Which of the ff is the main reason why older clients with AIDS need more care than their younger counterparts?
- A. Because the older clients lack balanced diet and activity
- B. Because older clients lack knowledge about disorders
- C. Because older clients have a faster progression of disease
- D. Because older clients do not generally adhere to a therapy
Correct Answer: C
Rationale: The main reason why older clients with AIDS need more care than their younger counterparts is because older clients have a faster progression of the disease. As a person ages, their immune system tends to weaken, making them more vulnerable to infections and complications from diseases like AIDS. Older individuals may have decreased immune function and lower resilience when combating HIV-related complications compared to younger clients. This faster disease progression necessitates more frequent monitoring, specialized care, and management strategies tailored to the specific needs of older patients with AIDS. Therefore, older clients with AIDS require more support, medical attention, and comprehensive care to address their complex health needs effectively.
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The nurse is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?
- A. uneven head shape
- B. respirations are irregular, abdominal, 30-60 bpm
- C. (+) Moro reflex
- D. heart rate is 80 bpm
Correct Answer: D
Rationale: The heart rate of a normal newborn is typically 120 to 160 bpm. Therefore, a heart rate of 80 bpm would be least likely to be observed in a normal newborn. This finding may indicate bradycardia, which should be further evaluated and managed by the healthcare provider. Other options such as an uneven head shape, irregular respirations, (+) Moro reflex are common and expected in newborns.
Which nursing action is most appropriate for the weak patient with osteoporosis?
- A. Maintain bedrest
- B. Ambulate with assistance
- C. Encourage fluids
- D. Provide a high-protein diet
Correct Answer: B
Rationale: For a weak patient with osteoporosis, it is important to promote mobility and weight-bearing activities to help maintain bone strength and prevent further bone loss. Ambulating with assistance can help improve muscle strength and balance, reducing the risk of falls and fractures. Maintaining bedrest can lead to further weakness and bone loss, so it is not the most appropriate action in this case. Encouraging fluids and providing a high-protein diet are important for overall health and healing but might not directly address the specific needs of a weak patient with osteoporosis.
A highly careful mother of a 10-month-old baby boy complains of inadequate weight gain due to refusal of spoon feeding. The LEAST helpful advice is to
- A. respect infant independence
- B. offer softer diet
- C. use 2 spoons (1 for the child and 1 for the parent)
- D. use finger foods
Correct Answer: B
Rationale: Offering softer food may not address the underlying issue of refusal.
To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should;
- A. Use aseptic technique for the insertion site.
- B. Use clean technique for cleansing connections and aseptic technique for the insertion site.
- C. Use sterile technique when cleansing the insertion site
- D. Close any leaks in the tubing with tape. SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Correct Answer: A
Rationale: To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should use aseptic technique for the insertion site. Aseptic technique involves maintaining a sterile field to prevent the introduction of microorganisms that could lead to infection. Using aseptic technique specifically for the insertion site helps reduce the risk of introducing pathogens into the patient's intracranial system, reducing the chances of infection. Additionally, maintaining a strict aseptic technique is crucial for preventing complications and ensuring patient safety when managing intracranial pressure monitoring systems.
Cow's milk allergy (CMA) is diagnosed in a 6-month-old infant. Which should the nurse recommend as a substitute formula?
- A. Nutramigen
- B. Goat's milk
- C. Similac
- D. Enfamil
Correct Answer: A
Rationale: Nutramigen is a hypoallergenic formula specifically designed for infants with cow's milk allergy (CMA). It is extensively hydrolyzed, which means the cow's milk proteins are broken down into smaller pieces, making it easier for babies with CMA to digest without triggering an allergic reaction. Other options such as goat's milk, Similac, and Enfamil are not suitable substitutes for an infant with CMA as they may still contain proteins that can cause an allergic response in these infants. Therefore, Nutramigen is the most appropriate recommendation for a 6-month-old infant diagnosed with cow's milk allergy.