Crumbley EAQ Burns/HIV/Endocrine

(17) A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the rule of nines. Record your answer using one decimal place. _______%

22.5 The front of the head is 4.5%, and the anterior torso is 9%, for a total of 13.5%.

(3) a HIV+ pregnant adolescence does not want a cesarean birth. which riding would indicate the increased risk of perinatal transmission via vaginal birth? a. viral load of 800 b. viral load of 1200 c. ruptured membranes ad rapidly progressing labor d. hx of receiving combination ART and having a viral load less than 400

b. viral load of 1200 A vaginal birth in the case of a woman with a viral load of more than 1,000 copies/mL (1,200 copies/mL) has a high chance of perinatal transmission, so cesarean birth is the preferred method. A viral load less than 1,000 copies/mL (800 copies/mL) is not threatening and lessens the chances of perinatal transmission via vaginal birth. Women with ruptured membranes have to take intravenous zidovudine injection and may proceed for vaginal birth. Women undergoing antiretroviral therapy with viral loads of less than 400 copies/mL can opt for vaginal birth.

(10) which complication may be caused by sepsis in burns? a. diarrhea b. constipation c. paralytic ileus d. curling's ulcer

c. paralytic ileus Paralytic ileus, or hypoactive bowel, is a complication caused by sepsis in clients with burns. Diarrhea can be caused by the use of enteral feedings or antibiotics. Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions. It is caused by a generalized stress response to decreased blood flow to the gastrointestinal tract in clients with burns.

(7) After recording the blood pressure of a client, the primary health care provider confirms a diagnosis of pheochromocytoma. What blood pressure may have helped confirm the diagnosis? a. 90/70 mmHg b. 80/60 mmHg c. 120/80 mmHg d. 190/90 mmHg

d. 190/90 mmHg Increased blood pressure indicates the presence of pheochromocytoma. The increase in blood pressure could be due to the increased production of catecholamines, indicating endocrine imbalance. Therefore, the client could have a blood pressure of 190/90 mmHg. The blood pressure values of 90/70 mmHg and 80/60 are below normal and indicate hypotension. A blood pressure value of 120/80 mmHg is a normal value.

(23) what determines if a client will develop AIDS from HIV? a. level of IgM in the blood b. the number ofCD4 cells available c. presence of antigen-antibody complexes d. speed with which the virus invades the RNA

b. the number ofCD4 cells available Whether HIV becomes AIDS depends upon the number of CD4+ T-cells. IgM and the presence of antigen-antibody complexes have no effect on HIV. The speed with which HIV invades the RNA has no impact on the future development of AIDS.

(40) a 3-year-old child is admitted with partial- and full-thickness burns over 30% of the body. what significant adverse outcome during the first 48 hours should the nurse attempt to prevent? a. shock b. pneumonia c. contractures d. hypertension

a. shock The immediate postburn period is marked by dramatic changes in fluid and electrolyte balance. Alterations in electrolyte balance can produce confusion, weakness, cardiac irregularities, and seizures. As a result of large fluid losses through the denuded skin, vasodilation, and edema formation, hypovolemic shock may develop. Pneumonia is a later complication associated with immobility. Contractures are a later complication associated with scarring and aggravated by improper positioning and splinting. Hypotension, not hypertension, occurs with hypovolemic shock.

(4) a client is admitted to the hospital dt electrical burns. which assessment findings does the nurse anticipate? (select all that apply) a. coughing b. burn odor c. smoky breath d. leathery skin e. cardiac arrest

b. burn odor d. leathery skin e. cardiac arrest A client with electrical burns may have assessment findings such as burn odor, leathery skin, and cardiac arrest due to hypovolemia and electrical disturbances. Coughing and smoky breath are assessment findings associated with inhalational injuries.

(18) A client is admitted with a diagnosis of chronic adrenal insufficiency. Which roommate should be avoided when assigning a room for this client? a. A young adult client with pneumonia b. An adolescent client with a fractured leg c. An older adult client who had a brain attack d. A middle-aged client who has cholecystitis

a. A young adult client with pneumonia Circulatory collapse can be caused by exposure to an infection, cold, or overexertion of a client with chronic adrenocortical insufficiency (Addison disease). Roommates with a fractured leg, a brain attack, or cholecystitis are appropriate room assignments because they do not have communicable infections.

(10) A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first? a. Start the time of the test after discarding the first voiding b. Discard the last voiding in the 24-hour time period for the test c. Insert a urinary retention catheter to promote the collection of urine d. Strain the urine following each voiding before adding the urine to the container

a. Start the time of the test after discarding the first voiding The first voiding is discarded because that urine was in the bladder before the test began and should not be included. The last voiding should be placed in the specimen container because the urine was produced during the 24-hour time frame of the test. Discarding the last void in the 24-hour time period for the test is not necessary; voided specimens are acceptable. Straining the urine following each voiding before adding the urine to the container is not necessary; this is done for clients with renal calculi.

(6) a client with burns is prescribed polymyxin by the PHCP. which action should the nurse take? a. apply the drug q2-8hours b. leave in place for 7 days c. use the drug with barrier dressing d. refrain from using with oil-based products

a. apply the drug q2-8hours Polymixin should be applied every 2-8 hours to keep the affected area moist. PolyMem, a dressing material containing silver granules, should be left in place for 7 days. Collagenase with polysporin powder can be applied once a day and can be used with barrier dressing such as xeroform. Acticoat should not be used with oil-based products.

(19) A nurse is caring for a client with myxedema who has undergone abdominal surgery. What should the nurse consider when administering opioids to this client? a. Tolerance to the drug develops readily. b. One-third to one-half the usual dose should be prescribed. c. Opioids may interfere with the secretion of thyroid hormones. d. Sedation will have a paradoxical effect, causing hyperactivity

b. One-third to one-half the usual dose should be prescribed. Because of a decreased metabolism, the usual adult dose of an opioid may result in an overdose. A decreased basal metabolic rate prolongs the time for drug detoxification and elimination. Hypothyroidism does not alter tolerance. Opioids do not alter the thyroid hormone; opioids will cause excessive sedation, not hyperactivity.

(30) a nurse is caring for a 7-year-old child with severe burns who has extensive eschar formation on the arms. what is the priority nursing intervention? a. removing blisters b. checking radial pulses c. maintaining respiratory isolation d. performing ROM exercises

b. checking radial pulses The radial pulses are a reflection of how the child is adapting to the eschar formation. Eschar is rigid and may restrict circulation, leading to loss of perfusion to the limbs. Blisters are a protective adaptation and should not be disturbed. There is no information to indicate that the child has a respiratory infection. Although range-of-motion exercises are important, adequate arterial perfusion is the priority.

