TESTS TWO
Which patient would benefit from education about HIV preexposure prophylaxis (PrEP)? a. A 23-yr-old woman living with HIV infection. b. A 52-yr-old recently single woman just diagnosed with chlamydia. c. A 33-yr-old hospice worker who received a needle stick injury 3 hours ago. d. A 60-yr-old male in a monogamous relationship with an HIV-uninfected partner.
A 52-yr-old recently single woman just diagnosed with chlamydia.
A patient who has had good control for chronic pain using a fentanyl (Duragesic) patch reports rapid onset pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." How will the nurse document the type of pain reported by this patient? a. Somatic pain b. Referred pain c. Neuropathic pain d. Breakthrough pain
Breakthrough pain
The nurse is teaching a patient who has Parkinson disease about the side effects of carbidopa-levodopa. Which statement by the patient indicates a need for further teaching? a. "I may experience nausea, vomiting, and dyskinesia." b. "I may feel dizzy at first, but this side effect will go away with time." c. "I should report nightmares and mental disturbances to my provider." d. "I should take the drug with food to increase absorption."
"I should take the drug with food to increase absorption."
The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? a. "I will die early." b. "I will have gradual deterioration with no healthy times." c. "Parts of my nervous system have plaques." d. "This was caused by getting too many x-rays as a child."
"Parts of my nervous system have plaques."
Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 (0.2 × 109/L) or less than 14% b. Infection with P. jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immunedeficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications f. Confusion, dementia, or memory loss
CD4+ cell count less than 200/mm3 (0.2 × 109/L) or less than 14% Infection with P. jiroveci Presence of HIV wasting syndrome Confusion, dementia, or memory loss
A nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all thatapply.) a. Decreased immune response b. Development of chronic pain c. Increased gastrointestinal (GI) motility d. Possible immobility e. Slower healing f. Negative quality of life
Decreased immune response Development of chronic pain Possible immobility Slower healing Negative quality of life
A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment findings will the nurse expect?(Select all that apply.) a. Ataxia b. Dysphagia c. Aphasia d. Apraxia e. Hemiparesis/hemiplegia f. Ptosis
Dysphagia Aphasia Apraxia Hemiparesis/hemiplegia Ptosis
The blood test first used to identify a response to HIV infection is: a. Western blot b. ELISA test c. CD4+ T-cell count d. CBC
ELISA test
The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia
Flexed trunk Slow movements Uncontrolled drooling
A patient with multiple sclerosis will be starting therapy with an immunosuppressant drug. The nurse expects that which drug will be used? a. Azathioprine (Imuran) b. Glatiramer acetate (Copaxone) c. Daclizumab (Zenapax) d. Sirolimus (Rapamune)
Glatiramer acetate (Copaxone)
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the mediation. Which finding indicates that the client is experiencing as adverse effect? A. Pruritus B. Tachycardia C. Hypertension D. Impaired voluntary movements
Impaired voluntary movements
A patient has been treated with antiparkinson medications for 3 months. What therapeutic responses should the nurse look for when assessing this patient? a. Decreased appetite b. Gradual development of cogwheel rigidity c. Newly developed dyskinesias d. Improved ability to perform activities of daily living
Improved ability to perform activities of daily living
Which patient problem should the nurse identify as of highest priority for a patient who has Parkinson's disease and is unable to move the facial muscles? a. Activity intolerance b. Inadequate nutrition c. Disturbed body image d. Impaired physical mobility
Inadequate nutrition
A patient is hospitalized with new onset of Guillain-Barré syndrome. What should the nurse recognize as the most essential assessment to complete? a. Determining level of consciousness b. Checking strength of the extremities c. Observing respiratory rate and effort d. Monitoring the cardiac rate and rhythm
Observing respiratory rate and effort
The nurse notes in the patient's medication orders that the patient will be starting anticoagulant therapy. What is the primary goal of anticoagulant therapy? a. Stabilizing an existing thrombus b. Dissolving an existing thrombus c. Preventing thrombus formation d. Dilating the vessel around a clot
Preventing thrombus formation
A 50-year-old male patient has been diagnosed with amyotrophic lateral sclerosis (ALS). What nursing intervention is most important to help prevent a common cause of death for patients with ALS? a. Reduce fat intake. b. Reduce the risk of aspiration. c. Decrease injury related to falls. d. Decrease pain secondary to muscle weakness.
