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A patient is in the primary infection stage of HIV. What is true of this patients current health status?
- A. The patients HIV antibodies are successfully, but temporarily, killing the virus.
- B. The patient is infected with HIV but lacks HIV-specific antibodies.
- C. The patients risk for opportunistic infections is at its peak.
- D. The patient may or may not develop long-standing HIV infection.
Correct Answer: B
Rationale: During the primary infection stage of HIV, the patient is newly infected with the virus. At this stage, the patient's immune system has not yet produced HIV-specific antibodies, making it difficult to detect HIV infection using standard antibody tests. Instead, the virus can be detected by testing for the presence of HIV RNA or p24 antigen. The primary infection stage is characterized by a high level of viral replication and rapid spread of the virus throughout the body. In this early stage, the patient may experience flu-like symptoms such as fever, sore throat, muscle aches, and swollen lymph nodes. The absence of HIV-specific antibodies means that the patient is highly infectious and can easily transmit the virus to others. As the infection progresses, the patient will eventually develop HIV-specific antibodies, which can be detected through antibody tests.
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The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
- A. Cool, clammy skin
- B. Altered sensorium
- C. Pulse oximeter reading of 95%
- D. Respiratory rate of less than 12 breaths per minute
Correct Answer: B
Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.
Which of the following individuals would be the most appropriate candidate for immunotherapy?
- A. A patient who had an anaphylactic reaction to an insect sting
- B. A child with allergies to eggs and dairy
- C. A patient who has had a positive tuberculin skin test
- D. A patient with severe allergies to grass and tree pollen
Correct Answer: D
Rationale: Immunotherapy, also known as allergy shots, is a form of treatment that can help reduce symptoms for individuals with severe allergies to substances such as pollen, dust mites, or pet dander. This treatment involves exposing the patient to small, increasing doses of the allergen over time to help the immune system gradually build up a tolerance. Patients with severe allergies to grass and tree pollen would most likely benefit from immunotherapy as it can help reduce their allergy symptoms and improve their quality of life. On the other hand, individuals with anaphylactic reactions to insect stings (Choice A), allergies to eggs and dairy (Choice B), or a positive tuberculin skin test (Choice C) are not typically candidates for immunotherapy as their conditions are not related to the type of allergies that are commonly treated with this method.
The nurse, upon reviewing the history, discoversthe patient has dysuria. Which assessment finding is consistent with dysuria?
- A. Blood in the urine
- B. Burning upon urination
- C. Immediate, strong desire to void
- D. Awakes from sleep due to urge to void
Correct Answer: B
Rationale: Dysuria is defined as a burning or painful sensation during urination. It is a common symptom of various urinary tract infections and other conditions affecting the urinary system. Patients experiencing dysuria often describe a discomfort or burning sensation while passing urine. Therefore, the assessment finding consistent with dysuria is the presence of burning upon urination.
A nurse is teaching a patient about the largeintestine in elimination. In which order will the nurse list the structures, starting with the first portion?
- A. Cecum, ascending, transverse, descending, sigmoid, and rectum
- B. Ascending, transverse, descending, sigmoid, rectum, and cecum
- C. Cecum, sigmoid, ascending, transverse, descending, and rectum
- D. Ascending, transverse, descending, rectum, sigmoid, and cecum
Correct Answer: A
Rationale: The order in which the structures of the large intestine are listed starting with the first portion is as follows: cecum (the pouch where the large intestine begins), ascending colon (runs vertically up the right side of the abdomen), transverse colon (crosses horizontally from the right side of the abdomen to the left), descending colon (descends vertically down the left side of the abdomen), sigmoid colon (the S-shaped curve that leads into the rectum), and rectum (the final portion where feces are stored before being eliminated from the body). Therefore, option A provides the correct order of structures in the large intestine during elimination.
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?
- A. Teach the patient about the risks of ototoxic medications.
- B. Instruct the patient to protect the ear from water for several weeks.
- C. Teach the patient to remove cerumen safely at least once per week.
- D. Instruct the patient to protect the ear from temperature extremes until healing is complete.
Correct Answer: B
Rationale: After a mastoidectomy, the ear should be protected from water for several weeks. This is because exposing the area to water can increase the risk of infection. Keeping the ear dry allows the surgical site to heal properly and reduces the likelihood of postoperative complications such as infection. Therefore, instructing the patient to protect the ear from water is an important intervention to prevent postoperative infection following a mastoidectomy.