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A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
- A. Elevated temperature
- B. Generalized weakness
- C. Diminished lung sounds
- D. Pain when swallowing
Correct Answer: D
Rationale: Pain when swallowing could indicate an opportunistic infection such as candidiasis, which requires prompt treatment.
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An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?
- A. Apply a cool compress to the affected fingers for 20 minutes
- B. Secure a pulse oximeter to monitor the client's oxygen saturation
- C. Report the finding to the healthcare provider as soon as possible
- D. Continue to monitor the fingers until color returns to normal
Correct Answer: D
Rationale: Monitoring is appropriate as the symptoms are consistent with Raynaud's phenomenon and should resolve with warming.
The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain?
- A. left lateral
- B. Supine, knees flexed
- C. Dorsal recumbent
- D. Knee-chest
Correct Answer: A
Rationale: The left lateral position promotes drainage of the abscess and improves ventilation.
A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client?
- A. Cheese pasta and a lettuce and tomato salad
- B. Beef steak with steamed broccoli and orange slices
- C. Broiled white fish with a baked sweet potato
- D. Grilled shrimp and season rice with asparagus salad
Correct Answer: B
Rationale: The client's lab results indicate iron deficiency anemia. Beef steak is rich in iron, and vitamin C from orange slices enhances iron absorption, making this the best choice to address the anemia.
Insulin-like growth factor-l (IGF-I):
- A. Increases during pubertal growth spurt
- B. Is a single polypeptide chain
- C. Is produced in pancreas
- D. Is secreted in a pulsatile manner
Correct Answer: A
Rationale: IGF-I levels rise significantly during the pubertal growth spurt, contributing to rapid growth and development.
A child with rheumatic fever begins involuntary, purposeless movements of her limbs. What does the nurse recognize that this indicates?
- A. Seizure activity
- B. Hypoxia
- C. Sydenham’s chorea
- D. Decreasing level of consciousness
Correct Answer: C
Rationale: As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenham’s chorea, manifested by involuntary, purposeless movements of the limbs.