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The nurse is caring for the client diagnosed with acquired immunodeficiency syndrome (AIDS) dementia. Which action by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse?
- A. The UAP is helping the client to sit on the bedside chair.
- B. The UAP is wearing sterile gloves when bathing the client.
- C. The UAP is helping the client shave and brush the teeth.
- D. The UAP is providing a back massage to the client.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for bathing, risking improper technique. Sitting, shaving, and massage are appropriate UAP tasks.
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The client is known to be HIV positive. Which data indicate to the nurse that the client has now progressed to the diagnosis of Acquired Immune Deficiency Syndrome (AIDS)?
- A. The client's CD4 count is 189.
- B. The client has an Hgb of 9.4 and Hct of 29.1.
- C. The client's chest x-ray show infiltrates.
- D. The client complains of a headache unrelieved by Tylenol.
Correct Answer: A
Rationale: A CD4 count below 200 defines AIDS in HIV-positive clients. Anemia, infiltrates, and headaches are non-specific.
The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which information should the nurse teach the client about the test?
- A. The client will have wires attached to the scalp and lights will flash off and on.
- B. The machine will be loud and the client must not move the head during the test.
- C. The client will drink a contrast medium 30 minutes to one (1) hour before the test.
- D. The test will be repeated at intervals during a five (5)- to six (6)-hour period.
Correct Answer: B
Rationale: MRI machines are loud, and head immobility is critical for clear images. Wires/lights describe EEG, oral contrast is not used for brain MRI, and the test is not repeated over hours.
The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse?
- A. Encourage the therapy if it is not contraindicated by the medical regimen.
- B. Tell the client only the health-care provider should discuss this with him.
- C. Ask how his significant other feels about this deviation from the medical regimen.
- D. Suggest the client research an investigational therapy instead.
Correct Answer: A
Rationale: Encouraging safe alternative therapies supports autonomy if they align with medical treatment. Deferring to HCP, involving significant other, or suggesting investigational therapies are less appropriate.
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome?
- A. An exaggerated startle reflex and memory changes.
- B. Cogwheel rigidity and inability to initiate voluntary movement.
- C. Sudden severe unilateral facial pain and inability to chew.
- D. Progressive ascending paralysis of the lower extremities and numbness.
Correct Answer: D
Rationale: Guillain-Barré syndrome presents with ascending paralysis and numbness due to peripheral nerve demyelination. Startle reflex, rigidity, and facial pain suggest other conditions.
The client diagnosed with RA is being seen in the outpatient clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits?
- A. Perform joint x-rays to determine progression of the disease.
- B. Send blood to the laboratory for an erythrocyte sedimentation rate.
- C. Recommend the flu and pneumonia vaccines.
- D. Assess the client for increasing joint involvement.
Correct Answer: C
Rationale: Flu and pneumonia vaccines prevent infections, critical in RA due to immunosuppression. X-rays, ESR, and joint assessments are diagnostic, not preventive.