Exam 2 Prep Questions from Virtual Clinical
Your client is in the special care area of your hospital with multiple trauma and severe bodily burns. This 45 year old male client has an advance directive that states that the client wants all life saving measures including cardiopulmonary resuscitation and advance cardiac life support, including mechanical ventilation. As you are caring for the client, the client has a complete cardiac and respiratory arrest. This client has little of no chance for survival and they are facing imminent death according to your professional judgement, knowledge of pathophysiology and your critical thinking. You believe that all life saving measures for this client would be futile. What is the first thing that you, as the nurse, should do? A. Call the doctor and advise them that the client's physical status has significantly changed and that they have just had a cardiopulmonary arrest. B. Begin cardiopulmonary resuscitation other emergency life saving measures. C. Notify the family of the client's condition and ask them what they should be done for the client. D. Insure that the client is without any distressing signs and symptoms at the end of life.
B. Begin cardiopulmonary resuscitation other emergency life saving measures. •You must immediately begin cardiopulmonary resuscitation and all life saving measures as requested.by the client in their advance directive despite the nurse's own beliefs and professional opinions. Nurses must uphold the client's right to accept, choose and reject any and all of treatments, as stated in the client's advance directive. •You would not call the doctor first; your priority is the sustaining of the client's life; you would also not immediately notify the family for the same reason and, when you do communicate with the family at a later time, you would not ask them what should or should not be done for the client when they wishes are already contained in the client's advance directive. •Finally, you would also insure that the client is without pain and all other distressing signs and symptoms at the end of life, but the priority and the first thing that you would do is immediately begin cardiopulmonary resuscitation and all life saving measures as requested by the client in their advance directive, according to the ABCs and Maslow's Hierarchy of Needs.
The nurse is assessing a client who fell into a cold lake. Which assessment finding indicates that the client's body is attempting to regulate its temperature? (Select all that apply.) A. Sweating B. Cold hands C. Thirst D. Shivering E. Sleepiness
B. Cold hands D. shivers Rationale: When the skin is chilled, the body attempts to regulate temperature by vasoconstriction of blood vessels. This could be why the client's hands are cold. The body also shivers to increase heat production. The body does not regulate temperature through sleep, thirst, or by sweating.
The nurse observes a mother stroking her child's arms and legs with a cool, damp washcloth. Which method of heat transfer is the mother using to reduce the fever? A. Radiation B. Evaporation C. Conduction D. Metabolism
B. Evaporation Rationale: Heat can be transferred between places or objects. Evaporation is the conversion of water to vapor, which is what occurs when the mother applies cool water to the child's limbs. Radiation is the release of heat through no physical contact. Conduction is the release of heat through physical contact. Metabolism is not a method of heat transfer
A 19-year-old patient who is taking azathioprine (Imuran) for systemic lupus erythematosus has a check-up before leaving home for college. The health care provider writes all of these orders. Which one should the nurse question? A. Naproxen (Aleve) 200 mg BID B. Give measles-mumps-rubella (MMR) immunization C. Draw anti-DNA titer D. Famotidine (Pepcid) 20 mg daily
B. Give measles-mumps-rubella (MMR) immunization Live virus vaccines, such as rubella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.
On a hot, humid day, a client presents with a body temperature of 40.9°C (105.6°F), dry and flush skin, vomiting, low blood pressure, and muscle cramps. Which type of injury should the nurse suspect based on the manifestations? A. Malignant hyperthermia B. Heat stroke C. Hypothermia D. Normothermia
B. Heat stroke Rationale: The nurse should suspect heat stroke, which can occur during hot weather and high humidity and results in dysfunction of the brain's thermoregulation center. Signs and symptoms of heat-related injuries include paleness, dizziness, nausea and vomiting, fatigue, low blood pressure, muscle cramps, and fainting. Late signs include irritability, confusion, stupor, and coma. Hypothermia is a core body temperature below 35°C (95°F), and is classified as mild, 32dash-35°C (89.6dash-95°F); moderate, 28dash-32°C (82.4dash-89.6°F), or severe, below 28°C (less than 82.4°F). The usual range of core body temperature is called normothermia. The normal range for adults is between 36°C and 38.5°C (96.8°F and 101.3°F). Malignant hyperthermia is a potentially fatal, inherited disorder that results from the body's reaction to volatile inhalation of anesthetic gases and succinylcholine, a depolarizing neuromuscular blocker.
