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Which of the following would the nurse evaluate as laboratory data that support the occurrence of AIDS?
- A. 900 CD 4+ cells
- B. 500 CD 4+ cells
- C. 700 CD 4+ cells
- D. 200 CD 4+ cells
Correct Answer: D
Rationale: The nurse would evaluate 200 CD 4+ cells as laboratory data that support the occurrence of AIDS. In patients with AIDS, there is a significant decrease in the CD4+ T-lymphocyte count, typically falling below 200 cells/mm³. This low CD4+ cell count increases the risk of opportunistic infections and indicates severe immune suppression, which is characteristic of AIDS. A CD4+ count of 200 or less is an important criterion for the diagnosis of AIDS according to the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) guidelines.
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Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?
- A. The Food Guide Pyramid
- B. The South Beach Diet
- C. The Step One Diet
- D. The Dash diet
Correct Answer: D
Rationale: The Dietary Approaches to Stop Hypertension (DASH) diet is recommended by healthcare professionals, including nurses, for clients with hypertension. This diet emphasizes consuming fruits, vegetables, whole grains, lean proteins, and low-fat dairy products while limiting sodium, saturated fats, and cholesterol. These dietary components are known to help lower blood pressure and improve overall health. The DASH diet has been proven effective in numerous studies and is endorsed by organizations like the American Heart Association for managing hypertension. It is important for clients to follow the DASH diet under the guidance of a physician to ensure it is tailored to their individual needs and health status.
Which action best explains the main role of surfactant in the neonate?
- A. Assists with ciliary body maturation in the upper airways
- B. Helps maintain a rhythmic breathing pattern
- C. Promotes clearing mucus from the respiratory tract
- D. Helps the lungs remain expanded after the initiation of breathing
Correct Answer: D
Rationale: Surfactant plays a crucial role in the neonate by helping the lungs remain expanded after the initiation of breathing. Surfactant is a substance produced by type II alveolar cells in the lungs that reduces surface tension in the alveoli. By lowering surface tension, surfactant prevents the alveoli from collapsing during expiration, thereby helping the lungs to remain expanded and functional. This function is particularly important in neonates, whose lungs are not yet fully developed and may have difficulty maintaining lung expansion without adequate levels of surfactant. Failure to produce enough surfactant can lead to respiratory distress syndrome in premature infants.
The American Academy of Pediatrics recommends the use of validated standardized developmental screening tools at three of the health maintenance visits, these are at
- A. 2 months, 6 months, and 12 months
- B. 6 months, 12 months, and 18 months
- C. 9 months, 18 months, and 30 months
- D. 12 months, 18 months, and 24 months
Correct Answer: C
Rationale: Developmental screenings are recommended at 9, 18, and 30 months.
A nurse is planning care for a preterm newborn. Which interventions should the nurse implement for skin care? (Select all that apply.)
- A. Use cleaning agents with neutral pH.
- B. Rub skin during drying.
- C. Use adhesive remover solvent when removing tape.
- D. Avoid removing adhesives for at least 24 hours.
Correct Answer: A
Rationale: Using cleaning agents with neutral pH is important for the delicate skin of a preterm newborn to prevent irritation and damage.
You are evaluating a 6-mo-old girl with a firm right suprarenal mass. Histologically, there is no bony involvement, 10% bone marrow involvement, subcutaneous nodules involvement, and massive abdominal mass. The N-myc oncogene is not amplified. According to the international neuroblastoma staging system, the infant is stratified as
- A. stage I
- B. stage II A
- C. stage III
- D. stage IV S
Correct Answer: D
Rationale: Stage IV S refers to infants <1 year with localized primary tumor, distant metastases limited to liver, skin, or bone marrow (with <10% involvement), and no amplification of N-myc.