Stroke, Intracranial Pressure, Increased Intracranial Pressure, HIV, Conflict Resolution

A client with human immunodeficiency virus (HIV) infection develops HIV-induced dementia. The client asks the nurse to aid in dealing with issues about death and dying. What is the most appropriate nursing diagnosis for this client? A. Grieving related to personal losses and potential loss of life B. Disturbed thought processes related to HIV-induced dementia C. Disturbed body image related to weight loss D. Anxiety related to changes in body images

A All the options may be appropriate for a client with HIV-induced dementia, but the only nursing diagnosis that addresses the client's request for assistance in dealing with death and dying is Grieving related to personal losses and potential loss of life.

The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be see first? A. The client who has flushed, warm skin with tented turgor B. The client who states the staff ignores the call light C. The client whose vital signs are T 99.9, P 101, R 26, and BP 110/68 D. The client who is unable to provide a sputum specimen

A Flushed warm skin with tented turgor indicated dehydration. The HCP should be notified immediately for fluid orders or other orders to correct the reason for the dehydration.

Which respiratory pattern indicates increasing intracranial pressure in the brain stem? A. Slow, irregular respirations B. Rapid, shallow respirations C. Asymmetric chest excursion D. Nasal flaring

A Neural control of respiration takes place in the brain stem. Deterioration and pressure produce slow and irregular respirations.

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

A Pneumocystis pneumonia (PCP) occurs in approximately 75% to 80% of clients diagnosed with AIDS. Signs/symptoms of it include fever, cough, and shortness of breath.

A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? A. Position the client sitting up in bed before he or she is fed. B. Check the client's gag and swallowing reflexes C. Feed the client quickly because there are three more clients to feed D. Suction the client's secretions between bites of food

A Positioning the client in a sitting position decreases the risk of aspiration.

A client who had a stroke needs to be fed. What instruction should you give to the UAP who will feed the client? A. Position the client sitting up in bed before you feed him B. Check the client's gag and swallowing reflexes C. Feed the client quickly, because there are three more you must feed D. Suction the client's secretions between bites of food

A Positioning the client in a sitting position decreases the risk of aspiration.

The client being admitted with transient ischemic attack is complaining of a headache. The client is allergic to morphine, iodine, and codeine. Which healthcare provider order should the nurse question? A. Schedule for CT scan with contrast in a.m. B. Administer acetaminophen 2 PO for headache C. Take client's vital signs per protocol D. Provide the client with a low-fat, low-cholesterol diet

A The client is allergic to iodine; therefore, the client cannot have the CT scan with contrast because it is iodine. The nurse should question this HCP order.

An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? A. Establish an airway B. Determine the identity of the client C. Stop bleeding from open wounds D. Check for neck fracture

A The highest priority for a client with multiple head and neck injuries is to establish an open airway for effective ventilation and oxygenation.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. An oral anticoagulant medication B. A beta blocker medication C. An anti-hyperuricemic medication D. A thrombolytic medication

A The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he has had a cough along with nausea and diarrhea. His temperature is 38.1 C orally. The client is afraid he has HIV. Which of the following actions should the nurse take? (Select all that apply) A. Perform a physical assessment B. Determine when manifestations began C. Teach the client about HIV transmission D. Draw blood for HIV testing E. Obtain a sexual history

A,B,E The nurse should perform a physical assessment to gather data about the client's condition, gather more data to determine whether the manifestations are acute or chronic, obtain a sexual history to determine how the virus was transmitted.

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? (Select all that apply) A. Systolic blood pressure B. Urine output C. Breath sounds D. Cerebral perfusion pressure E. Level of pain

A,D The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP.

Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? A. Place the client's feet against a firm footboard B. Reposition the client every 2 hours C. Have the client wear ankle-high tennis shoes at intervals throughout the day D. Massage the client's feet and ankles regularly

C The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion because they add support to the foot and keep in in the correct anatomic position.

The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? A. The client will return to work within six (6) months B. The client is able to focus and stay on task for 10 minutes C. The client will be able to dress self without assistance D. The client will regain bowel and bladder control

B "Cognitive" pertains to mental processes of comprehension, judgement, memory, and reasoning. Therefore, an appropriate goal would be for the client to stay on task for 10 minutes.

The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? A. Schedule a STAT magnetic Resonance Imaging of the brain B. Call a Code STROKE C. Notify the health-care provider (HCP) D. Have the client swallow a glass of water

B A Code STROKE has been instituted in most facilities to have personnel to respond so that there is no delay in initiating interventions, thus reducing the impact of a cerebrovascular accident (stroke) on a client.

The ambulance brings the client with a head injury to the emergency department. The client responds to painful stimuli by opening the eyes, muttering, and pulling away from the nurse. How would the nurse rate this client on the Glasgow Coma Scale? A. 3 B. 8 C. 10 D. 15

B A score of 8 indicates severe increased intracranial pressure, but with appropriate care the client may survive. The nurse would rate the client at an 8: 1 for opening the eyes; 3 for verbal responses; and 4 for motor response.

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring? A. Muscle relaxation B. Intake and output C. Widening of the pulse pressure D. Pupil dilation

B After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain.

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

B Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia.

A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2+V3+M5=10 B. E3+V4+M4=11 C. E4+V5+M6=15 D. E2+V2+M4=8

B The client's score is calculated correctly, indicating moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain.

You are working in an AIDS hospice facility that is also staffed with LPNs and UAPs. Which nursing action will you delegate to the LPN you are supervising? A. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition B. Collecting data about the patients' responses to medication used for pain and anorexia C. Teaching the UAPs about how to lower the risk for spreading infections D. Assisting patients with personal hygiene and other activities of daily living as needed

B The collection of data used to evaluate the therapeutic and adverse effects of medications is included in LPN education and scope of practice.

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? A. Hemiparesis of the client's left arm and apraxia B. Paralysis of the right side of the body and ataxia C. Homonymous hemianopsia and diplopia D. Impulsive behavior and hostility toward family

B The most common motor dysfunction of a CVA is paralysis of one side of the body, hemmiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection. In planning the client's care, the nurse should focus on his need for: A. Pain management B. Fluid replacement C. Antiretroviral therapy D. High-calorie nutrition

B The protozoal enteric infection caused by Cryptosporidium organisms results in profuse watery diarrhea. Because diarrhea will lead to dehydration, the nurse should focus on fluid replacement.

The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department? A. A 4-cm are of bright red drainage on the dressing B. A weak pulse, shallow respirations, and cool pale skin C. Pupils that are equal, react to light, and accommodate D. Complaints of a headache that resolves with medication

B These signs/symptoms - weak pulse, shallow respirations, cool pale skin - indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.

A client has right hemiparesis following a stroke. When creating a care plan for this client, which nursing intervention should take the highest priority? A. Perform passive range-of-motion (ROM) exercises B. Assess pharyngeal reflexes before meals C. Use hand rolls or pillows for support D. Apply antiembolism stockings

B To help prevent airway obstruction and reduce the risk of aspiration, the nurse should assess for pharyngeal reflexes before offering food or fluids.

