Nokea
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds:
- A. The complaints of at least 3 common findings.
- B. The absence of any opportunistic infection.
- C. CD4 lymphocyte count is less than 200.
- D. Developmental delays in children.
Correct Answer: C
Rationale: The correct answer is C. A CD4 count less than 200 cells/mm³ is a diagnostic criterion for AIDS. Choices A, B, and D are incorrect. Choice A is vague and does not reflect the diagnostic criteria for AIDS. Choice B is not accurate, as the presence of opportunistic infections, not their absence, is indicative of AIDS. Choice D is unrelated to the diagnosis of AIDS in adults.
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A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis?
- A. Low serum albumin
- B. High serum cholesterol
- C. Abnormally low white blood cell count
- D. Elevated creatinine phosphokinase (CPK)
Correct Answer: D
Rationale: The correct answer is D: Elevated creatinine phosphokinase (CPK). Elevated CPK levels indicate muscle damage, including damage to the cardiac muscle, which aligns with the diagnosis of myocardial infarction.
Choice A, low serum albumin, is not directly related to myocardial infarction. Choice B, high serum cholesterol, is more associated with conditions like atherosclerosis rather than acute myocardial infarction. Choice C, abnormally low white blood cell count, is typically not a lab value associated with myocardial infarction; instead, it could suggest other conditions like infections or bone marrow issues.
A client with a peptic ulcer is scheduled for a vagotomy and pyloroplasty. The nurse explains that the purpose of this surgery is to:
- A. Increase acid secretion
- B. Reduce acid secretion
- C. Promote gastric emptying
- D. Remove the ulcerated area
Correct Answer: B
Rationale: The correct answer is B: "Reduce acid secretion." Vagotomy is performed to reduce acid secretion by cutting the vagus nerve, which stimulates acid production. Choices A, C, and D are incorrect. A vagotomy does not increase acid secretion, promote gastric emptying, or remove the ulcerated area. It specifically aims to decrease acid production to help in the healing of peptic ulcers.
A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer?
- A. Measles-mumps-rubella.
- B. Hepatitis B.
- C. Human papillomavirus.
- D. Pneumococcal.
Correct Answer: B
Rationale: The correct answer is B: Hepatitis B. The Hepatitis B vaccine is crucial for pregnant women as it helps prevent transmission of the virus to the baby during childbirth. Measles-mumps-rubella vaccine (choice A) is not directly related to the current situation of the client being pregnant. Human papillomavirus vaccine (choice C) is recommended for adolescents but is not specifically indicated in this case. Pneumococcal vaccine (choice D) is not a priority in this scenario compared to Hepatitis B, which is crucial for preventing vertical transmission.
The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is
- A. Intravenous fluid infusion
- B. Level of consciousness
- C. Pulse and respirations
- D. Extremities for injuries
Correct Answer: B
Rationale: In status epilepticus, the most crucial nursing assessment is the level of consciousness. Assessing the client's level of consciousness is vital as prolonged seizures can result in hypoxia, brain damage, and require immediate intervention. Pulse and respirations (choice C) are important assessments, but in status epilepticus, the priority is to monitor the client's neurological status. Checking intravenous fluid infusion (choice A) and extremities for injuries (choice D) are not the primary assessments needed in managing a client experiencing status epilepticus.
What is a key component of a successful smoking cessation program?
- A. Providing nicotine replacement therapy
- B. Offering surgical interventions
- C. Conducting regular health screenings
- D. Promoting alcohol consumption
Correct Answer: A
Rationale: The correct answer is A. Providing nicotine replacement therapy is a key component of smoking cessation programs as it helps individuals manage nicotine withdrawal symptoms. Nicotine replacement therapy includes options like nicotine gum, patches, lozenges, or inhalers. Choice B, offering surgical interventions, is incorrect as smoking cessation programs primarily focus on behavioral and pharmacological interventions rather than surgical procedures. Choice C, conducting regular health screenings, is also incorrect as it is not a direct key component of smoking cessation programs. Choice D, promoting alcohol consumption, is not only incorrect but counterproductive, as it can be detrimental to overall health and hinder smoking cessation efforts.