Nokea
The nurse is interacting with a client who has just been told she is HIV positive. The client asks the nurse when she will die. What should the nurse plan to include when replying?
- A. HIV positive means that the client has antibodies against the virus. It does not mean that the client has AIDS. Most people do not develop AIDS or die for many years.
- B. Most persons who are HIV positive live 5 to 10 years with aggressive treatment.
- C. Life expectancy depends on whether there is further exposure to the virus.
- D. The progression from HIV positive to full-blown AIDS is usually quite rapid.
Correct Answer: A
Rationale: HIV positivity indicates antibodies, not AIDS; with modern antiretroviral therapy, progression is slow, and many live for decades, unlike rapid progression or fixed timelines.
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During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to
- A. increase fluids that are high in protein
- B. restrict fluids
- C. force fluids and reassess blood pressure
- D. limit fluids to non-caffeine beverages
Correct Answer: C
Rationale: Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.
The nurse is observing a 3-year-old client for expected developmental milestones. It would require follow-up if the client cannot
- A. catch a ball at least 50% of the time
- B. copy a square with a pencil or crayon
- C. eat with a spoon
- D. hop on one foot
Correct Answer: B
Rationale: Copying a square is expected by age 4-5, not 3, indicating a fine motor delay requiring follow-up. Catching a ball, eating with a spoon, and hopping are age-appropriate or slightly advanced for a 3-year-old.
A woman who comes in for prenatal care has a history of herpes with outbreaks that occur every six months to a year. She asks if this means she will have a cesarean delivery. How should the nurse respond?
- A. If you have active lesions when you go into labor, you will need a cesarean section.'
- B. Cesarean delivery is the only way to protect your baby from herpes.'
- C. Cesarean delivery is no longer recommended for persons with herpes.'
- D. Your obstetrician will decide at the time of delivery which is best for you.'
Correct Answer: A
Rationale: Active herpes lesions at labor necessitate a cesarean to prevent neonatal herpes transmission; otherwise, vaginal delivery may be possible.
A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain and is scheduled for paracentesis. Which of the following nursing actions should be implemented prior to the procedure? Select all that apply.
- A. Ensure that informed consent has been obtained
- B. Place the client in reverse Trendelenburg position
- C. Place the client on NPO status
- D. Request the client empty their bladder
- E. Take baseline vital signs and weight
Correct Answer: A,D,E
Rationale: Informed consent ensures understanding, emptying the bladder prevents injury during needle insertion, and baseline vital signs/weight monitor fluid shifts. Reverse Trendelenburg is inappropriate; upright positioning is typical. NPO status isn't required for paracentesis.
Which client would be at greatest risk for a fat emboli following a fracture?
- A. A 50-year-old with a fractured fibula
- B. A 20-year-old female with a wrist fracture
- C. A 21-year-old male with a fractured femur
- D. An 8-year-old with a fractured arm
Correct Answer: C
Rationale: Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults age 20-30. Answers A, B, and D are not high-risk incidents and do not fall in the greater risk category, so they are incorrect.