A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply) A. Suction the endotracheal tube frequently B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows D. Administer a stool softener E. Keep the client well hydrated

B,D Decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP. Administration of a stool softener will decrease the need to bear down during bowel movements, which can increase ICP.

The nurse is caring for a client newly diagnosed with 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. "My sexual practices will have to change" B. "I am afraid that I will give this disease to my nephew" C. "The disease can also be spread by body fluids" D. "I could pass this on to a baby before I give birth" E. "I will have this for the rest of my life" F. "Medications can cure the disease"

B,F 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 and the disease can be spread by body fluids and can also be passed on to a fetus.

A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "I will wear gloves while changing the pet litter box." B. "I will rinse raw fruits with water before eating them." C. "I will wear a mask when around family members who are ill." D. "I will cook vegetables before eating them."

D A client who has AIDS should cook vegetables before eating to kill bacteria that cause opportunistic infections.

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? A. Observe the client swallowing for possible aspiration B. Position the client in a semi-Fowler's position when sleeping C. Place a suction setup at the client's bedside during meals D. Refer the client to an occupational therapist for evaluation

D A collaborative intervention is an intervention in which another health-care discipline - in this case, occupational therapy - is used in the care of the client.

A patient seen in the sexually-transmitted disease clinic has just tested positive for HIV with a rapid HIV test. Which action will you take next? A. Ask about patient risk factors for HIV infections B. Send a blood specimen for Western blot testing C. Provide information about antiretroviral therapy D. Discuss the positive test results with the patient

D A major purpose of HIV testing for asymptomatic patients is to ensure that HIV-positive individuals are aware of their HIV status, take actions to prevent HIV transmission, and effectively treat the HIV infection.

The intensive care unit nurse is admitting a client with a traumatic brain injury. Which health-care provider medication order would the nurse question? A. Dexamethasone B. 0.9% NS C. Nicotine patch D. Morphine sulfate

D A narcotic analgesic is contraindicated until it is known that the client is neurologically stable. Narcotics, especially intravenous, can mask signs and symptoms of deterioration of the client's status.

A patient with human immunodeficiency virus (HIV) who has been started on antiretroviral therapy is seen in the clinic for follow-up. Which test will be best to monitor when determining the response to therapy? A. CD4 level B. Complete blood count C. Total lymphocyte percent D. Viral load

D Viral load testing measure the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the antiretroviral therapy is effective.

A client has delirium following a head injury. The client is disoriented and agitated. In which order form first to last should the nurse initiate care for this client? All options must be used A. Request a prescription for haloperidol B. Maintain a quiet environment C. Assure the client's safety D. Approach the client using short sentences

D,C,B,A The first step in providing care for a client with delirium is to approach the client calmly, introduce oneself, and use shout sentences when explaining the care given. The nurse should also assure the client's safety by protecting the client from injury. Maintaining a quiet and calm environment by removing extraneous noises will prevent overstimulation. Pharmacologic intervention is used only when other plans for care are not effective.

A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA) B. Discuss the precipitating factors that caused the symptoms C. Schedule for a STAT computed tomography (CT) scan of the head D. Notify the speech pathologist for an emergency consult

C A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or an ischemic accident and guide treatment.

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception

C A client who experienced a left-hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia.

A nurse is collecting data from a client who has suspected HIV-associated muscle wasting. Which of the following findings supports this diagnosis? A. BMI 26 B. Fecal impaction C. Report of fever for 30 days D. Report of high alcohol consumption

C A client who has HIV-associated muscle wasting will report elevated temperature of over 30 days duration.

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? A. Sit quietly with the client until the episode is over B. Ignore the behavior C. Attempt to divert the client's attention D. Tell the client that this behavior is unacceptable

C A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention.

The client diagnosed with a cerebrovascular accident (CVA) is confined to a wheelchair for most of the waking hours. Which intervention is priority for the nurse to implement? A. Encourage the client to move the buttocks every 2 hours B. Order a high-protein diet to prevent skin breakdown C. Get a pressure-relieving cushion to place in the wheelchair D. Refer the client to physical therapy for transfer teaching

C All clients remaining in a wheelchair for extended periods of time should have a wheelchair cushion that relieves pressure to prevent skin breakdown.

You are providing care for a client with an acute hemorrhagic stroke. The client's spouse tells you that he has been reading a lot about strokes and asks why his wife has not received alteplase (Activase). What is your best response? A. "Your wife was not admitted within the time from that alteplase is usually given." B. "This drug is used primarily for clients who experience an acute heart attack." C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." D. "Your wife had gallbladder surgery just 6 months ago, and this prevents the use of alteplase."

C Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug such as alteplase can worsen the bleeding.

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? A. "Your wife was not admitted within the time frame that alteplase is usually given." B. "This drug is used primarily for clients who experience an acute heart attack." C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." D. "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase."

C Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug, such as alteplase, dissolves the clot and can cause more bleeding in the brain.

A client with human immunodeficiency virus infection undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days after the tests, there's no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is that the: A. Client has no previous exposure to the antigens injected B. Results demonstrate that the client has antibodies to the antigens C. Client is immunodeficient and won't have a skin response D. Client isn't allergic to the antigens and therefore doesn't react

C Anergy testing determines the level of immune response an individual has to common microbes. A normal response is a local skin reaction to all the antigens injected intradermally. Absence of a response within 3 days suggests that the individual is immunodeficient and can't produce a normal immune response.

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

C Clients diagnosed with AIDS should be encouraged to discuss their end-of-life issue with the significant others and to put those wishes in writing. This is important for all clients, not just those diagnosed with AIDS.

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

C Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy.

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? A. Deep breathing B. Turning C. Coughing D. Passive range-of-motion (ROM) exercises

C Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP.

The client with acquired immunodeficiency syndrome (AIDS) dementia is referred to hospice. Which intervention has highest priority when caring for the client in the home? A. Assess the client's social support network B. Identify the client's usual coping methods C. Have consistent uninterrupted time with the client D. Discuss and complete an advance directive

C Developing a therapeutic relationship with the client is priority because the client probably has less than six months to live. All the other interventions can be implemented, but establishing a therapeutic relationship will allow the nurse to discuss and implement additional interventions.

Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding techniques will be most helpful at this time? A. Encourage sipping diluted liquid meal supplements from a straw B. Position the client with the bed at a 30-degree angle C. Offer solid foods from the unaffected side of the mouth D. Feed the client a soft diet from a spoon into the left side of the mouth

C Following a stroke, it is easiest for clients with dysphagia to swallow solid foods;the nurses introduces foods on the unaffected side.

A nurse is teaching high school students about human immunodeficiency virus (HIV) transmission. Which comment by a student requires clarification by the nurse? A. "A man should wear a latex condom during intimate sexual contact." B. "I've heard about people who've developed acquired immunodeficiency syndrome (AIDS) after receiving a blood transfusion." C. "I won't donate blood because I don't want to get AIDS." D. "I.V. drug users can get HIV from sharing needles."

C HIV is transmitted through infected blood, semen, and certain other body fluids. Although transfusion with infected blood can cause HIV infection in the recipient, blood donation can't cause it.