(36) a man who has 40% of TBSA burned is admitted to the hospital. fluid replacement of 7200 mL during the first 24 hours has been prescribed. 50% of fluid replacement should be administered in the first 8 hours; then the remaining 50% given over the next 16 hours. what does the nurse calculate the hourly IV fluid to be for the first 8 hours of fluid replacement therapy? Record your answer using a whole number. ___ mL/hr

450 Fifty percent of the total volume to be infused is 3600 mL (7200/2 = 3600). The total time of infusion for this volume is 8 hours. 3600 mL/8 hours = 450 mL/hr.

(9) a clients lab report reveals a CD4 count of 520. according to the CDC, which stage of HIV diseases is present in the client? a. stage 1 b. stage 2 c. stage 3 d. stage 4

a. stage 1 According to the CDC, HIV disease is divided into four stages. A client with a CD4+ T-cell count of greater than 500 cells/mm3 is in the first stage of HIV disease. A client with a CD4+ T-cell count between 200 and 499 cells/mm3 is in the second stage of HIV disease. A client with a CD4+ T-cell count of less than 200 cells/mm3 is in the third stage of HIV disease. The fourth stage of HIV disease indicates a confirmed HIV infection with no information regarding the CD4+ T-cell counts.

(12) a nurse is teaching a health class about HIV. which basic methods are used to reduce the incidence of HIV transmission? (select all that apply) a. using condoms b. using separate toilets c. practicing sexual abstinence d. preventing direct casual contacts e. sterilizing the household utensils

a. using condoms c. practicing sexual abstinence HIV is found in body fluids such as blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, and cerebrospinal fluid. Therefore a client should use condoms to prevent contact between the vaginal mucus membranes and semen. Practicing sexual abstinence is the best method to prevent transmission of the virus. The HIV virus is not transmitted by sharing the same toilet facilities, casual contacts such as shaking hands and kissing, or by sharing the same household utensils.

(27) a school-aged child is brought to the ED with partial- and full-thickness burns of the LEs. the HCP writes multiple prescription. what is the nurses priority intervention? a. administering O2 b. inserting a urinary catheter c. giving prescribed pain medication d. starting an IV line with a large-bore catheter

d. starting an IV line with a large-bore catheter Because of the location and degree of burns, an IV line for fluid restoration and access for pain medications is the priority. Oxygen is not needed because the airway is not involved and oxygen deprivation has not been identified. The insertion of a urinary catheter is a secondary action after fluid administration begins. Although giving pain medication is important, an IV infusion for fluid restoration to prevent hypovolemic shock is the priority. Pain medication for both children and adults with burns usually is administered through an IV catheter.

(16) A client is admitted for treatment of partial- and full-thickness burns of the entire R lower leg extremity and the anterior portion of the R upper arm. A nurse performs an immediate appraisal of the %TBSA burned using the rule of 9s. What percentage of body surface area does the nurse determine is affected? Record the answer to one decimal place. _______%

13.5 The entire right lower extremity is 18%; the anterior portion of the right upper extremity is 4.5%. 18 + 4.5 = 22.5.

(15) A 5-year-old child is admitted with burns covering the face and anterior arms and hands. Using the total body surface area (TBSA) percentages shown in the diagram, determine what percentage of the child's body has been burned. Record your answer using a whole number. ____%

15 The front of a 5-year-old's head accounts for 6.5% of the TBSA. The anterior portion of each arm and hand accounts for 4.25% of the TBSA. Adding 6.5 + 4.25 + 4.25 = 15.

(18) The nurse uses the rule of 9s to estimate the %TBSA on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the entire left leg. What is the percentage of burn injury for this client? Record your answer as a whole number. ________%

46 The Rule of Nines is used to determine the body surface area (BSA) of a burn injury. How the Rule of Nines estimates percent burn injury: 9% for the entire surface of one arm (a total of 9% x 2 for both arms); 18% for the posterior trunk, 1% for the genitals, and 18% for the entire left leg. Therefore, the percentage of body surface area sustaining a burn injury according to the Rule of Nines is: 9 + 9 + 18 + 1 + 18 = 55%.

(7) which action should be the nurse's first priority for a client with major burns? a. assessing airway patency b. checking the client from head to toe c. administering O2 as needed d. elevating the extremities if no fractures are noticed

a. assessing airway patency The first action of the nurse for a client with major burns should be assessing airway patency because airway obstruction will lead to the death of the client. Other subsequently important actions of the nurse for the client should be assessment of the client from head to toe. The client should be administered oxygen according to need. The extremities should be elevated if there are no fractures.

(9) A nurse is caring for a client newly admitted with a diagnosis of pheochromocytoma. Which clinical findings does the nurse expect when assessing this client? Select all that apply. a. Headache b. Palpitations c. Diaphoresis d. Bradycardia e. Hypotension

a. Headache b. Palpitations c. Diaphoresis A pounding headache is secondary to the severe hypertension associated with excessive amounts of catecholamines. Palpitations are associated with stimulation of the sympathetic nervous system caused by catecholamines (epinephrine and norepinephrine). Diaphoresis is associated with stimulation of the sympathetic nervous system because of excessive catecholamines. Tachycardia, not bradycardia, is associated with stimulation of the sympathetic nervous system caused by catecholamines. Hypertension, not hypotension, is the principal clinical manifestation associated with pheochromocytoma because of stimulation of the sympathetic nervous system.

(2) a pregnant adolescent already diagnosed as HIV+ with a viral load of more than 1,000 copies/mL is currently in her 38th week of gestation. which is the best method of delivery in this situation? a. cesarean section b. vaginal delivery with forceps extraction c. vaginal delivery with vacuum extraction d. fetal scalp electrode

a. cesarean section According to the Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission, antiretroviral therapy and a scheduled cesarean birth are recommended to prevent vertical transmission of HIV for adolescents with viral loads of more than 1,000 copies/mL. Normal vaginal delivery with forceps or vacuum extraction should be avoided. Use of a fetal scalp electrode is not a delivery method, and it is a procedure that should also be avoided to prevent transmission of the virus to the baby.

(16) the nurse is counseling a client infected with HIV regarding prevention of transmission. which statement by the client indicates the nurse needs to follow up? a. "I should abstain from sexual activity" b. "I can safely have anal sex without any barriers" c. "I should get HIV counseling if planning for pregnancy" d. "I will use condoms while having sexual intercourse"

b. "I can safely have anal sex without any barriers" The client with HIV should use barrier protection when engaging in insertive sexual activity such as anal, oral, and vaginal. Therefore the nurse should follow up to provide the client with the correct information. All the other statements are correct and need no follow up. Abstaining from all sexual activity is a safe way to eliminate the risk of exposure to HIV in semen and vaginal secretions. The client should undergo HIV counseling and routinely offer access to voluntary HIV-antibody testing when planning for pregnancy. The most commonly used barrier is a condom, which allows for protected intercourse.

(13) the RN is teaching a student nurse about the ongoing monitoring of a client with electrical burns. which statement made by the student nurse indicates the need for further teaching? a. "I should monitor the airway" b. "I should monitor the eye pH" c. "I should monitor VS" d. "I should monitor UOP"

b. "I should monitor the eye pH" The pH of the eye is monitored when chemical burns occur to the eye. The nurse should monitor the airway for breathing, vital signs, heart rhythm, neurovascular status of injured limbs, level of consciousness, and urine output.

