Nokea
A patient with AIDS is prescribed the nucleoside reverse transcriptase inhibitor lamivudine (Epivir). What information should the nurse ensure that the patient receives about this medication? (Select all that apply.)
- A. Report any onset of bleeding.
- B. Report any yellowing of the skin.
- C. Report any change in urine output.
- D. Report any symptoms similar to having the flu.
Correct Answer: B
Rationale: Step 1: Lamivudine (Epivir) can cause hepatotoxicity, leading to yellowing of the skin (jaundice).
Step 2: Yellowing of the skin is a serious side effect that should be reported immediately to prevent further liver damage.
Step 3: Reporting yellowing of the skin promptly allows for timely evaluation and necessary interventions.
Summary: Reporting bleeding, change in urine output, or flu-like symptoms are not specific to lamivudine and are not directly related to its side effects. Yellowing of the skin is a critical side effect that requires immediate attention.
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The nurse is concerned that a depressed client may be displaying a nonverbal suicidal threat when he presents another client with his favorite shirt as a 'gift.' The nurse's initial intervention is to:
- A. Place the client on suicide precautions including 15-minute checks.
- B. Ask the client if he is experiencing suicidal ideations with a plan to hurt himself.
- C. Support the client by telling him that he will need the shirt when he's discharged.
- D. Document that the client has shown behaviors that are likely subtle suicide threats.
Correct Answer: B
Rationale: The correct answer is B because asking the client directly about suicidal ideations with a plan to hurt himself is the most immediate and appropriate intervention to assess the client's safety. This approach allows the nurse to directly address the potential risk of suicide and initiate appropriate interventions if necessary. Placing the client on suicide precautions (choice A) without assessing the client's thoughts may be premature and intrusive. Supporting the client about the shirt (choice C) does not address the underlying concern of suicidal behavior. Simply documenting the behavior (choice D) without taking immediate action to assess and address the risk is insufficient in ensuring the client's safety.
An HIV-infected patient reports being a cat lover and says, 'I always get my pets from a known sanitary source.' What should the nurse instruct the patient about cats and the risk of infection?
- A. Keep cats outdoors most of the time.'
- B. Obtain only cats that are less than 1 year old.'
- C. Remove all pets from your home. Avoid all contact with cats.'
- D. Be sure all the cats have up-to-date immunizations, and avoid their feces.'
Correct Answer: D
Rationale: The correct answer is D because HIV-infected individuals are at higher risk for infections, including from Toxoplasma gondii found in cat feces. By ensuring cats have up-to-date immunizations and avoiding their feces, the patient can reduce the risk of infection.
A: Keeping cats outdoors most of the time does not address the risk from cat feces inside the house.
B: The age of the cat does not necessarily correlate with the risk of infection, so this advice is not relevant.
C: Removing all pets and avoiding all contact with cats is an extreme measure and not necessary if proper precautions are taken.
hich of the following terms refers to individual beliefs and actions that are rooted in stereotype behaviors?
- A. Gender segregation
- B. Intersequentialized sexism
- C. Gender socialization
- D. Individual sexism
Correct Answer: D
Rationale: Individual sexism reflects personal stereotypical beliefs and actions, unlike broader processes.
The nurse best engages in self-analysis that will benefit a specific nurse-client relationship when:
- A. Refraining from expressing any negative feelings about a client's behaviors.
- B. Asking, 'What barriers exist that make it difficult for me to provide effective care for this client?'
- C. Reporting to the nurse manager that, 'I've tried but I just can't work therapeutically with this client.'
- D. Avoiding conflict with the client by seldom setting boundaries or disagreeing with his or her beliefs.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates reflective practice by focusing on self-awareness and identifying potential barriers to effective care. This approach allows the nurse to address personal biases, limitations, and areas for growth, leading to improved nurse-client relationships.
Choice A is incorrect as it suggests suppressing negative feelings, which may hinder self-awareness and authenticity in the relationship. Choice C is incorrect as it avoids self-analysis and seeks external solutions, which may not address the root of the issue. Choice D is incorrect as it prioritizes avoiding conflict over establishing healthy boundaries, which is essential for therapeutic relationships.
The nurse demonstrates an understanding of the first assumption of Stuart's Stress Adaptation Model when:
- A. Encouraging a client's adult children to accompany their parent to family group therapy sessions.
- B. Discussing with a client's health team which interventions should be included in the plan of care.
- C. Planning interventions based on a particular nursing theory that is relevant to the client's problem.
- D. Identifying community resources that will help a mentally ill client live in his own home.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The first assumption of Stuart's Stress Adaptation Model is that the client is a part of a larger system involving family and social support. By encouraging a client's adult children to accompany their parent to family group therapy sessions, the nurse is acknowledging and incorporating the client's support system. This aligns with the model's focus on involving family members in the client's care to promote adaptation and stress management. This approach recognizes the importance of social support in the client's overall well-being.
Summary of Other Choices:
B: Discussing interventions with the health team focuses on collaboration and coordination but does not specifically address the client's family support system as required by the model.
C: Planning interventions based on a nursing theory is important but does not directly align with the first assumption of involving the client's family.
D: Identifying community resources is beneficial, but it does not specifically address the client's family support system, which is the primary focus of the first assumption in Stuart