. Allow him to wear his own clothing
- C. Encourage to perform his own personal
- D. Encourage him to be out of bed hygiene
Correct Answer: A
Rationale: The correct answer is A: Obtain his oral temperature. Seizure precautions typically include avoiding putting objects in the mouth to prevent injury during a seizure. Taking an oral temperature involves placing an object in the mouth, which could pose a risk if a seizure occurs. Choices B, C, and D are not contraindicated as they do not directly involve potential risks during a seizure. Allowing the patient to wear his own clothing, encouraging personal hygiene, and promoting mobility are safe practices that do not increase the risk of harm during a seizure.
The nurse has been teaching an adult who has iron deficiency anemia about those foods that she needs to include in her meal plans. Which of the following, if selected, would indicate to the nurse that the client understands the dietary instructions?
- A. Citrus fruits and green leafy vegetables
- B. Bananas and nuts
- C. Coffee and tea
- D. Dairy products
Correct Answer: A
Rationale: The correct answer is A: Citrus fruits and green leafy vegetables. Citrus fruits and green leafy vegetables are good sources of Vitamin C and iron, which are essential for individuals with iron deficiency anemia. Vitamin C enhances the absorption of iron from plant-based sources, while green leafy vegetables provide iron. Bananas and nuts (choice B) are not significant sources of iron. Coffee and tea (choice C) can inhibit iron absorption. Dairy products (choice D) are not high in iron and can also inhibit iron absorption. Therefore, choosing citrus fruits and green leafy vegetables indicates understanding of the dietary instructions for managing iron deficiency anemia.
In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
- A. Presence of opportunistic infections
- B. Extent of immune system damage
- C. Level of the viral load
- D. Resistance to antigens
Correct Answer: B
Rationale: Step-by-step rationale:
1. CD4+ cells are a type of white blood cell crucial for immune function.
2. HIV targets and destroys CD4+ cells, leading to immune system damage.
3. Measuring CD4+ levels helps determine the extent of this damage.
4. Therefore, the correct answer is B.
Summary:
A: Presence of opportunistic infections - CD4+ levels indirectly affect susceptibility, but not measured for this purpose.
C: Level of the viral load - Measured separately from CD4+ levels.
D: Resistance to antigens - CD4+ levels do not directly indicate resistance.
The nurse is aware that in communicating with an elderly client, the nurse will
- A. Lean and shout at the ear of the client
- B. Use a low-pitched voice
- C. Open mouth wide while talking to the client
- D. Use a medium-pitched voice
Correct Answer: B
Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals may have age-related hearing loss, making it difficult for them to hear higher frequencies. Using a low-pitched voice can help ensure that the client can hear and understand the nurse clearly.
A: Leaning and shouting at the ear of the client may come across as aggressive and disrespectful.
C: Opening the mouth wide while talking is not necessary and may be seen as patronizing.
D: Using a medium-pitched voice may still be too difficult for the elderly client to hear clearly due to age-related hearing loss.