Nokea
A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?
- A. Administer sleeping medication.
- B. Perform most activities for the client.
- C. Increase the client's oxygen during activity.
- D. Pace activities, allowing for adequate rest.
Correct Answer: D
Rationale: This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client's activity.
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A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?
- A. Consult with the pharmacy about drug interactions.
- B. Ensure the client understands the new medications.
- C. Give the new drugs without considering the old ones.
- D. Schedule all medications at standard times.
Correct Answer: A
Rationale: The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of disease.
Which statements are true about human immune deficiency virus (HIV)? (Select all that apply.)
- A. In HIV, CD4+ cells begin to create new HIV particles.
- B. Antibodies the client produces are incomplete and do not interact with macrophages.
- C. Macrophages also stop functioning properly.
- D. Opportunistic infections and cancer are leading causes of death.
- E. People with stage 1 HIV disease are not infectious to others.
Correct Answer: A,B,C,D
Rationale: In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not interact with macrophages. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.
A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Assess the client's mouth and throat.
- B. Determine if the client has a stiff neck.
- C. Ensure that the consent form is on the chart.
- D. Maintain NPO status as prescribed.
- E. Percuss the client's abdomen.
Correct Answer: A,C,D
Rationale: Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client's mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.
A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management?
- A. Infusions will be scheduled every 3 to 4 weeks.
- B. Treatment is aimed at treating specific infections.
- C. Unfortunately, there is no effective treatment.
- D. You will need many immunoglobulin A infusions.
Correct Answer: B
Rationale: Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.
An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?
- A. Initiate Contact Precautions.
- B. Place the client on Airborne Precautions.
- C. Place the client on Droplet Precautions.
- D. Use Standard Precautions consistently.
Correct Answer: D
Rationale: Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.