A nurse is working with a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress? A. Avoid the use of recreational drugs and alcohol B. Refrain from informing anyone about the diagnosis C. Follow safe-sex practices D. Tell potential sex partners about the diagnosis, as required by law

C It's essential that clients with AIDS follow safe-sex practices to prevent transmission of the human immunodeficiency virus (HIV).

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery for removal of a brain tumor. Which finding would indicate that the drug is producing its therapeutic effect? A. Decreased level of consciousness (LOC) B. Elevated blood pressure C. Increases urine output D. Decreased heart rate

C Mannitol is given to reduce intracranial pressure. The therapeutic effect of mannitol is diuresis, which is confirmed by increased urine output.

A client has an increased intracranial pressure (ICP) of 20 mm Hg. The nurse should: A. Give the client a warming blanket B. Administer low-dose barbiturates C. Encourage the client to take deep breaths to hyperventilate D. Restrict fluids

C Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg.

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? A. Providing passive range-of-motion exercises to the left extremities during the bed bath B. Elevating the foot of the bed to reduce edema C. Pulling up the client under the left shoulder when getting the client out of bed to a chair D. Putting high top tennis shoes on the client after bathing

C Pulling the client up under the arm can cause shoulder displacement.

The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first? A. Set the ventilator to hyperventilate the client in preparation for suctioning B. Assess the client's lung sounds and check for peripheral cyanosis C. Turn the client to the side to allow the secretions to drain from the mouth D. Suction the client using the in-line suction, wait 30 sections, and repeat

C Secretions can drain if the client is turned to the side unless the secretions are too heavy. The first action is to attempt to relieve the situation without increasing the ICP even further.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? A. Encourage coughing and deep breathing B. Position the client with his head turned toward the side of the brain tumor C. Administer stool softeners D. Provide sensory stimulation

C Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return.

A client arrives in the emergency department with an ischemic stroke. Because the healthcare team is considering administering tissue plasminogen activator (t-PA) administration, the nurse should first: A. Ask what medications the client is taking B. Complete a history and health assessment C. Identify the time of onset of the stroke D. Determine if the client is scheduled for an surgical procedures

C Studies show that client who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical.

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 client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours B. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6 D. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia

C The Glasgow Coma Scale is used to determine a client's response to stimuli secondary to a neurological problem; scores range from 3 to 15. A client with a score of 6 should be assessed first by the nurse.

A client who hit his head after falling from his roof has a Glasgow Coma Scale score of 15. Based on this information, the nurse expects the client to be: A. comatose B. confused C. alert and oriented D. unable to open his eyes

C The Glasgow Coma Scale measures a client's response in three categories: best eye-opening response, best verbal response, and best motor response. Fifteen is the highest score possible on the Glasgow Coma Scale and indicates that the client is alert and oriented.

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

C The basic problem with a client diagnosed with AIDS is that the immune system is not functioning normally. This increases the risk for infection. This is the priority client problem.

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? A. Compress the nares B. Tilt the head back C. Collect the drainage D. Administer an antihistamine for postnasal drip

C The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF).

The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do? A. Attempt to arouse the client B. Reposition the client with the extremities in normal alignment C. Chart the client's level of consciousness as coma D. Notify the healthcare provider (HCP)

C The client has a score of 6; a score <7 is indicative of coma.

The male client is in the emergency department after a fall, resulting in a closed head injury. The admitting nurse notes the client responds by opening his eyes and pushing the nurse's arm away when painful stimuli is applied, but does not make any verbal response which rating on the Glasgow Coma Scale should be documented by the nurse? A. Client scored a 12 on the GCS B. Client scored a 10 on the GCS C. Client scored an 8 on the GCS D. Client scored a 6 on the GCS

C The client received 2 points for lack of opening of eyes to previous stimuli but opens to pain; the client receives 1 point for lack of sound even with painful stimuli; 5 points for localizing pain, attempts to remove offending stimulus. This is a total of 8 points.

The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead? A. When the client's head is turned to the right, the eyes turn to the right B. The electroencephalogram (EEG) has identifiable waveforms C. No eye activity is observed when the cold caloric test is performed D. The client assumes decorticate posturing when painful stimuli are applied

C The cold caloric test, also called the oculovestibular test, is a test used to determine if the brain is intact or dead. No eye activity indicates brain death. If the client's eyes moved, that would indicate that the brainstem is intact.

The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this 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 health-care team should meet to discuss ways to best help the client deal with the anger being expressed, and the staff should be consistent in working with the client.

A nurse is preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to the home. Which instruction should the nurse be sure to include? A. Apply disposable gloves before showering B. Sterilize all plates and utensils in boiling water C. Avoid sharing such articles as toothbrushes and razors D. Avoid eating foods from serving dishes shared by other family members

C The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in blood. For this reason, the client shouldn't share personal articles that may be contaminated with blood, such as toothbrushes and razors.

The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? A. Notify the health-care provider immediately B. Prepare to administer an antihistamine C. Test the drainage for presence of glucose D. Place a 2x2 gauze under the nose to collect drainage

C The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid, and the HCP should be notified immediately once this is determined.

The client who has engaged in needle-sharing activities has developed a flu-like infection. An 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 the primary infection phase of an HIV infection D. The antibody test is negative because the client has a different flu virus

C The primary phase of infection ranges from being asymptomatic to severe flu-like symptoms, but during this time, the test may be negative although the individual is infected with HIV.

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. The assistant places a gait belt around the client's waist prior to ambulating B. The assistant places the client on the back with the client's head to the side C. The assistant places a hand under the client's right axilla to move up in bed D. The assistant praises the client for attempting to perform ADLs independently

C This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

A client diagnosed with AIDS dementia is angry and yells at everyone entering the room. None of the critical care staff want 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 the client's 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 This would be the most appropriate intervention because it allows the staff to have input into resolving the situation, then there is ownership of the problem.

What is the expected outcome of thrombolytic drug therapy for stroke? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage

C Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 B. A right-sided carotid bruit C. A blood pressure of 220/120 D. The presence of bronchogenic carcinoma

C Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

C Using the airway, breathing, and circulation priority-setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 min before permanent damage occurs.

The nurse is caring for clients on a medical unit. Which client would be most at risk for experiencing a stroke? A. A 92-year-old client who is an alcoholic B. A 54-year-old client diagnosed with hepatitis C. A 60-year-old client who has a Greenfield filter D. A 68-year-old client with chronic atrial fibrillation

D A client with atrial fibrillation is at high risk to have a stroke and is usually given oral anticoagulants to prevent a stroke.

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the healthcare provider (HCP) about which early change in the client's condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupils D. Decrease in level of consciousness (LOC)

D A decrease in the client's LOC is an early indication of deterioration of the client's neurologic status.

A patient seen in the sexually transmitted disease clinic has just tested positive for human immunodeficiency virus (HIV) with a rapid HIV test. Which action will the nurse take next? A. Ask the patient risk factors for HIV infections B. Send a blood specimen for Western blot testing C. Provide information about antiretroviral therapy D. Discuss the positive test results with the patient

D A major purpose of HIV testing for asymptomatic patients is to ensure that HIV-positive individuals are aware of their HIV status, take actions to prevent HIV transmission, and effectively treat the HIV infection.

