Nokea
A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
- A. Oral temperature of 100F
- B. Tachypnea and restlessness
- C. Frequent loose stools
- D. Weight loss of 1 pound since yesterday
Correct Answer: B
Rationale: The correct answer is B: Tachypnea and restlessness. This observation takes immediate priority as it indicates potential respiratory distress, a common complication of pneumonia in HIV patients. Tachypnea can be a sign of hypoxia, while restlessness may indicate increased work of breathing. Prompt intervention is crucial to prevent respiratory failure.
Choice A: Oral temperature of 100F is not an immediate priority as it is within normal range and may not directly impact the patient's immediate condition.
Choice C: Frequent loose stools may suggest gastrointestinal issues but are not as urgent as respiratory distress in this scenario.
Choice D: Weight loss of 1 pound since yesterday, while relevant in monitoring the patient's condition, does not require immediate intervention compared to respiratory distress.
You may also like to solve these questions
The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision?
- A. Im planning to avoid exposure to direct sunlight on my next vacation.
- B. Ive never exercised regularly, but Im going to start working out at the gym daily.
- C. Im planning to talk with my pharmacist to review my current medications.
- D. Im certainly going to keep a close eye on my blood pressure from now on.
Correct Answer: C
Rationale: The correct answer is C because reviewing current medications with a pharmacist is crucial in understanding potential threats to vision. Some medications can have side effects that impact eye health. This proactive approach shows an understanding of how medication can affect vision.
Choice A is incorrect because while avoiding direct sunlight is important for eye health, it does not address other potential threats. Choice B is incorrect because regular exercise, while beneficial for overall health, does not directly relate to understanding threats to vision. Choice D is incorrect because monitoring blood pressure is important for cardiovascular health but does not specifically address threats to vision.
A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses?
- A. Prepare an advance directive.
- B. Designate a most responsible physician (MRP) early in the course of the disease.
- C. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association.
- D. Ensure that witnesses are present when he provides instruction.
Correct Answer: A
Rationale: The correct answer is A: Prepare an advance directive. This allows the patient to document their healthcare preferences in advance, ensuring their wishes are known and honored as the disease progresses. It provides clear instructions for healthcare providers and family members, reducing potential conflicts and ensuring the patient's autonomy is respected.
Choice B is incorrect as designating an MRP focuses on medical decision-making but may not capture the full range of the patient's care preferences. Choice C involves collaboration with an organization, which may not fully represent the patient's individual wishes. Choice D is incorrect as witnesses are not always necessary for providing instructions, and the presence of witnesses does not guarantee that the patient's wishes will be followed accurately.
A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T- lymphocyte cell count drops below what threshold?
- A. 75 cells/mm3 of blood
- B. 200 cells/mm3 of blood
- C. 325 cells/mm3 of blood
- D. 450 cells/mm3 of blood
Correct Answer: B
Rationale: The correct answer is B (200 cells/mm3 of blood) because a patient with HIV is considered to have AIDS when their CD4+ T-lymphocyte cell count drops below 200 cells/mm3. This threshold signifies a significant decrease in the immune system's ability to fight off infections and indicates progression to AIDS.
Choice A (75 cells/mm3 of blood) is incorrect because this level is extremely low and would indicate severe immunosuppression, likely leading to AIDS much earlier than anticipated.
Choice C (325 cells/mm3 of blood) and D (450 cells/mm3 of blood) are also incorrect as these levels are within the normal range or slightly lower, which would not meet the criteria for a diagnosis of AIDS.
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?
- A. Rinsing the ears with normal saline after swimming
- B. Avoiding loud environmental noises
- C. Instilling antibiotic ointments on a regular basis
- D. Avoiding the use of cotton swabs
Correct Answer: A
Rationale: The correct answer is A: Rinsing the ears with normal saline after swimming. This is because rinsing with normal saline helps to remove excess moisture and debris, preventing bacterial growth that can lead to otitis externa. Avoiding loud noises (B) is important for overall ear health but does not specifically prevent otitis externa. Instilling antibiotic ointments regularly (C) is not recommended as it can disrupt the ear's natural flora. Avoiding cotton swabs (D) is important to prevent injury but does not directly prevent otitis externa.
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action?
- A. Assess the patient for additional signs and symptoms of Kaposis sarcoma.
- B. Review the patients most recent viral load and CD4+ count.
- C. Place the patient on respiratory isolation and inform the physician.
- D. Perform oral suctioning to reduce the patients risk for aspiration.
Correct Answer: C
Rationale: The correct answer is C: Place the patient on respiratory isolation and inform the physician. This is the most appropriate action because the patient is exhibiting symptoms that could be indicative of a potentially infectious respiratory condition, such as tuberculosis or pneumonia. Placing the patient on respiratory isolation helps prevent the spread of infection to others and protects healthcare workers. Informing the physician promptly allows for further evaluation and appropriate treatment.
Choice A is incorrect as Kaposi's sarcoma typically presents with skin lesions rather than respiratory symptoms. Choice B is incorrect as reviewing viral load and CD4+ count would not address the immediate concern of respiratory symptoms. Choice D is incorrect as oral suctioning is not the appropriate intervention for night sweats and coughing up blood.