(13) the nurse instructs a HIV+ client about ways to prevent infections. during a follow-up cities, which statement made by the client indicates a need for more education? a. "I refuse cups after washing them" b. "I wash my hands with tap water after gardening" c. "I rinse my toothbrush in liquid laundry bleach every week" d. "I wash my armpits, groin, and genitals with antimicrobial soap twice a day"

b. "I wash my hands with tap water after gardening" An HIV-positive client should refrain from digging in soil and performing gardening activities. Soil contains several infectious microorganisms. In unavoidable circumstances, the client should wear gloves and wash hands thoroughly with antimicrobial soap after gardening. The client should refrain from reusing cups without washing them. Weekly rinsing of a toothbrush in liquid laundry bleach helps prevent infectious pathogens from accumulating on the brush. The armpits, groin, and genitals tend to house higher amounts of microorganisms and should be cleaned twice a day with antimicrobial soap.

(15) After stabilization of an acute adrenal insufficiency (addisonian crisis), intravenous medications are decreased gradually, and the client now is receiving hydrocortisone by mouth. What instruction should the nurse include when performing discharge teaching? a. Eat a diet high in sodium. b. Take the medication with food. c. Maintain the same dose indefinitely. d. Eliminate a dose if side effects occur.

b. Take the medication with food. Taking the medication with food minimizes the side effect of gastrointestinal irritation; the health care provider should be notified immediately if abdominal pain or tarry stools occur. The diet should be low in sodium because cortisone can cause fluid retention. The dose may have to be adjusted with health care provider supervision when the client is under physical or emotional stress. Cortisone levels must be maintained; changes in dosage must be supervised by the health care provider.

(26) a nurse is assessing the adequacy of a client's IV fluid replacement therapy during the first 2-3 days after sustaining full-thickness burns to the trunk and R thigh. what assessment will provide the nurse with the most significant data? a. weights qday b. UOP qhour c. BP q15 min d. extent of peripheral edema q4 hours

b. UOP qhour A client with extensive burns has an indwelling urinary catheter so that urine output can be measured hourly. Urinary output reflects circulating blood volume; it is the most reliable, immediately available information to assess fluid needs. Although daily weights reflect fluid retention or loss, they are not as immediately accurate as hourly urine measurements. A blood pressure reading may indicate hypervolemia or hypovolemia, but it is not as accurate an indicator of fluid replacement as hourly urine output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.

(11) what is a clinical manifestation of hypernatremia in burns? a. fatigue b. seizures c. paresthesias d. cardiac dysrhythmias

b. seizures Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

(6) the lab report if a client reveals a CD4 count of 350. according to the CDC, which stage of HIV disease is present in this client? a. stage 1 b. stage 2 c. stage 3 d. stage 4

b. stage 2 According to the CDC, human immunodeficiency disease is divided into four stages. A client with a CD4+ T-cell count between 200 and 499 cells/mm3 (499 cells/uL) is in the second stage of HIV disease. A client with a CD4+ T-cell count of greater than 500 cells/mm3 (500 cells/uL) is in the first stage of HIV disease. A client with a CD4+ T-cell count of less than 200 cells/mm3 (200 cells/uL) is in the third stage of HIV disease. The fourth stage of HIV disease indicates confirmed HIV infection with no information regarding CD4+ T-cell counts.

(22) which stage HIV woulda client with a CD4 count of 325 be classified? a. stage 1 b. stage 2 c. stage 3 d. stage 4

b. stage 2 Stage 2 describes a client with a CD4+ T-cell count between 200 and 499 cells/mm3. Stage 1 describes a client with a CD4+ T-cell count of greater than 500 cells/mm3. Stage 3 describes a client with a CD4+ T-cell count of less than 200 cells/mm3. Stage 4 describes a client with a confirmed HIV infection but no information regarding CD4+ T-cell counts is available.

(39) a 6-year-old child who was rescued from a burning building is admitted to the burn unit with a diagnosis of smoke inhalation. for which priority complication should the nurse assess the child? a. systemic infection b. tracheobronchial edema c. PTSD d. generalized adaptation to stress

b. tracheobronchial edema Heat and inhaled smoke-related irritants may cause fluid to shift from the intravascular compartment into the interstitial compartment, resulting in edema, which obstructs the airway. Although monitoring for infection is important, a patent airway is the priority. Although monitoring for posttraumatic stress disorder is important because the condition could occur later, maintaining a patent airway is the priority. Although monitoring for physical and emotional responses to stress is important, maintaining a patent airway is the priority.

(4) Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? a. Providing oxygen b. Encouraging carbohydrates c. Administering fluid replacement d. Teaching facts about dietary principles

c. Administering fluid replacement As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.

(2) a client is severely injured with burs and sustained major trauma from a fire incident. what is the order of assessments according to priority in this situation? a. Monitoring systolic blood pressure b. Assessing the score of eye opening c. Using a jaw-thrust maneuver to establish an airway d. Removing the clothing with scissors e. Palpating for the presence of a radial pulse f. Providing bag-valve-mask (BVM) ventilation

c. Using a jaw-thrust maneuver to establish an airway f. Providing bag-valve-mask (BVM) ventilation e. Palpating for the presence of a radial pulse a. Monitoring systolic blood pressure b. Assessing the score of eye opening d. Removing the clothing with scissors A client with trauma should be assessed for airway, breathing, circulation, disability, and exposure. A jaw-thrust maneuver helps to establish an airway and breathing, and bag-valve-mask (BVM) ventilation with 100 percent oxygen source ensures ventilatory assistance. Following respiratory assessment is the circulation assessment. The pulse of the client is palpated at the radial, femoral, and carotid areas, and the systolic blood pressure is monitored. Disability is assessed using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. The clothes of the client are removed with scissors to prevent fabric melting into the skin.

(24) a 16-year-old client has a steady boyfriend with whom she is having sexual relations. she asks the nurse how she can protect herself from contracting HIV. which guidance is most appropriate for the nurse to provide? a. ask her partner to withdraw before ejaculating b. make certain their relationship is monogamous c. insist that her partner use a condom when having sex d. seek counseling about various contraceptive methods

c. insist that her partner use a condom when having sex A condom covers the penis and contains the semen when it is ejaculated; semen contains a high percentage of HIV in infected individuals. Preejaculatory fluid carries HIV in an infected individual, so withdrawing before ejaculation is not effective. Although a monogamous relationship is less risky than having multiple sexual partners, if one partner is HIV positive, the other person is at risk for acquiring HIV. The client is not asking about various contraceptive methods. Most contraceptives do not provide protection from HIV.