The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? A. Females taking birth control pulls are protected from becoming infected with HIV B. Protected sex is no longer an issue because there is a vaccine for the HIV virus C. Adolescents 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 Abstinence is the only guarantee the client will not contract a sexually transmitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relationship is the safest sexual relationship.

A client recently suffered a stroke and has temporal lobe deficits. When communicating with a client who has sensory (receptive) aphasia, the nurse should: A. Allow time for the client to respond B. Speak loudly and articulate clearly C. Give the client a writing pad D. Use short, simple sentences

D Although a client with receptive aphasia can hear words, he or she has difficulty comprehending their meaning. Therefore, the nurse should use short, simple sentences to promote comprehension.

The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first? A. Administer the medication in pudding B. Check the client's armband C. Crush the tablet and dissolve in juice D. Have the client sip some water

D Asking the client to sip some water assesses the client's ability to swallow, which is a priority when placing anything in the mouth of the client who has had a stroke.

After change-of-shift report, which newly admitted patient should the nurse assess first? A. A patient with human immunodeficiency virus (HIV) whose CD4 count is 45 B. A patient with acute kidney transplant rejection who has a scheduled dose of prednisone due C. A patient with graft0verus-host disease who has frequent liquid stools D. A patient with hypertension who has angioedema after receiving lisinopril

D Because angioedema may cause airway obstruction, this patient should be assessed for any difficulty breathing, and treatment should be started immediately.

The client diagnosed with a right-sided cerebrovascular accident (CVA) is complaining of a severe headache. Which intervention should Elizabeth implement first? A. Administer acetaminophen, a narcotic analgesic B. Prepare for STAT computed tomography (CT) scan C. Notify the client's healthcare provider D. Assess the client's neurological status

D Elizabeth must first assess the client to determine whether the client's neurological status is deteriorating, which requires notifying the HCP; or, if the headache is expected, then it would require a narcotic analgesic.

During a late stage of acquired immunodeficiency syndrome (AIDS), a client demonstrates signs of AIDS-related dementia. The nurse should give the highest priority to which nursing diagnosis? A. Bathing self-care deficit B. Ineffective tissue perfusion C. Grieving D. Risk for injury

D In a client with AIDS, deterioration of the central nervous system (CNS) can lead to AIDS-related dementia. Because the type of dementia impairs cognition and judgement, it places the client at risk for injury.

During a late stage of acquired immunodeficiency syndrome (AIDS), a client demonstrates signs of AIDS-related dementia. Which nursing diagnosis should receive the highest priority? A. Bathing self-care deficit B. Risk for ineffective cerebral tissue perfusion C. Complicated grieving D. Risk for injury

D In a client with AIDS, deterioration of the central nervous system (CNS) can lead to AIDS-related dementia. Because this type of dementia impairs cognition and judgement, it places the client at risk for injury.

You are evaluating an HIV-positive patient who is receiving IV pentamidine (Pentam) as a treatment for Pneumocystis jiroveci (PCP) pneumonia. Which information is most important to communicate to the physician? A. The patient is reporting pain at the site of the infusion B. The patient is not taking in an adequate amount of oral fluids C. Blood pressure is 104/76 after pentamidine administration D. Blood glucose level is 55 after medication administration

D Pentamidine can cause fatal hypoglycemia, so the low blood glucose level indicates a need for a change in therapy.

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? A. Obtain a rubber mat to place under the dinner plate B. Purchase a long-handled bath sponge for showering C. Purchase clothes with Velco closure devices D. Obtain a raised toilet seat for the client's bathroom

D Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

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

D Safety is always an issue with a client with diminished mental capacity.

Which type of isolation techniques is designed to decrease the risk of transmission of recognized and unrecognized sources of infections? A. Contact precautions B. Airborne precautions C. Droplet precautions D. Standard precautions

D Standard precautions are used for all contact with blood and body secretions.

After experiencing a transient ischemic attack (TIA), a client is prescribed aspirin, 81 mg by mouth daily. The nurse should teach the client that this medication has been prescribed to: A. Control headache pain B. Enhance immune response C. Prevent intracranial bleeding D. Decrease platelet aggregation

D TIAs are considered forerunners of stroke. Because strokes may result from clots in cerebral vessels, aspirin is prescribed to prevent clot formation by reducing platelet aggregation.

The nurse is performing a Glasgow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client's GCS one (1) hour ago was scored at 10. Which datum indicated the client is improving? A. The current GCS rating is 3 B. The current GCS rating is 9 C. The current GCS rating is 10 D. The current GCS rating is 12

D The GCS rating is going up. which means the client is improving.

A client was injured in a motor vehicle accident. He hasn't regained consciousness since being hospitalized. The nurse's neurologic assessment includes determining level of consciousness using the Glasgow Coma Scale. The client briefly opens his eyes in response to painful stimulus, but he doesn't verbally respond to the nurse. The client demonstrates decorticate posturing. The client doesn't attempt to move his arms and legs away from painful stimulus. What is this client's Glasgow Coma Scale score? A. 3 B. 4 C. 5 D. 6

D The Glasgow Coma Scale score for this client is 6, the client doesn't respond verbally and opens his eyes in response to pain. The client's decorticate posturing, which indicates cerebral brain injury, involves abnormal flexion.

A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching. A. "I will choose a diet high in fat to help gain weight." B. "I will be sure to eat three large meals daily." C. "I will drink up to 1 liter of liquid each day." D. "I will add high-protein foods to my diet."

D The client should be taught to add high-protein, high-calorie foods to the diet daily as the best way to gain weight and maintain health.

The nurse obtains this information when assessing a patient with human immunodeficiency virus (HIV) who is taking antiretroviral therapy. Which finding is most important to report to the health care provider? A. The blood glucose level is 144 mg/dL B. The hemoglobin level is 10.9 g/dL C. The patient reports frequent nausea D. The patient's viral load has increased

D The increase in viral load indicates ineffective therapy, which will require further evaluation and treatment.

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 blood pressure C. Initiate an intravenous access D. Maintain an adequate airway

D The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.

The home health (HH) nurse enters the home of an 80-year-old female client who had a cerebrovascular accident (CVA), or "brain attack" 2 months ago. The client is complaining of a severe headache. Which intervention should the nurse implement first? A. Determine what medication the client has taken B. Assess the client's pain on a pain scale of 1 to 10 C. Ask whether the client has any acetaminophen (Tylenol) D. Tell the client to sit down, and take her blood pressure

D The number 1 risk factor for a CVA is arterial hypertension. Because the client has a history of a CVA and is complaining of a severe headache, which is a symptom of hypertension, the nurse should first take the client's blood pressure. If it is elevated, the client needs to be taken to the emergency department. In the home setting, asking about the pain scale would not affect the care the nurse provides.

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? A. Administer a nonnarcotic analgesic B. Prepare for STAT magnetic resonance imaging (MRI) C. Start an intravenous infusion with D5W at 100 mL/hr D. Complete a neurological assessment

D The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

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 the client's level of consciousness B. Organize onlookers to remove the client form the lake C. Perform a head-to-toes assessment to determine injuries D. Stabilize the client's cervical spine

D The nurse should always assume that a client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord and cause paralysis; therefore, the nurse should stabilize the cervical spinal cord as best as possible prior to removing the client from the water.

