Nokea
A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiologic mechanism should the nurse describe in response to this client's question?
- A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
- B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.
- C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
- D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
Correct Answer: B
Rationale: Inadequate numbers of CD4+ T cells, due to HIV infection, impair cellular immunity, leading to susceptibility to opportunistic infections like Pneumocystis jiroveci pneumonia.
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The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding(s) should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)
- A. Abdominal obesity.
- B. Blood pressure of 150/96 mm Hg.
- C. Elevated high density lipoproteins.
- D. Increased triglyceride levels.
- E. Hyperglycemia.
- F. Hypothyroidism.
Correct Answer: A,B,D,E
Rationale: Abdominal obesity, elevated blood pressure, increased triglyceride levels, and hyperglycemia are components of metabolic syndrome that increase the risk of diabetes and vascular disease, requiring intervention.
Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- C. Report the COVID-19 result to the local health department according to CDC guidelines.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: B
Rationale: Isolating the client from others not wearing proper PPE is the most important action to prevent transmission of COVID-19, given the client's symptoms suggestive of the virus.
After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?
- A. Canned vegetables with additional table salt.
- B. Pasta with herbal butter and no meat sauce.
- C. Citrus fruit and melon with a salt substitute.
- D. Whole milk and daily servings of ice cream.
Correct Answer: D
Rationale: Eliminating whole milk and daily ice cream indicates successful teaching, as these high-fat foods can worsen gallbladder inflammation and increase gallstone formation risk.
Flow sheets
1915
Arrival at emergency department
1920
Vital Signs:
- Temperature: 98.2° F (36.8° C)
- Heart rate: 92 beats/minute
- Respirations: 24 breaths/minute
- Blood pressure: 210/98 mmHg
- Oxygen saturation: 95% on room air
Imaging studies
1935
Head CT scan results:
- No evidence of intracranial hemorrhage
- No evidence of acute disease
Orders
- Obtain CT scan of the head.
- Insert a large bore peripheral IV.
- Start normal saline infusion at 50 mL/hour.
The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand. Select the interdisciplinary team members who should assist the client in recovery.
- A. Occupational Therapist
- B. Speech Therapist
- C. Case manager
- D. Physical therapist
- E. Chief Nursing Officer
- F. Pharmacy Technician
Correct Answer: A,B,C,D
Rationale: Occupational, speech, and physical therapists address stroke-related impairments in daily activities, communication, and mobility, while a case manager coordinates care and discharge planning.
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
- A. Applies prescribed lotions to the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Wears clothing to cover the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing the radiation site with antibacterial soap and water can cause dryness, inflammation, and infection, indicating a need for further teaching on using mild soap or saline.