NURB 445 - Exam 2
A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? a. "Be sure that you use a wheelchair when you go out in public." b. "Wear an undergarment brief at all times in case of incontinence." c. "Avoid overexertion, stress, and extreme temperature if possible." d. "Avoid having sexual intercourse to conserve energy."
"Avoid overexertion, stress, and extreme temperature if possible."
The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? a. "I will rotate injection sites to prevent skin irritation." b. "I need to avoid large crowds and people with infection." c. "I should report any flulike symptoms to my primary health care provider." d. "I will report any signs of infection to my primary health care provider."
"I should report any flulike symptoms to my primary health care provider."
A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which statement(s) would the nurse include in this education? (Select all that apply.) a. "Participate in an exercise program to strengthen back muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight." e. "Avoid prolonged standing or sitting, including driving."
"Participate in an exercise program to strengthen back muscles." "Wear flat instead of high-heeled shoes to work each day." "Avoid prolonged standing or sitting, including driving."
12. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for the repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener bid. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.
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31. Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching? 1. "I will not have any menstrual cycles because of this disease." 2. "I should avoid people with respiratory infections." 3. "I should not take a hot bath or swim in cold water." 4. "I will drink at least 2,500 mL of water a day."
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53. The nurse is describing HIV infection to a client diagnosed with HIV. Which information regarding the virus is important to teach? 1. HIV is a retrovirus, which means it never dies as long as it has a host to live in. 2. HIV can be eradicated from the host body with the correct medical regimen. 3. It is difficult for HIV to replicate in humans because it is a monkey virus. 4. HIV uses the client's own red blood cells to reproduce the virus in the body.
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12. The nurse is admitting a client diagnosed with MS. Which clinical manifestation should the nurse assess? Select all that apply. 1. Muscle flaccidity. 2. Epistaxis. 3. Dysmetria. 4. Fatigue. 5. Dysphagia.
1, 3, 4, 5 1. Muscle flaccidity is a hallmark clinical manifestation of MS. 2. Epistaxis, nosebleed, is not associated with MS. 3. Dysmetria is the inability to control muscular action characterized by overestimating or underestimating range of movement. 4. Fatigue is a clinical manifestation of MS. 5. Dysphagia, or difficulty swallowing, is associated with MS.
33. The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply. 1. Assist the client to turn and cough every 2 hours. 2. Place the client in a high or semi-Fowler's position. 3. Assess the client's pulse oximeter reading every shift. 4. Plan meals to promote medication effectiveness. 5. Monitor the client's serum anticholinesterase levels.
1,2,4 1. Position changes promote lung expansion, and coughing helps clear secretions from the tracheobronchial tree. 2. This position expands the lungs and alleviates pressure from the diaphragm. 4. The medications should be administered 30 minutes before the meal to provide optimal muscle strength for swallowing and chewing.
4. The client diagnosed with a right-sided CVA is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three times a day. 5. Instruct the client to hold the fingers in a fist.
1,3 1. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. 2. The client should be repositioned at least every 2 hours to prevent contractures, pneumonia, skin breakdown, and other complications of immobility. 3. 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. 4. These exercises are recommended, but they must be done at least five times a day for 10 minutes to help strengthen the muscles for walking. 5. The fingers are positioned so that they are barely flexed to help prevent contracture of the hand.
10. Which assessment data would indicate to the nurse that the client is at risk for a hemorrhagic stroke? Select all that apply. 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure (BP) of 220/120 mmHg. 4. The presence of bronchogenic carcinoma. 5. A lithium level of 0.8 mEq/L.
1,3 1. This glucose level is elevated and could predispose the client to ischemic neurological changes due to blood viscosity. However, research indicates diabetes and elevated glucose levels are risk factors for both ischemic and hemorrhagic strokes (Snarska et al., 2017). 2. A carotid bruit predisposes the client to an embolic or ischemic stroke but not to a hemorrhagic stroke. 3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium. 4. Cancer is not a precursor to developing a hemorrhagic stroke. 5. A lithium level of 0.8 is within the therapeutic level of long-term treatment. Research indicates many mood stabilizers can increase the risk of stroke in patients with bipolar disorder, but not lithium (Chen et al., 2019).
