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The concept of impaired immunity has been identified by the nurse as it applies to the client diagnosed with Acquired Immune Deficiency Syndrome (AIDS). Which interventions should the nurse implement?
- A. Keep fresh flowers and raw vegetables out of the client's room.
- B. Have the Unlicensed Assistive Personnel (UAP) assist with ADLs.
- C. Encourage the client to perform active range of motion.
- D. Teach the client about the cardiovascular medications.
Correct Answer: A
Rationale: Avoiding flowers and raw vegetables reduces infection risk in AIDS. UAP assistance, ROM, and cardiovascular teaching are unrelated to immunity.
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The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis 'anticipatory grieving related to progressive loss.' Which intervention should be implemented first?
- A. Consult the physical therapist for assistive devices for mobility.
- B. Determine if the client has a legal power of attorney.
- C. Ask if the client would like to talk to the hospital chaplain.
- D. Discuss the client's wishes regarding end-of-life care.
Correct Answer: C
Rationale: Addressing anticipatory grieving involves exploring spiritual or emotional support, like a chaplain visit. Mobility devices, legal documents, and end-of-life discussions are secondary.
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 an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented?
- A. Discuss discontinuing the proton pump inhibitor with the HCP.
- B. Hold the medication until after all cultures have been obtained.
- C. Monitor the client's serum blood glucose levels frequently.
- D. Provide supplemental dietary sodium with the client's meals.
Correct Answer: C
Rationale: High-dose corticosteroids can cause hyperglycemia, requiring frequent glucose monitoring. Proton pump inhibitors are unrelated, cultures are not needed, and sodium supplementation is unnecessary.
Which intervention has the highest priority when caring for a client diagnosed with rheumatoid arthritis?
- A. Encourage the client to ventilate feelings about the disease process.
- B. Discuss the effects of disease on the client's career and other life roles.
- C. Instruct the client to perform most important activities in the morning.
- D. Teach the client the proper use of hot and cold therapy to provide pain relief.
Correct Answer: D
Rationale: Hot and cold therapy directly relieves RA pain, a priority. Emotional ventilation, career impact, and morning activity are secondary.
Which assessment data should make the nurse suspect the client has chronic allergies?
- A. Jaundiced sclera and jaundiced palms of hands.
- B. Pale, boggy, edematous nasal mucosa.
- C. Lacy white plaques on the oral mucosa.
- D. Purple or blue patches on the face.
Correct Answer: B
Rationale: Pale, boggy, edematous nasal mucosa indicates chronic allergic rhinitis. Jaundice, oral plaques, and facial patches suggest other conditions.