(14) the RN instructs the NS about caring for a hospitalized client with HIV. which action made by the NS indicates effective learning? a. keeping fresh flowers in the client's room b. encouraging the client to eat fresh fruits and veggies c. keeping a dedicated disposable glove box in the client's room d. changing gauze-containing wound dressings every other day

c. keeping a dedicated disposable glove box in the client's room A client with an HIV infection is at a high risk of contracting infections. Therefore the nurse should keep a dedicated disposable glove box in the client's room and avoid using supplies from a common area. The nurse should refrain from keeping potted plants and flowers in the client's room because they act as source of potentially infectious bacteria and fungi. A client with an HIV infection should be discouraged from consuming raw fruits and vegetables and should be given well-cooked food to reduce risk of food borne pathogens. In order to reduce the risk of infections, the nurse should change gauze-containing wound dressings every day.

(33) a client is brought to the ED with deep partial-thickness burns on the face and full-thickness burns on the neck, anterior chest, and one arm. to assess for heat inhalation, the nurse should first observe for which finding? a. changes in CXR findings b. sputum that contains blood c. nasal discharge containing carbon particles d. changes in the ABG consistent with acidosis

c. nasal discharge containing carbon particles Singed nasal hair and nasal discharges that contain carbon are warning signs of respiratory inhalation. Changes in chest x-ray findings are a late sign of respiratory problems. Sputum that contains particles of blood may be a sign of pneumonia or tuberculosis. Changes in arterial blood gases are late signs of respiratory problems.

(1) A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? a. Nervousness and tachycardia b. Erythema toxicum rash and pruritus c. Diaphoresis and altered mental state d. Deep respirations and fruity odor to the breath

d. Deep respirations and fruity odor to the breath Deep respirations and a fruity odor to the breath are classic signs of DKA, because of the respiratory system's attempt to compensate by blowing off excess carbon dioxide, a component of carbonic acid. Nervousness and tachycardia are indicative of an insulin reaction (diabetic hypoglycemia). When the blood glucose level decreases, the sympathetic nervous system is stimulated, resulting in an increase in epinephrine and norepinephrine; this causes clinical findings such as nervousness, tachycardia, palpitations, sweating, tremors, and hunger. Erythema toxicum rash and pruritus are unrelated to diabetes; they indicate a hypersensitivity reaction. Although an altered mental state is associated with both hypoglycemia and DKA, diaphoresis is associated only with hypoglycemia. Diaphoresis occurs when the blood glucose level decreases and stimulates an increase in epinephrine and norepinephrine.

(1) what would be the priority nursing intervention in a client with electric burns? a. gently removing the burned cloth b. wrapping the client in a dry clean sheet c. cooling the burns for no more than 10 min d. checking the airway, breathing, and circulation

d. checking the airway, breathing, and circulation Electrical burns may be large (greater than 10% TBSA) and therefore the priority is to focus on airway, breathing, and circulation. After ensuring proper airway, breathing, and circulation the nurse then cools the burns for no more than 10 minutes to prevent hypothermia. After cooling, the burned clothing must be removed to prevent further tissue damage. Lastly, wrap the client in a dry, clean sheet to prevent further contamination of the wound and to provide warmth.

(26) a client who abused IV drugs was diagnosed with HIV several years ago. what does the nurse explain to the client regarding the diagnostic criterion for AIDS? a. contracts HIV-specific antibodies b. develops an acute retroviral syndrome c. is capable of transmitting the virus to others d. has a CD4 count of less than 200 (60%)

d. has a CD4 count of less than 200 (60%) AIDS is diagnosed when an individual with human immunodeficiency virus (HIV) develops one of the following: a CD4+T-cell lymphocyte level of less than 200 cells/µL (60%), wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flulike syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain) 1 to 3 weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.

(21) which statement indicates that a client understands the ways HIV is transmitted? (select all that apply) a. "I can contract HIV by participating in oral sex" b. "I can contract HIV by eating from used utensils" c. "HIV is contracted by using contaminated needles" d. "I can contract HIV by using the bathroom of a person who is HIV positive" e. "babies can contract HIV because of contact with lateral blood during birth"

a. "I can contract HIV by participating in oral sex" c. "HIV is contracted by using contaminated needles" e. "babies can contract HIV because of contact with lateral blood during birth" HIV is transmitted sexually through oral sex. HIV is transmitted through the use of contaminated needles. HIV is transmitted by contact with maternal blood during the birthing process. HIV cannot be transmitted by sharing eating utensils or using the bathroom of a person who is HIV positive.

(2) The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? a. Intravenous administration of regular insulin b. Administer insulin glargine subcutaneously at hour of sleep c. Maintain nothing prescribed orally (NPO) status d. Intravenous administration of 10% dextrose

a. Intravenous administration of regular insulin A client admitted with DKA will have a blood glucose value greater than 250 and blood ketones. Intravenous (IV) administration of regular insulin is needed to rid the body of ketones and regulate blood glucose. Administration of insulin glargine is not going to reverse the ketoacidosis. The client will be allowed fluids to maintain hydration. Administration of 10% dextrose IV will increase the client's blood glucose.

(6) The nurse is caring for a client who is going to undergo surgery for pheochromocytoma. Which action of the nurse needs correction to ensure client safety? a. Palpating the abdomen b. Providing fluids before surgery c. Administering phenoxybenzamine d. Initiating an intravenous bolus of alpha-adrenergic blockers

a. Palpating the abdomen The nurse should not palpate the abdomen of a client with pheochromocytoma. Abdominal palpation can cause sudden release of catecholamines and induce hypertension in the client. Hydration before surgery can reduce the risk of hypotension due to decreased blood volume. Phenoxybenzamine is an adrenergic blocking agent that is administered for a week prior to surgery to stabilize the client's blood pressure. Anesthetic agents can induce the release of catecholamines; therefore intravenous bolus of short-acting alpha-adrenergic blockers are administered to the client.

(21) A client has been taking levothyroxine for hypothyroidism for 3 months. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply. a. Tremors b. Bradycardia c. Somnolence d. Heat intolerance e. Decreased blood pressure

a. Tremors d. Heat intolerance Excessive levothyroxine produces adaptations similar to hyperthyroidism, including tremors, tachycardia, hypertension, heat intolerance, and insomnia. These adaptations are related to the increase in the metabolic rate associated with hyperthyroidism. Bradycardia is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Somnolence is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Hypotension is a sign of hypothyroidism and a need to increase the dose of levothyroxine.

(9) the wound characteristics of 4 different client's with burns are mentioned below. which client most likely suffers skin injury from sunburn a. client 1 - pink to red, mild edema, painful, 3-6 days of healing time b. client 2 - red to white, moderate edema, painful, about 2 weeks of healing time c. client 3 - black-brown, severe edema, no pain, eschar that is hard and elastic, weeks to months of healing time d. client 4 - black, no edema, no pain, eschar that is hard and elastic, weeks to months of healing time

a. client 1 - pink to red, mild edema, painful, 3-6 days of healing time Client 1, with the affected skin color of pink to red, mild edema, and pain, may have sunburn. The healing time for the sunburn is 3 to 6 days. Client 2 has red-to-white-colored skin with pain and moderate edema. However no eschar is present. Therefore it might have occurred due to scalds or flames. Healing takes about 2 weeks. Client 3 has a black-brown burn wound with severe edema. The hard and inelastic eschar is present. Therefore the reason could be electric burns. This type of burn takes weeks to months for proper healing. The black-colored burn wound with the absence of edema and pain in client 4 may signify burns due to tar or chemicals. This type of burn also takes weeks to months for healing.