The nurse is instructing an unlicensed health care worker on the care of the client with HIV who also has active genital herpes. Which statement by the health care worker indicates effective teaching of standard precautions? A) ''I need to know my HIV status, so I must get tested before caring for any clients." B) ''Putting on a gown and gloves will cover up the itchy sores on my elbows.'' C) ''Washing my hands and putting on a gown and gloves is what I must do before starting care.'' D) ''I will wash my hands before going into the room, and then put on gown and gloves only for direct contact with the client's genitals."
C) ''Washing my hands and putting on a gown and gloves is what I must do before starting care.'' Rationale: Standard precautions include whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes.
Which interventions does the home health nurse teach to family members to reduce confusion in the client diagnosed with AIDS dementia? (Select all that apply.) A) Report any behavior changes. B) Use the Glasgow Coma Scale on a daily basis. C) Change the decorations in the home according to the season. D) Put the bed close to the window. E) Write out all instructions and have the client read them over before performing a task. F) Ask the client when he or she wants to shower or bathe. G) Mark off the days of the calendar, leaving open the current date. H) For continuity, the primary caregiver should be the only person reorienting the client
C) Change the decorations in the home according to the season. D) Put the bed close to the window. F) Ask the client when he or she wants to shower or bathe. G) Mark off the days of the calendar, leaving open the current date. Rationale: Seasonal decorations in the home helps with maintaining orientation. Window allows the client to visualize seasonal and weather changes and assists in orientation. Involving the client in planning the daily schedule helps with orientation. Using calendars and crossing off past dates helps with orientation.
A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections."
C. "I'm hoping that surgery will be an option for me in the future." Rationale: SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.
A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes the information that SLE is a(n): A. Hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant. B. Autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body. C. Disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression. D. Disease that causes production of antibodies that bind with cellular estrogen receptors, causing an inflammatory response.
C. Disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression. Rationale: SLE has an unpredictable course, even with appropriate treatment. Women are more at risk for SLE, but it is not confined exclusively to women. Clinical symptoms may worsen during pregnancy but are not confined to pregnancy or the perinatal period. All nucleated cells are not destroyed by the antinuclear antibodies. The inflammation in SLE is not caused by antibody binding to cellular estrogen receptors.
A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which nursing diagnosis would be most appropriate? 1. Activity intolerance related to fatigue and pain. 2. Self-care deficit related to increasing joint pain. 3. Ineffective coping related to chronic pain. 4. Disturbed body image related to fatigue and joint pain.
1. Activity intolerance related to fatigue and pain. Based on the client's complaints, the most appropriate nursing diagnosis would be Activity intolerance related to fatigue and pain. Nursing interventions would focus on helping the client conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the activity intolerance and increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may develop ineffective coping or body image disturbance as the disorder becomes chronic with increasing pain and fatigue.
Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply. 1. Adults between the ages of 20 and 50 years. 2. Adults who have had an infectious disease with the Epstein-Barr virus. 3. Adults that are of the male gender. 4. Adults who possess the genetic link, specifically HLA-DR4. 5. Adults who also have osteoarthritis.
1. Adults between the ages of 20 and 50 years. 2. Adults who have had an infectious disease with the Epstein-Barr virus. 4. Adults who possess the genetic link, specifically HLA-DR4. Rheumatoid arthritis (RA) affects women three times more often than men, between the ages of 20 and 55 years. Research has determined that RA occurs in clients who have had infectious disease, such as the Epstein-Barr virus. The genetic link, specifically HLA-DR4, has been found in 65% of clients with RA. People with osteoarthritis are not necessarily at risk for developing rheumatoid arthritis.
A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following? 1. Development of a cataract. 2. Possible retinal degeneration. 3. Part of the disease process. 4. A coincidental occurrence.
