Nokea
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.
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An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patients plan of nursing care should prioritize which of the following?
- A. Assess the patient hourly for signs of compartment syndrome.
- B. Assess the patients fine motor skills once per shift.
- C. Assess the patients wound for dehiscence every 4 hours.
- D. Maintain the patients head of bed at 45 degrees or more at all times.
Correct Answer: C
Rationale: The correct answer is C because assessing the patient's wound for dehiscence every 4 hours is crucial post hemicolectomy to monitor for any signs of wound complications, such as infection or tissue breakdown. This allows for early detection and intervention, promoting optimal wound healing and preventing potential complications.
Choice A is incorrect as compartment syndrome is not a common complication after a hemicolectomy, and assessing for it hourly would be excessive and unnecessary.
Choice B is incorrect as assessing fine motor skills is not a priority in the immediate postoperative period following a hemicolectomy.
Choice D is incorrect as maintaining the patient's head of bed at 45 degrees or more is important for preventing respiratory complications, but it is not the top priority compared to wound assessment for dehiscence in this scenario.
A nurse is completing an OASIS data set on apatient. The nurse works in which area?
- A. Home health
- B. Intensive care unit
- C. Skilled nursing facility
- D. Long-term care facility
Correct Answer: A
Rationale: The correct answer is A: Home health. The Outcome and Assessment Information Set (OASIS) data set is specifically used in the home health care setting to assess the patient's condition and needs. This includes collecting data on the patient's health, functional status, and living environment to determine the appropriate care plan. In contrast, choices B, C, and D are incorrect because OASIS is not utilized in the intensive care unit, skilled nursing facility, or long-term care facility settings. These settings have their own assessment tools and documentation requirements that are different from OASIS used in home health care.
When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
- A. Loss of muscle tone in the vaginal wall
- B. Excessive synthesis and release of unopposed estrogen
- C. Invasion of the uterine wall by endometrial tissue
- D. Proliferation of tumors in the uterine wall
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus.
Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall.
Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis.
Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
- A. Maximize the patients fluid intake.
- B. Provide total parenteral nutrition (TPN).
- C. Keep the patients bed linens free of wrinkles.
- D. Provide the patient with snug clothing at all times.
Correct Answer: C
Rationale: The correct answer is C: Keep the patient's bed linens free of wrinkles. This intervention is important in preventing pressure ulcers, a common complication in patients with impaired skin integrity. Wrinkles in bed linens can create pressure points on the skin, leading to skin breakdown. By keeping the bed linens smooth and wrinkle-free, the patient's skin is protected from excessive pressure, reducing the risk of impaired skin integrity.
A: Maximizing fluid intake is important for overall health but is not directly related to preventing impaired skin integrity.
B: Providing total parenteral nutrition may support the patient's nutritional needs but does not specifically address the risk of impaired skin integrity.
D: Providing snug clothing can increase friction and pressure on the skin, potentially worsening the risk of impaired skin integrity.
What is the priority nursing intervention for the patient who has had an incomplete abortion?
- A. Methylergonovine (Methergine), 0.2 mg IM
- B. Preoperative teaching for surgery
- C. Insertion of IV line for fluid replacement
- D. Positioning of patient in left side-lying position
Correct Answer: C
Rationale: The correct answer is C because the priority nursing intervention for a patient with incomplete abortion is to ensure adequate fluid replacement to prevent hypovolemic shock due to potential blood loss. Inserting an IV line allows for immediate administration of fluids and medications if necessary. Choice A (Methylergonovine) is used to manage postpartum hemorrhage, not incomplete abortion. Choice B (Preoperative teaching) and choice D (Positioning) are important but not the priority in this situation.