(17) the nurse is reviewing the lab reports of 4 clients. which clients in the 3rd stage of HIV? a. client a - CD4 count is 180 b. client b - CD4 count is 250 c. client c - CD4 count is 380 d. client d - CD4 count is 600

a. client a - CD4 count is 180 According to HIV disease classification, a client with HIV disease is in the third stage of the disease if the CD4+ T-cell count is less than 200 cells/mm3. Therefore, client A is in third stage of HIV disease. A client is in second stage of HIV disease if the CD4+ T-cell count is between 200 and 499 cells/mm3. Therefore, client B and client C are in the second stage of HIV disease. A client is in the first stage of HIV disease if the CD4+ T-cell count is greater than 500 cells/mm3. Therefore, client D is in first stage of HIV disease.

(8)the nurse is taking care of 4 clients with HIV. which client's condition should the nurse report to the PHCP within 24 hours after observation? a. client a - burning, itching, and discharge from the eyes b. client b - blood in the urine c. client c - yellow discoloration of the skin d. client d - N/V accompanied by abdominal pain

a. client a - burning, itching, and discharge from the eyes A client with an HIV infection is at risk for multiple diseases. Burning, itching and discharge from the eyes are not life-threatening and can be reported within 24 hours. Therefore client A's condition can be reported within 24 hours. All the other clients' conditions should be reported immediately.

(21) a client who experienced extensive burns is receiving IV fluids to replace fluid loss. the nurse should monitor for which initial sign of fluid overload? a. crackles in the lungs b. decreased HR c. decreased BP d. cyanosis

a. crackles in the lungs Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.

(20) which reasons should the nurse suggest that a client be tested for HIV? (select all that apply) a. diagnosed with TB in 1985 b. travelled to Italy and Greece in the late 1990s c. received blood transfusions in 1980 during total hip replacement surgery d. engaged in sexual relations with someone of the same gender for several years e. spent several nights in jail waiting for bond to be raised for a DUI charge

a. diagnosed with TB in 1985 c. received blood transfusions in 1980 during total hip replacement surgery d. engaged in sexual relations with someone of the same gender for several years Reasons for a client to be tested for HIV include diagnosis with a communicable disease such as tuberculosis, receiving blood transfusions before blood was routinely tested for HIV contamination, and engaging in sexual relations with a member of the same gender. Travel to Italy and Greece and spending several nights in jail waiting for bond due to a DUI would not require testing for HIV.

(27) a nurse is caring for a client who is HIV+. which complication associated with this diagnosis is most important for the nurse to teach prevention strategies? a. infection b. depression c. social isolation d. Kaposi sarcoma

a. infection The client has a weakened immune response. Instructions regarding rest, nutrition, and avoidance of unnecessary exposure to people with infections help reduce the risk for infection. Clients can be taught cognitive strategies to cope with depression, but the strategies will not prevent depression. The client may experience social isolation as a result of society's fears and misconceptions; these are beyond the client's control. Although Kaposi sarcoma is related to HIV infection, there are no specific measures to prevent its occurrence.

(12) arrange the order of airway management in a client with burns. a. intubate the client within 1-2 hours after injury b. escharotomies of the chest wall, if necessary c. place the client one ventilatory support d. extubation is indicated when edema resolves

a. intubate the client within 1-2 hours after injury c. place the client one ventilatory support d. extubation is indicated when edema resolves b. escharotomies of the chest wall, if necessary Airway management frequently involves endotracheal intubation. In general, the client with burns to the face and neck may require intubation within 1 to 2 hours after injury. After intubation, the client is placed on ventilatory support, providing oxygen concentration based on arterial blood gas values. Extubation may be indicated when edema resolves, usually 3 to 6 days after initial injury, unless severe inhalation injury is involved. Escharotomies of the chest wall may be necessary to relieve respiratory distress.

(29) a client comes to the ED reporting symptoms of the flu. when the health history reveals IV drug use and multiple sexual partners, acute retroviral syndrome is suspected. a test for HIV is performed and acute retroviral syndrome is diagnosed. which clinical responses are associated most commonly with this syndrome? (select all that apply) a. malaise b. confusion c. constipation d. swollen lymph glands e. oropharyngeal candidiasis

a. malaise d. swollen lymph glands Development of HIV-specific antibodies (seroconversion) is accompanied by a flu-like syndrome called acute retroviral syndrome. This syndrome includes malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle/joint pain, or a diffuse rash. It occurs 1 to 3 weeks after infection and may continue for several months. Acute retroviral syndrome over time is followed by the early-chronic, intermediate-chronic, and late-chronic stages of HIV infection. Development of HIV-specific antibodies, accompanied by flu-like syndrome, includes swollen lymph glands. Confusion is associated with the intermediate-chronic and late-chronic stages of HIV infection when the individual develops AIDS-dementia complex or an opportunistic infection that affects the neurologic system. Diarrhea, not constipation, is associated with this syndrome. Oropharyngeal candidiasis occurs during the intermediate-chronic stage of HIV infection.

(19) which is the most common opportunistic infection in a client infected with HIV? a. oropharyngeal candidiasis b. cryptosporidiosis c. toxoplasmosis encephalitis d. pneumocystis jiroveci pneumonia

a. oropharyngeal candidiasis Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer control Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is the more common in a client infected with AIDs. It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat.

(34) a firefighter is admitted to the ED with severe dermal and inhalation burns. on assessment, a nurse identifies tachycardia, tachypnea, dyspnea, and a high-pitched, shrill, hash sound generally occurring one inspiration. what term should the nurse document in the medical record when the following is heard on auscultation of the lungs of this client? a. stridor b. rhonchi c. crackles d. wheezes

a. stridor Stridor is an adventitious breath sound. It is a high-pitched, shrill, harsh sound generally occurring on inspiration, but it can occur on expiration. Depending on its severity, it can be heard on auscultation of the lung or with the naked ear. Inhalation burns can cause a heat injury of the upper respiratory tract (nasopharynx, oropharynx, and larynx). Edema in response to an upper respiratory tract heat injury can produce airway obstruction, especially the epiglottitis, resulting in stridor. Rhonchi (gurgles) are adventitious breath sounds. They are continuous, low-pitched, coarse sounds often described as having a snoring or moaning quality. Rhonchi indicate partial bronchial obstruction caused by mucus or other fluids in the airway, bronchial hyperreactivity, or the presence of a tumor. Crackles (rales) are adventitious breath sounds. Crackles are fine, short, interrupted crackling sounds best heard on inspiration but may be heard on expiration. They are heard on auscultation of the base of the lung as air passes over retained secretions within the alveoli. A wheeze is an adventitious breath sound. It is a continuous, high-pitched, squeaky, musical sound best heard on exhalation. It is commonly heard over all lung fields and can be auscultated or heard by the naked ear. Wheezes are caused by narrowing of the lumen of the respiratory passages; they are associated with asthma, bronchitis, croup syndromes, lung infections, pulmonary edema, emphysema, or other chronic obstructive lung conditions.

