520 Exam 4

A clinic nurse is caring for a client admitted with AIDS. The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication?

HIV encephalopathy

While undergoing a kidney transplant from a non-family member, the client's transplanted kidney has just had the arterial clamps removed. The OR staff notices that the organ is turning purple with no urine output. When explaining to the family why they had to remove the donor kidney, the nurse will anticipate that the surgeon would likely include which statement?

Hyperacute rejection occurs because antibodies against HLA antigens are deposited in vessels, causing necrosis.

A 60-year-old patient with rheumatoid arthritis visits the health care facility for a regular checkup. The patient informs the nurse that the patient has been using an over-the-counter NSAID for the last few days. Why should the nurse caution the patient against the use of NSAIDs on a long-term basis?

Increased risk of GI bleeding

A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA?

Joint stiffness, especially in the morning

While caring for a patient with pneumocystis pneumonia, the nurse assesses flat, purplish lesions on the back and trunk. What does the nurse suspect these lesions indicate?

Kaposi's sarcoma

A client who has been brought to the ED is unresponsive, and has an elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. The client's labs show an elevated white blood cell count; cultures are forthcoming. What does the nurse suspect may be the cause of the client's present condition?

septic shock

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient?

Disseminated intravascular coagulation (DIC)

A pregnant client who is HIV positive asks the nurse if she will be able to breastfeed the newborn. Which response by the nurse is most appropriate?

"Breastfeeding will increase your newborn's risk of contracting HIV."

A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse?

"It is important that you continue to take your medication to avoid an acute exacerbation."

A client with early stage rheumatoid arthritis asks the nurse what to do to help ease the symptoms of the disease. What would be the best response by the nurse?

"The health care provider could prescribe anti-inflammatory drugs."

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

Alteration in level of consciousness (LOC)

The nurse is monitoring the labs of a child admitted for an exacerbation of juvenile pauciarticular arthritis. Which lab result does the nurse expect to be elevated?

Erythrocyte sedimentation rate (ESR)

A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which of the following complications of therapy?

Immunosuppression

The nurse is required to manage and minimize sepsis in a client with severe infection. Which would be an appropriate nursing intervention?

Monitor the client's vital signs.

A client with human immunodeficiency virus (HIV) develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this client?

Pneumocystis pneumonia

When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?

Risk for infection related to altered immune cell function

An infant has been born to a client who is HIV positive. What is the infant's most likely prognosis for developing AIDS?

The infant can be HIV antibody positive by ELISA for up to 18 months of age without being actively infected with HIV.

A nurse practitioner is explaining the current methods of detection of HIV to a community group. In explaining the definitive method of detection, which statement is most accurate?

The most sensitive and specific test is the Western blot analysis.

Which are realistic goals for HIV clients being treated with highly active antiretroviral therapy (HAART)? Select all that apply.

Undetectable viral load Suspension of HIV replication Slower progression to AIDS Increased CD4+ count

A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test?

Western blot assay

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

platelet count, prothrombin time, and partial thromboplastin time

As the nurse is performing a physical assessment of a client, the client begins to have seizure activity including loss of consciousness and limb jerking. The nurse's priority is to:

protect the client from injury.

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the heatlchare provider (HCP) immediately?

urine output of 20 ml/hour

Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury?

Altered level of consciousness

Which clients would have a confirmed diagnosis of AIDS? Select all that apply.

An HIV-positive client with a CD4+ count of 300 cells/μL and wasting syndrome An HIV-positive client with a CD4+ count of 100 cells/μL with pulmonary tuberculosis

The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)?

Assess the client's eye opening and response to stimuli.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is:

Blood pressure.

Which of these is an AIDS-defining condition?

CD4+ count less than 200 cells/μL

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find?

Elevated erythrocyte sedimentation rate

The nurse is teaching a male client who has been diagnosed as HIV positive. The client asks what precautions he should take to prevent his family members from contracting HIV. Which statement will the nurse include in teaching this client?

Family members should not come in contact with your blood.

The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply.

Motor function Cognition Level of consciousness Sensory function

The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?

Observe for any signs of behavioral changes.

A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions?

Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens.

A client is diagnosed with human immunodeficiency virus (HIV). What information does the nurse provide to best protect the client from advancing to the acquired autoimmodeficiency syndrome (AIDS) phase of this infection?

Strictly adhere to antiviral medication therapy.

A 30-year-old male knows that he contracted HIV a month ago. Place the following steps in the order of the progression of the disease, starting with what he could expect first if he does not receive treatment.

There is a rapid increase in viral replication, which leads to very high viral loads. Viral symptoms such as fatigue, lymphadenopathy, headaches, and gastrointestinal disturbances and the CD4+ T-cell count begins to fall. There is a period (up to 10 years) of being symptom-free as CD4+ T cells decrease. CD4+ T-cell count is 200 cells/μL, confirming the diagnosis of AIDS. The risk of opportunist infection is highest. Death

You are teaching a health class in the local public health center. What instructions should you provide as the single most important measure to prevent the spread of infection?

Thorough hand washing

A client who has been exposed to the human immunodeficiency virus (HIV) tests negative. Which explanation by the nurse would be most appropriate?

Your body may not have developed antibodies yet, so we need to follow up."

When counseling a male client with suspected HIV, the nurse informs him that if the enzyme-linked immunosorbent assay (ELISA) comes back positive, then:

a second test known as the Western blot assay will be ordered to confirm positive HIV status.

A client was admitted to the hospital unit with an elevated leukocyte count and a fever accompanied by warm, flushed skin. These symptoms suggest that the client has:

an overwhelming bacterial infection.