20. The client diagnosed with Guillain-Barré syndrome asks the nurse, "Will I ever get back to normal? I am so tired of being sick." Which statement is the best response by the nurse? 1. "You should make a full recovery within a few months to a year." 2. "Most clients diagnosed with this syndrome have some type of residual disability." 3. "This is something you should discuss with the health-care team." 4. "The rehabilitation is short, and you should be fully recovered within a month."
1. "You should make a full recovery within a few months to a year."
15. Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? 1. Assess deep tendon reflexes. 2. Complete a Glasgow Coma Scale. 3. Check for Babinski's reflex. 4. Take the client's vital signs.
1. Assess deep tendon reflexes. Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. Therefore, assessing deep tendon reflexes is appropriate.
1. 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 a priority? 1. Prepare to administer recombinant tissue plasminogen activator (rtPA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.
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82. Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.
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28. The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others? 1. Discuss ways to help prevent choking episodes. 2. Explain how to care for a client on a ventilator. 3. Teach how to perform passive range-of-motion exercises. 4. Demonstrate how to care for the client's feeding tube.
1. Discuss ways to help prevent choking episodes.
59. The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? 1. The client with flushed, warm skin with tented turgor. 2. The client reporting the staff ignores the call light. 3. The client with vital signs of T 99.9°F, P 101, R 26, and BP 110/68. 4. The client unable to provide a sputum specimen.
1. Flushed warm skin with tented turgor indicates dehydration. The HCP should be notified immediately for fluid orders or other orders to correct the reason for the dehydration.
36. The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering pyridostigmine? 1. Administer the medication 30 minutes before meals. 2. Instruct the client to take with 8 ounces of water. 3. Explain the importance of sitting up for 1 hour after taking medication. 4. Assess the client's blood pressure before administering medication.
1. The anticholinesterase pyridostigmine (Mestinon) will increase muscle strength to help enhance swallowing and chewing during meals (Vallerand & Sanoski, 2019).
35. The client diagnosed with myasthenia gravis is prescribed neostigmine. Which data indicate the medication is effective? 1. The client is able to feed self independently. 2. The client is able to blink the eyes without tearing. 3. The client denies any nausea or vomiting when eating. 4. The client denies any pain when performing ROM exercises.
1. The cholinesterase inhibitor neostigmine (Prostigmin) promotes muscle contraction, which improves muscle strength, which in turn allows the client to perform ADLs without assistance.
55. The nurse caring for a client diagnosed with HIV is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? 1. Flush the skin with water and try to get the area to bleed. 2. Notify the charge nurse and complete an incident report. 3. Report to the employee health nurse for prophylactic medication. 4. Follow up with the infection control nurse to have laboratory work done.
1. 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 before infecting the nurse.
The client newly diagnosed with MS states, "I don't understand how I got multiple sclerosis. Is it genetic?" On which statement should the nurse base the response? 1. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. 2. There is no evidence suggesting there is any chromosomal involvement in developing MS. 3. MS is caused by a recessive gene, so both parents had to have the gene for the client to get MS. 4. MS is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.
1.Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus.
The client diagnosed with Parkinson's disease is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations would explain these assessment data? 1. Masklike face and shuffling gait. 2. Difficulty swallowing and immobility. 3. Pill rolling of fingers and flat affect. 4. Lack of arm swing and bradykinesia.
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Which surgical procedure should the nurse anticipate the client diagnosed with myasthenia gravis undergoing to help prevent the clinical manifestations of the disease process? 1. There is no surgical option. 2. Transsphenoidal hypophysectomy. 3. Thymectomy. 4. Adrenalectomy.
3. In about 75% of clients diagnosed with MG, the thymus gland (which is usually inactive after puberty) continues to produce antibodies, triggering an autoimmune response in MG. After a thymectomy, the production of autoantibodies is reduced or eliminated, and this may resolve the clinical manifestations of MG.
14. Which statement by the client supports the diagnosis of Guillain-Barré syndrome? 1. "I just returned from a short trip to Japan." 2. "I had a really bad cold just a few weeks ago." 3. "I think one of the people I work with had this." 4. "I have been taking some herbs for more than a year."
2. "I had a really bad cold just a few weeks ago."
