Nokea
A parent is admitted to a chemical dependency treatment unit. The patients spouse and adolescent children participate in a family session. What is the most important aspect of this familys assessment?
- A. Spouses codependent behaviors
- B. Interactions among family members
- C. Patients reaction to the familys anger
- D. Childrens responses to the family sessions
Correct Answer: B
Rationale: Interactions among all family members are the raw material for family problem solving. By observing interactions, the nurse can help the family make its own assessments of strengths and deficits. The other options are narrower in scope when compared with the correct option.
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contribute(s) to homeostasis by selfregulation and helps to maintain the stability of relationships.
- A. Open systems
- B. Closed systems
- C. Negative feedback
- D. Positive feedback
Correct Answer: C
Rationale: Negative feedback stabilizes systems by counteracting deviations.
When administering medications, a nurse would hold which medication for a patient who presents with jaundice? A. Valium B. Divalproex (Depakote) C. Lithium D. Verapamil
- A. Valium
- B. Divalproex (Depakote)
- C. Lithium
- D. Verapamil
Correct Answer: B
Rationale: The correct answer is B: Divalproex (Depakote). Jaundice is a condition characterized by yellowing of the skin and eyes due to liver dysfunction. Divalproex is metabolized in the liver, and in patients with jaundice, liver function may be compromised, leading to potential toxicity. Therefore, holding Divalproex for a patient with jaundice is essential to prevent further liver damage.
A: Valium is primarily metabolized in the liver, but it is generally safe to use in patients with mild to moderate liver impairment.
C: Lithium is primarily cleared through the kidneys, so liver dysfunction would not directly impact its clearance.
D: Verapamil is also primarily metabolized in the liver, but it is not contraindicated in patients with jaundice unless there is severe liver impairment.
The nurse is reviewing laboratory results for a patient who has HIV. Which result would be strongly suggestive of a diagnosis of AIDS?
- A. CD4+ = 180/μL
- B. CD4+ percentage = 68%
- C. CD8+ = 650/μL
- D. CD4+/CD8+ ratio = 1.5
Correct Answer: A
Rationale: The correct answer is A because a CD4+ count of 180/μL is significantly below the normal range (500-1500/μL) and indicative of severe immunosuppression, which is a hallmark of AIDS. CD4+ percentage alone (choice B) may not provide the full picture. CD8+ count (choice C) doesn't directly indicate immune system status in HIV/AIDS. The CD4+/CD8+ ratio (choice D) may be altered in various conditions, not specific to AIDS.
A patient with AIDS-related wasting syndrome is very weak, lies listlessly in bed, has an intravenous (IV) drip, and receives antiretroviral medications via injection. What should be the priority nursing diagnosis for this patient?
- A. Pain related to immobility
- B. Ineffective Individual Coping due to terminal stage of HIV
- C. Risk for Injury due to impaired mobility, weakness, and weight loss
- D. Risk for Infection due to weak immune system and parenteral therapy
Correct Answer: D
Rationale: The correct answer is D: Risk for Infection due to weak immune system and parenteral therapy. This is the priority nursing diagnosis because a patient with AIDS-related wasting syndrome is at high risk for infections due to their weak immune system and parenteral therapy, which can introduce pathogens into the body. Addressing the risk for infection is crucial in preventing further complications and promoting the patient's overall well-being.
Choice A (Pain related to immobility) is not the priority as the patient's immobility is not the immediate concern compared to the risk of infection.
Choice B (Ineffective Individual Coping due to terminal stage of HIV) may be a valid concern, but ensuring the patient's physical health and preventing infections take precedence.
Choice C (Risk for Injury due to impaired mobility, weakness, and weight loss) is important but does not address the immediate threat of infection that the patient faces.
Which mode of decisionmaking is prevalent among families of Asian Indian origin?
- A. Individual deliberation
- B. Conscious belief-based deliberation
- C. Instinct-based deliberation
- D. Communal deliberation
Correct Answer: D
Rationale: Communal decision-making is typical in Asian Indian families, involving multiple members.