A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? A. Wear a patch over one eye B. Place personal items on the sighted side C. Lie in bed with the unaffected side toward the door D. Turn the head from side to side when walking

D To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight.

An HIV-positive patient who has been started on HAART is seen in the clinic for follow-up. Which test will be most helpful in determining the response to therapy? A. CD4 level B. Complete blood count C. Total lymphocyte percent D. Viral load

D Viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the HAART is effective.

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bmp, respirations are 22 breaths/min, bilateral rhonchi are auscultated, oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? (All options must be used) A. Suction the airway B. Hyperoxygenate C. Suction the mouth D. Provide sedation

D,B,A,C Increased agitation with suctioning will increase ICP; therefore, sedation should be provided first. The client should be hyperoxygenated before and after suctioning to prevent hypoxia since hypoxia causes vasodilation of the cerebral vessels and increases ICP. The airway should then be suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to remove oral secretions. Once the mouth is suctioned, the suction catheter should be discarded.

A nurse is planning care for a client with human immunodeficiency virus (HIV). The registered nurse (RN) is delegating responsibilities to a licensed practical nurse (LPN). Which statements by the LPN indicated understanding of HIV transmission? (Select all that apply) A. "I will wear a gown, mask, and gloves for all client contact" B. "I do not need to war any personal protective equipment because nurses have a low risk of occupational exposure" C. "I will wear a mask if the client has a cough caused by an upper respiratory infection" D. "I will wear a mask, gown, and gloves when splashing body fluids is likely" E. "I will wash my hands after client care"

D,E When the RN delegates to the LPN, it is important to make sure that the LPN understands the client condition and task of delegation. In caring for a client with HIV, standard precautions include wearing gloves for any known or anticipated contact with blood, body fluids, tissue, mucous membranes, or nonintact skin. If the task may result in splashing or splattering of blood or body fluids, a mask and goggles or a face shield and a fluid-resistant gown or apron would be worn. Hands would be washed before and after client care and after removing gloves.

Which action is not appropriate when providing oral hygiene for a client who has had a stroke? A. Placing the client on the back with a small pillow under the head B. Keeping portable suctioning equipment at the bedside C. Opening the client's mouth with a padded tongue blade D. Cleaning the client's mouth and teeth with a toothbrush

A A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration.

A patient with newly diagnosed acquired immunodeficiency syndrome (AIDS) has a 6-mm induration at 48 hours after a skin test for tuberculosis (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 test results are negative C. Teach the patient about multidrug treatment for TB D. Schedule TB skin testing again in 12 months

A According to National Institutes of Health guidelines, an induration of 5 mm or greater indicates TB infection in patients with HIV and a chest radiograph will be needed to determine whether the patient has active or latent TB infection.

A hospitalized patient with AIDS has a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to nausea and anorexia. Which nursing action is most appropriate to delegate to an LPN who is providing care to this patient? A. Administering oxandrolone (Oxandrin) 5mg daily 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 Administration of oral medication is included in LPN education and scope of practice.

A hospitalized patient with acquired immunodeficiency syndrome (AIDS) has wasting syndrome. Which nursing action is appropriate to assign to an LPN who is providing care to this patient? A. Administering oxandrolone 5 mg/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 Administration or oral medication is included in LPN education and scope of practice.

Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)? A. A 55-year-old African American male B. An 84-year-old Japanese female C. A 67-year-old Caucasian male D. A 39-year-old pregnant female

A African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans also suffer more extensive damage from a CVA than do people of other cultural groups.

The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? A. Awaken the client every two (2) hours B. Monitor for increased intracranial pressure (ICP) C. Observe frequently for hypervigilance D. Offer the client food every three (3) to four (4) hours

A Awakening the client every two hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety - all signs of post-concussion syndrome - that would warrant the significant other's taking the client back to the emergency department.

The nurse is evaluating a patient with human immunodeficiency virus (HIV) who is receiving trimethoprim-sulfamethoxazole (TMP-SMX) as a treatment for Pneumocystis jiroveci pneumonia. Which information is most important to communicate to the health care provider? A. The patient reports a blistering rash B. The patient's fluid intake is 2 L/day C. The patient's potassium is 3.4 mg D. The patient enjoys spending time outside in the sun

A Because TMP-SMX can cause Stevens-Johnson syndrome a blistering rash indicates a need to discontinue the medication immediately.

A client is receiving zidovudine (Retrovir) to treat acquired immunodeficiency syndrome. For this client, which laboratory test results should the nurse monitor? A. Red blood cell (RBC) count B. Fasting blood glucose level C. Serum calcium level D. Platelet count

A Because anemia is a major adverse effect of zidovudine, the nurse should monitor the client's RBC count and assess him for signs of decreased cellular oxygenation.

The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? A. Instructing the client to sit up straight and the client responds with a puzzled expression B. Moving the client's food tray to the right side of his over-bed table C. Assisting the client with passive range-of-motion (ROM) exercises D. Combing the hair on the left side of the client's head when the client always combs his hair on the right side

A Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight.

You are supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that you intervene? A. Instructing the client to sit up straight, and the client responding with a puzzled expression. B. Moving the client's food tray to the right side of his over-bed table. C. Assisting the client with passive range-of-motion exercises. D. Combing the hair on the left side of the client's head when the client always combs his hair on the right side.

A Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight.They often neglect the left side of their bodies and ignore food on the left side of their food trays.

Which statement about infection assessment in an immunocompromised client is true? A. Clients with infections often are asymptomatic, except for fever B. Daily assessments usually reveal drainage in infected areas C. Infections usually produce few symptoms, but cultures usually are positive D. Systemic symptoms of infection, such as leukocytosis and myalgia, are pronounced

A Fever, usually low-grade, is commonly the only sign of infection in an immunocompromised client. The lack of an immune system response or an inflammatory response in immunocompromised individuals leads to few clinical symptoms of infection; despite systemic fever it can often lead to negative cultures, possible indicating infection.

A client is at risk for increase intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature

A Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve.

A patient with newly diagnosed AIDS has a negative result on a skin test for TB. Which action will you anticipate taking next? A. Obtain a chest radiograph and sputum smear B. Tell the patient that the TB test results are negative C. Teach the patient about the anti-TB drug isoniazid D. Schedule TB testing again in 12 months

A Patients with severe immunodeficiency may be unable to produce an immune response, so a negative TB skin test result does not completely rule out a TB diagnosis for this patient. The next steps in diagnosis are chest radiography and sputum culture.

The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) 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 are applied D. Pupils that are 6 mm is size and non reactive on painful stimuli

A Purposeless movement indicates that the client's cerebral edema is decreasing. The best motor response is purposeful movement, but purposeless movement indicates an improvement over decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.

The concept of impaired immunity has been identified by the nurse as it applies to the client diagnosed with Acquired Immune Deficiency Syndrome (AIDS). Which interventions should the nurse implement? A. Keep fresh flowers and raw vegetables out of the client's room B. Have the Unlicensed Assistive Personnel (UAP) assist with ADLs C. Encourage the client to perform active range of motion D. Teach the client about the cardiovascular medications

A Raw fruits and vegetables and fresh flowers can harbor parasites and bacteria and should be kept out of the client's room.

