Nokea
The client with systemic sclerosis (Scleroderma) is experiencing Raynaud's
phenomenon. What assessment finding does the nurse anticipate?
- A. Excessive heartburn
- B. Cyanosis of the lips
- C. Excess wrinkled skin
- D. Cold and purple nailbeds
Correct Answer: D
Rationale:
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The nurse will be using the Braden Scale with each admit to the long-term care
center. Which of these will NOT be utilized in a Braden Scale Assessment?
- A. Mental state
- B. Friction and shear
- C. Nutrition
- D. Sensory perception
Correct Answer: A
Rationale:
Which among the following is NOT the cause of pressure ulcers?
- A. Immobility
- B. Poor nutrition
- C. Moisture
- D. Adequate perfusion
Correct Answer: D
Rationale:
The client is at risk for impaired skin integrity related to the need for several
weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best
action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are
still present
Correct Answer: D
Rationale:
Which client is at highest risk of compromised immunity?
- A. A client who just had surgery
- B. A client who just delivered a baby
- C. A client with extreme anxiety
- D. A client who is awaiting surgery
Correct Answer: A
Rationale:
What is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV)?
- A. A few missed doses per month are acceptable
- B. Only specific licensed drugs are effective
- C. These drugs inhibit viral replication
- D. These drugs eradicate the virus
Correct Answer: C
Rationale: The correct answer is that antiretroviral drugs inhibit viral replication. These medications work by interfering with the ability of the HIV virus to multiply in the body, helping to control the infection. Choice A is incorrect because consistency in taking antiretroviral drugs is crucial to their effectiveness. Missing doses can lead to treatment failure and the development of drug-resistant strains of HIV. Choice B is incorrect as there are multiple licensed drugs that are effective in treating HIV. Choice D is also incorrect as antiretroviral drugs do not kill the virus but rather suppress its replication.