(5) which is the first medication approved to reduce the risk of HIV infection in unaffected individuals? a. truvada b. abacavir c. cromolyn d. methdilazine

a. truvada Truvada is the first medication approved to reduce the risk of HIV infection in unaffected individuals who are at a high risk of HIV infection. Abacavir is administered to treat HIV infection and is a reverse transcriptase inhibitor. Cromolyn is administered in the management of allergic rhinitis and asthma. Methdilazine, an antihistamine, is administered to treat the skin and provide relief from itching.

(3) a RN teaches a new orienting nurse about interventions to be followed for a client with burns due to inhalation injury. which statement made by the new orienting nurse indicated the new nurse needs more orientation? a. "I should administer IV analgesia" b. "I should check pulses distal to burns" c. "I should prepare for an ETT intubation" d. "I should anticipate the need for fiberoptic bronchoscopy"

b. "I should check pulses distal to burns" Inhalation injury burns occur in the nose, mouth, throat, and airway. The peripheral and central pulses are assessed, but they are not considered distal to the burn. The nurse should administer intravenous analgesia. The nurse should anticipate both endotracheal intubation and a need for fiberoptic bronchoscopy.

(4) the nurse is counseling an HIV+ coma on precautions to be followed. which statement by the client indicates the need for further counseling? a. "I will avoid smoking and have nutritious food" b. "I will go for pelvic exam every 12 months" c. "I will undergo regular screening for syphilis, gonorrhea, and other vaginal infections" d. "I will use female condoms if my parter refuses to use condoms"

b. "I will go for pelvic exam every 12 months" The routine gynecological care for HIV positive clients includes pelvic examination every 6 months. General prevention strategies such as smoking cessation and sound nutrition are an important part of care in HIV positive clients. HIV positive clients are at increased risk for opportunistic infections. Therefore they should be regularly screened for syphilis, gonorrhea, and other vaginal infections. Women should use female condoms or prefer abstinence if the partner is not willing to use condoms in order to prevent the transmission of HIV to the partner.

(18) which dietary changes does the nurse suggest for a client who has diarrhea associated with HIV? (select all that apply) a. "eat more fatty food" b. "eat much less roughage" c. "drink 2 cups of coffee a day" d. "eat more spicy and sweet food" e. "drink plenty of fluids between meals"

b. "eat much less roughage" e. "drink plenty of fluids between meals" Clients infected with the HIV virus often suffer from diarrhea. Roughage should be limited in the diet of a client who has diarrhea associated with HIV disease, as it is not easy digestible. Drinking plenty of fluids helps to compensate for the fluid loss. Fatty foods are avoided as they alter the process of digestion. Coffee is avoided as it stimulates the gastrointestinal tract and leads to diarrhea. Spicy and sweet foods are avoided as they trigger the gastrointestinal tract and acidify the stomach contents that lead to diarrhea.

(38) a client is rescued from a house fire and arrives at the ED 1 hour after the rescue. the client weighs 60 kg and is burned over 35% of the body. the nurse expects that the amount of LR solution that will be prescribed to be infused in the next 8 hours is what? a. 2100 mL b. 4200 mL c. 6300 mL d. 8400 mL

b. 4200 mL In the first 8 hours 4200 mL should be infused. According to the Parkland (Baxter) formula, one half of the total daily amount of fluid should be administered in the first 8 hours. Because the client weighs 60 kg (132 pounds ÷ 2.2 kg = 60 kg), the calculation is 60 kg × 4 mL/kg × 35% burns = 8400 mL per day; half of this amount should be infused within the first 8 hours. 2100 mL, 6300 mL, and 8400 mL are incorrect calculations.

(24) the nurses is caring for a client with wound dressings to the burs on 55% of the body. the dressing changes are very painful, and the client rates them 7/0 on the pain scale. the client has morphine 2 mg to be administered PO q2hours PRN. when planning the client's care, when does the nurse decide to administer the medication? a. 15 min before the dressing change b. 60 min before the dressing change c. along with a stool softener each time it is administered d. only if the client rates pain between 8-10 on the pain scale

b. 60 min before the dressing change Oral morphine takes 30 to 90 minutes to reach peak effect and can be administered at least 60 minutes before the dressing change. Although pain medications can cause constipation, the nurse would not administer a stool softener each time the morphine is administered. If the client is experiencing pain and rates it anywhere on the pain scale, the client can receive pain medication if it is within the timeframe. It is important to premedicate a client before a painful procedure.

(15) which finding in the client's lab report eagles the nurse to conclude that the client has a stage 3 HIV infection according to the CDC classification? (select all that apply) a. CD4 count of 800 (32%) b. CD4 count of 100 (11%) c. CD4 count of an unknown percentage and kaposi's sarcoma d. CD4 count of an unknown percentage and burkitt's lymphoma e. CD4 count of 150 (12%) and kaposi's sarcoma

b. CD4 count of 100 (11%) e. CD4 count of 150 (12%) and kaposi's sarcoma The CDC has classified four stages of HIV infection. Stage 3 is characterized by a CD4+ T-cell count less than 200 cells/mm3 or a percentage less than 14%. A T-cell count of greater than 500 cells/mm3 or a percentage of 29% or greater is regarded as stage 1 HIV. A client whose HIV infection is confirmed with no information on the CD4+ T-cell count but who has an acquired immunodeficiency syndrome-defining illness such as Kaposi's sarcoma or Burkitt's lymphoma is considered to be in stage 4 HIV.

(28) a client who has acquired HIV develops bacterial pneumonia. on admission to the ED, the client's PaO2 is 80 mm Hg. when the ABGs are drawn again, the level is 65 mm Hg. what should the nurse do first? a. prepare to intubate the client b. increase the oxygen flow rate per facility protocol c. decrease the tension of oxygen in the plasma d. have the arterial blood gases redone to verify accuracy

b. increase the oxygen flow rate per facility protocol This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation. Most facilities have a protocol to increase the oxygen flow rate to keep oxygen saturation greater than 92%. The client PaO2 of 65 mm Hg is not severe enough to intubate the client without first increasing flow rate to determine if the client improves. Decreasing the tension of oxygen in the plasma is inappropriate and will compound the problem. The PaO2 is a measure of the pressure (tension) of oxygen in the plasma; this level is decreased in individuals who have perfusion difficulties, such as those with pneumonia. Having the arterial blood gases redone to verify accuracy is negligent and dangerous; a falling PaO2 level is a serious indication of worsening pulmonary status and must be addressed immediately. Drawing another blood sample and waiting for results will take too long.

