Nokea
The LPN is caring for a client newly diagnosed with HIV. Which statement made by the client regarding antiretroviral therapy (ART) would require correction from the nurse?
- A. If I start ART and use condoms, I'm less likely to transmit HIV to my partner.
- B. I can still use ART even though I am Hepatitis C positive.
- C. I will need to be on ART indefinitely.
- D. I know I will need to come back for blood draws so that I can begin ART when my CD4 count is over 1,000 cells/mm3.
Correct Answer: D
Rationale: The World Health Organization (WHO) recommends making treatment for those with a CD4 count of ≤ 350 cells/mm3 a priority, as early intervention can help delay disease progression. Studies have shown that ART can reduce HIV transmission to sexual partners by up to 96%. Conditions such as pregnancy and Hepatitis B and C increase the need to initiate therapy sooner and are in no way contraindicated. ART does not cure HIV, but to maintain viral suppression, it should be continued indefinitely.
You may also like to solve these questions
The 5-year-old is receiving an IV infusion of D5 with 0.45 NaCl at 100 mL/hr. Which assessment findings suggest excessive parenteral fluid intake? Select all that apply.
- A. Dyspnea
- B. Lethargy
- C. Gastric distention
- D. Crackles in lung bases
- E. Temperature of 102°F (38.9°C)
Correct Answer: A,B,D
Rationale: A: Dyspnea indicates fluid volume overload and occurs from fluid rapidly shifting between the intracellular and extracellular compartments. B: Lethargy and change in level of consciousness can occur from fluid shifting in brain cells. C: Gastric distention can occur from excessive oral (not IV) fluid intake or infection. D: Crackles indicate fluid volume overload and occur from fluid rapidly shifting into the alveoli. E: An elevated temperature is a sign of fluid volume deficit, not excess.
The nurse is discussing the prescribed atypical antipsychotic medication therapy with the client with schizophrenia. What information should the nurse include in this discussion? Select all that apply.
- A. Atypical antipsychotic medications will affect the client's hallucinations and inappropriate emotional responses.
- B. Atypical antipsychotic medications are prescribed after other medications have proven ineffective in treating symptoms.
- C. The greatest concern with taking atypical antipsychotic medications is that they produce extrapyramidal side effects.
- D. Regular laboratory appointments will need to be scheduled to monitor the client's blood glucose levels.
- E. The client may experience an increase in appetite and weight gain when taking an atypical antipsychotic medication.
Correct Answer: A,D,E
Rationale: Atypical antipsychotics target hallucinations and emotional responses, require blood glucose monitoring, and may cause increased appetite and weight gain.
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary.
Correct Answer: D
Rationale: It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed.
The nurse is observing a client self-administer two medications that are in a crushable pill form through their G tube. Which of the following would indicate a need for further instruction?
- A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
- B. The client states they will remain in the Semi-Fowler's position for 30 minutes following administration of the medications.
- C. The client mixes their medications with their tube-feeding formula.
- D. The client mixes each medication separately in warm water.
Correct Answer: C
Rationale: Medication should not be mixed with tube-feeding formula or other medications. The G-tube should be flushed before, between, and after the medications, and the client should remain in the Semi-Fowler's position for at least 30 minutes after medications are administered.
The client taking rifampin brings a sample of urine that is orange in color to the clinic. Which interventions should the nurse implement? Select all that apply.
- A. Send the urine to the lab for culture and sensitivity (C&S).
- B. Reassure the client that this is normal and harmless.
- C. Teach that the urine that is orange can stain clothing.
- D. Question continuation of rifampin with the HCP.
- E. Inform that sweat and tears can also turn orange-colored.
Correct Answer: B,C,E
Rationale: A: A C&S is unnecessary because orange-colored urine is a normal finding in the client taking rifampin. B: The nurse should reassure the client that orange-colored urine is a normal finding in the client taking rifampin (Rifadin). C: The nurse should teach the client that the orange-colored urine and sweat can stain clothing and that the client should consider wearing nonwhite clothing or using undergarments if sweating is excessive. D: It is unnecessary to question continuation of rifampin if the urine is orange-colored because this is a normal finding. E: The nurse should inform the client that other body fluids, such as tears, sweat, and saliva, can also turn orange-colored with the use of rifampin (Rifadin).