Nokea
A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?
- A. Hyperactive deep tendon reflexes.
- B. Peripheral neuropathy affecting the hands.
- C. Disorientation to person, place, and time.
- D. Impaired concentration and memory loss.
Correct Answer: C
Rationale: approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation
You may also like to solve these questions
The nurse is caring for a client who is postoperative day 1 after a total knee replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of the incentive spirometer.
- B. Administer pain medication as needed.
- C. Apply a continuous passive motion (CPM) machine.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Applying the CPM machine prevents stiffness and promotes mobility post-knee replacement. Options A, B, and D are secondary.
A client is scheduled for a cardiac catheterization at 8 AM. The client's laboratory work was completed five days ago. The results were: K⺠3.0 mEq/L, Na⺠148 mEq/L, glucose 178 mg/dL. He complains of muscle weakness and cramps.
Which of the following nursing actions is BEST?
- A. Administer the 7 AM dose of spironolactone (Aldactone).
- B. Encourage eating bananas for breakfast.
- C. Obtain stat K⺠level.
- D. Call for twelve-lead EKG.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) Aldactone is potassium-sparing diuretic and is an oral medication, patient is NPO for procedure (2) is not feasible prior to the cardiac cath because the client is NPO (3) correct-signs and symptoms are indicative of hypokalemia; stat serum K⺠level is needed to confirm the K⺠level prior to going for cardiac catheterization (4) is unnecessary at this time
A 56-year-old woman hospitalized with bipolar disorder. While the patient is in the manic phase.
Nursing interventions should involve
- A. talking to the patient and reinforcing behaviors.
- B. distracting the patient and redirecting behaviors.
- C. limit-setting and isolating the patient.
- D. orienting to and reminding the patient of the rules of the hospital.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not be effective in changing behaviors, requires an attentive listener (2) correct-patient experiences hyperactivity, poor concentration, and distractibility, redirect into activity that promotes rest, nourishment, reduce stimuli (3) isolation not required, would increase anxiety and hostility (4) disorientation usually not seen, no memory disturbance
The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most expect to find in the client's history?
- A. Postcoital vaginal bleeding
- B. Nausea and vomiting
- C. Foul-smelling vaginal discharge
- D. Hyperthermia
Correct Answer: A
Rationale: Postcoital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor involvement of the cervix. Nausea, vomiting, foul-smelling discharge, and hyperthermia may occur in advanced stages or infections but are less specific, so B, C, and D are incorrect.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should
- A. place a call to the client's provider for instructions
- B. send him to the emergency room for evaluation
- C. reassure the client's partner that the symptoms are transient
- D. instruct the client's partner to call the provider if his symptoms become worse
Correct Answer: B
Rationale: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.