Unit 3

A 30-year-old gravida six, para five woman at 12 weeks gestation has just began prenatal care, and her initial laboratory work reveals that she has tested positive for HIV. What would be priority evidence-based nursing education for this patient today? A. Medication for HIV infection is safe and Great can greatly reduce transmission of HIV to the infant B. Breast-feeding is still recommended due to the great benefits to the infant C. Pregnancy is known to accelerate the course of HIV disease in the mother D. Cesarean section is not recommended because the increased risk of HIV transmission with the bleeding at surgery

a

A hospitalized patient with aids has wasting syndrome. Which intervention is appropriate to assign to an LPN who is providing care to this patient? A. Administering oxandrolone 5 mg per day B. Assessing the patient for other nutritional risk factors C. Developing a plan of care to improve the patient's appetite D. Providing instructions about a high calorie high-protein diet

a

A nurse is caring for a client in the ICU who is hospitalized after not sure of cerebral aneurysm. the client was responsive to painful stimuli with decorticate posturing an initial assessment by the nurse. which of the following findings 4 hours later require immediate intervention by the nurse a. The client extends all extremities in response to sternal rub b. the client responds to sternal rub by localizing movement c. the client responds purposefully to verbal stimuli d. the client opens eyes in response to sternal rub

a

A patient with newly diagnosed acquired immunodeficiency syndrome has a 6 mm induration at 48 hours after skin test for TB. Which action will the nurse anticipate taking next? A. Arrange for a chest x-ray to check for active TB B. Tell the patient that the TB results are negative C. Teach the patient about multi drug treatment for TB D. Schedule TB testing again in 12 months

a

A​ 16-year-old client presents with clinical manifestations of juvenile idiopathic arthritis​ (JIA). Which diagnostic test should the nurse anticipate being​ ordered? A. Erythrocyte sedimentation rate​ (ESR) B. Electrolyte panel C. Coagulation tests D. Urine cultures

a

The UAP in the critical care unit tells a primary nurse angrily, "you are the worst nurse I have ever worked with and I really hate working with you" which action should the primary nurse implement first a. don't respond to the comments and appraise the situation b. tell the UAP to leave the critical care unit immediately c. report this comment in behavior to the charge nurse d. explain that the UAP cannot talk to the primary nurse like this

a

The charge nurse notices that one of the staff nurses takes frequent breaks has unpredictable mood swings and often volunteers to care for clients who require narcotics. which priority action should the charge nurse implement regarding this employee a. discuss the nurses actions with the unit manager b. confront the nurse about the behavior c. do not allow the nurse to take breaks alone d. prepare in occurrence report on the employee

a

The charge nurse of a critical care unit is making assignments for the night shift which pt should be assigned to the graduate nurse who has just completed an internship a. the client diagnosed with a head injury resulting from a motor vehicle accident whose Glasgow coma skill is 13 b. the client diagnosed with inflammatory bowel disease who had severe diarrhea and a serum potassium level of 3.2 c. the client diagnosed with Addisons disease who was lethargic and has a BP of 80/45, P 124, RR 28 d. the client diagnosed with hyperthyroidism who has positive trousseau sign

a

The nurse is caring for a client who is deficient in T cells. The nurse should anticipate that the cause of​ T-cell deficiency is related to which​ manifestation? (Select all that​ apply.) A. Decrease in leukocytes B. Decrease in monocytes C. Decrease in granulocytes D. Hypersensitivity reaction E. Impaired cellular immunity

a, e

The client diagnosed with a gunshot wound to the head assumes the decorticate posturing when the nurse applies painful stimuli which assessment data obtained three hours later would indicate the client is improving a. purposeless movement in response to painful stimuli b. Flaccid paralysis in all four extremities c. decerebrate posturing when painful stimuli is applied d. people that are 6mm in size and non-reactive long painful stimuli

a

The client diagnosed with a mild concussion is being discharged from the ED which discharge instruction should the nurse teach the client significant other a. Awaken the client every two hours b. monitor for increased intracranial pressure c. observe frequently for hyper vigilance d. offer the client food every three to four hours

a

The client is diagnosed with a head injury and is in a coma the nurse writes the clients problem as high risk for mobility complications which intervention should be included in the plan of care a. position the client with the head of the bed elevated at intervals b. perform active range of motion exercises every four hours c. turn the client every shift and massage boney prominences d. Explain all procedures to the client before performing them

a

The client is known to be HIV positive. Which data indicate to the nurse that the client has now progressed to the diagnosis of aids? A. The client CD4 count is 189 B. The client has a hemoglobin of 9.4 and hematocrit of 29.1 C. The clients chest x-ray shows infiltrates D. The client complains of a headache I'm relieved by Tylenol

a

The client returns to a clinic for a follow up visit and is diagnosed as positive for HIV the client expresses fear related to lack of finances social avoidance and hopelessness which nursing intervention provides the most client support a. referral to a community based HIV clinic b. referral to the local public health Department c. referral to an HCP who specializes in infectious diseases d. recommend that the client disclose the diagnosis to the family

a

The concept of impaired immunity has been identified by the nurse as it applies to the client diagnosed with aids. Which intervention should the nurse implement? A. Keep fresh flowers and raw vegetables out of the clients room B. Have the UAP assist with ADLs C. Encourage the client to perform active range of motion D. Teach the client about cardiovascular medication's

a

The nurse is a describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? A. The HIV virus is a retrovirus which means never dies as long as it has a house to live in B. The HIV virus can be eradicated from the host body with the correct medical regimen C. It is difficult for the HIV virus to replicate in humans because it is a monkey virus D. The HIV virus uses the clients on red blood cells to reproduce the virus in the body

a

The nurse is administering man at all IV to decrease the clients AICP following a craniotomy, which lab test result should the nurse monitor during the clients treatment with mannitol a. serum osmolarity b. WBC count c. serum cholesterol d. erythrocyte sedimentation rate

a

The nurse is admitting a client diagnosed with protein calorie malnutrition secondary to AIDS. Which intervention should be the nurses first intervention? A. Assess the clients body weight and ask what the client has been able to eat B. Place the patient in contact isolation and Don a mask and gown before entering the room C. Check the HCP orders and determine what lab test will be done D. Teach the client about total parenteral nutrition and monitor the subclavian IV site

a

The nurse is caring for a child with a skull fracture who is unconscious and has severely increased intracranial pressure. the nurse next said the child temperature to be 104 F what should the nurse do first a. place a cooling blanket on the child b. administer acetaminophen via NGT c. administer acetaminophen rectally d. place ice packs in the Childs axillary areas

a

The nurse is caring for a client I was HIV positive and is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? A. Flush the skin with water and try to get the area to bleed B. Notify the charge nurse and complete an incident report C. Report to the employee health nurse for prophylactic medication D. Follow up with the infection control nurse to have laboratory work done

a

The nurse is caring for the pediatric client who was diagnosed with AIDS which assessment findings should alert the nurse to be a development of Pneumocystis carinii pneumonia a. dyspnea elevated temperature nonproductive cough and fatigue b. weight loss night sweats persistent diarrhea hypothermia c. dyspnea yellow white plaques in the mouth sore throat d. lung crackles chest pain small painless purple blue skin lesions