Reduce the risk of aspiration.
A client with HIV is treated with the nonnucleoside reverse transcriptase inhibitor (NNRTI) efavirenz (Sustiva). The nurse is aware that other agents may be used because of which significant problem with NNRTIs? a. Alopecia b. Resistance c. Coma d. Hepatic dysfunction
Resistance
The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment findings will the nurse expect for this client? a. Expressive aphasia b. Ptosis (eyelid drooping) c. Slurred speech d. Severe facial pain
Severe facial pain
A patient with Parkinson's disease has bradykinesia. Which action should the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.
Suggest that the patient rock from side to side to initiate leg movement.
What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia? a. Visual problems caused by ptosis. b. Poor appetite caused by loss of taste. c. Triggers leading to facial discomfort. d. Weakness on the affected side of the face.
Triggers leading to facial discomfort.
The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient? a. "You may be able to prevent Bell's palsy by doing facial exercises regularly." b. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "Call the doctor if you experience pain or develop herpes lesions near the ear."
"Call the doctor if you experience pain or develop herpes lesions near the ear."
A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? a. "Be sure that you use a wheelchair when you go out in public." b. "Wear an undergarment brief at all times in case of incontinence." c. "Avoid overexertion, stress, and extreme temperature if possible." d. "Avoid having sexual intercourse to conserve energy."
"Avoid overexertion, stress, and extreme temperature if possible."
A patient with chronic neck pain is seen in the clinic for follow-up. To evaluate whether the pain management is effective, which question is best for the nurse to ask? a. "Has there been a change in pain location?" b. "Can you describe the quality of your pain?" c. "How would you rate your pain on a 0 to 10 scale?" d. "Does pain keep you from activities that you enjoy?"
"Does pain keep you from activities that you enjoy?"
The nurse has completed medication education about pyridostigmine (Mestinon), an indirect cholinergic drug, for the patient with myasthenia gravis. The nurse determines that learning has occurred when the patient makes which statement? a. "My heart may beat slower while I am on this drug." b. "I will need to increase my fluid intake with this medication." c. "I must take this medication immediately before eating a full meal." d. "It is really important to take my medication on time."
"It is really important to take my medication on time."
The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. "Are you worried about addiction to pain pills?" b. "Do you attach any spiritual meaning to pain?" c. "How high would you say your pain tolerance is?" d. "What pain rating would be acceptable to you?"
"What pain rating would be acceptable to you?"
The client diagnosed with Guillain-Barré syndrome asks the nurse, "Will I ever get back to normal? I am so tired of being sick." Which statement is the best response by the nurse? 1. "You should make a full recovery within a few months to a year." 2. "Most clients with this syndrome have some type of residual disability." 3. "This is something you should discuss with the health-care team." 4. "The rehabilitation is short and you should be fully recovered within a month."
"You should make a full recovery within a few months to a year."
What should the nurse include in a focused assessment of a patient's left posterior temporal lobe functions? a. Sensation on the left side of the body b. Reasoning and problem-solving ability c. Ability to understand written and oral language d. Voluntary movements on the right side of the body
Ability to understand written and oral language
A patient with terminal cancer-related pain and a history of opioid abuse reports breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? a. Use distraction by talking about things the patient enjoys. b. Suggest the use of alternative therapies such as heat or cold c. Administer the prescribed PRN immediate-acting morphine. d. Consult with the doctor about increasing the MS Contin dose.
Administer the prescribed PRN immediate-acting morphine.
When assessing the medication history of a patient with a new diagnosis of Parkinson's disease, which conditions are contraindications for the patient who will be taking carbidopa-levodopa? (Select all that apply.) a. Angle-closure glaucoma b. History of malignant melanoma c. Hypertension d. Benign prostatic hyperplasia e. Concurrent use of monoamine oxidase inhibitors (MAOIs)
Angle-closure glaucoma History of malignant melanoma Concurrent use of monoamine oxidase inhibitors (MAOIs)
A client with HIV-II has had a sudden decline in status with a large increase in viral load. What action would the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.
Assess the client for adherence to the drug regimen.
