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 correct answer is D: 200 CD4+ cells. In AIDS, the immune system is severely compromised, leading to a decrease in CD4+ T cells. A CD4+ count below 200 cells/mm3 is a key indicator of AIDS, as it signifies advanced immunodeficiency. Choices A, B, and C all have CD4+ cell counts above 200, which would not support the occurrence of AIDS. Therefore, the nurse would evaluate a CD4+ count of 200 cells as laboratory data that support the occurrence of AIDS.
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After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
- A. Esophageal carcinoma
- B. Laryngeal carcinoma
- C. Pituitary carcinoma
- D. Colorectal carcinoma
Correct Answer: C
Rationale: Rationale:
1. Transsphenoidal adenohypophysectomy is the surgical removal of the pituitary gland's adenohypophysis.
2. The procedure is used to treat pituitary tumors, which can be benign or malignant, but commonly referred to as pituitary adenomas.
3. Pituitary adenomas may secrete hormones excessively, leading to various endocrine disorders.
4. Hormone replacement therapy is required post-surgery to manage hormonal deficiencies.
5. Therefore, the correct answer is C (Pituitary carcinoma).
Summary:
A, B, and D are incorrect as they do not involve the pituitary gland, which is the primary target of a transsphenoidal adenohypophysectomy.
A client asks the nurse about the four-point gait when partial weight bearing is permitted. What is the nurse’s BEST response?
- A. move the right crutch ahead, then follow with the left foot
- B. move both crutches forward together, then swing legs through
- C. move the left crutch and the right foot forward together
- D. move both crutches and the weaker leg forward at the same time
Correct Answer: A
Rationale: The correct answer is A because in the four-point gait with partial weight bearing, the client should move the right crutch ahead first to provide support and stability, followed by the left foot. This sequence ensures proper weight distribution and balance. Moving both crutches together (B) may compromise stability. Moving the left crutch and right foot together (C) may cause uneven weight distribution. Moving both crutches and weaker leg together (D) may not provide adequate support for the weaker leg.
Another girl was bitten by a poisonous snake. All of the following are true except
- A. The victim of a snake bite should be made to exercise the bitten extremity to hasten circulation
- B. The bite of a poisonous snake is distinguished by two fang marks
- C. Immediate severe pain and swelling distinguished the bite of a poisonous snake
- D. The tourniquet should be tight enough to prevent superficial circulation of blood thus stopping absorption of the poison
Correct Answer: A
Rationale: The correct answer is A because exercising the bitten extremity can increase the spread of the venom. Choice B is correct as poisonous snake bites typically leave two fang marks. Choice C is correct as immediate severe pain and swelling are common symptoms of a poisonous snake bite. Choice D is incorrect as a tourniquet should not be used for snake bites as it can lead to complications such as tissue damage and increased risk of infection.
A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?
- A. Continue to follow the written plan of care.
- B. Make recommendations for revising the plan of care.
- C. Ask another health care professional to design a plan of care.
- D. State 'goal will be met at a later date.'
Correct Answer: B
Rationale: The correct answer is B: Make recommendations for revising the plan of care. When client outcomes are not met within the specified time frame, the nurse should reassess the plan of care to identify any potential reasons for the lack of progress. By making recommendations for revising the plan of care, the nurse can adjust interventions to better align with the client's needs and facilitate goal achievement. Continuing to follow the written plan of care (choice A) without modification may not address the underlying issues preventing goal attainment. Asking another health care professional to design a plan of care (choice C) may not be necessary if the nurse can assess and revise the current plan. Stating 'goal will be met at a later date' (choice D) does not address the need for immediate action to reassess and modify the plan for better outcomes.
Which of the ff vitamins does a client lack if there is a problem with the absorption of calcium?
- A. Vitamin A
- B. Vitamin B
- C. Vitamin C
- D. Vitamin D
Correct Answer: D
Rationale: The correct answer is D: Vitamin D. Vitamin D is essential for the absorption of calcium in the intestines. Without sufficient vitamin D, the body cannot effectively absorb calcium, leading to potential issues with calcium absorption. Vitamin A (choice A) is not directly involved in calcium absorption. Vitamin B (choice B) and Vitamin C (choice C) also do not play a significant role in calcium absorption. Therefore, the lack of Vitamin D is the most likely cause for problems with calcium absorption.