a

The nurse is evaluating a patient with HIV who is receiving trimethoprim sulfamethoxazole as a treatment for pneumocystis jiroveci pneumonia. Which information is most important to communicate with the healthcare provider? A. The patient reports a blistering rash B. The patient's fluid intake is 2 L per day C. The patient's potassium is 3.4 D. The patient enjoy spending time outside in the sun

a

The nurse manager in a public health department is implementing a plan to reduce the incidence of HIV in the community. Which nursing action will be delegated to the UAP working for the agency? A. Supplying injection drug users with sterile injection equipment such as needles and syringes B. Interviewing patients about behaviors that include a need for annual HIV testing C. Teaching high-risk community members about the use of condoms in preventing HIV infection D. Assessing the community to determine which population groups to target for education

a

The nurse on a medical floor is caring for a client diagnosed with aids. Which client should be seen first? A. The client who has flushed warm skin with tinted turgor B. The client who states the staff ignores the call light C. The client his vital signs are 99.9, 101, 26, 110/68 D. The client was unable to provide a sputum specimen

a

The nursing student approaches the instructor after being stuck by a bloody needle which instructor statement is most accurate knowing that the client was HIV positive a. wash with soap and water and see the HCP now treatment should begin within one to two hours b. the first HIV antibody testing is completed in six weeks and then repeated in three months c. wash with soap and water now at the end of the clinical shift notify your physician d. flush immediately with water for 10 minutes and then cover with a bandage and glove

a

The parents of a 12 month old with HIV are concerned about his receiving routine immunizations. what will the nurse tell them about immunizations a. you are concerned about your child receiving immunization. let me explain why your child will not receive routine immunizations today b. your child will receive the recommended vaccines today c. your child is not severely immunocompromised, but I would still be concerned about his receiving routine immunizations d. Your child may develop infections if he gets his routine immunizations your child will not be immunized today

a

The staff nurse is working with a colleague who begins to act erratically and is loud and argumentative. which action should the nurse implement a. ask the supervisor to come to the unit b. determine what is bothering the nurse c. suggest the nurse go home d. smell the nurses breath for alcohol

a

Which intervention has the highest priority for the client in the ED who has been in a motorcycle collision with an automobile and has a fractured left leg a. assessing the neurological status b. immobilizing the fractured leg c. monitoring the clients output d. starting an 18 gauge Saline lock

a

Which signs/symptoms make the nurse suspect the most common opportunistic infection in a female recently diagnosed with aids? A. Fever, cough, and shortness of breath B. Oral thrush, esophagitis, and vaginal candidiasis C. Abdominal pain, diarrhea, weight loss D. Painless violet lesions in the face and tip of the nose

a

Which stage of HIV infection is considered the beginning stage of aids? A. Stage 3 B. Stage 1 C. Stage 2 D. Stage four

a

A nurse is a system with admitting a child who has HIV. the nurse should identify which of the following findings as indications that the child is in the moderately symptomatic category B? select all that apply a. herpes zoster b. bronchitis c. oral candidiasis d. mycobacterial pneumonia e. tuberculosis

a, b, c

The community health nurse is conducting a teaching session for community members on rheumatoid arthritis​ (RA). Which characteristic should the nurse list as being a risk factor for the development of​ RA? (Select all that​ apply.) A. Family history B. Genetic predisposition C. Psychological stressors D. Male sex E. Diet

a, b, c

The nurse is caring for a client newly diagnosed with protein calorie malnutrition secondary to AIDS and write a nursing problem of "altered nutrition: less than body requirements". Which nursing intervention should the nurse implement? Select all that apply. A. Place the client on daily weights B. Have the client identify preferred foods C. Refer to dietitian D. Monitor bedside glucose levels four times a day E. Preform central line dressing changes every 72 hours

a, b, c

The nurse is reviewing the medical record of a client with a diagnosis of​ AIDS-related dementia. Which clinical manifestation should the nurse expect to find during the physical​ assessment? (Select all that​ apply.) A. Ataxia B. Urinary incontinence C. Lethargy D. Rash E. Myalgia

a, b, c

A client is admitted for uncontrolled pain caused by rheumatoid arthritis​ (RA). Which ongoing problem should the nurse assess in relation to the​ RA? (Select all that​ apply.) A. Poor​ self-esteem B. Fatigue C. Ineffective role performance D. Chronic pain E. Weight gain

a, b, c, d

A client with a history of joint pain and autoimmune disease presents to the clinic. Which question should the nurse include in the nursing assessment for this​ client? (Select all that​ apply.) A. "Do you have any​ rashes?" B. "Have you had any recent​ infections?" C. "Have you had any fever or generalized​ weakness?" D. "What kind of medications are you taking​ currently?" E. "Do you have any numbness or tingling in your​ extremities?"

a, b, c, d

The client states to the nurse Im done from AIDS and nothing but a bag of bones all these sores make my family uncomfortable, and they wont come near me which intervention should the nurse implement to assist the client to cope with the disturbed body image select all that apply a. spend extra time grooming the client b. limit the clients self-negation statements c. initiate a psychiatric consultant referral d. assess the families coping and reaction e. tell the family to spend more time with the client

a, b, c, d

A client with newly diagnosed HIV​ states, "I​ don't know if I want to take the mediation.​ What's the​ point?" Which information should the nurse include when explaining the goals of pharmacologic management to the​ client? (Select all that​ apply.) A. It will decrease the symptoms. B. It will treat opportunistic infections and cancers. C. It will stimulate hematopoietic response. D. It will cure the infection. E. It will prolong life for the affected individual

a, b, c, e

A nurse in an outpatient clinic is collecting data from a male client who reports night sweats in fatigue. the client's temperature is 100.6 F orally. the client is afraid he has HIV. which of the following actions should the nurse take? select all that apply a. measure vital signs b. determine when manifestations began c. weight to client d. provide teaching about opportunistic infections e. obtaining sexual history

a, b, c, e

A nurse is working with a patient who has a new diagnosis of HIV and reports current use of injectable heroin and methamphetamine. Which action by the nurse are appropriate? Select all that apply. A. Refer the patient to a substance-abuse treatment program B. Plan for the patient to participate in a needle exchange program C. Coordinate the patient schedule for directly observed anti-retroviral drive treatment D. Instruct the patient that I'm going injectable drug use is a contradiction for anti-retroviral therapy E. Provide patient education about the risk of transmitting HIV to others and sharing needles

a, b, c, e

The nurse is providing discharge instructions for a client with AIDS. Which instruction should the nurse​ emphasize? (Select all that​ apply.) A. Infection prevention and transmission B. Medications and side effects C. Signs and symptoms of opportunistic infections and cancers D. Necessity of spiritual counseling E. Importance of regular​ follow-up examinations and monitoring of immune status

a, b, c, e

The nurse prepares a presentation about AIDS for a group of students. Which info is important for the nurse to include? SATA a. Abstinence is the most effective preventative method for HIVE r/t sexual transmission b. Limit the number of sexual partners & engage only in protected sex c. Use latex condoms for oral, vaginal, or anal intercourse d. Avoid use of spermicides with condoms e. Do not share items that may be contaminated with blood or body fluids, such as razors or needles f. Petroleum jelly is an acceptable lubricant to use with a condom

