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How should the nurse respond when asked his or her opinion about treatment decisions by the client or their family?
- A. Provide evidence-based recommendations while respecting autonomy.
- B. Defer all decisions to the physician.
- C. Share personal opinions openly.
- D. Avoid giving any opinion.
Correct Answer: A
Rationale: Providing evidence-based recommendations while respecting the client's autonomy ensures informed decision-making and maintains professionalism.
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The nurse knows that the most likely cause of the HSV-1 infection in a client with HIV infection is:
- A. Immunosuppression.
- B. Emotional stress.
- C. Unprotected sexual activities.
- D. Contact with saliva.
Correct Answer: A
Rationale: HSV-1 thrives in immunocompromised individuals due to weakened immune defenses.
Vince has been taking excessive amounts of over-the-counter antacid tablets. He has been exhibiting signs of irritability, anxiety, muscle cramping, and weakness, and has recently developed tetany. The physician has initiated seizure precautions. He recognizes that the patient is being monitored and treated for:
- A. Hyperkalemia.
- B. Hyperphosphatemia.
- C. Metabolic acidosis.
- D. Metabolic alkalosis.
Correct Answer: D
Rationale: The correct answer is Metabolic alkalosis (D). Excessive intake of antacids containing bicarbonate or calcium carbonate can lead to metabolic alkalosis. Symptoms such as irritability, anxiety, muscle cramping, weakness, and tetany are consistent with elevated blood pH levels due to increased bicarbonate levels.
List in order the steps that are required to perform this function.
- A. Obtain an order for a chest x-ray to document tube placement
- B. Secure the tube in place
- C. Auscultate the chest during assisted ventilation
- D. Confirm that the breath sounds are equal and bilateral
Correct Answer: B
Rationale: Securing the tube ensures it remains in place during further assessments.
For your patient with a CD4 count, less than 200, the most important nursing assessment would include
- A. Bowel movements.
- B. Urinary output.
- C. Fever.
- D. Blood pressure.
Correct Answer: C
Rationale: Fever can indicate opportunistic infections in immunocompromised patients.
Which of the following is a definitive sign of pregnancy?
- A. Amenorrhea
- B. Positive hCG
- C. Morning sickness
- D. Fetal heart sounds
Correct Answer: D
Rationale: Fetal heart sounds are a definitive sign of pregnancy, confirming the presence of a viable fetus.