Nokea
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
- A. E-rosette immunofluorescence
- B. Enzyme-linked immunosorbent assay
- C. Quantification of T-lymphocytes (ELISA)
- D. Western blot test with ELISA
Correct Answer: D
Rationale: The correct answer is D, the Western blot test with ELISA. First, ELISA is used as a screening test for HIV antibodies. If positive, a confirmatory test like Western blot is needed to detect specific antibodies. Western blot is highly specific and confirms the presence of HIV antibodies. E-rosette immunofluorescence is not typically used for HIV diagnosis. Quantification of T-lymphocytes is used to monitor disease progression in HIV but does not confirm HIV infection. ELISA alone is not confirmatory; it needs to be followed by a more specific test like Western blot.
You may also like to solve these questions
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation.
Incorrect Choices:
A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns.
C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication.
D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.
An adult has a central line in his right subclavian vein. The nurse is to change the tubing. Which of the following should be done?
- A. Use the present solution with the new tubing
- B. Connect the new tubing to the hub prior to running any fluid through the tubing
- C. Close the roller clamp on the new tubing after priming it
- D. Have the client roll to the right side to prevent an air embolus
Correct Answer: C
Rationale: The correct answer is C: Close the roller clamp on the new tubing after priming it. This step ensures that the tubing is primed with the solution and ready for use while preventing air from entering the central line. Option A is incorrect because using the present solution may introduce contamination. Option B is incorrect as connecting tubing before running fluid can introduce air into the line. Option D is incorrect as positioning the client on the right side does not prevent air embolism during tubing change.
Which of the ff is the most severe complication among clients with allergies, regardless of type?
- A. Bronchitis
- B. Anaphylactic shock and angioneurotic
- C. Cardiac arrest edema
- D. Asthma and nasal polyps
Correct Answer: B
Rationale: The correct answer is B, anaphylactic shock and angioedema, as it is the most severe complication of allergies and can be life-threatening. Anaphylactic shock can lead to airway constriction, severe drop in blood pressure, and organ failure. Angioedema can cause swelling of the face, lips, and throat, leading to difficulty breathing. Bronchitis (A) is a respiratory condition that can occur due to allergies but is not typically life-threatening. Cardiac arrest (C) is a serious complication but not directly related to allergies. Asthma and nasal polyps (D) are common allergic conditions but are not as immediately life-threatening as anaphylactic shock.
A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client’s signs/symptoms is:
- A. fluid volume deficit related to depletion of intravascular volume
- B. altered thought process related to toxic effects of elevated ammonia levels
- C. abdominal pain related to increased intestinal peristalsis
- D. altered nutrition: less than body requirements related to malabsorption
Correct Answer: A
Rationale: The correct answer is A: fluid volume deficit related to depletion of intravascular volume. Peritonitis causes inflammation of the peritoneum, leading to fluid shifting into the peritoneal cavity, causing hypovolemia. Hypotension and tachycardia are signs of decreased intravascular volume. Rigid abdominal muscles and rebound tenderness indicate peritoneal irritation. Choice B is incorrect because elevated ammonia levels are not associated with the client's symptoms. Choice C is incorrect because increased peristalsis does not explain the client's hypotension and tachycardia. Choice D is incorrect because malabsorption does not align with the client's acute presentation of severe abdominal pain and peritonitis.
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
- A. “Choose all the interventions and perform them in order of time needed for each one.”
- B. “Make sure you identify the scientific rationale for each intervention first.”
- C. “Decide on goals and outcomes you have chosen for the patients.”
- D. “Begin with the highest priority diagnoses, then select appropriate interventions.”
Correct Answer: D
Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions."
Rationale:
1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being.
2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery.
3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient.
4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes.
Summary:
A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs.
B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses.
C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.