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The client is known to be HIV positive. Which data indicate to the nurse that the client has now progressed to the diagnosis of Acquired Immune Deficiency Syndrome (AIDS)?
- A. The client's CD4 count is 189.
- B. The client has an Hgb of 9.4 and Hct of 29.1.
- C. The client's chest x-ray show infiltrates.
- D. The client complains of a headache unrelieved by Tylenol.
Correct Answer: A
Rationale: A CD4 count below 200 defines AIDS in HIV-positive clients. Anemia, infiltrates, and headaches are non-specific.
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The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included?
- A. Females taking birth control pills are protected from becoming infected with HIV.
- B. Protected sex is no longer an issue because there is a vaccine for the HIV virus.
- C. Adolescents with a normal immune system are not at risk for developing AIDS.
- D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.
Correct Answer: D
Rationale: Abstinence is the only certain way to prevent sexually transmitted HIV. Birth control pills, vaccines, and immune status do not eliminate risk.
Which nursing intervention should the nurse include when teaching the client diagnosed with polymyositis?
- A. Explain the care of a percutaneous endoscopic gastrostomy tube.
- B. Discuss the need to take corticosteroids every day.
- C. Instruct to wear long-sleeved shirts when exposed to sunlight.
- D. Teach the importance of strict hand washing.
Correct Answer: B
Rationale: Corticosteroids are mainstay treatment for polymyositis, reducing muscle inflammation. PEG tubes, sun protection, and handwashing are less relevant.
The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention?
- A. The client has scanning speech and diplopia.
- B. The client has dysarthria and scotomas.
- C. The client has muscle weakness and spasticity.
- D. The client has a congested cough and dysphagia.
Correct Answer: D
Rationale: Congested cough and dysphagia indicate potential airway and swallowing issues, requiring immediate intervention to prevent aspiration or respiratory distress. Neurological symptoms like speech issues, diplopia, scotomas, weakness, and spasticity are expected in MS but less acute.
The nurse is caring for a client who has Systemic Inflammatory Response Syndrome (SIRS) following a major abdominal surgery. Which signs and symptoms would the nurse observe that indicate SIRS? Select all that apply.
- A. Bleeding times are increased and platelet counts decreased.
- B. Increased urine osmolality and decreased urine output.
- C. Four plus pitting edema of the lower extremities.
- D. Confusion, disorientation, delirium.
- E. Heart rate 78, blood pressure 124/84, and RR of 20.
Correct Answer: A,B,D
Rationale: SIRS presents with coagulopathy (bleeding/platelet issues), renal dysfunction (oliguria, high osmolality), and altered mental status. Pitting edema and normal vital signs are not diagnostic.
The nurse is developing a care plan for a client diagnosed with allergic rhinitis. Which independent problem has priority?
- A. Ineffective breathing pattern.
- B. Knowledge deficit.
- C. Anaphylaxis.
- D. Ineffective coping.
Correct Answer: A
Rationale: Ineffective breathing pattern is a priority in allergic rhinitis due to potential airway obstruction. Knowledge, anaphylaxis risk, and coping are secondary.