A nurse is teaching a client who has ALS about a new medication for riluzole. Which of the following instructions should the nurse give to the patient ? A. Take this medication immediately prior to eating B. Drink a glass of milk with this medication C. Avoid consuming alcoholic beverages D. Monitor your blood pressure daily
Avoid consuming alcoholic beverages
When providing discharge teaching for a client with MS, the nurse should include which instruction? A. Avoid taking daytime naps B. Avoid hot baths and showers C. Limit your fruit and vegetable intake D. Restrict fluid intake to 1,500 mL/day
Avoid hot baths and showers
A patient who is HIV-positive has been receiving medication therapy that includes zidovudine (Retrovir). However, the prescriber has decided to stop the zidovudine because of its dose-limiting adverse effect. Which of these conditions is the dose-limiting adverse effect of zidovudine therapy? a. Retinitis b. Renal toxicity c. Hepatotoxicity d. Bone marrow suppression
Bone marrow suppression
Which antiviral drug causes lipodystrophy as a major adverse effect? a. Darunavir b. Zalcitabine c. Zidovudine d. Didanosine
Darunavir
The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? a. Projectile vomiting b. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness
Decreased level of consciousness
What concern should the nurse anticipate for a patient who had a right hemisphere stroke? a. Right-sided hemiplegia b. Speech-language deficits c. Denial of deficits and impulsiveness d. Depression and distress about disability
Denial of deficits and impulsiveness
A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions
Difficulty comprehending instructions
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.
Discuss a change in antiretroviral therapy.
A cholinergic drug is prescribed for a patient. The nurse checks the patient's medical history, knowing that this drug is contraindicated in which disorders? (Select all that apply.) a. Bladder atony b. Gastrointestinal obstruction c. Bradycardia d. Alzheimer's disease e. Hypotension f. Chronic obstructive pulmonary disease
Gastrointestinal obstruction Bradycardia Hypotension Chronic obstructive pulmonary disease
The nurse assesses a client who is experiencing a common migraine without an aura. Which assessment finding(s) would the nurse expect? (Select all that apply.) a. Headache lasting up to 72 hours b. Unilateral and pulsating headache c. Abrupt loss of consciousness d. Acute confusion e. Pain worsens with physical activities f. Photophobia
Headache lasting up to 72 hours Unilateral and pulsating headache Pain worsens with physical activities Photophobia
A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because it is an early stage of HIV infection, the infant will not contract HIV. d. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).
Most infants born to HIV-positive mothers are not infected with the virus.
After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness. b. Patient with a bilateral headache described as "like a band around my head." c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin). d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms.
Patient with myasthenia gravis who is reporting increased muscle weakness.
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. CD4+ cell count b. How the patient obtained HIV c. Patient's tolerance for potential medication side effects d. Patient's ability to follow a complex medication regimen
Patient's ability to follow a complex medication regimen
Which assessment should the nurse identify as most important regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness
Respiratory effort
A nurse sustains a needlestick injury and is exposed to an HIV-positive patient's blood. What is the highest priority action for the nurse? a. Wait for appearance of symptoms to receive treatment. b. Begin triple antibiotic therapy to prevent symptoms. c. Start 4 weeks of antiretroviral therapy. d. Start 10 days to 2 weeks of antibiotic therapy.
Start 4 weeks of antiretroviral therapy.
A cholinergic drug is prescribed for a patient with a new diagnosis of myasthenia gravis, and the nurse provides instructions to the patient about the medication. What is important to include in the teaching? a. Give daytime doses close together for maximal therapeutic effect. b. Take the medication with meals to avoid gastrointestinal distress. c. Take the medication 30 minutes before eating to improve swallowing and chewing. d. Take the medication only if difficulty swallowing occurs during a meal.
Take the medication 30 minutes before eating to improve swallowing and chewing.
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important tocommunicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).
The patient has atrial fibrillation and takes warfarin (Coumadin).
A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.
The patient reports that symptoms began with a severe headache.
What will the nurse monitor to evaluate the effectiveness of antiviral agents administered to treat human immunodeficiency virus infection? a. Viral load b. Lymphocyte counts c. Red blood cell counts d. Megakaryocyte counts
Viral load
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay
Viral load testing
During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipate? a. Dysphasia b. Confusion c. Visual deficits d. Poor judgment
Visual deficits
The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue
Visual disturbances
A patient who is HIV-infected takes 800 mg of indinavir (Crixivan), a protease inhibitor medication. The provider has ordered adding ritonavir (Norvir) to the regimen. The nurse will teach the patient that the addition of ritonavir a. allows decreasing the dosing from 3 times daily to twice daily. b. can lead to increased cholesterol and triglycerides. c. may worsen insulin resistance. d. will require increased dietary restrictions.
allows decreasing the dosing from 3 times daily to twice daily.
