Kaplan Immune and Neuro

The nurse provides care for a client diagnosed with AIDS. The client is now in the advanced stage of the disease and reports severe diarrhea. The nurse intervenes if the client makes which statement?

"' will take a liquid nutritional supplement at least twice a day."

The nurse provides care for a client diagnosed with acquired immunodeficiency syndrome (AIDS). The client's sibling asks the nurse, "What kills people who have AIDS?" Which is the best response by the nurse?

"AIDS virtually cripples the body's normal protective immune response."

A client has just been diagnosed with the HIV virus. The nurse provides information on the transmission of the virus. Which client statement indicates the best understanding of the information provided by the nurse?

"It is OK for someone to share food with me."

A client asks the nurse, "What is the difference between rheumatoid arthritis and osteoarthritis?" Which response by the nurse is correct?

"Rheumatoid arthritis is a systemic disease and osteoarthritis is not."

The nurse provides discharge instructions to the parents of a preschool-age client diagnosed as HIV positive. Which statement by the parents indicates an understanding of the guidelines for preventing HIV transmission?

"We can cuddle and kiss our child when the child cries."

The nurse provides care for a child client diagnosed with HIV. The parents ask the nurse if they must always wear a gown, mask, and gloves when near the child. Which is the best response for the nurse to give?

"You should wear gloves when touching any body fluids."

The nurse follows up with a client who has just been told the HIV test is positive. The client states, "I don't deserve to have AIDS. I'm not gay. The test must be wrong." Which response by the nurse is both accurate and therapeutic?

"Your past drug use put you at high risk for HIV. I can see this news is distressing. Let's talk about it."

The nurse assesses a client diagnosed with a transient ischemic attack (TIA). The nurse anticipates the client will report which symptom?

Acute right lower extremity weakness that lasts about 15 minutes.

Which assessment does the nurse make first when providing care for a client diagnosed with a closed head injury?

Airway and respiratory status.

A client is diagnosed with systemic lupus erythematosus (SLE). The nurse understands which is an adverse effect of prednisone?

Alteration in mental status.

The nurse provides care for a client at risk for an intracranial hemorrhage. Which are risk factors for an intracranial hemorrhage?

Arteriosclerosis and hypertension.

An unconscious client arrives in the emergency department following a fall that resulted in a severe head injury. Which action does the nurse take first?

Assess the patency of the airway.

Which nursing intervention is most appropriate for a client diagnosed with rheumatoid arthritis and reporting generalized pain?

Assist the client with heat application and range-of-motion exercises.

The nursing provides care for a client who is at high risk for a stroke. Which is a known risk factor for a stroke?

Atrial fibrillation.

Following the transfusion of one unit of packed red blood cells, the nurse prepares to administer another unit. Which initial action is most appropriate for the nurse to take?

Check the type and cross-match with another nurse.

A client diagnosed with AIDS asks the clinic nurse about the risk of opportunistic infections. Which risk factor increases the client's risk of acquiring opportunistic infections?

Decreased T cell or CD4 cell count.

The school nurse teaches an adolescent client diagnosed with acquired immunodeficiency syndrome (AIDS) how to prevent transmission of the virus. Which information does the nurse include in the teaching plan?

Don't share needles.

A client diagnosed with a stroke resulting in right-sided hemiplegia is in a rehabilitation program. The client tells the nurse, "When I sit up in a chair, my right shoulder is painful." Which nursing measure does the nurse initiate?

Elevate the arm on a pillow.

The nurse provides care for a client who has a 15-year history of systemic lupus erythematosus (SLE). The client's blood pressure is 158/94 and 2 + pretibial edema is present. The nurse notes an elevated serum potassium level and decreased serum hemoglobin level. Which process best describes the reason for these findings?

Formation of antigen-antibody complexes that lodge in small blood vessels.

A client with a history of intravenous drug use and numerous sexual partners requests HIV testing. The HIV test returns a negative result. Which is the priority action for the nurse?

Help the client identify high-risk behaviors and provide information to help decrease these risks.

The nurse provides care for a client receiving a blood transfusion. The nurse is most concerned if which observation is made?

Hematuria occurs.

A client with a history of poorly controlled hypertension is diagnosed with a possible stroke. The client takes antihypertensive medication and hormone replacement therapy. The client is overweight and admits to watching television or working on the computer all day. The nurse identifies which risk factor as most significant for development of a stroke for this client?

Hypertension.

The nurse inserts an intravenous catheter (IV) into a client diagnosed with acquired immunodeficiency syndrome (AIDS). The client moves, and the used needle sticks into the nurse's forearm. Which action best describes the Occupational Safety and Health Administration (OSHA) requirements for what the employer must provide in this situation?

Immediate medical evaluation and treatment

The nurse assesses a client reporting fatigue and shortness of breath due to AIDS. Which action does the nurse take first?

Instruct the client to sit while preparing meals.

The nurse provides care for a client with acquired immunodeficiency syndrome (AIDS). The nurse knows the client is at high risk to develop which disease?

Kaposi sarcoma

The nurse identifies which group of symptoms is indicative of a hemolytic transfusion reaction?

Kidney pain hematuria cyanosis

The nurse provides care for a client diagnosed with a stroke resulting in right hemiplegia, sensory loss, and cognitive dystunction. During the clients first 72 hours of hospitalization, which is the priority nursing action?

Perform neurological assessments every 2 hours.

The nurse provides care for a client with acquired immunodeficiency syndrome (AIDS) who has a CD4 + T cell count of 120 cells/microL. The nurse knows the client is at risk to develop which infection?

Pneumocystis pneumonia (PCP).

How is an altered mental status an AE of prednisone?

Prednisone increases Na+ —> affects the brain

The nurse provides care for a client diagnosed with right-sided hemiplegia due to a stroke. The nurse observes the client has an inability to eat without total assistance. Which intervention is most appropriate to improve the client's nutrition?

Provide a pureed diet.

The nurse understands that hematocrit measures which data about the blood?

Ratio of red blood cells to fluid volume.

The nurse provides care for a client diagnosed with rheumatoid arthritis. Which finding is the priority for the nurse when assessing and planning the client's care?

Slight contracture of the right wrist.

The nurse provides care for a client who has a blood transfusion reaction. Which is the nurse's first action?

Stop the transfusion.

The nurse monitors a client receiving a blood transfusion. The nurse should intervene if which situation is observed?

The blood infuses at 10 mL/min for the first 15 min.

The nurse instructs a client diagnosed with HIV about barrier precautions and methods to prevent HIV transmission. Which best indicates to the nurse that the client understands the teaching?

The client states, "I will not have unprotected sexual intercourse."

The nurse provides care for an older client diagnosed with stroke earlier that day. Which nursing assessment is priority?

The level of consciousness.

The nurse provides care for a client admitted to the medical/surgical unit with a diagnosis of stroke. The nurse plans care to prevent the client from experiencing sensory overload. The nurse determines which plan is most effective?

The nurse obtains vital signs and assists the client with morning care in one visit. (Clustered care)

The nurse provides care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse explains to the client that the client will receive steroids for which reason?

To control inflammation.

The home care nurse visits a client diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse intervenes if which observation of the caregiver is made?

Touches the client's soiled linens.