(22) a 15-year-old adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. what are the purposes of administering pain medication by way of IV route rather than the IM route? (select all that apply) a. adolescents are afraid of injections b. it decreases the risk of tissue irritation c. severe pain is reduced more effectively d. impaired peripheral circulation is bypassed e. it provides for more prolonged relief of pain

b. it decreases the risk of tissue irritation c. severe pain is reduced more effectively d. impaired peripheral circulation is bypassed Decreasing the risk for tissue irritation can reduce the risk of infection, which is also one of the top care priorities after a burn injury. The medication begins to work in minutes; doses can be controlled. Intramuscular medications are avoided when possible to prevent inadequate absorption of the medication because of damaged tissue. Stating that adolescents are afraid of injections is a generalization that is not necessarily true. The duration of effectiveness of an analgesic is based on its therapeutic level in the body, regardless of what route is used.

(5) the PHCP instructs the nurse to place a client with burns in the supine position with the affected arm over the head to reduce the risk of contractures. which part of the client is affected dt burns? a. wrist b. lateral trunk c. anterior shoulder d. posterior shoulder

b. lateral trunk A client whose lateral trunk is affected due to burns should be placed in supine position with the affected arm over the head to reduce the risk of contractures. A client whose wrist is affected should use a splint. The nurse should maintain the upper arm at 90 degrees of abduction from the lateral aspect of the trunk of a client whose anterior shoulder is affected. The nurse should keep the arm slightly behind the midline of a client whose posterior shoulder is affected.

(20) while the nurse was caring for a client with chemical burns after a factory explosion, there was increased edema in the surrounding tissues. what might have led to increased edema? a. stabilizing the cervical spine b. lowering burned limbs below the heart c. brushing dry chemical from skin before irrigation d. flushing chemical from wound with sterile saline solution

b. lowering burned limbs below the heart The initial interventions for a client with a chemical burn include elevating the burned limbs above the heart. This helps in decreasing the edema of the localized tissue. Stabilizing the cervical spine is required as an immediate intervention for a client with chemical burns. Brushing any dry chemical from the skin before irrigation should be performed as a primary intervention. Flushing any chemicals from the wound with saline solution is done immediately and may not cause increased edema.

(29) a school-aged child is admitted to the hospital with severe burns on the arms. therapeutic escharotomy is planned. what is the priority nursing action at this time? a. removing blisters b. monitoring radial pulses c. maintaining airborne precautions d. performing passive ROM exercises

b. monitoring radial pulses Eschar is rigid and may restrict circulation and lead to loss of limb perfusion. Blisters are associated with superficial and deep partial-thickness burns; eschar is associated with full-thickness burns. Blisters are not removed because they protect the underlying skin. Maintaining airborne precautions is unnecessary; the client is not the source of infection but must be protected from infection because the first line of defense has been compromised. Performing passive range-of-motion exercises is unnecessary.

(23) a client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. how should the nurse apply the prescribed antimicrobial medication? a. place medication directly on the dressing in a thick layer using clean gloves b. place medication directly on the burn wound in a thin layer using sterile gloves c. put medication in a Hubbard tank and saturate sterile dressing with it before applying the dressings to the burns d. put medication in a Hubbard tank and allow the PT to soak in the tank for several minutes every day

b. place medication directly on the burn wound in a thin layer using sterile gloves Sterile aseptic technique is necessary for an open wound, and a thin layer of ointment is applied directly to the affected area. Surgically aseptic, not medically aseptic, technique is used. Although some medications may be placed directly in the tank, antimicrobial medications are placed directly on the affected area using surgically aseptic technique.

(28) a 6-year-old child has partial-thickness burns of the face and upper chest. what is the priority nursing assessment for the first 24 hours? a. wound sepsis b. pulmonary distress c. fear and separation anxiety d. fluid and electrolyte imbalance

b. pulmonary distress Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia resulting from irritation and edema of the respiratory passages and lungs. Although wound sepsis is a possible complication, it will not be evident until the third to fifth day. Although the child is probably fearful, maintaining a patent airway is the priority. This child is too old for separation anxiety; however, complications related to stress may occur later. Fluid losses may be extremely high but reach their maximum about the fourth day; the initial priority is maintaining a patent airway.

(11) a nurse is teaching a client about HIV. what are the various ways HIV is transmitted? (select all that apply) a. mosquito bites b. sharing syringe needles c. BF a newborn d. dry kissing the infected parter e. anal intercourse

b. sharing syringe needles c. BF a newborn e. anal intercourse Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites or dry kissing.

(7) a RN is teaching a SN regarding the interventions for a client with HIV. which statement by the SNN indicated the nurse needs to follow up? a. "I will ask the client to avoid exposure to new infectious agents" b. "I will ask the client about intake of vitamins and micronutrients" c. "I will ask the client to avoid involvement in community activities" d. "I will ask the client if he or she is up to date with recommended vaccines"

c. "I will ask the client to avoid involvement in community activities" HIV-infected clients may feel isolated and lonely; therefore they should be involved in support groups and community activities. The nurse should follow up to correct this misconception. All the other statements are correct. The HIV infection decreases the client's immunity making the client prone to infection. Therefore HIV-infected clients should avoid exposure to new infectious agents. They should consume nutritional support to maintain lean body mass and ensure appropriate levels of vitamins and micronutrients. They need to be updated with recommended vaccines to prevent vaccine-preventable diseases.

(10) a nurse is educating a client with HIV about self-management. which suggestion by the nurse benefits the client? a. "limit your daily fluid intake" b. "eat more roughage" c. "rinse your mouth with NS after every meal" d. "maintain a 4-5 hour gap in between meals"

c. "rinse your mouth with NS after every meal" A client infected with HIV should maintain proper oral care to improve his or her appetite. The client should rinse his or her mouth with sterile water or normal saline several times a day, especially after meals, to maintain proper oral hygiene. The client should drink plenty of fluids to maintain proper body fluid balance. Roughage should be limited in a client's diet because it is not easily digestible and may lead to severe diarrhea and contains microorganisms that can lead to infection. The client should consume small, frequent meals to maintain adequate caloric intake.

(32) the nurse is caring for a client with deep partial-thickness burns who is receiving an opioid for pain management. what is the preferred mode of medication administration for this client? a. oral b. rectal c. IV d. IM

c. IV The intravenous route provides for the quickest onset of action of the opioid; pain relief occurs almost immediately. Nausea, vomiting, and paralytic ileus may occur postburn, making oral medications impractical. The rectal route does not provide uniform absorption; also, relief of pain will be delayed. With the intramuscular route, medication may be sequestered in the tissues, and with fluid shifts it takes time for the medication to take effect.

(3) The nurse is assessing a client experiencing diabetic ketoacidosis (DKA). Which unique response associated with DKA that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client? a. Fluid loss b. Glycosuria c. Kussmaul respirations d. Increased blood glucose level

c. Kussmaul respirations Kussmaul respirations occur in diabetic ketoacidosis (DKA) as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones. Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.

