Nokea
The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk?
- A. Providing thorough oral care before and after meals
- B. Administering prophylactic antibiotics
- C. Promoting nutrition and adequate fluid intake
- D. Applying skin emollients as needed
Correct Answer: A
Rationale: The correct answer is A: Providing thorough oral care before and after meals. This addresses the risk for impaired skin integrity related to Candidiasis in patients with stage 3 HIV by preventing oral Candidiasis, a common fungal infection. Poor oral hygiene can lead to Candidiasis, which can spread to the skin. Thorough oral care reduces the risk of oral Candidiasis, thereby preventing skin integrity issues. Administering prophylactic antibiotics (B) is not indicated for preventing Candidiasis. Promoting nutrition and fluid intake (C) is important for overall health but does not directly address the risk of impaired skin integrity. Applying skin emollients (D) may help with skin dryness but does not directly address the underlying cause of Candidiasis.
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A patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle?
- A. The patient is likely to have an increased appetite.
- B. The patient is likely to required enzyme supplements.
- C. The patient will likely require a clear liquid diet.
- D. The patient will benefit from a low-protein diet.
Correct Answer: D
Rationale: The correct answer is D - The patient will benefit from a low-protein diet. Patients with Huntington disease often experience difficulty swallowing and may have involuntary movements, leading to weight loss. A low-protein diet can help manage these symptoms and reduce the risk of aspiration pneumonia. This diet can also help control the chorea movements associated with the disease.
Choice A is incorrect as patients with Huntington disease often have reduced appetite due to swallowing difficulties. Choice B is incorrect as enzyme supplements are not typically indicated in the management of Huntington disease. Choice C is incorrect as a clear liquid diet is not suitable for meeting the nutritional needs of a patient with Huntington disease, who may already be at risk for malnutrition.
A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T- lymphocyte cell count drops below what threshold?
- A. 75 cells/mm3 of blood
- B. 200 cells/mm3 of blood
- C. 325 cells/mm3 of blood
- D. 450 cells/mm3 of blood
Correct Answer: B
Rationale: The correct answer is B (200 cells/mm3 of blood) because a patient with HIV is considered to have AIDS when their CD4+ T-lymphocyte cell count drops below 200 cells/mm3. This threshold signifies a significant decrease in the immune system's ability to fight off infections and indicates progression to AIDS.
Choice A (75 cells/mm3 of blood) is incorrect because this level is extremely low and would indicate severe immunosuppression, likely leading to AIDS much earlier than anticipated.
Choice C (325 cells/mm3 of blood) and D (450 cells/mm3 of blood) are also incorrect as these levels are within the normal range or slightly lower, which would not meet the criteria for a diagnosis of AIDS.
Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility?
- A. Arrange for the administration of prophylactic antibiotics to unaffected residents.
- B. Instill normal saline into the eyes of affected residents two to three times daily.
- C. Swab the conjunctiva of unaffected residents for culture and sensitivity testing.
- D. Isolate affected residents from residents who have not developed conjunctivitis.
Correct Answer: D
Rationale: The correct answer is D: Isolate affected residents from residents who have not developed conjunctivitis. This is the most appropriate action to prevent the spread of viral conjunctivitis in a long-term care facility. By isolating affected residents, the nurse can minimize the risk of transmission to other residents.
Choice A is incorrect because prophylactic antibiotics are not effective against viral conjunctivitis. Choice B is also incorrect as normal saline does not treat viral conjunctivitis but may provide comfort. Choice C is unnecessary as viral conjunctivitis is typically diagnosed clinically and does not require culture testing.
A patient has herpes simplex 2 viral infection (HSV2). The nurse recognizes that which of the following should be included in teaching the patient?
- A. The virus causes cold sores of the lips.
- B. The virus may be cured with antibiotics.
- C. The virus, when active, may not be contracted during intercourse.
- D. Treatment is aimed at relieving symptoms.
Correct Answer: D
Rationale: The correct answer is D because treatment for HSV2 focuses on relieving symptoms since the virus cannot be cured. Antiviral medications can help manage outbreaks and reduce the frequency and severity of symptoms. Option A is incorrect as HSV2 typically presents as genital herpes, not cold sores on the lips (usually caused by HSV1). Option B is incorrect since antibiotics are ineffective against viruses. Option C is incorrect as HSV2 is most contagious during active outbreaks, making it important to practice safe sex to prevent transmission.
A nurse is caring for an 8-year-old patient whois embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence?
- A. “Set your alarm clock to wake you every 2 hours, so you can get up to void.”
- B. “Line your bedding with plastic sheets to protect your mattress.”
- C. “Drink your nightly glass of milk earlier in the evening.”
- D. “Empty your bladder completely before going to bed.”
Correct Answer: C
Rationale: The correct answer is C: “Drink your nightly glass of milk earlier in the evening.” By suggesting the patient to drink milk earlier, it allows more time for the body to process and excrete the fluids before bedtime, reducing the likelihood of bedwetting. This intervention targets the root cause of the issue by addressing the timing of fluid intake.
Explanation for why the other choices are incorrect:
A: “Set your alarm clock to wake you every 2 hours, so you can get up to void.” This intervention disrupts the patient's sleep pattern and may not address the underlying cause of bedwetting.
B: “Line your bedding with plastic sheets to protect your mattress.” This intervention focuses on managing the consequences of bedwetting rather than preventing it.
D: “Empty your bladder completely before going to bed.” While important, this suggestion alone may not be sufficient to address the timing of fluid intake, which is crucial in reducing bedwetting frequency.