Nokea
The nurse is assessing a client who is suspected of being in the early symptomatic stages of human immunodeficiency virus (HIV) infection. Which of the following signs and symptoms of infection should the nurse detect during this stage?
- A. Whitish yellow patches in the mouth.
- B. Dyspnea.
- C. Mild diarrhea.
- D. Raised, hyperpigmented lesions on the legs.
Correct Answer: C
Rationale: Mild diarrhea is a common early symptom of HIV infection, unlike the other options, which appear in later stages.
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You are caring for an acute care adult client in the medical unit who has no history of a psychiatric mental health disorder. This 76 year old client has suddenly and abruptly started to exhibit episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity. The client reports to you that they are seeing clowns in their room. This client is dehydrated and has just begun taking an anticholinergic medication. Which of the following is the most appropriate nursing diagnosis for this client?
- A. Psychotic symptoms related to sensory overload
- B. Psychotic symptoms related to a previously undiagnosed psychosis
- C. Visual disturbances related to dementia
- D. Visual disturbances related to delirium
Correct Answer: D
Rationale: The sudden onset of impaired cognition, fluctuating mental status, and visual hallucinations in the context of dehydration and anticholinergic medication use strongly suggests delirium, not dementia or psychosis.
The nurse is caring for a client with a ventricular shunt for hydrocephalus. Which finding requires immediate reporting?
- A. Clear drainage from the incision
- B. Mild headache
- C. Temperature of 98.6°F (37°C)
- D. Pupils equal and reactive
Correct Answer: A
Rationale: Clear drainage from a shunt incision may indicate cerebrospinal fluid leakage, a serious complication requiring immediate reporting.
A client with a history of schizophrenia is prescribed olanzapine (Zyprexa). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Olanzapine commonly causes weight gain, requiring monitoring.
A client with a history of depression is prescribed trazodone (Desyrel). The nurse should instruct the client to take the medication:
- A. In the morning to avoid sedation.
- B. At bedtime to promote sleep.
- C. With meals to enhance absorption.
- D. As needed for low mood.
Correct Answer: B
Rationale: Trazodone is sedating and should be taken at bedtime to promote sleep and manage depression.
A client with a history of multiple sclerosis is admitted with muscle weakness. The nurse should include which of the following in the plan of care?
- A. Assist with activities of daily living.
- B. Restrict physical activity.
- C. Provide a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Assisting with activities of daily living supports safety and independence in multiple sclerosis.