A client with a stroke has a nursing diagnosis of Ineffective airway clearance. The goal for this client is to mobilize pulmonary secretions. Which action should the nurse plan to take to meet this goal? A. Reposition the client every 2 hours B. Restrict fluids to 34 oz in 24 hours C. Administer oxygen by cannula, as ordered D. Keep the head of the bed at a 30-degree angle

A Repositioning the client every 2 hours helps prevent secretions from pooling in dependent areas of the lungs.

The nurse is 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 it never dies as long as it has a host 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 client's own red blood cells to reproduce the virus in the body

A Retroviruses never die; the virus may become dormant, only to be reactivated at a later time.

The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will be delegated to unlicensed assistive personnel (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 indicate 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 Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with UAP education.

As the nurse manager in a public health department, you are implementing a plan to reduce the incidence of infection with HIV in the community. Which nursing action will you delegate to health assistants working for the agency? A. Supplying injection drug users with sterile injection equipment such as needles and syringes B. Interviewing patients about behaviors that indicate 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 Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with health assistant education.

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

A The client has a malnutrition syndrome. The nurse assesses the body and what the client has been able to eat.

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? A. Administer a stool softener bid B. Encourage the client to cough hourly C. Monitor neurological status every shift D. Maintain the dopamine drip to keep BP at 160/90

A The client is at risk for increased intracranial pressure whenever performing the Valsalca maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

Elizabeth, who is the day staff nurse, and the UAP are caring for a client with a right-sided cerebrovascular accident (CVA) with hemi-paralysis. Which action by the UAP requires Elizabeth to intervene? A. The UAP places the call light on the client's left side B. The UAP assists the client to eat the breakfast meal C. The UAP uses the draw sheet to move the client up in bed D. The UAP places a small pillow under the client's left shoulder

A The client with a right-sided CVA has left-sided paralysis, so placing the call light on the left side is inappropriate. The client would not be able to use the call light since the left side is paralyzed; Elizabeth should intervene.

The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? A. The head of the bed elevated 15 to 20 degrees B. Trendelenburg's position C. Left Sims' position D. The head elevated on two pillows

A The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 15 to 20 degrees to drain the venous sinuses and thus decrease the ICP.

The client is known to be HIV positive. Which data indicate to the nurse that the client has now progressed to the diagnosis of Acquired Immune Deficiency Syndrome (AIDS)? A. The client's CD4 count is 189 B. The client has an Hgb of 9.4 and Hct of 29.1 C. The client's chest x-ray show infiltrates D. The client complains of a headache unrelieved by Tylenol

A The diagnosis of AIDS is determined by predefined criteria: A CD4 count less than 200.

A client is hospitalized with Pneumocystis jiroveci pneumonia. The nurse observes that the client has had no visitors, seems withdrawn, avoids eye contact, and refuses to engage in conversation. The client also demands in a loud and angry voice that the nurse leave the room. The nursing diagnosis for this client is Social isolation. Based on this diagnosis, what is an appropriate goal for this client's care? A. Identify one way to increase social interaction B. Report increased adaptation to changes in health status C. Identify at least one factor contributing to altered sexuality patterns D. Return a demonstration of measures that can increase independence

A The goal for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly.

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized B. Insert nasogastric tube C. Monitor pulse and blood pressure frequently D. Establish IV access and start fluid replacement

A The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out.

The client is diagnosed with a closed head injury and is in a coma. the nurse writes the client problem as "high risk for immobility complications." Which intervention would 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 (ROM) exercises every four (4) hours C. Turn the client every shift and massage bony prominences D. Explain all procedures to the client before performing them

A The head of the client's bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.

The nurse caring for a client who is HIV positive 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 should attempt to flush the skin and get the area to bleed. It is hoped this will remove contaminated blood from the body prior to infecting the nurse.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. To reduce the risk of increasing intracranial pressure (ICP), the nurse should: A. Encourage oral fluid intake B. Suction the client once per shift C. Elevate the head of the bed to 90 degrees D. Administer a stool softener as prescribed

A The nurse should institute a regular bowel program that includes the use of a stool softner to prevent the client form straining at stool, which can cause a Valsalva maneuver and thus increase ICP.

In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because: A. The rehabilitation plan will be guided by it B. Functional status before the stroke will help predict outcomes C. It will help the client recognize physical limitations D. The client can be expected to regain most functional status

A The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan.

The charge nurse observes the client's nurse telling the UAP to feed an elderly client diagnosed with a cerebrovascular accident (CVA). Which question should the charge nurse ask the client's nurse? A. "How does the client swallow the medications?" B. "Did you complete your head to toe assessment?" C. "Does the client have some Thick-It in the room?" D. "Why would you delegate feeding to a UAP?"

A This question will determine whether the nurse has assessed the client's ability to swallow. The nurse cannot delegate unstable clients, and a client newly diagnosed with a CVA may be unstable and have difficulty swallowing.

Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? (Select all that apply) A. Position the client with the head of the bed up 30 degrees B. Cluster activities of care C. Suction the client every three (3) hours D. Administer soapsuds enemas until clear E. Place the client in Trendelenburg position

A,B Elevating the head of the bed 30 degrees will decrease ICP by using gravity to drain cerebrospinal fluid. Minimizing disturbing the client and allowing rest in between activities will decrease ICP.

A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply) A. Western blot B. Indirect immunofluorescence assay C. CD4 + T-lymphocyte count D. HIV RNA quantification test E. Cerebrospinal fluid analysis

A,B Positive results of a Western blot test confirm the presence of HIV infection and an indirect immunofluorescence assay confirm the presence of HIV infection.

The nurse caring for a client newly diagnosed with protein calorie malnutrition secondary to acquired immune deficiency syndrome (AIDS) writes a nursing problem of "altered nutrition: less than body requirements." Which nursing interventions 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 the dietician D. Monitor beside glucose levels four times a day E. Perform central line dressing changes every 72 hours

A,B,C The client's daily weights will provide information as to fluid balance and nutrition deficits. The client's preferred foods can be used to help increase the client's appetite and should be provided whenever possible on the meal trays. The dietician can be the nurse's best ally when caring for a client with nutritional problems.

The client diagnosed with a right-sided cerebral vascular accident (CVA), or brain attack, is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? (Select all that apply) A. Position the client to prevent shoulder adduction B. Refer the client to occupational therapy daily C. Encourage the client to move the affected side D. Perform quadriceps exercises five times a day E. Instruct the client to hold the fingers in a fist

A,B,C,D Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should be referred to occupational therapy for assistance with performing activities of daily living. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising. These exercises should be done at least five times a day for 10 minutes at a time to help strengthen the muscles used for walking.

Which actions should you delegate to an experienced UAP when caring for a client with a thrombotic stroke who has residual left-sided weakness? (Select all that apply) A. Assisting the client to reposition every 2 hours B. Reapplying pneumatic compression boots C. Reminding the client to perform active ROM exercises D. Assessing the extremities for redness and edema E. Setting up meal trays and assisting with feeding

A,B,C,E An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform.