2. Possible retinal degeneration. Difficulty seeing out of one eye, when evaluated in conjunction with the client's medication therapy regimen, leads to the suspicion of possible retinal degeneration. The possibility of an irreversible retinal degeneration caused by deposits of hydroxychloroquine (Plaquenil) in the layers of the retina requires an ophthalmologic examination before therapy is begun and at 6-month intervals. Although cataracts may develop in young adults, they are less likely, and damage from the hydroxychloroquine is the most obvious at-risk factor. Eyesight is not affected by the disease process of rheumatoid arthritis.
The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit? 1. "I can use heat and cold as often as I want." 2. "With heat, I should apply it for no longer than 20 minutes at a time." 3. "Heat-producing liniments can be used with other heat devices." 4. "Ten to 15 minutes per application is the maximum time for cold applications."
3. "Heat-producing liniments can be used with other heat devices." Heat-producing liniment can produce a burn if used with other heat devices that could intensify the heat reaction. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat, and vasodilation instead of vasoconstriction with cold.
•On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for: 1. Limited motion of joints. 2. Deformed joints of the hands. 3. Early morning stiffness. 4. Rheumatoid nodules.
3. Early morning stiffness. Initially, most clients with early symptoms of rheumatoid arthritis complain of early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules.
A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate? 1. "You are probably exercising too much. Decrease your exercise to every other day." 2. "Tell the physician about your symptoms. Maybe your analgesic medication can be increased." 3. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." 4. "Take a warm tub bath or shower before exercising. This may help with your discomfort."
4. "Take a warm tub bath or shower before exercising. This may help with your discomfort." Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.
The nurse presents a seminar on HIV testing to a group of seniors and their caregivers in an assisted living facility. Which responses fit the Centers for Disease Control and Prevention's (CDC's) recommendations for HIV testing? (Select all that apply.) A) ''I am 78 years old and I was treated and cured of syphilis many years ago.'' B) ''In 1986, I received a transfusion of platelets.' 'C) ''Seven years ago, I was released from a penitentiary.'' D) ''I used to smoke marijuana 30 years ago, but I have not done any drugs since.'' E) ''I had sex with a man with a disreputable past from New York back in the late 1960s, but I have been happily married since 1971.'' F) ''At 68, I am going to get married for the fourth time.''
A) ''I am 78 years old and I was treated and cured of syphilis many years ago.'' 'C) ''Seven years ago, I was released from a penitentiary.'' F) ''At 68, I am going to get married for the fourth time.'' Rationale: People who have had sexually transmitted diseases should be tested for HIV. HIV testing is recommended for people who are or have been in jails or prisons. People who are planning to get married should be tested for HIV.
An 18-year-old male who fell through the ice on a pond near his farm was admitted to the ED with somnolence. Vital signs are BP 82 mm Hg systolic with Doppler, respirations 9/min, and core temperature of 90° F (32.2° C). The nurse should anticipate which intervention? A. Active core rewarming B. Immersion in a hot bath C. Rehydration and massage D. Passive external rewarming
A. Active core rewarming Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.
The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas where it has been 100° F (37.7° C) or more for the last 2 weeks. With assessment, the nurse finds hypotension, body temperature of 104° F (40° C), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate (select all that apply)? A. Administer 100% O2. B. Immerse in an ice bath. C. Administer cool IV fluids. D. Cover the patient to prevent chilling. E. Administer acetaminophen (Tylenol).
A. Administer 100% O2. C. Administer cool IV fluids. The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient's ABC and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.
A 47-year-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6o F (30.3o C). Which action is most appropriate for the nurse to take? A. Administer warmed IV fluids. B. Position patient under a radiant heat lamp C. Place an air-filled warming blanket on the patient. D. Immerse the extremities in a water bath (102° to 108° F [38.9° to 42.2° C]).
A. Administer warmed IV fluids. A patient with a core body temperature of 86.6o F (30.3o C) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4° F [43° C]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite.
Which is a noninvasive method that the nurse uses to assess a client's temperature? (Select all that apply.) A. Axillary B. Rectal C. Oral D. Temporal artery E. Tympanic membrane
A. Axillary D. Temporal Artery
A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that treatment will include A. Core rewarming with warm fluids. B. Ambulation to increase metabolism. C. Frequent oral temperature assessment. D. Gastric tube feedings to increase fluids.
