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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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Which referral should the nurse implement for a client with severe multiple allergies?
- A. Registered dietitian.
- B. Occupational therapist.
- C. Recreational therapist.
- D. Social worker.
Correct Answer: A
Rationale: A dietitian helps identify food allergens, critical for severe allergies. Other therapists are less relevant.
The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply.
- A. Assist the client to turn and cough every two (2) hours.
- B. Place the client in a high or semi-Fowler's position.
- C. Assess the client's pulse oximeter reading every shift.
- D. Plan meals to promote medication effectiveness.
- E. Monitor the client's serum anticholinesterase levels.
Correct Answer: A,B,C,D
Rationale: Turning/coughing, Fowler’s position, pulse oximetry, and meal timing address respiratory risk and medication efficacy in myasthenia gravis. Serum anticholinesterase levels are not routinely monitored.
The nurse is caring for a client who has Systemic Inflammatory Response Syndrome (SIRS) following a major abdominal surgery. Which signs and symptoms would the nurse observe that indicate SIRS? Select all that apply.
- A. Bleeding times are increased and platelet counts decreased.
- B. Increased urine osmolality and decreased urine output.
- C. Four plus pitting edema of the lower extremities.
- D. Confusion, disorientation, delirium.
- E. Heart rate 78, blood pressure 124/84, and RR of 20.
Correct Answer: A,B,D
Rationale: SIRS presents with coagulopathy (bleeding/platelet issues), renal dysfunction (oliguria, high osmolality), and altered mental status. Pitting edema and normal vital signs are not diagnostic.
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.
The nurse is developing a care plan for a client diagnosed with allergic rhinitis. Which independent problem has priority?
- A. Ineffective breathing pattern.
- B. Knowledge deficit.
- C. Anaphylaxis.
- D. Ineffective coping.
Correct Answer: A
Rationale: Ineffective breathing pattern is a priority in allergic rhinitis due to potential airway obstruction. Knowledge, anaphylaxis risk, and coping are secondary.