a, b, c, e

A nurse in an emergency Department is completing an admission assessment of a client who has a gun shot wound to the head. which of the following findings are indicative of increased intracranial pressure. select all that apply a. Vomiting b. dilated pupils c. tachycardia d. decorticate posturing e. hypertension

a, b, d

A nurse in an outpatient clinic is assessing a client who reports night sweats, fatigue, nausea, cough and diarrhea. if it is possible he has HIV. which of the following actions should the nurse take initially? select all that apply a. perform a physical assessment b. determine when manifestations began HIV 13 c. provide education about HIV transmission d. draw blood for HIV testing e. obtain a sexual history from the client

a, b, e

The nurse assessing a client diagnosed with rheumatoid arthritis​ (RA) notes the presence of joint deformities. Which additional​ extra-articular manifestation of RA should the nurse look for in the​ client? (Select all that​ apply.) A. Pericarditis B. Splenomegaly C. Hearing loss D. Hepatitis E. Subcutaneous nodule

a, b, e

Which independent nursing intervention should the nurse implement to treat a client diagnosed with rheumatoid arthritis​ (RA)? (Select all that​ apply.) A. Promoting a​ well-balanced diet B. Instructing the client to alternate periods of activity and rest C. Suggesting arthrodesis for joint fusion D. Advising the client to avoid sun exposure E. Teaching about​ low-impact aerobics

a, b, e

Which of the following can lead to a possible diagnosis of HIV in a child? select all that apply a. repeated respiratory infections b. intermittent diarrhea c. excessive weight gain d. irregular heartbeat e. poor weight gain

a, b, e

A nurse is caring for a client with suspected HIV. which of the following diagnostic tests in laboratory values are used to confirm HIV infection? select all that apply a. western blot b. indirect immunofluorescence assay c. CD 4 + T lymphocyte count d. HIV RNA quantification test e. cerebrospinal fluid analysis f. Enzyme linked immunosorbent assay

a, b, f

A nurse is admitting an adolescent who has severely symptomatic HIV. which of the following findings might the nurse expect? select all that apply a. Kaposi sarcoma b. pneumonitis c. encephalopathy d. pulmonary candidiasis e. swollen lymph nodes

a, c, d

The pregnant client with HIV is receiving highly active antiretroviral therapy HAART at an outpatient HIV center the nurse should monitor the client for which potential pregnancy related problems associated with HAART therapy select all that apply a. preterm labor b. preeclampsia c. low birth weight d. gestational diabetes e. birth defects

a, c, d

A client is admitted with a suspected autoimmune deficiency in which the number of leukocytes is decreased. Which intervention should the nurse include in the​ client's plan of​ care? (Select all that​ apply.) A. Rest periods B. Fluid support C. Moderate exercise D. Nutritional support E. Infection prevention

a, c, d, e

A nurse is providing info about TB to a group of pts at a local community center which of the following manifestations should the nurse include? a. Persistent cough b. Wt gain c. Fatigue d. Night sweats e. Purulent sputum

a, c, d, e

Which intervention should the nurse discuss with a female client who is positive for HIV? Select all that apply. A. Recommend the client not to engage in unprotected sexual activity B. Instruct the client not to inform past sexual partners of HIV status C. Tell the client to not donate blood, organs, or tissues D to suggest the client not get pregnant E. Explain the client does not have to tell the healthcare personnel of HIV status

a, c, d, e

The healthcare team is discussing the care of a client with wasting syndrome secondary to AIDS. Which intervention would be appropriate for the nurse to include in the plan of care to address the​ client's nutritional​ needs? (Select all that​ apply.) A. Infusing total parenteral nutrition B. Turning the client every 2 hours C. Obtaining daily weights D. Administering intravenous fluids E. Reviewing total protein and albumin levels

a, c, e

The intensive care nurse is caring for the client who has intra cranial surgery which interventions should the nurse implement select all that apply a. assess for DVT b. administer intravenous anticoagulant c. monitor intake and output strictly d. apply warm compresses to the eyes e. performed passive range of motion exercises

a, c, e

A nurse is completing the admission hx of a pt who has HIV. Which risk factors does the nurse identify as being associated with this virus? SATA a. Perinatal exposure b. Pregnancy c. Monogamous sex partner d. Menopause e. Occupational exposure

a, d, e

The 28-year-old female client is the outpatient clinic has been told that her test for HIV is positive. Which intervention should the nurse implement? Select all that apply. A. Discuss having regular gynecological examinations B. Assist the client to make her funeral arrangements C. Refer the client to a social worker D. Encourage the client to take a highly active anti-retroviral therapy E. Teach the client to follow a healthy lifestyle

a, d, e

What should a nurse do uniquely after sticking a finger with their contaminated needle from a client with HIV infection. select all that apply a. notify the nursing supervisor b. try a tumor blood to determine the patients viral load c. notify risk management d. remove the gloves e. report to employee health

a, d, e

A patient is newly prescribed isoniazid to treat their active tuberculosis what instructions are the most important to teach this patient select all that apply a. Monitor for numbness and tingling b. Report blurred vision c. use additional forms of birth control d. avoid wine at night e. Notify HCP if urine turns dark f. Take B6 daily

a, d, e, f

A client admitted to the hospital with classic symptoms of tuberculosis (TB) tests positive on a purified protein derivative (PPD) skin test. Several months later, the nurse who cared for the client also tests positive on annual TB skin test. What would be the most likely course of treatment if the nurses' chest x-ray's (CXR) is negative? a. Repeat a TB skin test in 6 months b. Treat the nurse with an anti-infective agent for 6 months c. Monitor for SSx within the next year

b

A client newly diagnosed with rheumatoid arthritis​ (RA) tells the​ nurse, "I understand that RA affects my joints. Does it have any other effects on my body that I should know​ about?" In​ response, which additional effect of RA should the nurse​include? A. Stomach ulcers B. Anemia C. Headaches D. Liver failure

b

A client who is HIV positive and is taking anti-retroviral medications as why he was told that a change in medication might be needed during the course of treatment what would be the best explanation for the nurse to give the client? A. The medication regimens may be changed to prevent expected toxicity to major organs B. Anti-retroviral resistance is a major challenge to long-term management of HIV infection and drug therapy may change based on research results C. Monotherapy is recommended for the treatment of HIV and must be adjusted D. Your treatment regimen will remain in place and is unlikely to change

b

A nurse in the emergency Department is assigned to care of four clients. which client is a priority for assessment and treatment a. a patient with diabetes and increased thirst with a temperature of 100.6 F in a finger glucose reading of 380 b. a patient who takes warfarin and fell from a ladder who had a brief loss of consciousness and now complains of a severe headache c. a woman who is crying after an argument with her husband with bruises on both arms d. an older patient with a swollen and deformed ankle complaining of 8/10 pain after stepping off a curb with equal pulses in both feet