A. Core rewarming with warm fluids. Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.
The nurse is preparing a presentation to parents about vehicle safety and heat-related injuries. Which important teaching point should be included? A. Keep important articles in the backseat to ensure checking the area before leaving the vehicle. B. Store car keys in a visible place and within the children's reach in case of an emergency. C. Leave a child alone in the car only if the outside temperature is below 80degrees°F. D. Stay with a child in the car for up to 10 minutes with the windows cracked open.
A. Keep important articles in the backseat to ensure checking the area before leaving the vehicle Rationale: Estimates indicate that numerous children die from vehicle hyperthermia, or sustain heat exhaustion, heat stroke, and thermal burn after being left in vehicles on warm days. One way of ensuring that such incidents do not happen is to teach caregivers to place something important, such as their wallet or cell phone, in the backseat of the car. This will ensure that they check the backseat before leaving the vehicle. Advise them to always look before they lock, when not in use. According to reports and findings, leaving a child in a car with a cracked window for even a short amount of time, holds the potential for lethal consequences. Children should never be left unattended or around vehicles. Though it is a good practice to keep car keys in a visible place, ensure that they are out of reach of children.
A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for manifestations of hypothermia, including A. Stupor. B. Erythema. C. Increased anxiety. D. Rapid respirations.
A. Stupor. Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.
The nurse is planning to assess a 4-year-old child to help determine the cause of the child's fever. Which body system is a priority to assess? (Select all that apply.) A. Urinary B. Musculoskeletal C. Respiratory D. Gastrointestinal E. Neurologic
A. Urinary C. Respiratory D. Gastrointestinal Rationale: Infections of the urinary, respiratory, and gastrointestinal systems are the most common reason for a fever in this age range. The neurologic and musculoskeletal systems are not common systems for infections in children.
The nurse provided teaching to an older adult client about fevers. Which client statement indicates that the teaching was effective? A. "The rectal route is the best way to have my temperature taken." B. "I may not have a fever when I get sick or have an infection." C. "I am less sensitive to environmental temperatures than when I was younger." D. "Cancer is the top source of fever in older adults."
B. "I may not have a fever when I get sick or have an infection." Rationale: Older adults do not exhibit the sign/symptom of fever with infection, as do younger persons. However, the top source of fever is still infection or an inflammatory process, not cancer. Rectal route for taking a temperature is not the best route due to discomfort and increased prevalence of hemorrhoids. Older adults are more sensitive to extreme environmental temperature changes due to decreased thermoregulatory controls.
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when the child's nurse A. Places a hypothermia blanket at the bedside. B. Adjusts the bed to the Trendelenburg position. C. Obtains electronic equipment for monitoring the vital signs. D. Secures a pump to administer the ordered intravenous fluids.
B. Adjusts the bed to the Trendelenburg position. It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.
The patient is admitted to the ED with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing measures will help identify the need for further assessment of the cause of this patient's manifestations (select all that apply)? A. Assessment of lung sounds B. Assessment of sexual behavior C. Assessment of living conditions D. Assessment of drug and syringe use E. Assessment of exposure to an ill person
B. Assessment of sexual behavior D. Assessment of drug and syringe use With these symptoms, assessing this patient's sexual behavior and possible exposure to shared drug equipment will identify if further assessment for the HIV virus should be made or the manifestations are from some other illness (e.g., lung sounds and living conditions may indicate further testing for TB).
An older adult client asks the nurse, "Why is my body temperature only 99°F if I have this serious infection?" Which is the nurse's best response? A. "Your body temperature fluctuates significantly, so a true temperature is difficult to obtain." B. "I will to take your temperature rectally, since it is the only reliable route in somebody your age." C. "The true temperature will not register because you are a mouth breather." D. "Body temperature in an older adult is not a reliable indicator of the seriousness of an illness."