80. The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."
3. Scheduling appointments late in the morning gives the client a chance to complete ADL without pressure and allows the medications time to give the best benefits.
The client diagnosed with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? 1. Elevate the head of the bed 30 degrees. 2. Administer oxygen via nasal cannula. 3. Assess the client's lung sounds. 4. Obtain a pulse oximeter reading.
2. Oxygen should be given immediately to help alleviate the difficulty in breathing. Remember that oxygenation is a priority.
Which ocular or facial clinical manifestations should the nurse expect to assess for the client diagnosed with myasthenia gravis? 1. Weakness and fatigue. 2. Ptosis and diplopia. 3. Breathlessness and dyspnea. 4. Weight loss and dehydration.
2. Ptosis and diplopia.
2. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.
2. The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case, with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.
3. The 30-year-old female client is admitted with reports of numbness, tingling, a crawling sensation affecting the extremities, and double vision, which has occurred two times in the month. Which question is most important for the nurse to ask the client? 1. "Have you experienced any difficulty with your menstrual cycle?" 2. "Have you noticed a rash across the bridge of your nose?" 3. "Do you get tired easily and sometimes have problems swallowing?" 4. "Are you taking birth control pills to prevent conception?"
3 "Do you get tired easily and sometimes have problems swallowing?" These are clinical manifestations of MS and can go undiagnosed for years because of the remitting-relapsing nature of the disease. Fatigue and difficulty swallowing are other clinical manifestations of MS.
The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? 1. Discuss the need to be placed in a long-term care facility. 2. Explain how to care for a sigmoid colostomy. 3. Assist the client to prepare an advance directive. 4. Teach the client how to use a motorized wheelchair.
3. A client diagnosed with ALS usually dies within 5 years. Therefore, the nurse should offer the opportunity to determine how the client wants to die.
22. The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse? 1. The ventilator rate is set at 14 breaths per minute. 2. A manual resuscitation bag is at the client's bedside. 3. The client's pulse oximeter reading is 85%. 4. The ABG results are pH 7.4, Po2 88, Pco2 35, and Hco3 24.
3. The client's pulse oximeter reading is 85%.
54. The client engaging 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? 1. The client is fortunate not to have contracted HIV from an infected needle. 2. The client must be repeatedly exposed to HIV before becoming infected. 3. The client may be in the primary infection phase of an HIV infection. 4. The antibody test is negative because the client has a different flu virus.
3. 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 client diagnosed with Parkinson's disease is being discharged on carbidopa and levodopa. Which statement is the scientific rationale for combining these medications? 1. There will be fewer side effects with this combination than with carbidopa alone. 2. Dopamine D requires the presence of both of these medications to work. 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.
3. Carbidopa enhances the effects of levodopa by inhibiting decarboxylase in the periphery, thereby making more levodopa available to the central nervous system. Carbidopa and levodopa (Sinemet), an antiparkinsonian drug, are effective treatment for Parkinson's disease.
Which time frame is the window of opportunity to begin postexposure prophylaxis (PEP) with combination antiretroviral therapy (cART) for a nurse who has been exposed to the blood of a patient who is positive for HIV? a. 36 hours b. 72 hours c. 2 weeks d. 1 month
36 hours
75. The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? 1. Request the physical therapist to consult for equipment needed. 2. Request a low-fat, low-sodium diet from the dietary department. 3. Provide three meals per day that include nuts and whole-grain breads. 4. Offer six meals per day with a soft consistency.
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81. The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike face and a shuffling gait.
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The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis (MS). Which clinical manifestation warrants immediate intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia.
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The client is being evaluated to rule out ALS. Which clinical manifestations would the nurse note to confirm the diagnosis? 1. Muscle atrophy and flaccidity. 2. Fatigue and malnutrition. 3. Slurred speech and dysphagia. 4. Weakness and paralysis.
4. ALS results from the degeneration and demyelination of motor neurons in the spinal cord, which results in paralysis and weakness of the muscles.
17. Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome? 1. High risk for injury. 2. Fear and anxiety. 3. Altered nutrition. 4. Ineffective breathing pattern.
4. Ineffective breathing pattern.
Which clinical manifestations should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.
