Nokea
Which intervention is an important psychosocial consideration for the client diagnosed with AIDS?
- A. Perform a thorough head-to-toe assessment.
- B. Maintain the client's ideal body weight.
- C. Complete an advance directive.
- D. Increase the client's activity tolerance.
Correct Answer: C
Rationale: Completing an advance directive addresses end-of-life wishes, a key psychosocial need in AIDS. Assessment, weight, and activity are physiological.
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The nurse on a medical unit has received the morning shift report. Which client should the nurse assess first?
- A. The client who has a 0730 sliding-scale insulin order.
- B. The client who received an initial dose of IV antibiotic at 0645.
- C. The client who is having back pain at a '4' on a 1-to-10 scale.
- D. The client who has dysphagia and needs to be fed.
Correct Answer: A
Rationale: The 0730 insulin order is time-sensitive to prevent hyperglycemia or hypoglycemia. Antibiotic monitoring, mild pain, and dysphagia are less urgent.
The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention?
- A. Assess the client's body weight and ask what the client has been able to eat.
- B. Place in contact isolation and don a mask and gown before entering the room.
- C. Check the HCP's orders and determine what laboratory tests will be done.
- D. Teach the client about total parenteral nutrition and monitor the subclavian IV site.
Correct Answer: A
Rationale: Assessing weight and dietary intake provides baseline data for malnutrition management. Isolation is unnecessary, lab orders are secondary, and TPN teaching is premature.
The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented?
- A. Discuss discontinuing the proton pump inhibitor with the HCP.
- B. Hold the medication until after all cultures have been obtained.
- C. Monitor the client's serum blood glucose levels frequently.
- D. Provide supplemental dietary sodium with the client's meals.
Correct Answer: C
Rationale: High-dose corticosteroids can cause hyperglycemia, requiring frequent glucose monitoring. Proton pump inhibitors are unrelated, cultures are not needed, and sodium supplementation is unnecessary.
Which assessment data should make the nurse suspect the client has chronic allergies?
- A. Jaundiced sclera and jaundiced palms of hands.
- B. Pale, boggy, edematous nasal mucosa.
- C. Lacy white plaques on the oral mucosa.
- D. Purple or blue patches on the face.
Correct Answer: B
Rationale: Pale, boggy, edematous nasal mucosa indicates chronic allergic rhinitis. Jaundice, oral plaques, and facial patches suggest other conditions.
The client diagnosed with Multiple Organ Dysfunction Syndrome (MODS) is admitted to the intensive care department. Which assessment data are most important for the nurse to collect/monitor?
- A. Lung sounds, heart sounds, and blood pressure.
- B. The client's psychological response to the illness.
- C. The client's family's expectations of the hospitalization.
- D. Amount of emesis, bile secretions, and mouth ulcers.
Correct Answer: A
Rationale: Lung sounds, heart sounds, and BP monitor respiratory, cardiac, and hemodynamic status, critical in MODS. Psychological, family, and GI data are secondary.