D. "Body temperature in an older adult is not a reliable indicator of the seriousness of an illness." Rationale: Body temperature may not be a valid indication of serious illness in an older adult. The older adult may have an infection and exhibit only a slight temperature elevation. Other symptoms, such as confusion and restlessness, may be present. These require follow-up to determine whether an underlying disease process is present. There is no evidence to support that the client is a mouth breather. Rectal temperatures in older adult clients may be contraindicated if hemorrhoids are present. Body temperature in an older adult does not fluctuate significantly.
A priority nursing intervention for a patient with hyperthermia would be A. Initiating seizure precautions. B. Limiting oral intake. C. Providing a blanket. D. Removing excess clothing.
D. Removing excess clothing. Rationale: The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, but seizure precautions should not be the first intervention. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates A. Increased respirations. B. Rapid pulse rate. C. Red, sweaty skin. D. Slow capillary refill.
D. Slow capillary refill. With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.
A healthy 2-month-old infant is being seen in the local clinic for a well-child checkup and initial immunizations. When analyzing the pediatric record, which immunizations would the nurse anticipate administering at this appointment? Select all that apply. a) IPV (inactivated polio vaccine) b) Hib (Haemophilus influenzae vaccine) c) Varicella (chickenpox) vaccine d) PCV (pneumococcal vaccine) e) DTaP (diphtheria, tetanus, and acellular pertussis) f) MMR (measles, mumps, and rubella)
a) IPV (inactivated polio vaccine) b) Hib (Haemophilus influenzae vaccine) d) PCV (pneumococcal vaccine) e) DTaP (diphtheria, tetanus, and acellular pertussis) At age 2 months, the American Academy of Pediatrics and Public Health Agency in Canada recommends the administration of DTaP, IPV, (Hep B in the United States), Hib, Rotavirus vaccine, and PCV. The MMR and varicella immunizations would be administered at 12 to 15 months.
When caring for a patient in acute septic shock, what should the nurse anticipate? a- Infusing large amounts of IV fluids b- Administering osmotic and/or loop diuretics c- Administering IV diphenhydramine (Benadryl) d- Assisting with insertion of a ventricular assist device (VAD)
a- Infusing large amounts of IV fluids Rationale: Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock but would not be helpful with septic shock.
•A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. "I don't need to go to the hospital after using it." b. "I must carry two EpiPens with me at all times." c. "I will write the expiration date on my calendar." d. "This can be injected right through my clothes."
a. "I don't need to go to the hospital after using it." Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.
A 62-year-old patient has acquired immunodeficiency syndrome (AIDS), and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study result? a. The patient has the virus present and can transmit the infection to others. b. The patient is not able to transmit the virus to others through sexual contact. c. The patient will be prescribed lower doses of antiretroviral medications for 2 months. d. The syndrome has been cured, and the patient will be able to discontinue all medications.
a. The patient has the virus present and can transmit the infection to others. In human immunodeficiency virus (HIV) infections, viral loads are reported as real numbers of copies/μL or as undetectable. "Undetectable" indicates that the viral load is lower than the test is able to report. "Undetectable" does not mean that the virus has been eliminated from the body or that the individual can no longer transmit HIV to others.
Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply): a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. Trendelenburg positioning to facilitate venous return and increase preload.
a. dobutamine to increase myocardial contractility. c. circulatory assist devices such as an intraaortic balloon pump. Rationale: Dobutamine (Dobutrex) is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device.
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a- Increased serum albumin b- Decreased respiratory compliance c- Increased gastrointestinal (GI) motility d- Decreased blood urea nitrogen (BUN)/creatinine ratio
b- Decreased respiratory compliance Rationale: Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.
The nurse would recognize which clinical manifestation as suggestive of sepsis? a- Sudden diuresis unrelated to drug therapy b- Hyperglycemia in the absence of diabetes c-Respiratory rate of seven breaths per minute d-Bradycardia with sudden increase in blood pressure
b- Hyperglycemia in the absence of diabetes Rationale: Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.
A 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of: a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.
b. septic shock. Rationale: Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temperature must be higher than 100.9° F (38.3° C), or the core temperature must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure, blood pressure, systemic vascular resistance, central venous pressure, and pulmonary artery wedge pressure; normal or elevated pulmonary vascular resistance; and decreased, normal, or increased pulmonary artery pressure, cardiac output, and mixed venous oxygen saturation.
