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The nurse is teaching a patient newly diagnosed with AIDS about complications of the disease. Which of the following is the most common opportunistic infection in AIDS?
- A. Pneumocystis carinii pneumonia
- B. Toxoplasmosis
- C. Candidiasis
- D. Mycoplasma pneumoniae
Correct Answer: A
Rationale: Pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection in individuals with AIDS. PCP is caused by a fungus called Pneumocystis jirovecii (formerly known as Pneumocystis carinii). Patients with AIDS have compromised immune systems, making them susceptible to opportunistic infections like PCP. This infection can be life-threatening if not treated promptly with appropriate antibiotics. Symptoms of PCP include fever, cough, and difficulty breathing. Early recognition and treatment of PCP are crucial in patients with AIDS to prevent severe complications.
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An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client's fluid balance?
- A. Maintain strict records of intake and output
- B. Monitor skin turgor
- C. Weigh the client daily
- D. Check for edema
Correct Answer: A
Rationale: Maintaining strict records of intake and output is the best way to assess the client's fluid balance in this situation. Severe burns can lead to fluid loss, which can result in dehydration and other complications. By carefully monitoring the amount of fluid the client is taking in (intake) and the amount of fluid being eliminated from the body (output), healthcare providers can assess the client's fluid balance and make necessary adjustments to prevent dehydration or fluid overload. This approach provides accurate and specific information to guide fluid management and ensure optimal recovery for the client with burns. Monitoring skin turgor, daily weight, and checking for edema are also important measures, but maintaining strict records of intake and output is the most direct and effective method for assessing fluid balance in a client with burns.
The nurse is teaching the parent about the diet of a child experiencing severe edema associated with acute glomerulonephritis. Which information should the nurse include in the teaching?
- A. "You will need to decrease the number of calories in your child's diet."
- B. "Your child's diet will need an increased amount of protein."
- C. "You will need to avoid adding salt to your child's food."
- D. "Your child's diet will consist of low-fat, low-carbohydrate foods."
Correct Answer: C
Rationale: The nurse should include in the teaching that the parent will need to avoid adding salt to the child's food. This is important because reducing salt intake helps to decrease fluid retention and swelling in the body, which is critical for managing edema associated with acute glomerulonephritis. Excessive salt intake can worsen edema by causing the body to retain more fluid, so it is crucial to limit salt in the child's diet. This dietary modification can help improve the child's condition and overall health outcome.
Which symptoms should the nurse expect to observe during the physical assessment of an adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa?
- A. Dysmenorrhea and oliguria
- B. Tachycardia and tachypnea
- C. Heat intolerance and increased blood pressure
- D. Lowered body temperature and brittle nails
Correct Answer: B
Rationale: An adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa is likely to exhibit tachycardia (rapid heart rate) and tachypnea (rapid breathing). These symptoms are common manifestations of the body's response to malnutrition and starvation. Tachycardia occurs as a compensatory mechanism to maintain an adequate supply of oxygen to vital organs, while tachypnea helps to eliminate excess carbon dioxide due to metabolic imbalances. It is essential for the nurse to recognize these signs during the physical assessment as they indicate the severity of the condition and the need for immediate intervention to prevent further complications. Dysmenorrhea and oliguria, heat intolerance and increased blood pressure, and lowered body temperature and brittle nails are not typically associated with the physical manifestations of anorexia nervosa.
Which of the ff signs may be revealed by a visual examination in a client with tonsillar infection if group A streptococci is the cause?
- A. White patches on the tonsils
- B. Hypertrophied tonsils
- C. Hemorrhage in the tonsils
- D. Bleeding in the tonsils
Correct Answer: A
Rationale: The presence of white patches on the tonsils is a visual sign that may be revealed by a visual examination in a client with a tonsillar infection caused by group A streptococci. These white patches are known as exudates and can be a characteristic feature of streptococcal tonsillitis. These exudates may range in appearance from small white spots to larger patches that cover the tonsils. Additionally, other signs commonly associated with streptococcal tonsillitis may include swollen and red tonsils, fever, sore throat, and sometimes swollen lymph nodes in the neck. It is important to note that definitive diagnosis often requires laboratory testing such as a rapid strep test or throat culture to confirm the presence of group A streptococci.
The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct?
- A. "You may need to increase the caloric density of your infant's formula."
- B. "You should feed your baby every 2 hours."
- C. "You may need to increase the amount of formula your infant eats with each feeding."
- D. "You should place a nasal oxygen cannula on your infant during and after each feeding."
Correct Answer: A
Rationale: In infants with heart failure, they may have increased metabolic demands due to their condition. Thus, it may be necessary to increase the caloric density of the infant's formula to ensure adequate nutrition and energy intake. This can help support the infant's growth and provide the necessary energy for their increased metabolic needs. Increasing the amount of formula or feeding too frequently (every 2 hours) may not be necessary and could lead to other issues like overfeeding. Placing a nasal oxygen cannula on the infant during and after each feeding (Option D) is not typically related to feeding practices for an infant with heart failure.