b

A nurse is caring for a 25 year old pt with AIDS who has small, painless purplish red spots on the lower extremities. How should the nurse advise the pt to cleanse the lesions to reduce the risk of secondary infection? a. Use povidone iodine solution when cleansing the spots b. Wash the spots with mild soap placed in a pump dispenser c. Rub spots using a warm washcloth d. Cleanse the spots with warm water every other day

b

A nurse is caring for a client with AIDS who is complaining about chills night sweats fever and diarrhea. the client has significant weight loss and malabsorption. which of the following may have caused the client symptoms a. tuberculosis b. cryptosporidiosis c. candidiasis d. pneumocystis carinii

b

A nurse is counseling a client who is HIV positive on her initial prenatal visit. Which of the following should the nurse include in the teaching the client? A. Anti-retroviral therapy should be discontinued during pregnancy B. Breast-feeding is contraindicated for mothers who are HIV-positive C. Intramuscular influenza vaccine is contradicted during pregnancy D. The newborn develops antibodies the HIV in utero and will not require treatment

b

A nurse is evaluating a tuberculin skin test for a client with HIV the nurse should document a positive reaction if there is an area of induration measuring which of the following A. 1 mm B. 7 mm C. 4 mm D. 2 mm

b

A nurse is reading a client's TB skin test at 48 hours in notes that the client has 6 mm of redness and 3 mm of induration. the client is HIV positive. which of the following is a correct reading for the clients test a. 9 mm and negative b. 6 mm and positive c. 3 mm and positive d. 3 mm and negative

b

A nurse is teaching a pt who has TB, which of the following statements should the nurse include a. You will need to continue to take the multimedication regimen for 4 months b. You will need to provide sputum samples q4 wks to monitor the effectiveness of the meds c. You will need to remain hospitalized for treatment d. You will need to wear a mask at all times

b

A patient who has HIV is taking nucleoside reverse trips transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the healthcare provider? A. The patient exclaims "I'm afraid to die right here" B. The prescribe patient medication includes midazolam 2 mg IV immediately C. The patient is diaphoretic the patient was diaphoretic and tremulous and reports dizziness D. The symptoms occurred suddenly while the patient was driving to work

b

The 29 year old client who was employed as a forklift operator sustains a traumatic brain injury secondary to a motor vehicle accident the client is being discharged from the rehab unit after three months and has cognitive deficits which goal would be the most realistic for this client a. the client will return to work within six months b. the client is able to focus and stay on task for 10 minutes c. the client will be able to address self without assistance d. the client will regain bowel and bladder control

b

The 30 year old client recently diagnosed with HIV is being counseled by the nurse which statement by the nurse is correct a. unless you give consent, your information will be kept private, and your sexual partners will not be informed of your diagnosis b. the CDC must be informed of this HIV diagnosis for epidemiological purposes c. in order to protect all the nursing staff on this unit all nurses will be informed of your HIV status d. you may require that each health care provider caring for you obtain your consent to discuss her HIV status with anyone

b

The 45 year old diagnosed with HIV presents to the clinic requesting to receive herpes zoster vaccine live which statement by the nurse is accurate concerning administration of zoster vaccine live to this client a. zoster vaccine live is an appropriate vaccine for someone at your age b. zoster vaccine live is a live virus that could be problematic for you c. zoster vaccine live is best administered in childhood to be effective d. softer vaccine live will prevent you from contracting Chickenpox

b

The adolescent client enters a clinic alone for treatment of a productive cough and low grade fever the client discloses being HIV positive which is the best action by the nurse a. nothing can be done without the consent of the parents b. treat and then educate about birth control safe sex and partner disclosure c. draw an HIV titer to confirm the HIV positive status of the client d. obtain a sexual risk history and notify the parents of the clients visit

b

The charge nurse is counseling a female staff nurse because the nurses clocked in late multiple times for the 7:00 AM to 7:00 PM shift. which conflict resolution utilizes the win win strategy a. the charge nurse terminates the staff nurse per hospital policy so that a new nurse can be transferred to the unit b. the charge nurse discovers that the staff nurse is having problems with childcare therefore the charge nurse allows a staff nurse to work at 9:00 AM to 9:00 PM shift c. the charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work she will be terminated d. the staff nurse ask another staff member to talk to the charge nurse to explain that she is a valuable part of the team

b

The charge nurse observes 2 UAPs arguing in the hallway. which action should the nurse implement first in this situation a. tell the manager to check on the UAPs b. instruct the UAPs to stop arguing in the hallway c. have the UAPs virtual private room to talk d. mediate the dispute between the UAPs

b

The client diagnosed with a closed head injury is admitted to the rehabilitation Department which medication order would the nurse question a. a subcutaneous anticoagulant b. an intravenous osmotic diuretic c. an oral anti-convulsant d. an oral proton pump inhibitor

b

The client diagnosed with aids is complaining of a sore mouth and tongue. When the nurse assesses the Beukelman mucosa the nurse notes white, patchy lesions covering the hard and soft palate in the right inner cheek. Which intervention should the nurse implement? A. Teach the client to brush the teeth and patchy area with a soft bristle toothbrush B. Notify the HCP for an order for an antifungal swish and swallow medication C. Have the client gargle with an antiseptic-based mouthwash several times a day D. Determine what type food the client has been eating within the last 24 hours

b

A nurse is assessing a school age child who has nephrotic syndrome. which of the following findings should the nurse report to the provider a. mild hypertension b. Cola colored urine c. photophobia d. fatigue

c

The client diagnosed with pneumocystis pneumonia is being admitted to the ICU. Which HCP orders for the nurse implement first? A. draw a serum for CD4 and CBC STAT B. administer oxygen to the client via nasal cannula C. Administer trimethoprim-sulfamethizole, a sulfa antibiotic IVPB D. Obtain a sputum specimen for culture and sensitivity

b

The critical care nurse is caring for a client with a head injury secondary to a motor vehicle accident who, on morning rounds is responsive to painful stimuli and assumes decorticate posturing. two hours later which data would warrant immediate intervention by the nurse a. the client has purposeful movement when the nurse rubs the sternum b. the client extends upper and lower extremities in response to painful stimuli c. the client is aimlessly thrashing in the bed when a noxious stimulus is applied d. the client is able to squeeze the nurses hands on verbal requests

b

The nurse accidentally sticks herself with a needle she used to administer an intradermal injection for a PPD. which action should the nurse implement a. take no action because it's an injection under the skin b. immediately wash the area with soap and water c. ask client whether he or she has AIDS for hepatitis d. place an antibiotic ointment & band aid over the site

b

The nurse determines that which of the following nursing diagnosis has the highest priority for a client who has rheumatoid arthritis? A. Fatigue B. Chronic pain C. Ineffective role performance D. Disturbed body image

b

The nurse is admitting a client with rheumatoid arthritis in the hands have swan neck fingers. Which concept with the nurse identify as a priority? A. Mobility B. Functional ability C. Coping D. Rehabilitation

b

The nurse is assigned to care for four clients today in the clinic. Which client has the highest risk for contracting HIV​ infection? A. A​ 30-year-old female in a heterosexual monogamous relationship B. A​ 60-year-old male who has unprotected sex C. A​ 40-year-old male who smokes marijuana D. A​ 50-year-old female with cervical dysplasia