The nurse is working with a patient who has a new diagnosis of human immunodeficiency virus (HIV) and who reports current use of injectable heroin and methamphetamine. Which actions 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's schedule for directly observed antiretroviral drug treatment D. Instruct the patient that ongoing injectable drug use is a contraindication for antiretroviral therapy E. Provide patient education about the risk of transmitting HIV to other when sharing needles

A,B,C,E Current guidelines indicate that antiretrovial therapy for HIV should be initiated as soon as possible after HIV diagnosis. Although ongoing substance abuse is a risk factor for poor adherence, antiretroviral therapy can be initiated when strategies to improve adherence are used. Strategies include directly observing patients taking medications, needle exchange programs, and referring patients for substance abuse treatment.

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply) A. Have suction equipment available for use B. Feed the client thickened liquids C. Place food on the unaffected side of the client's mouth D. Assign an assistive personnel to feed the client slowly E. Teach the client to swallow with her neck flexed

A,B,C,E Suction equipment should be available in case of choking and aspiration, the client should be given liquids that are thicker than water to prevent aspiration, placing food on the unaffected side of the client's mouth will allow her to have better control of the food and reduce the risk of aspiration, and the client should be taught to flex her neck, tucking the chin down and under to close the epiglottis during swallowing.

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply) A. Impulse control difficulty B. Left hemiplegia C. Loss of depth perception D. Aphasia E. Lack of situational awareness

A,B,C,E a client who has experienced a right-hemispheric stroke will exhibit impulse control difficulty, such as the urgency to use the restroom, will exhibit left-sided hemiplegia, will experience a loss in depth perception, and will demonstrate a lack of awareness of surroundings.

Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness? (Select all that apply) A. Assisting the client to reposition every 2 hours B. Reapplying pneumatic compression boots C. Reminding the client to perform active range-of-motion (ROM) exercises D. Assessing the extremities for redness and edema E. Setting up meal trays and assisting with feeding F. Using a life to assist the client up to a bedside chair

A,B,C,E,F An experienced UAPwould know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. UAPs are also trained to use a client lift to get clients into or out of bed.

A nurse on the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A,B,D Headache is a finding associated with increased ICP. Dilated pupils is a finding associated with increased ICP. Decorticate or decerebrate posturing is a finding associated with increased ICP.

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? (Select all that apply) A. Position the client to prevent shoulder adduction B. Turn and reposition the client every shift C. Encourage the client to move the affected side D. Perform quadriceps exercises three (3) times a day E. Instruct the client to hold the fingers in a fist

A,C Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? (Select all that apply) A. Maintaining an upright position while eating B. Restricting the diet to liquids until swallowing improves C. Introducing foods on the unaffected side of the mouth D. Keeping distractions to a minimum E. Cutting food into large pieces of finger food

A,C,D A client with dysphagia commonly has the most difficulty ingesting this liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided.

Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (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. Suggest the client not get pregnant E. Explain the client does not have to tell healthcare personnel of HIV status

A,C,D,E HIV is transmitted via sexual activity. Blood donations are screened and excluded for this virus, as are organs/tissues from a client with HIV, because the virus can be transmitted to clients receiving the organ or tissue. HIV can be transmitted to the fetus from the pregnant woman with HIV. The client should tell the HCP, especially dentists, about the HIV status, but the client does not have to tell health-care personnel about the HIV status. Health-care personnel should always follow Standard Precautions.

When communicating with a client who has aphasia, which approaches are helpful? (Select all that apply) A. Present one thought at a time B. Avoid writing messages C. Speak with normal volume D. Make use of gestures E. Encourage pointing to the needed object

A,C,D,E The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating.

Which outcomes indicate effective management of a conscious client who is being treated with recombinant tissue plasminogen therapy during the initial phase of an ischemic cerebral vascular accident (CVA)? (Select all that apply) A. Headache reduced B. Dysphagia improved C. Visual disturbances improved D. Responds to comfort measures E. No signs or symptoms of bleeding

A,D,E A headache is commonly associated with an ischemic CVA. A conscious client responds to comfort measures. Bleeding is a side effect of recombinant tissue plasminogen (t-PA) therapy to dissolve the clots; absence of bleeding is a desired outcome.

The 28-year-old female client in the outpatient clinic has been told that her test for the human immune deficiency virus (HIV) is positive. Which interventions 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 the highly active antiretroviral therapy (HAART) E. Teach the client to follow a healthy life style

A,D,E Females who are HIV positive are at risk for multiple gynecological problems. HAART regimens are responsible for the improved prognosis of HIV+ clients. A healthy life style will improve the client's ability to maintain her health.

A nurse is assessing a client for HIV. The nurse should identify that which of the following are risk factors associated with this virus? (Select all that apply) A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult women E. Occupational exposure

A,D,E Perinatal exposure is a risk factor associated with HIV. Women who are pregnant should take precautionary measures to prevent HIV exposure, being an older adult woman is a risk factor associated with the HIV virus due vaginal dryness and the thinning of the vaginal wall, and occupational exposure, such as being a health care worker, is a risk factor associated with the HIV virus.

The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? (Select all that apply) A. Stabilize the client's neck and spine B. Contact the organ procurement organization to speak with the family C. Elevate the head of the bed to 70 degrees D. Perform a Glasgow Coma Scale assessment E. Ensure the client has a patent peripheral venous catheter in place F. Check the client's driver's license to see if he will accept blood

A,D,E The first nursing action is to ensure that the client does not sustain further damage to the spinal cord. The nurse does this by placing sandbags around the client's head or by maintaining the client on a backboard with the head securely affixed to the board. The Glasgow Coma Scale is a systematic tool used to assess a client's neurological status. It gives health-care workers a standard method to determine the progress of a client's condition. The client should have an access to be able to administer emergency medications.

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 anticonvulsant D. An oral proton pump inhibitor

B An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.

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

B Because anal intercourse allows contact of the infected semen with mucous membrane and causes tearing of mucous membrane, there is a high risk of transmission of HIV.

A patient who has human immunodeficiency virus (HIV) and is taking nucleoside reverse 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 health care provider? A. The patient exclaims, "I'm afraid I'm going to die right here!" B. The prescribed patient medications include midazolam 2 mg IV immediately C. The patient is diaphoretic and tremulous and reports dizziness D. The symptoms occurred suddenly while the patient was driving to work

B Because protease inhibitors decrease the metabolism of many drugs, including midazolam, serious toxicity can develop when protease inhibitors are given with other medications.

A patient who is HIV-positive and is taking nucleoside reverse transcriptase nhibitors 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 health care provider? A. The patient states, "I'm afraid I'm going to die right here!" B. The patient has an order for midazolam (Versed) 2mg IV immediately (STAT) C. The patient is diaphorectic and tremulous, and reports dizziness D. The patient's symptoms occurred suddenly while she was driving to work

B Because protease inhibitors decrease the metabolism of many drugs, including midazolam, serious toxicity can develop when protease inhibitors are given with other medications. Midazolam should not be given to this patient.