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?
impaired voluntary movements
Which question asked by the nurse will give the most information about the patient's metastatic bone cancer pain? a. "How long have you had this pain?" b. "How would you describe your pain?" c. "How often do you take pain medication?" d. "How much medication do you take for the pain?"
"How would you describe your pain?"
A patient who has parkinsonism will begin taking carbidopa-levodopa. What information will the nurse include when teaching this patient about this medication? a. "Call your health care provider immediately if your urine or perspiration turn a dark color." b. "Rise slowly from your bed or your chair to avoid dizziness and falls." c. "Take the drug with foods high in protein to improve drug delivery." d. "Discontinue the drug if you experience insomnia."
"Rise slowly from your bed or your chair to avoid dizziness and falls."
The nurse is advising a patient who was exposed 4 days ago to human immunodeficiency =virus (HIV) through unprotected sexual intercourse. The patient's antigen-antibody test has just been reported as negative for HIV. What information should the nurse give to this patient? a. "You will need to be retested in 2 weeks." b. "You do not need to fear infecting others." c. "We won't know for about 10 years if you have HIV infection." d. "With no symptoms and this negative test, you do not have HIV."
"You will need to be retested in 2 weeks."
Which action would the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia? a. Assess fluid and dietary intake. b. Apply ice packs for 20 minutes. c. Teach facial relaxation techniques. d. Spend time talking with the patient.
Assess fluid and dietary intake.
What should the nurse advise a patient with myasthenia gravis (MG) to do? a. Anticipate the need for weekly plasmapheresis treatments. b. Complete physically demanding activities early in the day. c. Protect the extremities from injury due to poor sensory perception. d. Perform frequent weight-bearing exercise to prevent muscle atrophy.
Complete physically demanding activities early in the day.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (chest x-ray) c. Computed tomography (CT) scan d. 12-Lead electrocardiogram (ECG)
Computed tomography (CT) scan
An HIV-negative client who has an HIV-positive partner asks the nurse about receiving tenofovir/emtricitabine. What information is most important to teach the client about this drug? a. Does not reduce the need for safe sex practices. b. Has been taken off the market due to increases in cancer. c. Reduces the number of HIV tests you will need. d. Is only used for postexposure prophylaxis
Does not reduce the need for safe sex practices.
Carbidopa-levodopa (Sinemet) is prescribed for a patient with Parkinson's disease. The nurse informs the patient that which common adverse effects can occur with this medication? a. Drowsiness, headache, weight loss b. Dizziness, insomnia, nausea c. Peripheral edema, fatigue, syncope d. Heart palpitations, hypotension, urinary retention
Heart palpitations, hypotension, urinary retention
Which nursing action will be most useful in assisting a young adult to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Help the patient develop a schedule to decide when the drugs should be taken. d. Encourage the patient to join a support group for adults who are HIV positive.
Help the patient develop a schedule to decide when the drugs should be taken.
A nurse is caring for a client admitted to the hospital with respiratory difficulty after being diagnosed with amyotrophic lateral sclerosis (ALS) approximately 1 year ago. Which of the following client finding should the nurse anticipate? Select all that apply. A. Loss of sensation B. Fluctuations in blood pressure C. Incontinence D. Ineffective cough E. Loss of cognitive function
Incontinence Ineffective cough
The U.S. Food and Drug Administration has issued a warning for users of antiepileptic drugs. Based on this report, the nurse will monitor for which potential problems with this class of drugs? a. Increased risk of suicidal thoughts and behaviors b. Signs of bone marrow depression c. Indications of drug addiction and dependency d. Increased risk of cardiovascular events, such as strokes
Increased risk of suicidal thoughts and behaviors
A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate? a. Infusion of immunoglobulin b. Administration of corticosteroids c. Intubation and mechanical ventilation d. Insertion of a nasogastric (NG) feeding tube
Infusion of immunoglobulin
What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)? a. Assess for the presence of chest pain. b. Inquire about urinary tract problems. c. Inspect the skin for rashes or discoloration. d. Ask the patient about any increase in libido
Inquire about urinary tract problems.