b

The nurse is caring for a client and is accidentally stuck with the style it used to start an IV infusion. The nurse flashes his skin with water and tries to get the area to bleed. which action should the nurse implement next a. have the lab draw the clients blood b. notify the charge nurse and complete the incident report c. contact the employee health nurse to start prophylactic medication d. follow up with the employee health nurse to have lab work drawn

b

The nurse is caring for a client recently diagnosed with rheumatoid arthritis​ (RA). Which clinical manifestation found during the​ nurse's assessment supports the diagnosis of​ RA? A. Weight gain over the last several months B. Low-grade fever C. Increased energy D. Morning stiffness that lasts for 30 minutes

b

The nurse is caring for a client with a history of headaches. the client has talked to the nurse, smiled at guests, and maintain stable vital signs. the nurse notes the following changes in the client status. which assessment finding is critical to report to the HCP? a. blood pressure 136/88 b. flat affect and drowsiness c. poor appetite d. respiratory rate 12

b

The nurse is supervising student nurse who is caring for a patient with HIV. The patient has severe esophagitis caused by Candida albicans.. Which action by the student nurse requires the most rapid intervention by the nurse? A. Putting on a mask and gown before entering the patient's room B. Giving the patient a glass of water after administering the prescribed all nystatin suspension C. Suggesting that the patient should order Chile con Carne or chicken soup for the next meal D. Placing a no visitor sign on the door of the patients room

b

The nurse is working in a hospice facility for patients with aids. The facility staff with LPN and UAP. Which action will the nurse assigned to the LPN? A. Assessing patients nutritional need an individualized diet plans to improve nutrition B. Collecting data about the patient's responses to medication used for pain and anorexia C. Developing UAP training for programs about how to lower the risk for spreading infection D. Assessing the patient with personal hygiene and other activities of daily living as needed

b

The nurse writes a nursing diagnosis altered body temperature related to damaged temperature regulating mechanism for a client with a head injury which would be the most appropriate goal a. administer acetaminophen for elevated temperature b. the clients temperature will remain less than 100 degrees Fahrenheit c. maintain the hypothermia blanket at 99 degrees for 24 hours d. the basal metabolic temperature will fluctuate no more than two degrees

b

The parent of a 2 year old who is HIV positive questions the nurse about placing the child in daycare. which of the following is the best response a. the child should not go to daycare until older because there is a high risk for transmission of the disease b. the child can go to daycare without restrictions and should be allowed to participate in all activities c. the child can go to daycare but should avoid physical activity d. the child may go to daycare but the parent must inform all the parents at the daycare that the child is HIV positive

b

The patient with elevated intracranial pressure has been intubated and placed on a mechanical ventilator for the purpose of hyperventilation which carbon dioxide value indicates that the optimal amount of hyperventilation has been achieved a. PaCO 2 18 mmHg b. PaCO 2 30 mmHg c. PaCO 2 38 mmHg d. PaCO 2 46 mmHg

b

The student nurse accidentally punctured her finger with a contaminated needle. Which action should the student nurse take first? A. Notify the infection control nurse B. Allow the puncture site to bleed C. Report to the emergency department D. Cleanse the site with Betadine

b

When the occupational health nurse is teaching unlicensed assistive personnel about blood-borne pathogen exposure and HIV risk, which information is most important to emphasize? A. Occupational transmission of HIV from patients to healthcare workers is relatively rare B. Occupational exposure to HIV containing fluid should be reported immediately to the supervisor C. Treatment for occupational exposure to HIV may include the use of anti-retroviral medications D. Post exposure treatment will include HIV testing at baseline and at several weeks after the exposure

b

Which assessment data indicate that the client with a traumatic brain injury exhibiting the corticate posturing on admission is responding effectively to treatment a. the client has flaccid paralysis b. the client has purposeful movement c. the client has decerebrate posturing with painful stimuli d. the client does not move the extremities

b

Which of the following patients cared for by the nurse in the clinic presents the highest risk for infection with HIV during sexual intercourse? A. Uninfected man who reports performing oral intercourse with an HIV infected woman B. Uninfected man who is a receiver during anal intercourse with an HIV infected man C. Uninfected woman who had vaginal intercourse with an HIV infected man D. Uninfected woman who has performed oral intercourse with an HIV infected woman

b

A home health nurse is teaching a pt who has active TB & is following a med regimen that includes a combo of isoniazid, rifampin, pyrazinamide & ethambutol. Which of the following pt statements indicate understanding? SATA a. I can substitute on med for another if I run out bc they all fight infection b. I will wash my hands ea time I cough c. I will wear a mask when I am in public areas d. I am glad I don't have to have any more sputum specimens e. I don't need to worry where I go once, I start taking my meds

b, c

A nurse is caring for a client in the ICU who has suffered a head injury and requires a monitor to check intracranial pressure. Which of the following are late signs of increased ICP. select all that apply a. contracted extremities b. loss of reflexes c. tachycardia d. hyper response to painful stimuli e. arm drift

b, c

The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data should be considered antecendents (risk factor) for becoming HIV positive? Select all that apply. A. The client is pregnant B. The client is an IV drug abuser C. The client has multiple sexual partners D. The client does not have available health care E. The client does not have adequate bathroom facilities F. The client spends her money on nonessential items

b, c

The nurse is caring for a client diagnosed with an epidural hematoma which nursing intervention should the nurse implement select all that apply a. maintain the head of the bed at 60 degrees b. administer stool softeners daily c. ensure the pulse ox is higher than 93% d. perform deep nasal section every two hours e. administer mild sedatives

b, c, d

A client with rheumatoid arthritis​ (RA) complains of pain and discomfort in the hands and knees. Which intervention should the nurse implement to reduce the pain and discomfort that the client is​ experiencing? (Select all that​ apply.) A. Providing periods of sun exposure B. Providing a balanced diet C. Administering prescribed corticosteroids D. Providing periods of exercise E. Administering prescribed NSAIDs

b, c, d, e

In reviewing a​ client's health​ history, which factor should the nurse consider to be a risk for developing a disorder of the immune​ system? (Select all that​ apply.) A. Male sex B. Physical stressors C. African American race D. Genetic predisposition E. Psychological stressors

b, c, d, e

Which item should the nurse include in a focused immune system​ assessment? (Select all that​ apply.) A. Assess the genitourinary system. B. Inspect the mucous membranes. C. Observe for fatigue and weakness. D. Assess the musculoskeletal system. E. Observe skin​ color, moisture, and temperature

b, c, d, e

Which clinical manifestation should the nurse expect to find in a client with a diagnosis of Pneumocystis jiroveci​ pneumonia? (Select all that​ apply.) A. Diarrhea B. Dyspnea C. Fever D. Oral lesions E. Cough

b, c, e

Which personal protective equipment should be utilized when using a bulb syringe to suction the nose of an infant infected with​ HIV? (Select all that​ apply.) A. N-95 respirator B. Gloves C. Goggles. D. Covered footwear E. Masks

b, c, e

A nurse is caring for a client who is in labor with HIV. which of the following procedures should the nurse identify as being safe for the client? select all that apply a. vacuum extraction b. oxytocin infusion c. use a forceps d. cesarean birth e. internal field monitoring

