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The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement?
- A. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush.
- B. Notify the HCP for an order for an antifungal swish-and-swallow medication.
- C. Have the client gargle with an antiseptic-based mouthwash several times a day.
- D. Determine what types of food the client has been eating for the last 24 hours.
Correct Answer: B
Rationale: White, patchy lesions suggest oral candidiasis, common in AIDS, requiring antifungal medication. Brushing may worsen lesions, antiseptic mouthwash is insufficient, and diet history is secondary.
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Which signs/symptoms should the nurse expect to assess in the client diagnosed with Sjögren's syndrome?
- A. Complaints of dry mouth and eyes.
- B. Complaints of peripheral joint pain.
- C. Complaints of muscle weakness.
- D. Complaints of severe itching.
Correct Answer: A
Rationale: Dry mouth and eyes (sicca symptoms) are hallmark signs of Sjögren’s syndrome. Joint pain, weakness, and itching are less specific.
The nurse caring for a client diagnosed with Multi Organ Dysfunction Syndrome (MODS) is preparing to administer morning medications. Which medication would the nurse question?
- A. Cefazolin sodium IVPB every six (6) hours.
- B. Furosemide by mouth twice daily.
- C. Metoprolol IVP every four (4) hours and prn.
- D. Acetaminophen by mouth every four (4) hours prn.
Correct Answer: C
Rationale: Metoprolol IVP every 4 hours in MODS risks hypotension in cardiovascular dysfunction. Cefazolin, furosemide, and acetaminophen are appropriate.
The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data would be considered antecedents (risk factor) for becoming HIV positive? Select all that apply.
- A. The client is pregnant.
- B. The client is an intravenous drug abuser.
- C. The client has multiple sexual partners.
- D. The client does not have available health care.
- E. The client does not have adequate bathroom facilities.
- F. The client spends her money on nonessential items.
Correct Answer: B,C,D
Rationale: IV drug use, multiple sexual partners, and lack of healthcare increase HIV risk. Pregnancy, bathroom facilities, and spending are not direct risk factors.
Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply.
- A. Recommend the client not to engage in unprotected sexual activity.
- B. Instruct the client not to inform past sexual partners of HIV status.
- C. Tell the client to not donate blood, organs, or tissues.
- D. Suggest the client not get pregnant.
- E. Explain the client does not have to tell health-care personnel of HIV status.
Correct Answer: A,C,D
Rationale: Unprotected sex, blood/organ donation, and pregnancy risk HIV transmission or complications. Partner notification and informing healthcare personnel are recommended.
The client with myasthenia gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is effective?
- A. The client is able to feed self independently.
- B. The client is able to blink the eyes without tearing.
- C. The client denies any nausea or vomiting when eating.
- D. The client denies any pain when performing ROM exercises.
Correct Answer: A
Rationale: Independent feeding indicates improved muscle strength, the goal of neostigmine. Blinking, nausea, and pain are less directly related.