Other signs of hypovolemia includes all of the following except:
- A. Dry mucous membranes and soft eyeballs
- B. Increased hematocrit and hemoglobin
- C. Decreased pulse rate and widened pulse pressure
- D. Increased lethargy and confusion
Correct Answer: A
Rationale: When assessing for signs of hypovolemia, dry mucous membranes and soft eyeballs are actually indicative of dehydration, not specifically hypovolemia. In hypovolemia, the body loses both fluid and electrolytes, leading to decreased circulating blood volume. Other signs of hypovolemia include increased hematocrit and hemoglobin levels due to hemoconcentration, decreased pulse rate and widened pulse pressure as compensatory mechanisms to maintain perfusion to vital organs, and increased lethargy and confusion due to impaired perfusion to the brain.
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Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: For HIV positive clients, one of the most important nursing interventions is to provide referral to support groups and resources where they can find emotional support, information, and guidance. Support groups can offer a sense of community, a safe space to share experiences, and practical advice on living with HIV. These groups can also provide valuable resources on managing HIV, accessing treatment, and coping with any associated stigma or discrimination. By connecting HIV positive clients to support groups and resources, nurses can help them navigate the challenges of living with HIV and promote their overall well-being and quality of life. This intervention fosters a holistic approach to care that goes beyond just medical treatment to address the social, emotional, and psychological needs of the client.
Which food is recommended for the patient who must increase intake of potassium?
- A. Bread
- B. Potato
- C. Egg
- D. Cereal
Correct Answer: B
Rationale: Potassium is an essential mineral that plays a key role in numerous bodily functions, including muscle contractions and maintaining proper heart function. Among the options given, potatoes are an excellent source of potassium. One medium-sized potato can provide around 900 mg of potassium, making it a great choice for individuals who need to increase their potassium intake. Therefore, potatoes are recommended for the patient who must increase their intake of potassium.
A 17-year-old boy is admitted in sickle cell crisis. Which of the ff. events most likely contributed to the onset of the crisis?
- A. He started a new job last week.
- B. He had seafood for dinner last night.
- C. He walked home in a cold rain
- D. He has not exercised for a week. yesterday.
Correct Answer: C
Rationale: Walking home in a cold rain can trigger a sickle cell crisis in individuals with sickle cell disease. Exposure to cold temperatures or getting wet can lead to vasoconstriction, causing the blood vessels to narrow and slow down blood flow. This reduced blood flow can increase the likelihood of sickle cells sticking together and blocking blood vessels, leading to pain and tissue damage characteristic of a sickle cell crisis. It is essential for individuals with sickle cell disease to avoid exposure to extreme temperatures, including cold rain, to prevent the onset of a crisis.
A 34 year old client is diagnosed with AIDS. His pharmacologic management includes zidovudine (AZT). During a home visit, the client states, "I don't understand how this medication works. Will it stop the infection?" What is the nurse's best response?
- A. The medication helps to slow the disease process, but it won't cure or stop it totally
- B. The medication blocks reverse transcriptase, the enzyme required fro HIV replication
- C. Don't you know? There aren't medication to stop or cure HIV
- D. No. it won't stop the infection. In fact, sometimes the HIV can become immune to the drug itself
Correct Answer: B
Rationale: The nurse's best response is, "The medication blocks reverse transcriptase, the enzyme required for HIV replication." This response provides the client with a clear and accurate explanation of how zidovudine (AZT) works. AZT is a nucleoside reverse transcriptase inhibitor (NRTI) that works by blocking the activity of reverse transcriptase, an enzyme needed for HIV replication. By inhibiting this enzyme, AZT helps to slow down the replication of the virus, reducing the viral load in the body and slowing the progression of the disease. It is important for the client to understand that while AZT can help manage HIV/AIDS, it is not a cure and will not completely eliminate the infection.
Which nursing consideration is important when caring for a child with impetigo contagiosa?
- A. Apply topical corticosteroids to decrease inflammation.
- B. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris.
- C. Carefully wash hands and maintain cleanliness when caring for an infected child.
- D. Examine child under a Wood lamp for possible spread of lesions.
Correct Answer: C
Rationale: Carefully washing hands and maintaining cleanliness when caring for an infected child with impetigo contagiosa is important due to its highly contagious nature. Impetigo is a skin infection that is easily spread through direct contact with the lesions or with items contaminated by the infected person such as towels, clothing, or bedding. By washing hands and maintaining cleanliness, caregivers can help prevent the spread of infection to others and minimize the risk of re-infection to the child. This nursing consideration is crucial in managing impetigo and promoting the child's recovery.