b, d

A nurse is creating a plan of care for an infant who has an ET tube in place due to increased intracranial pressure. which of the following interventions should the nurse include in the plan of care to reduce ICP. select all that apply a. section the ET tube every two hours b. maintain a quiet environment c. use two pillows to elevate the infant's head d. administer a stool softener e. place the infant in the Trendelenburg position

b, d

A patient with TB has been taking ethambutol for two months which adverse effects should be reported to the HCP select all that apply a. red orange tears b. blurred vision c. new numbness or tingling d. color changes e. elevated liver enzymes

b, d

The nurse is caring for a​ 59-year-old woman who is recently divorced. The nurse understands that this client falls into the population of individuals who are called the​ "invisible population" due to which​ factor? (Select all that​ apply.) A. They will frequently engage in​ same-sex relationships. B. They may not understand the importance of HIV testing. C. They commonly experiment with drugs. D. They are not comfortable talking about condom use. E. Their HIV symptoms may be overlooked

b, d, e

The nurse working in a clinic discusses HIV prevention with an adolescent. Which behavior should the nurse instruct the adolescent to avoid to minimize the risk of contracting​ HIV? (Select all that​ apply.) A. Smoking crack cocaine B. Having unprotected sex C. Using public restrooms D. Getting tattoos E. Sharing needles

b, d, e

A client is admitted to the emergency Department following a motor vehicle crash while completing a neurologic assessment the client pulls his arms inward an upward while the nurse is eliciting a pain response. the nurse identifies that this positioning its significant for which of the following select all that apply a. decerebrate posturing b. decorticate posturing c. injury to the brainstem d. injury to the pons e. injury to the midbrain

b, e

A nurse is caring for a 40 year old male client who is diagnosed with AIDS. the client developed kaposi sarcoma. which of the following is an appropriate nursing action in caring for the lesions associated with this condition a. apply antibiotic ointment as prescribed b. apply topical corticosteroid cream as prescribed c. cleanse area and keep dry d. place sterile Saline soaked gauze over the lesions

c

A client considering pregnancy has a family history of primary immune deficiencies and wants to know the risk for their child. Which statement by the nurse is​ appropriate? A. "Tell me more about your concerns regarding​ pregnancy." B. "A weight-loss program prior to pregnancy will decrease your​ infant's risk of getting one of these​ diseases." C. "You may want to seek genetic counseling to determine the specific​ risk." D. "You should consider​ long-term contraceptive use to prevent severe immunodeficiency in your​ offspring."

c

A client diagnosed with aids dementia is angry and yells at everyone entering the room none of the critical care staff wants to be assigned to this client. which intervention would be most appropriate for the nurse manager to use in resolving this situation a. explain that this attitude is a violation of clients rights b. request the HCP to transfer the client to the medical unit c. discuss some possible options with the nursing staff d. try to find a nurse who does not mind being assigned to the client

c

A client with HIV is taking Didanosine, pentamide, and trimethoprim-sulfamethoxazole. Elevated serum amylase was noted in the lab report. which of the following is the best course of action for the nurse a. determine if the client is compliant b. provide instructions about the effect of drugs on serum amylase c. hold the doctor immediately d. assessment the client has a complaint about a symptom

c

A client with rheumatoid arthritis​ (RA) states,​ "My disease is normally well controlled with a regimen of medications and treatments.​ However, I'm experiencing a​ flare-up of the disease in the right​ knee." Which collaborative intervention should the nurse expect to​ implement? A. Sulfasalazine administration B. Oral gold salts administration C. Intra-articular corticosteroid injection D. Hydroxychloroquine administration

c

A client with tuberculosis is being admitted to the MedSurg unit which type of precaution should the nurse institute to protect the client and start from possible exposure to this infection? A. Standard precaution B. Contact precaution C. Airborne precaution D. Droplet precaution

c

A nurse is assessing a client who has HIV. which finding should the nurse identify as a manifestation of HIV associated muscle wasting? a. unintentional weight loss of 15% of body weight in six months b. fecal impaction c. diminished strength d. reports of increased back pain on the back of the neck

c

A nurse is caring for apt who has a new diagnosis for TBand has been placed on a multimedication regimen. Which of the following instructions should the nurse given the pt related to ethambutol? a. Your urine can turn a dark orange b. Watch for change in the sclera of your eyes c. Watch for any changes in your vision d. Take vitamin B6 daily

c

A nurse is preparing to administer a new prescription for isoniazid to a light skinned pt who has TB. The nurse should instruct the pt which of the following findings as an adverse effect of the med a. You might notice yellowing of your skin b. You might experience pain in your joints c. You might notice tingling of your hands d. You might experience a loss of appetite

c

A nurse is preparing to administer mannitol 1 g/kg of 20% solution IV. which of the following conditions should be considered a contraindication for using this type of medication ? a. Cerebral edema b. Oliguria c. heart failure d. increased intraocular pressure

c

The adolescent client diagnosed with HIV has a CD 4 positive T lymphocyte count of 160 the nurse evaluates that intervention has been most effective when which outcome in the clients plan of care is achieved a. Soft, formed stools daily b. skin integrity non intact c. free of opportunistic infections d. weight gain of £1.00 weekly

c

The charge nurse in a large outpatient clinic notices the staff is arguing and irritable with one another and the atmosphere has been very tense for the past week. which action should the charge nurse implement a. wait for another week to see whether the situation resolves itself b. write a memo telling all staff members to stop arguing c. schedule a meeting with the staff to discuss the situation d. tell the staff to stop arguing or staff will be terminated

c

The client diagnosed with aids is angry and yells at everyone entering the room and none of the staff members want to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving the situation? A. Assign a different nurse every shift to the client B. Ask the HCP to tell the client not to yell at the staff C. call a team meeting and discuss options with the staff D. Tell one staff member to care for the client a week at a time

c

The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is brain dead which data supports that the client is brain dead a. when the clients head is turned to the right the eyes turned to the right b. the EG has identifiable waveforms c. no activity is observed when the cold caloric test is performed d. the client assumes the core ticket posturing when painful stimuli is applied

c

The client was engaged and needle sharing activities has developed a flu like infection. And HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? A. The client is fortunate not to have contracted HIV from an infected needle B. The client must be repeatedly exposed to HIV before becoming infected C. The client may be in primary infection phase of HIV infection D. The antibody test is negative because the client has a different flu virus

c

The client with a close head injury has clear fluid draining from the nose which action should the nurse implement first a. notify the HCP immediately b. prepare to administer an antihistamine c. test the drainage for presence of glucose d. place a 2 x 2 gauze under the nose to collect the drainage

c

The director of nurses in the clinic is counseling a UAP in the clinic who returned late from her lunch break seven times in the last two weeks. which conflict resolution utilizes the win lose strategy a. the UAP explains she is checking on her ill mother during lunch and the nurse allows her to take a longer lunch break if she comes in early b. the director of nurses offers the UAP a transfer to the emergency weekend clinic so that she will be off during the week c. the director of nurses terminates the UAP explaining that all staff must be on time so that the clinic runs smoothly d. the UAP this placed on a one month probation and any further occurrences will result in being terminated from this position

