Nokea
The client who has engaged in needle-sharing activities has developed a flu-like illness. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding?
- A. The client is fortunate not to have contracted HIV from an infected needle.
- B. The client must be repeatedly exposed to HIV before becoming infected.
- C. The client may be in the primary infection phase of an HIV infection.
- D. The antibody test is negative because the client has a different flu virus.
Correct Answer: C
Rationale: A negative antibody test during flu-like symptoms may indicate the primary HIV infection phase, before seroconversion. Single exposure can infect, and flu viruses are unrelated.
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The client recently diagnosed with rheumatoid arthritis is prescribed aspirin, a nonsteroidal anti-inflammatory medication. Which comment by the client warrants immediate intervention by the nurse?
- A. I always take the aspirin with food.
- B. If I have dark stools, I will call my HCP.
- C. Aspirin will not cure my arthritis.
- D. I am having some ringing in my ears.
Correct Answer: D
Rationale: Ringing in the ears (tinnitus) indicates aspirin toxicity, requiring immediate intervention. Taking with food, reporting dark stools, and understanding no cure are correct.
The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention?
- A. Assess the client's body weight and ask what the client has been able to eat.
- B. Place in contact isolation and don a mask and gown before entering the room.
- C. Check the HCP's orders and determine what laboratory tests will be done.
- D. Teach the client about total parenteral nutrition and monitor the subclavian IV site.
Correct Answer: A
Rationale: Assessing weight and dietary intake provides baseline data for malnutrition management. Isolation is unnecessary, lab orders are secondary, and TPN teaching is premature.
The client diagnosed with Systemic Response Inflammatory Syndrome (SIRS) asks the nurse what the diagnosis means. Which is the nurse's best response?
- A. SIRS is a localized response to major trauma that has occurred within the last three (3) months.
- B. SIRS is a syndrome of potential responses to illness that has an optimum prognosis.
- C. SIRS is a respiratory response to the client having had a myocardial infarction or pneumonia.
- D. SIRS is a systemic response to a variety of insults, including infection, ischemia, and injury.
Correct Answer: D
Rationale: SIRS is a systemic response to insults like infection or trauma. It is not localized, has variable prognosis, and is not solely respiratory.
The client newly diagnosed with multiple sclerosis (MS) states, 'I don't understand how I got multiple sclerosis. Is it genetic?' On which statement should the nurse base the response?
- A. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus.
- B. There is no evidence suggesting there is any chromosomal involvement in developing MS.
- C. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS.
- D. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.
Correct Answer: A
Rationale: MS has a genetic susceptibility component (e.g., HLA genes), but environmental factors like viral infections may trigger it. There is chromosomal involvement, MS is not purely recessive or dominant, and it is not Y-linked.
The client recently diagnosed with SLE asks the nurse, 'What is SLE and how did I get it?' Which statement best explains the scientific rationale for the nurse's response?
- A. SLE occurs because the kidneys do not filter antibodies from the blood.
- B. SLE occurs after a viral illness as a result of damage to the endocrine system.
- C. There is no known identifiable reason for a client to develop SLE.
- D. This is an autoimmune disease that may have a genetic or hormonal component.
Correct Answer: D
Rationale: SLE is an autoimmune disease with genetic and hormonal influences. Kidney issues are a complication, viral triggers are secondary, and the cause is partially understood.