4. Progressive ascending paralysis of the lower extremities and numbness.
The client diagnosed with ALS is prescribed riluzole. Which instructions should the nurse discuss with the client? Select all that apply. 1. Take the medication with food. 2. Do not eat green, leafy vegetables. 3. Use SPF 30 when going out in the sun. 4. Report any febrile illness. 5. Throw away unused medication after 15 days.
4. Riluzole, a benzothiazole, can cause blood dyscrasias. Therefore, the client is monitored for liver function, blood count, blood chemistries, and alkaline phosphatase. The client should report any febrile illness. This is the first medication developed to treat ALS. 5. Riluzole is an oral suspension, and 15 days after opening the bottle, the unused portion should be discarded.
11. The 85-year-old client diagnosed with a stroke is reporting a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.
4. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.
A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurseinclude as part of this teaching? a. "Allow the client to be as independent as possible with activities." b. "Assist the client with frequent and meticulous oral care." c. "Assess the client's ability to eat and swallow before each meal." d. "Schedule appointments early in the morning to ensure rest in the afternoon."
a. "Allow the client to be as independent as possible with activities."
The nurse is teaching a patient about multiple sclerosis. Which statement by the patient indicates a need for further teaching? a. there's a good chance MS is related to viruses b. people in colder climates are more prone to developing MS c. people with asian ancestry are more likely to get MS d. I am at a higher risk for developing MS if my mother had it
c. people with asian ancestry are more likely to get MS
Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.) a. Blood pressure control b. Aspirin use c. Smoking cessation d. Low carbohydrate diet e. Cholesterol management f. Increased red wine consumption
Blood pressure control Aspirin use Smoking cessation Cholesterol management
The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client's symptoms occurred slowly over several hours. b. Client because increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation
Client has a long history of atrial fibrillation
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)
Clopidogrel (Plavix)
The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immunedeficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands "HIV+" d. Wearing a mask within 3 feet (1 m) of the client
Consistent use of Standard Precautions
Which diagnostic tests are used to confirm the diagnosis of ALS? Select all that apply. 1. Electromyogram (EMG). 2. Nerve conduction study (NCS). 3. Serum creatine kinase (CK). 4. Pulmonary function test. 5. Magnetic resonance imaging.
Correct answers are 1, 2, 3, and 5. 1. EMG is done to differentiate a neuropathy from a myopathy and can help diagnose ALS. 2. Nerve conduction studies (NCS) can help diagnose forms of peripheral neuropathy or myopathy. If other problems are not present, this can help diagnose ALS. 3. CK can indicate some disorders of the musculoskeletal system and can help diagnosis ALS. 4. This is done as ALS progresses to determine respiratory involvement, but it does not diagnose ALS. 5. An MRI is performed to reveal disorders of the brain and spinal cord and can assist in diagnosis of ALS (National Institute of Neurological Disorders and Stroke, 2019).
The nurse is caring for a client diagnosed with HIV-II. The client's CD4+ cell count is 399/mm3 (0.399 × 109/L). What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.
Counsel the client on safer sex practices/abstinence.
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? a. Peripheral edema b. Facial flushing c. Tachycardia d. Fever
Facial flushing
The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.) a. Heavy alcohol intake b. Diabetes mellitus c. Elevated cholesterol d. Obesity e. Smoking f. Hypertension
Heavy alcohol intake Diabetes mellitus Elevated cholesterol Obesity Smoking Hypertension
A client with known HIV-II is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include aCD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the primary health care provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.
Place the client under Airborne Precautions
A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance.
Request a prescription for an antispasmodic drug such as baclofen.
The nurse is taking a history on an older adult. Which factors would the nurse assess as potential risks for low back pain? (Select all that apply.) a. Scoliosis b. Spinal stenosis c. Hypocalcemia d. Osteoporosis e. Osteoarthritis
Scoliosis Spinal stenosis Hypocalcemia Osteoporosis Osteoarthritis
The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department. b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy.
The drug is not given to clients who are already on anticoagulant or antiplatelet therapy.