c

The nurse has been asked to perform a home assessment on a client with a long-standing rheumatoid arthritis. Which of the following findings should receive the highest priority for follow up teaching? A. Client lives in apartment building that has an elevator B. Client has installed handrails to support in the bathroom C. Client has area rug scattered throughout the apartment D. Client keeps medication is in a plastic case on the kitchen counter

c

The nurse is caring for a client diagnosed with aids. Which client problem is priority? A. Body image disturbance B. Impaired coping C. Risk for infection D. Self-care deficit

c

The nurse is caring for several clients which client would the nurse assess first after receiving the shift report a. the 22 year old male diagnosed with a concussion who is complaining someone is waking him up every two hours b. the 36 year old female admitted with complaints a left sided weakness who is scheduled for an MRI scan c. a 45 year old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow coma scale score of 6 d. the 62 year old client diagnosed with a cerebral vascular accident who has expressive aphasia

c

The nurse is planning here for the adolescent client being admitted with newly diagnosed active TB secondary to AIDS which intervention is most important for the nurse to plan a. monitor for signs of bleeding b. teach strategies for skin care c. Institute airborne precautions d. assess CD four and T lymphocyte counts

c

The nurse is teaching the client and the family members about protection measures when the client diagnosed with AIDS returns home which instruction indicates that the nurse is unclear about the disease transmission a. disinfect items in your home using a bleach solution of one part bleach to 10 parts water b. place contaminated items except sharps in a plastic bag and then put them in the garbage c. use separate dishes and wash them with hot soapy water or place them in the dishwasher d. wear gloves to clean body fluid spills with soap and water then clean with bleach solution

c

Which action would be most appropriate for the clinic nurse who suspects another staff nurse of stealing narcotics from the clinic a. confront the staff nurse with the suspicion b. call the State Board of nurse examiners c. notify the director of nurses immediately d. report the suspicion to the HCP

c

Which client should the nurse assess first after receiving shift report a. the client diagnosed with a stroke who has right sided paralysis b. the client diagnosed with meningitis who has complaints of photo sensitivity c. the client with a brain tumor who has projectile vomiting d. the client with epilepsy who complains of tender gums

c

Which intervention is an important psychosocial consideration for a client diagnosed with aids? A. Perform a thorough head to toe assessment B. Maintain the clients ideal body weight C. Complete an advance directive D. Increase the clients activity tolerance

c

While assessing a pediatric​ client's laboratory​ results, the nurse notes a high eosinophil count. Which diagnosis should the nurse anticipate based on this laboratory​ result? A. Lyme disease B. Rubella C. Allergies D. Salmonella

c

The nurse admits a client to the hospital who is suspected of having rheumatoid arthritis​ (RA). Which diagnostic test should the nurse expect to be ordered for the​ client? (Select all that​ apply.) A. Antinuclear antibody​ (ANA) test B. Kidney biopsy C. C-reactive protein​ (CRP) levels D. Erythrocyte sedimentation rate​ (ESR) E. Renal function test

c, d

A client reports to the nurse that they have not been feeling well and is concerned about being exposed to HIV. Which assessment finding supports a diagnosis of clinical stage 1​ (acute) HIV​ infection? (Select all that​ apply.) A. Oral hairy leukoplakia B. Ataxia C. Presence of arthralgia and myalgia D. Malaise and​ flu-like symptoms E. CD4+ T-lymphocyte count higher than ​500/mm3

c, d, e

A nurse is caring for a school age child who has a concussion. which of the following manifestations are late indications increased I CP? select all that apply a. reportes of headache b. nausea c. decreased motor response d. increased sleeping e. Brady cardia

c, e

Which signs best indicate increased intracranial pressure in an infant? select all that apply a. Sunken anterior fontanelles b. complaints of blurred vision c. high pitched cry d. increased appetite e. sleeping more than usual

c, e

A client has unexplained weight loss of more than 10% of ideal body weight and voices non-specific complaints of fatigue and nausea over the last six month period. The nurse should place the highest priority on assessing the client for aids when the client makes which statement? A. I had a low-grade fever for the past week B. I had a blood transfusion several years ago after having surgery C. My stools have changed from a brown color to a pale beige color D. I have this odd purple spot that has developed on the tip of my ear

d

A client who has tested positive for HIV now presents with a CD4 count of less than 200 cells per microliter and an invasive cervical cancer how would the nurse evaluate these findings in terms of current CDC definitions? A. Client has seroconverted B. Client continues to remain at HIV positive status C. Client is in a latent period of the disease process D. Client has acquired immunodeficiency syndrome

d

A client with a new diagnosis of HIV infection asks the nurse how to control the disease. Which statement is most accurate regarding HIV management to prevent disease​ progression? A. "You should refrain from having unprotected​ sex." B. "You should obtain routine​ vaccinations." C. "You should eat healthy meals and​ exercise." D. "You should take antiretroviral medications as​ prescribed."

d

A nurse is caring for a client who has undergone craniotomy. which of the following nursing interventions is appropriate for this client a. keep the client in the supine position b. encourage the client to cough and take deep breaths every hour c. encourage the client to perform active range of motion exercises d. use a Glasgow coma scale to monitor the client's mental status

d

A nurse is monitoring a client who is sustained a head injury for signs of increasing intracranial pressure the nurse concludes that which vital sign trends are consistent with increasing ICP a. increase temperature, decrease pulse, increased RR, decrease BP b. Decrease temperature, increased pulse, decreased RR, increased BP c. decreased temp, increase pulse, increase RR, decreased BP d. increased temps, decreased pulse, decreased RR, increased BP

d

A nurse is providing teaching for a client who has HIV. Which of the following statements by the client indicates an understanding of the teaching? A. I will wear gloves while changing the cats litter box B. I will rinse raw fruits with water before eating them C. I will wear a mask when I'm around sick family or friends D. I will cook vegetables before eating them

d

A nurse is reinforcing teaching for a client who has stage to HIV infection and is having difficulty maintaining a normal weight which of the following client statements indicates understanding? A. I will choose a diet high in fat to gain weight B. I will be sure to eat three large meals a day C. I will drink up to 1 L of liquid each day D. I will add high protein foods to my diet

d

A patient with HIV who has been started up on anti-retroviral therapy as seen in the clinic for a follow up. Which test will be the best to monitor when determining the response to therapy? A. CD4 level B. Complete blood count C. Total lymphocyte percent D. Viral load

d

After change of shift report which newly admitted patient should the nurse see first? A. A patient with HIV who's CD4 count is 45 cells per microliter B. A patient with acute kidney transplant rejection who has a scheduled dose of prednisone due C. A patient with graft versus host disease who has frequent liquid stools D. A patient with hypertension who has angioedema after receiving lisinopril

d

Patient seen in the sexually transmitted disease clinic has just had a positive for HIV with the rapid HIV test. Which action will the nurse take first? A. Ask about patient risk factors for HIV infection capital B. Send a blood specimen for Western blot test C. Provide information about anti-retroviral therapy D. Discuss the positive test results with the patient

d

The 24 year old client diagnosed with a traumatic brain injury is being transferred to a rehab unit. which HCP order should the nurse question a. physical therapy to work on lower extremities daily b. occupational therapy to work on cognitive functioning BID c. a soft diet with mechanical ground meats and thickening agents in fluid d. Methylprednisolone IVP q 6h

d

The client is admitted to the medical floor with a diagnosis of closed head injury which nursing intervention has priority a. assess neurological status b. monitor pulse, respiration, and BP c. initiate an intravenous access d. maintain an adequate airway

d

The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority? 1. Altered nutrition, less than body requirements. 2. Anticipatory grieving. 3. Knowledge deficit, procedures and prognosis. 4. Risk for injury.

