172 exam 4
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate?
"Can you tell me more about the thoughts that you are having?"
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ count of less than 200 cells/μL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?
"The patient has developed acquired immunodeficiency syndrome (AIDS)." Development of PCP meets the diagnostic criterion for AIDS.
Which of the following is the drug of choice for initial treatment of acute otitis media?
Amoxicillin
A new clinic patient with joint swelling and pain is having diagnostic tests. Which test should the nurse identify as specific to systemic lupus erythematosus?
Anti-Smith antibody (Anti-Sm)
A mother and her children have been diagnosed with pediculosis corporis at a health care clinic. An appropriate treatment is:
Apply pyrethrins to the body
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
Attempt to remove the patient's rings.
The nurse is assessing a child with bacterial conjunctivitis (pink eye). Which of the following would the nurse most likely assess?
Crusting of eyelids and eyelashes
Which of the following instructions by the nurse is most appropriate for a client using contact lenses who is diagnosed with bacterial conjunctivitis?
Discard all opened or used lens care products.
A patient who is receiving an IV antibiotic develops wheezes and dyspnea. Which interventions by the nurse would be appropriate? (Select all that apply)
Discontinue the antibiotic infusion. Give diphenhydramine (Benadryl) IV. Inject epinephrine (Adrenalin) IM or IV. Prepare an infusion of dopamine (Intropin). Start 100% oxygen using a nonrebreather mask.
The community health nurse is teaching parents about prevention of the spread and reoccurrence of pediculosis (head lice). Which would the nurse include in the teaching session? (Select all that apply.)
Discourage sharing of personal items Boil combs and brushes for 10 minutes Dryclean nonwashable items.
The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct?
Document the patient's history and teach about clinical manifestations of a type I latex allergy.
A child is seen at a clinic for a beesting. The nurse should remove the stinger as soon as possible using a pair of tweezers.
False
An appropriate home remedy for removal of a tick is the use of petroleum jelly.
False
A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?
Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy.
A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?
Papular, wheal-like lesions with white deposits on the hair shaft
What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)?
Plasmapheresis will remove antibody-antigen complexes from circulation. Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood.
A patient informed of a positive rapid screening test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?
Remind the patient to return for retesting to verify the results.
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?
Sexual transmission is the most common way that HIV is transmitted.
A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. What should the nurse anticipate giving?
TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)
A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?
Teach the patient the reason for the use of prophylactic antibiotics.
A pediatric client has been diagnosed with otitis media. The nurse should place highest priority on teaching the parent:
The importance of completing the full course of antibiotic therapy.
A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Considering this treatment, which information should the nurse report to the health care provider?
The patient is trying to get pregnant before her disease becomes more severe.
Lyme Disease is the most common tick-borne disease in the United States.
True
The two viruses most likely to precipitate otitis media (OM) are respiratory syncytial virus (RSV) and influenza.
True
The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
Use tweezers to remove any remaining ticks.
Which of the following laboratory results is the best indicator that a client's infection is improving?
WBC of 8200/ul
The nurse informs the patient with a bacterial pneumonia that the most important factor in antibiotic treatment is:
all of the supplied antibiotics should be taken even when symptoms have resolved.
An important nursing intervention in the care of a child with conjunctivitis is
applying intermittent warm, moist compresses to remove crusts in the eye area.
A patient is taking methotrexate to treat rheumatoid arthritis (RA). Which laboratory result is important for the nurse to communicate to the health care provider?
blurred vision
The nurse is teaching a newly diagnosed 34-year-old male about his HIV infection. Which statement by the patient would indicate the patient needs additional education? a. "I will need to take my HIV medication daily for the rest of my life." b. "Although I only take one pill, it has multiple medications combined into a single tablet." c. "I should notify my HIV provider if I get fevers that do not go away with Tylenol or aspirin." d. "Once my viral load is undetectable, I don't h
d. "Once my viral load is undetectable, I don't have to worry about taking my medication."
A diagnosis of AIDS can be made for a patient with HIV with a. a WBC count less than 3000/µL. b. a CD4+ T-cell count less than 500/µL. c. development of oral candidiasis (thrush). d. onset of Pneumocystis jiroveci pneumonia.
d. onset of Pneumocystis jiroveci pneumonia
The nurse is caring for a patient who is receiving antiretroviral therapy (ART) for treatment of HIV infection. Which assessment best indicates that the patient's condition is improving?
decreased viral load
The nurse would assess a client admitted with cellulitis for which of the following localized signs?
pain
In a client admitted with cellulitis of the left foot, which of the following clinical manifestations would the nurse expect to find on assessment of the left foot?
redness and swelling
A 25-yr-old female patient with systemic lupus erythematosus (SLE) has a facial rash and alopecia. She tells the nurse, "I never leave my house because I hate the way I look." Which patient problem should the nurse plan to address?
social isolation r/t embarrassment about the effects of SLE
The nurse should teach the parents of a toddler scheduled for a myringotomy and tympanostomy tube placement that:
the procedure is usually performed in a day-surgery center.