(31) a 10-year-old child who was rescued from a house fire is brought to the ED with burns of the extremities. during assessment, what finding is of most concern to the nurse? a. increased temp b. increasing activity level c. burns around the mouth d. edema distal to the burns

c. burns around the mouth Burns around the mouth indicate that the child may have inhalation burns; respiratory tract injury may result in edema, causing an airway obstruction. An increase in temperature indicates the presence of an infection; it is too early for an infection to occur. Increased activity is promising because it indicates that the burns were not severe. Edema distal to burns of the extremities is an expected finding.

(14) the nurse is examining 4 different clients who present with thermal burns. which client does the nurse diagnose as having 2nd degree burns? a. client a - waxy white, dark-brown appearance b. client b - redness, pain, minimal edema c. client c - moist blebs, blisters, severe pain d. client d - dry, leathery eschar, absence of pain

c. client c - moist blebs, blisters, severe pain Client C has second-degree burns. The client is experiencing severe pain and the skin shows moist blebs and blisters. Client A may have third- and fourth-degree burns, in which the skin is waxy white, dark brown in appearance. Client B may have first-degree burns, in which the skin is red in color with minimal edema and pain. Client D may have third- and fourth-degree burns as the skin is dry, leathery eschar and there is absence of pain.

(8) a client with burns is hospitalized in the ED and advised to get an ECG done. which type of bur injury has the client most likely sustained? a. flame burn b. chemical burn c. electrical burn d. radiation burn

c. electrical burn In an electrical burn injury, changes in the ECG may indicate damage to the heart. In flame burn injuries, the smoldering clothing and all metal objects are removed. If a client suffers from chemical burns, the dried chemicals present on skin should not be made wet but should be brushed off. If the client has radiation burn injuries, then the source should be removed using tongs or lead protective gloves.

(37) the nurse is caring for a client who has been admitted with partial- and full-thickness burns over 25% of the TBSA. LR solution and 5% dextrose have been prescribed. what is the purpose of these fluids? a. prevent fluid shifts b. expand the plasma c. maintain blood volume d. replace electrolytes lost

c. maintain blood volume Fluids during the first 48 hours are given to replace fluid lost from the intravascular compartment to interstitial spaces. Administration of fluids treats the fluid shifts but does not prevent them. Lactated Ringer solution and 5% dextrose in saline are not plasma expanders, as is albumin. Electrolytes specifically are replaced based on serial assessments of serum electrolytes and arterial blood gases.

(35) a nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. what should the nurse assess for in this client? a. dehydration b. dry brittle hair c. prolonged wound healing d. clubbing of the fingertips

c. prolonged wound healing Adequate intake of protein, carbohydrates, vitamin C, and minerals is necessary for tissue building and wound healing. There are no data to indicate dehydration; although the client is not eating, the client may be drinking fluids. Dry brittle hair will take a prolonged period of time; it will not occur during a short period. Clubbing of the fingertips is associated with prolonged hypoxia.

(25) a nurse is administering a H2 antagonist to a client who has extensive burns. the nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. what complication of burns will it prevent? a. colitis b. gastritis c. stress ulcer d. metabolic acidosis

c. stress ulcer An ulcer of the upper gastrointestinal tract is related to excessive secretion of stress-related hormones, which increases hydrochloric acid production. Histamine H2 antagonists decrease acid secretion. Colitis is not a complication of burns. Gastritis is not a complication of burns. Metabolic acidosis is not a complication of burns unless hypermetabolism or renal failure occurs; metabolic acidosis is not treated with H2 antagonists.

(1) which interventions would reduce the risk of perinatal transmission via vaginal birth in an adolescent who is diagnosed with HIV infection? a. using forceps during delivery b. using a fetal scalp electrode during delivery c. using antiretroviral during the intrapartum period d. administering zidovudine an hour before labor

c. using antiretroviral during the intrapartum period In the intrapartum period, antiretroviral therapy is recommended to prevent transmission of HIV. Therefore the risk of perinatal transmission may be reduced in an adolescent who receives antiretroviral therapy in the intrapartum period. Use of forceps or fetal scalp electrode during delivery may result in inoculation of the virus into the fetus; therefore, this should be avoided. Intravenous zidovudine should be given during labor, not an hour before it, if the adolescent is having a vaginal birth.

(19) following a fire, the disaster management team assesses burn injuries of the survivors. the team finds that most survivors have pink to cherry red skin with blisters. which type of burns does this nurse identify on the survivors? a. 1st degree b. 3rd degree c. 4th degree d. 2nd degree

d. 2nd degree Blister formation and pink to cherry red skin indicates partial thickness burns that are second degree burns. In first degree burns, the client experience moderate to severe tenderness and redness of the skin. Third degree and fourth degree burns involve dry and leathery skin with impaired sensation when touched.

(5) A client is diagnosed with pheochromocytoma. Which finding in the urinalysis report supports the diagnosis? a. Sodium - 200 mmol/24 hr b. Calcium - 5.6 mmol/24 hr c. Urea nitrogen - 0.5 mmol/24 hr d. Total catecholamines - 640 mmol/24 hr

d. Total catecholamines - 640 mmol/24 hr Total catecholamines increase in pheochromocytoma, stress, neuroblastoma, and heavy exercise. A total catecholamine level below 591 mmol/24 hr is normal. The client's report shows 640 mmol/24 hr of total catecholamines, which is higher than the normal range. Therefore the total catecholamine levels in the client's urinalysis report suggest pheochromocytoma. Sodium concentrations in the range of 40-220 mmol/24 hr are normal. The client has a sodium concentration of 200 mmol/24 hr, which is a normal finding. The normal levels of calcium in the urine range between 2.5-7.5 mmol/kg/24 hr. The client has a calcium concentration of 5.6 mmol/24 hr, which is a normal value. The normal values of urea nitrogen range from 0.43 to 0.71 mmol/24 hr. The client has a urea nitrogen of 0.5 mmol/24 hr, which is a normal finding.

(25) what does the nurse explains a client that a positive diagnosis for HIV infection based on? a. performance of high-risk sexual behaviors b. evidence of extreme weight loss and high fever c. identification of an associated opportunistic infection d. positive ELISA and western blot tests

d. positive ELISA and western blot tests Positive ELISA and Western blot tests confirm the presence of HIV antibodies that occur in response to the presence of the HIV. Performance of high-risk sexual behaviors places someone at risk but does not constitute a positive diagnosis. Evidence of extreme weight loss and high fever do not confirm the presence of HIV; these adaptations are related to many disorders, not just HIV infection. The diagnosis of just an opportunistic infection is not sufficient to confirm the diagnosis of HIV. An opportunistic infection (included in the Centers for Disease Control and Prevention surveillance case definition for acquired immunodeficiency syndrome [AIDS]) in the presence of HIV antibodies indicates that the individual has AIDS.