The nurse is performing a health history on a patient who has multiple sclerosis. The patient reports episodes of muscle spasticity and recurrence of muscle weakness and diplopia. The nurse will expect this patient to be prescribed which medication? a. Methylprednisolone (Solu-Medrol) b. Mitoxantrone c. Cyclobenzaprine (Flexeril) d. Interferon-B (IFN-B)
Interferon-B (IFN-B)
Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient reports having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
The patient's blood pressure (BP) is 90/50 mm Hg.
Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.
The patient's usual blood pressure (BP) is 170/94 mm Hg.
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset
Time of symptom onset
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient? a. Surgical endarterectomy b. Transluminal angioplasty c. Intravenous heparin drip administration d. Tissue plasminogen activator (tPa) infusion
Tissue plasminogen activator (tPa) infusion
When a nurse is diagnosing the type and cause of a headache that a patient has, the most important tool is 1. MRI of the brain. 2. electromyography. 3. the patient history. 4. CT imaging of the brain.
the patient history.
The nurse assesses that a home hospice patient with terminal cancer who reports severe pain has a respiratory rate of 11 breaths/min. Which action should the nurse take? a. Tell the patient that increasing the morphine will cause the respiratory drive to fail. b. Titrate the prescribed morphine dose up until the patient indicates adequate pain relief. c. Inform the patient that more morphine can be given if the respiratory rate is at least 12. d. Administer a nonsteroidal antiinflammatory drug (NSAID) to improve patient pain control.
Titrate the prescribed morphine dose up until the patient indicates adequate pain relief.
A patient with multiple sclerosis has a nursing diagnosis of urinary retention related to sensorimotor deficits. An appropriate nursing intervention for this problem is to 1. decrease fluid intake to prevent overdistention of the bladder. 2. teach the patient that anticholinergic drugs will decrease spasticity. 3. teach the patient the techniques of intermittent self-catheterization. 4. use incontinence briefs to decrease embarrassment of urinary dribbling.
teach the patient the techniques of intermittent self-catheterization.
A patient who uses injectable illegal drugs asks the nurse how to prevent acquired immunodeficiency syndrome (AIDS). Which response by the nurse is most accurate? a. "Clean drug injection equipment before each use." b. "Ask those who share equipment to be tested for HIV." c. "Consider participating in a needle-exchange program." d. "Avoid sexual intercourse when using injectable drugs."
"Consider participating in a needle-exchange program."
The health care provider orders ritonavir (Norvir) for a patient who has acquired immune deficiency syndrome. About what adverse effect will the nurse inform the patient? a. Pancreatitis b.. Photophobia c. Bone marrow suppression d. Bony appearance of the face
Bony appearance of the face
An older patient exhibits a shuffling gait, lack of facial expression, and tremors at rest. The nurse will expect the provider to order which medication for this patient? a. Carbidopa-levodopa (Sinemet) b. Donepezil (Aricept) c. Rivastigmine (Exelon) d. Tacrine (Cognex)
Carbidopa-levodopa (Sinemet)
A patient has been admitted to the emergency department with a suspected overdose of a tricyclic antidepressant. The nurse will prepare for what immediate concern? a. Hypertension b. Renal failure c. Cardiac dysrhythmias d. Gastrointestinal bleeding
Cardiac dysrhythmias
The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client's symptoms occurred slowly over several hours .b. Client because increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation
Client has a long history of atrial fibrillation
A new nurse asks the precepting nurse "What is the best way to assess a client's pain?" Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Client's self-report d. Objective observation
Client's self-report
The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immunedeficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands "HIV+" d. Wearing a mask within 3 feet (1 m) of the client
Consistent use of Standard Precautions
Which of the following is NOT considered a potential life-threatening adverse reaction to clopidogrel (Plavix) use? a. Hepatic failure b. Ischemic stroke c. Thrombocytopenia d. Stevens-Johnson syndrome
Ischemic stroke
A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the prescribed PRN O2 at 6 L/min. b. Put a moist hot pack on the patient's neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.
Start the prescribed PRN O2 at 6 L/min.