The nurse is caring for a client newly diagnosed with human immunodeficiency virus (HIV) obtained from unprotected sex. The nurse is in the room when the client is explaining the disease to another person. Which statement by the client would the nurse clarify? Select all that apply. a) "I will have this for the rest of my life." b) "The disease can also be spread by body fluids." c) "I am afraid that I will give this disease to my nephew." d) "I could pass this on to a baby before I give birth." e) "My sexual practices will have to change." f) "Medications can cure the disease."
c) "I am afraid that I will give this disease to my nephew." f) "Medications can cure the disease." Human immunodeficiency virus (HIV) is a sexually transmitted infection. Casual contact such as that with a family member will not spread the disease. Unfortunately, at this time, there is no cure for the disease. The client is correct in stating that sexual practices will have to change to prevent further spread of the disease, the disease can be spread by body fluids and can also be passed on to a fetus.
A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? a-Insulin infusion b- IV administration of epinephrine c- Aggressive IV crystalloid fluid resuscitation d- Administration of nitrates and β-adrenergic blockers
c- Aggressive IV crystalloid fluid resuscitation Rationale: Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be).
When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information? a) The vaccine prevents a future fetus from developing congenital anomalies .b) The client should avoid contact with children diagnosed with rubella. c) The injection will provide immunity against the chickenpox. d) Pregnancy should be avoided for 4 weeks after the immunization
d) Pregnancy should be avoided for 4 weeks after the immunization. After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 4 weeks to prevent the possibility of the vaccine's teratogenic effects to the fetus. The vaccine does not protect a future fetus from infection. Rather it protects the woman from developing the infection if exposed during pregnancy and subsequently causing harm to the fetus. The vaccine will provide immunity to rubella, also known as German measles. The injection immunizes the client against the 3-day or German measles, not chickenpox.
The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? a-22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident b-48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c-65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina d-82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection
d-82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection Rationale: A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.
What laboratory finding fits with a medical diagnosis of cardiogenic shock? a-Decreased liver enzymes b-Increased white blood cells c-Decreased red blood cells, hemoglobin, and hematocrit d-Increased blood urea nitrogen (BUN) and serum creatinine levels
d-Increased blood urea nitrogen (BUN) and serum creatinine levels Rationale: The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a-Acute pain b-Impaired tissue integrity c-Decreased cardiac output d-Ineffective tissue perfusion
d-Ineffective tissue perfusion Rationale: The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.
A patient with ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? a. "Is there any family history of heart disease?" b. "Do you take aspirin on a daily basis?" c. "Can you describe the quality of your chest pain?" d. "What time did your chest pain begin?"
d. "What time did your chest pain begin?" Rationale: Fibrinolytic therapy should be started within 6 hours of the onset of the MI, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about fibrinolytic therapy.
The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient's blood glucose level is 142 mg/dL. b. The patient complains of feeling "constantly tired." c. The patient is unable to state the side effects of the medications. d. The patient states, "Sometimes I miss a dose of zidovudine (AZT)."
d. The patient states, "Sometimes I miss a dose of zidovudine (AZT)." Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Elevated blood glucose and fatigue are common side effects of ART. The nurse should discuss medication side effects with the patient, but this is not as important as addressing the skipped doses of AZT.
The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature
d. level of consciousness, urine output, and skin color and temperature Rationale: Adequate tissue perfusion in a patient with multiple-organ dysfunction syndrome is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity skin temperature, and peripheral pulses.
A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing: a. a relative hypervolemia. b. an absolute hypovolemia. c. neurogenic shock from low blood flow. d. neurogenic shock from massive vasodilation.
d. neurogenic shock from massive vasodilation. Rationale: Neurogenic shock results in massive vasodilation without compensation as a result of the loss of sympathetic nervous system vasoconstrictor tone. Massive vasodilation leads to a pooling of blood in the blood vessels, tissue hypoperfusion, and, ultimately, impaired cellular metabolism. Clinical manifestations of neurogenic shock are hypotension (from the massive vasodilation) and bradycardia (from unopposed parasympathetic stimulation).