d

The client recently diagnosed with rheumatoid arthritis is prescribed aspirin, and nonsteroidal anti-inflammatory medicine. Which comment by the client warrants in immediate intervention by the nurse? A. I always take the aspirin with food B. If I have dark stools, I will call my healthcare provider C. Aspirin will not cure my arthritis D. I am having some ringing in my ears

d

The clinic nurse reads the patients Mantoux test as positive what does a positive Mantoux test indicate a. The patient is immune to TB b. the induration is at least 2 millimeters c. the patient has an active case of TB d. the patient has been exposed to the mycobacterium tuberculosis

d

The high school student is crying and says to the school nurse I had unprotected sex last week with someone who has been doing IV drugs now Im scared I might have HIV which is a nurses best initial response a. dont worry Im sure one incidence of unprotected sex will not cause you to contract HIV b. you need to have a blood test immediately to test for the presence of HIV antigens c. have you talked to your parents about this so you can go in and get tested for HIV d. youre frightened because you think your actions may have caused you to contract HIV

d

The most important reason health care providers prescribe a combination of antiviral drugs to children with HIV is to delay a. progression to AIDS b. enable treatment of multiple symptoms c. recurrence of symptoms d. drug resistance

d

The mother of an unconscious child has been calling her name repeatedly and gently shaking her shoulders in an attempt to wake her up. the nurse notes that the child is flexing her arms and wrists while bringing her arms closer to the midline of the body. the childs mother asks what is going on selected nurses best response a. I think your daughter she is attempting to reach out for you b. your child is responding to you please continue trying to stimulate her c. it appears that your child is having a seizure d. your child is demonstrating a reflex that indicates she is overwhelmed with stimulation shes receiving

d

The nurse is assessing the client following a closed head injury. when applying nail bed pressure the clients body suddenly stiffens, the eyes roll upward and there is an increase in Salvation and loss of swallowing reflex which observation should the nurse document a. decerebrate posturing observed b. decorticate posturing observed c. positive Kernig sign observed d. seizure activity observed

d

The nurse is caring for a client with increased ICP. Which statement by the UAP would require immediate intervention by the nurse a. I will raise the head of the bed so it is easier to see the television b. I will turn down the lights when I leave c. let me move your belongings closer so you can reach them d. you should do deep breathing and coughing exercises

d

The nurse is enjoying a day at the Lake and witnesses a water skier hit the boat ramp the water skier is in the water not responding to verbal stimuli. the nurse is the first health care provider to respond to the accident. which intervention should be implemented first a. assess a clients level of consciousness b. organize onlookers to remove the client from the Lake c. perform a head to toe assessment to determine injuries d. stabilizer client cervical spine

d

The nurse is providing post-mortem care to a patient diagnosed with and treated for tuberculosis. Which action by the nurse is most appropriate? a. Wait 60 minutes until the room has been decontaminated b. wait 45 minutes until the room has been decontaminated c. Don a gown mask eye protection and gloves before entering the room d. Don a gown respirator eye protection and gloves before entering the room

d

The nurse is teaching colleagues about nonspecific immune responses. Which response should the nurse exclude from the​ presentation? A. Mucus B. Skin C. Body fluids D. Antigens

d

The nurse is working with the LPN who is caring for the HIV positive client with severe esophagitis caused by candida albicans. which action by the LPN requires the nurse to intervene immediately HIV 10 a. suggests that the client might like to order chili con carne for the next meal b. place a no visitor sign on the door of the room at the clients request c. performs hand hygiene and puts on a mask and gown before entering the clients room d. give the client a glass of water after administration of nystatin and oral suspension

d

The nurse obtained this information when assessing a patient with HIV who is taking anti-retroviral therapy. Which finding is most important to report to the HCP? A. The blood glucose is 144 B. The hemoglobin is 10.9 C. The patient reports frequent nausea D. The patient's viral load has increased

d

The nurse provides care for a client diagnosed with AIDS. client is now in the advanced stage of the disease in reports severe diarrhea. dinners intervenes if the client makes which statement a. I will eat cooked canned fruits or vegetables b. I will eat high potassium foods such as bananas c. I will drink plenty of fluids between meals d. I will take him liquid nutritional supplement at least twice a day

d

The school nurse is preparing to teach her health class tonight graders regarding sexually transmitted diseases. Which information regarding aids should be included? A. Female taking birth control are protected from becoming infected with IV B. Protected sex is no longer an issue because there is a vaccine for the HIV virus C. Adolescence with a normal immune system are not at risk for developing aids D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV

d

Which client would the nurse exclude from being a potential organ/tissue donor? A. The 60-year-old female with an in operable primary brain tumor B. The 45-year-old female with a subarachnoid hemorrhage C. The 22-year-old male client who has been in a motor vehicle accident D. The 36-year-old male client recently released from prison

d

Which intervention has the highest priority when caring for a client with rheumatoid arthritis? A. Encourage the client of ventilate feelings about the disease process B. Discuss the effects of disease on the clients career and other life roles C. Instruct the client to perform most important activities in the morning D. Teach the client proper use of hot and cold therapy to provide pain relief

d

Which medical record should indicate to the nurse that the client has converted from being HIV positive to having fully contracted​ AIDS? A. Weight loss of​ 5% of total body weight B. Herpes zoster infection C. CD4 count of ​400/mm3 D. Pneumocystis jiroveci pneumonia

d

Which of the following is the most common opportunistic infection in children infected with HIV a. CMV b. encephalitis c. meningitis d. pneumocystis pneumonia

d

Which of the following lab tests will be ordered to determine the presence of the HIV antigen in an infant whose mother is HIV positive a. CD4 cell count b. western blot c. IgG levels d. P 24 antigen assay

d

Which statement made by a​ 34-week pregnant client who is HIV positive indicates a need for further​ teaching? A. "I will enter the hospital in a month for a planned cesarean​ section." B. "My newborn baby will begin treatment with zidovudine after​ birth." C. "If I follow the treatment​ regimen, my baby may not develop HIV​ infection." D. "I plan to breastfeed my baby to save money on infant​ formula."

d

The nurse is instructing the parent of a child with HIV about immunizations which of the following should the nurse tell the parents. Select all that apply a. hepatitis B vaccine will not be given to this child b. members of the family should be cautioned not to receive the varicella vaccine c. the child will need to have a western blot done prior to all immunizations d. pneumococcal and influenza vaccines are recommended e. meningitis immunization

d, e