The nurse is providing counseling to a woman who is HIV positive and has just discovered that she is pregnant. Which anti-HIV drug is given to HIV-infected pregnant women to prevent transmission of the virus to the infant? a. Acyclovir (Zovirax) b. Zidovudine (Retrovir) c. Ribavirin (Virazole) d. Foscarnet (Foscavir)
Zidovudine (Retrovir)
A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. During assessment of the patient, the nurse would expect manifestations of the ALS to include 1. psychotic behavior. 2. muscle weakness and wasting. 3. a decline in cognitive function. 4. abnormal and excessive involuntary movements.
muscle weakness and wasting.
Opportunistic diseases in HIV infection a. are usually benign. b. are generally slow to develop and progress. c. occur in the presence of immunosuppression. d. are curable with appropriate drug interventions.
occur in the presence of immunosuppression.
A child with AIDS is placed on antiretroviral therapy. The nurse's instructions to the child and family are based on the premise that the goals of antiretroviral therapy include: a. increasing viral load to detectable levels. b. slowing the decline in the number of CD4 cells. c. increasing resistance to opportunistic infections. d. decreasing the severity of opportunistic infections.
slowing the decline in the number of CD4 cells.
1. When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about a. triggers that lead to facial pain. b. visual problems caused by ptosis. c. poor appetite caused by a loss of taste. d. decreased sensation on the affected side.
triggers that lead to facial pain.
A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Begin tissue plasminogen activator (tPA) intravenously per protocol.
Start a labetalol drip to keep BP less than 140/90 mm Hg.
A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Notify the patient's health care provider immediately. b. Start the ordered PRN oxygen at 9 L/min. c. Give the ordered prn acetaminophen (Tylenol). d. Put a moist hot pack on the patient's neck.
Start the ordered PRN oxygen at 9 L/min.
Which finding should the nurse expect when assessing a patient who is experiencing a cluster headache? a. Nuchal rigidity b. Unilateral ptosis c. Projectile vomiting d. Bilateral facial pain
Unilateral ptosis
A patient is receiving instructions regarding the use of caffeine. The nurse shares that caffeine should be used with caution if which of these conditions is present? a. A history of peptic ulcers b. Migraine headaches c. Asthma d. A history of kidney stones
A history of peptic ulcers
The nurse is caring for a patient who is receiving warfarin (Coumadin) and notes bruising and petechiae on the patient's extremities. The nurse will request an order for which laboratory test? a. International normalized ratio (INR) b. Platelet level c. PTT and aPTT d. Vitamin K level
International normalized ratio (INR)
The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions? a. "Riluzole should be taken with food." b. "I plan to take riluzole once daily." c. "I will call the health care provider if my pulse goes below 50." d. "I will need frequent checks of my liver enzymes."
"I will need frequent checks of my liver enzymes."
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for DiseaseControl and Prevention (CDC), which statement by the nurse is correct? a. "The patient meets the criteria for a diagnosis of acute HIV infection." b. "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient will likely develop symptomatic HIV infection within 1 year." d. "The patient has developed acquired immunodeficiency syndrome (AIDS)."
"The patient has developed acquired immunodeficiency syndrome (AIDS)."
A nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct?(Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with HIV-I disease are not infectious to others. f. The CD4+ T-cell is only affected when the disease has progressed to HIV-III
Antibodies produced are incomplete and do not function well. Macrophages stop functioning properly. Opportunistic infections and cancer are leading causes of death.
A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.
Ask the patient to keep a headache diary.
The health care provider orders ritonavir for a patient who has acquired immune deficiency syndrome. About what adverse effect will the nurse inform the patient? a. Pancreatitis b. Photophobia c. Bone marrow suppression d. Bony appearance of the face
Bony appearance of the face
A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.
Check the respiratory rate and effort.
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.
Progressive ascending paralysis of the lower extremities and numbness.
A patient who has fibromyalgia reports pain at level 7 (0 to 10 scale). The patient tells the nurse, "I feel depressed because I ache too much to play golf." Which patient goal has the highest priority when the nurse is developing the treatment plan? a. The patient will report pain at a level 2 of 10. b. The patient will be able to play a round of golf. c. The patient will exhibit fewer signs of depression. d. The patient will say that the aching has decreased.
The patient will be able to play a round of golf.