When the occupational health nurse is teaching unlicensed assistive personnel (UAP) about bloodborne pathogen exposure and human immuniodeficiency virus (HIV) risk, which information is most important to emphasize? A. Occupational transmission of HIV from patients to health care workers is relatively rare. B. Occupational exposure to HIV - containing fluids should be reported immediately to the supervisor C. Treatment for occupational exposure to HIV may include use of antiretroviral medications D. Postexposure treatment will include HIV testing at baseline and at several intervals after the exposure

B Centers for Disease Control and Prevention guidelines indicate that if postexposure prophylaxis is to be used, antiretroviral drugs should be started as soon as possible, preferably withing hours of the exposure. It is important that staff understand that reporting the possible exposure is a priority so that rapid assessment and treatment can be initiated.

After interviewing an HIV-positive patient who is considering starting highly active antiretrovial therapy (HAART), which patient information concerns you the most? A. The patient has been HIV positive for 8 years and has never taken any drug therapy for the HIV infection B. The patient tells you, "I have never been very consistent about taking medications." C. The patient is sexually active with multiple partners and says "I always use a condom." D. The patient has many questions and concerns regarding the effectiveness and safety of the medications

B Drug therapy for HIV infection requires taking medications very consistently. Failure to take the medications daily can lead to mutations and the emergence of more virulent forms of the virus.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? A. Speaking loudly and slowly B. Using a "picture board" for the client to point to pictures C. Writing directions so the client can read them D. Speaking in short sentences

B Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? A. Potential for injury B. Powerlessness C. Disturbed thought process D. Sexual dysfunction

B Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this lead to frustration, anger, depression, and the inablility to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: A. Have a preference for goods high in salt B. Eat food on only half of the plate C. Forget the names of foods D. Not be able to swallow liquids

B Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships.

After sustaining a stroke. A client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurologic deficits with the rehabilitation nurse. Which neurologic deficit places the client at risk for skin breakdown? A. Right-sided visual deficit and dysarthria B. Incontinence and right-sided hemiparesis C. Dysarthria and left-sided visual deficit D. Constipation and lower extremity weakness

B Incontinence and right-sided hemiparesis place the client at risk for skin breakdown.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)? A. Place the client in a jacket restraint B. Wrap the hands in soft "mitten" restraints C. Tuck the arms and hands under the sheet D. Apply a wrist restraint to each arm

B It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

B It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.

You are working with a student nurse to care for an HIV-positive patient with severe esophagitis caused by Candida albicans. Which action by the student indicates that you need to intervene most quickly? A. Putting on a mask and gown before entering the patient's room B. Giving the patient a glass of water after administering the ordered oral nystatin (Mycostatin) suspension C. Suggesting that the patient should order chile con carne or chick soup for the next meal D. Placing a "No Visitors" sign on the door of the patient's room

B Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect.

The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP's order should the nurse implement first? A. Draw a serum for CD4 and complete blood count STAT B. Administer oxygen to the client via nasal cannula C. Administer trimethoprim-sulgamethoxazole, a sulfa antibiotic, IVPB D. Obtain a sputum specimen for culture and sensitivity

B Oxygen is a priority, especially with a client diagnosed with a respiratory illness.

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? A. The client's condition is improving B. The client's condition is deteriorating C. The client will need intubation and mechanical ventilation D. The client's medication regime will need adjustments

B The GCS is used in many acute care settings to establish baseline data in these areas: eye opening, motor response, and verbal response. The client is assigned a numeric score for each of these areas. The lower the score, the lower the client's neurologic function.

The nurse is caring for the client diagnosed with acquired immunodeficiency syndrome (AIDS) dementia. Which action by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse? A. The UAP is helping the client to sit on the bedside chair B. The UAP is wearing sterile gloves when bathing the client C. The UAP is helping the client shave and brush the teeth D. The UAP is providing a back massage to the client

B The UAP should wear non-sterile gloves, not sterile gloves. Wearing sterile gloves is not cost effective.

A 70-year-old alcoholic client who has become lethargic, confused, and incontinent during the last week is admitted to the ED. His wife tells you that he fell down the stairs about a month ago, but that "he didn't have a scratch afterward." Which collaborative interventions will you implement first? A. Place the client on the hospital alcohol withdrawal protocol B. Transport the client to the radiology department for a computed tomographic CT scan C. Make a referral to the social services department D. Give the client phynytoin 100mg PO

B The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated.

The nurse is working in a hospice facility for patients with acquired immunodeficiency syndrome (AIDS). The facility is staffed with LPNs and unlicensed assistive personnel (UAP). Which action will the nurse assign to the LPN? A. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition B. Collecting data about the patients' responses to medications used for pain and anorexia C. Developing UAP training programs about how to lower the risk for spreading infections D. Assisting patients with personal hygiene and other activities of daily living as needed.

B The collection of data used to evaluate the therapeutic and adverse effects of medications i included in LPN education and scope of practice.

The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions 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 types of food the client has been eating for the last 24 hours

B This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition.

Which action should take the highest priority in the care of a client with hemiparesis caused by a stroke? A. Performing passive range-of-motion (ROM) exercises B. Placing the client in an upright lateral position C. Using hand rolls or pillows for support D. Applying antiembolism stockings

B To help prevent airway obstruction and reduce the risk of aspiration, the nurse should position a client with hemiparesis upright, in a lateral position, to allow secretions to drain.

The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data would be considered antecedents (risk factor) for becoming HIV positive? (Select all that apply) A. The client is pregnant B. The client is an intravenous 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 Intravenous drug use does create a risk for becoming HIV positive. When the drug user shares the needle used to inject the drugs, then body fluids are directly injected into the next person to use the syringe and needle. Unprotected sex involves sharing of body fluids, and even if using a condom, there is no guarantee the condom does not break, resulting in shared fluids. The more partners, the greater the risk.

A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his pregnant wife to the hospital. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? (Select all that apply) A. Find a television so the client can view the football game B. Determine if the client's pupils are equal and react to light C. Ask the client if he has a headache D. Arrange for the client to be with his wife and baby E. Administer a sedative

B,C The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache.

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? (Select all that apply) A. Encourage the client to cough to expectorate secretions B. Elevate the head of the bed 15 to 20 degrees C. Contact the healthcare provider (HCP) if ICP is >15 mm Hg D. Monitor neurologic status using the Glasgow Coma Scale E. Stimulate the client with active range-of-motion exercises

B,C,D The nurse should maintain ICP by elevating the head of the bed 15 to 20 degrees and monitoring neurologic status. An ICP >15 mm Hg with 20 to 25 mm Hg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP.

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? (Select all that apply) A. Maintain the head of the bed at 60 degrees of elevation B. Administer stool softeners daily C. Ensure the pulse oximeter reading is higher than 93% D. Perform deep nasal suction every two (2) hours E. Administer mild sedatives

B,C,E Stool softeners are initiated to prevent the Valsalca maneuver, which increases intracranial pressure. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness.

A nurse is caring for a comatose client who has suffered a closed-head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)? (Select all that apply) A. Suction the airway every hour and as needed B. Elevate the head of the bed 15 to 30 degrees C. Turn the client and change his position every 2 hours D. Keep the lights dim E. Maintain a quiet room F. Keep the client cool

B,D,E To facilitate venous drainage and avoid jugular vein compression, the nurse should elevate the head of the bed 15 to 30 degrees. The room should be kept quiet and dimly lit.