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The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach?
- A. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in.
- B. The HIV virus can be eradicated from the host body with the correct medical regimen.
- C. It is difficult for the HIV virus to replicate in humans because it is a monkey virus.
- D. The HIV virus uses the client's own red blood cells to reproduce the virus in the body.
Correct Answer: A
Rationale: HIV is a retrovirus that persists in the host, integrating into DNA. It cannot be eradicated, is not a monkey virus, and infects CD4 cells, not red blood cells.
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The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse?
- A. The nurse explains the IVP diuretic will make the client urinate.
- B. The nurse dons nonsterile gloves to remove the client's dressing.
- C. The nurse administers a medication without checking for allergies.
- D. The nurse asks the UAP for help moving a client up in bed.
Correct Answer: C
Rationale: Administering medication without checking allergies risks allergic reactions, requiring immediate intervention. Diuretic explanation, glove use, and UAP assistance are appropriate.
The nurse is caring for clients on a medical floor. Which client should the nurse assess first?
- A. The client diagnosed with RA complaining of pain at a '3' on a 1-to-10 scale.
- B. The client diagnosed with SLE who has a rash across the bridge of the nose.
- C. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV.
- D. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.
Correct Answer: C
Rationale: Antineoplastic drugs (e.g., methotrexate) pose risks like toxicity, requiring immediate assessment. Mild pain, rashes, and scleroderma are less acute.
Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis?
- A. Occupational therapist.
- B. Recreational therapist.
- C. Vocational therapist.
- D. Speech therapist.
Correct Answer: D
Rationale: Speech therapists address dysphagia and communication issues in late-stage myasthenia gravis. Other therapists are less relevant.
Which discharge instruction should the nurse implement for the client newly diagnosed with myasthenia gravis (MG)?
- A. Identify specific measures to help avoid fatigue and undue stress.
- B. Instruct the client to pad bony prominences, especially the sacral area.
- C. Discuss complementary therapies to help manage pain.
- D. Explain the possibility of having a splenectomy to help control the symptoms.
Correct Answer: A
Rationale: Avoiding fatigue and stress prevents myasthenia gravis exacerbations. Padding, pain therapies, and splenectomy are irrelevant.
The client with multiple sclerosis is prescribed the muscle relaxant baclofen (Lioresal). Which statement by the client indicates the client needs more teaching?
- A. This medication may cause drowsiness so I need to be careful.
- B. I should not drink any type of alcohol or take any antihistamines.
- C. I will increase the fiber in my diet and increase fluid intake.
- D. I stopped taking the medication because I can't afford it.
Correct Answer: D
Rationale: Stopping baclofen due to cost risks symptom worsening, indicating a need for teaching on adherence. Drowsiness, alcohol avoidance, and fiber/fluid intake are correct.