Nokea
When evaluating the success of adding raltegravir to the drug regimen of a 42-year-old female patient with HIV, which laboratory value should the nurse prioritize?
- A. The patient's C-reactive protein levels
- B. The patient's erythrocyte sedimentation rate (ESR)
- C. The patient's viral load
- D. The patient's CD4 count
Correct Answer: C
Rationale: The correct answer is C: The patient's viral load. In HIV management, monitoring the viral load is crucial to assess the effectiveness of antiretroviral therapy. A decrease in viral load indicates the treatment's success in controlling the HIV infection. Choices A, B, and D are less relevant in this context. C-reactive protein levels and erythrocyte sedimentation rate are markers of inflammation and non-specific indicators of infection, not specifically for HIV. CD4 count is important but not as immediate for evaluating the response to the newly added medication compared to monitoring the viral load.
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A patient taking hormonal contraceptives will soon turn 35 years of age. She is moderately obese and has smoked for 15 years. Which of the following is most important?
- A. Begin an exercise regimen.
- B. Begin smoking cessation.
- C. Begin daily aspirin therapy.
- D. Begin taking a loop diuretic to aid weight loss.
Correct Answer: B
Rationale: The most important action for a patient taking hormonal contraceptives, who is nearing 35 years of age, moderately obese, and has a history of smoking for 15 years, is to begin smoking cessation. Women over 35, especially smokers, are at an increased risk of blood clots and cardiovascular issues when using hormonal contraceptives. Smoking cessation is crucial to reduce this risk. Beginning an exercise regimen may be beneficial for overall health but is not as critical as stopping smoking in this scenario. Daily aspirin therapy or taking a loop diuretic are not indicated in this situation and may not address the primary risk associated with hormonal contraceptives and smoking.
The nurse is planning care for a client with damage to the vestibular area of the vestibulocochlear nerve. What should the nurse include in the plan of care? Select all that apply.
- A. Assistance with ambulation
- B. Regular hearing tests
- C. Monitoring for nausea
- D. Vision assessments
Correct Answer: A
Rationale: Damage to the vestibular area affects balance and may cause nausea. Therefore, the nurse should include assistance with ambulation in the care plan to help the client maintain stability while walking. Regular hearing tests (choice B) are not directly related to damage in the vestibular area of the vestibulocochlear nerve. While nausea (choice C) may occur due to vestibular damage, monitoring for it alone is not as essential as providing assistance with ambulation. Vision assessments (choice D) are important for assessing visual function but are not the priority when dealing with vestibular issues.
How should rifampin most likely be administered to a patient diagnosed with tuberculosis?
- A. Orally, with food
- B. Orally, on an empty stomach
- C. Intramuscularly
- D. Intravenously, as a bolus
Correct Answer: A
Rationale: Rifampin is typically administered orally, and it is recommended to be taken with food to enhance its absorption and reduce gastrointestinal side effects. Administering rifampin intramuscularly or intravenously is not the standard route of administration for this medication used in tuberculosis treatment.
A client with cystic fibrosis is admitted with a pulmonary exacerbation. Which intervention should the nurse prioritize?
- A. Administer a high-calorie, high-protein diet.
- B. Initiate airway clearance techniques.
- C. Encourage the client to maintain an active lifestyle.
- D. Monitor for signs of respiratory distress.
Correct Answer: B
Rationale: During a pulmonary exacerbation in cystic fibrosis, the priority intervention is to initiate airway clearance techniques. These techniques help clear mucus from the airways, improving ventilation and reducing the risk of respiratory complications. Administering a high-calorie, high-protein diet is beneficial for overall nutrition but is not the priority during an exacerbation. Encouraging an active lifestyle is important for long-term health but does not address the immediate need for managing exacerbations. Monitoring for signs of respiratory distress is important, but initiating airway clearance techniques takes precedence in the management of pulmonary exacerbations in cystic fibrosis.
What is the purpose of the inflammatory response?
- A. Prevents blood from entering the injured tissue
- B. Elevates body temperature to prevent spread of infection
- C. Prevents formation of abscess
- D. Minimizes injury and promotes healing
Correct Answer: D
Rationale: The inflammatory response is a protective mechanism triggered by tissue damage or infection. It aims to minimize injury by removing harmful stimuli and initiating the healing process. Choice A is incorrect because blood flow to the injured tissue is actually increased to deliver immune cells and nutrients. Choice B is incorrect because while fever is a response to infection, it is not the primary purpose of the inflammatory response. Choice C is incorrect because abscess formation can occur as part of the inflammatory response in an attempt to contain an infection.