A client has just been informed of a positive HIV test. The client is distraught and does not know what to do. What intervention bythe nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.
a
A client with HIV-II is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times
a
A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The nurse dresses them with sterile gauze. Whenchanging these dressings, which action is most important for the nurse's safety? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after cared. d. Disposing of soiled dressings properly
a
An HIV-negative client who has an HIV-positive partner asks the nurse about receiving tenofovir/emtricitabine. What information is most important to teach the client about this drug? a. Does not reduce the need for safe sex practices. b. Has been taken off the market due to increases in cancer. c. Reduces the number of HIV tests you will need. d. Is only used for postexposure prophylaxis
a
A nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct?(Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with HIV-I disease are not infectious to others. f. The CD4+ T-cell is only affected when the disease has progressed to HIV-III
a, b, c, d CD4+ cells begin to create new HIV virus particles. Antibodies produced are incomplete and do not function well. Macrophages stop functioning properly. Opportunistic infections and cancer are leading causes of death.
A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate? a. "He is NPO until the speech-language pathologist performs a swallowing evaluation." b. "You may give him a full-liquid diet, but please avoid solid foods until he gets stronger." c. "Just be sure to add some thickener in his liquids to prevent choking and aspiration." d. "Be sure to sit him up when you are feeding him to make him feel more natural."
a. "He is NPO until the speech-language pathologist performs a swallowing evaluation."
A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform postvoid residuals
a. Ambulate only with a gait belt.
Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 (0.2 × 109/L) or less than 14% b. Infection with P. jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immunedeficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications f. Confusion, dementia, or memory loss
a. CD4+ cell count less than 200/mm3 (0.2 × 109/L) or less than 14% b. Infection with P. jiroveci d. Presence of HIV wasting syndrome f. Confusion, dementia, or memory loss
The nurse is educating a client with HIV-II and the partner on self-care measures to prevent infection when blood counts are low.What information does the nurse provide? (Select all that apply.) a. Do not work in the garden or with houseplants. b. Do not empty the kitty litter boxes. c. Clean your toothbrush in the dishwasher daily. d. Bathe daily using antimicrobial soap. e. Avoid people who are sick and large crowds. f. Make sure meat, fish, and eggs are cooked well.
a. Do not work in the garden or with houseplants. b. Do not empty the kitty litter boxes. d. Bathe daily using antimicrobial soap. e. Avoid people who are sick and large crowds. f. Make sure meat, fish, and eggs are cooked well.
The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia
a. Flexed trunk c. Slow movements d. Uncontrolled drooling
The nurse assesses a client who is experiencing a common migraine without an aura. Which assessment finding(s) would the nurseexpect? (Select all that apply.) a. Headache lasting up to 72 hours b. Unilateral and pulsating headache c. Abrupt loss of consciousness d. Acute confusion e. Pain worsens with physical activities f. Photophobia
a. Headache lasting up to 72 hours b. Unilateral and pulsating headache e. Pain worsens with physical activities f. Photophobia
Which factor would the nurse consider a potential trigger of a patient's migraine attack? select all that apply. a. anger b. stroke c. fatigue d. hypoglycemia e. increased physical activity
a. anger c. fatigue d. hypoglycemia
Which clinical manifestation would the nurse associate with the postprodromal phase of a migraine headache? Select all that apply. a. fatigue b. irritability c. muscle pain d. phonophobia e. increase in headache pain
a. fatigue b. irritability c. muscle pain
Which assessment finding would the nurse anticipate for a patient with an acute exacerbation of MS? Select all that apply. a. fatigue b. hypertension c. double vision d. muscle spasms e. negative babinski reflex
a. fatigue c. double vision d. muscle spasms
Which clinical manifestation is consistent with a migraine headache? Select all that apply. a. nausea b. bilateral pain c. phonophobia d. hypertension e. throbbing pain
a. nausea c. phonophobia e. throbbing pain
Which clinical manifestations would the nurse associate with a migraine headache? Select all that apply. a. nausea b. bilateral pain c. sharp pain d. photophobia e. phonophobia
a. nausea d. photophobia e. phonophobia pain is unilateral and throbbing
Which finding is consistent with a diagnosis of MS? a. vertigo b. tinnitus c. dysmetria d. intention tremor e. dysarthria
a. vertigo b. tinnitus c. dysmetria d. intention tremor e. dysarthria
Which laboratory changes are most likely in a patient whose immune system is being overwhelmed by HIV? a. CD4+ T cell counts and viral numbers fall b. CD4+ T cell counts fall and viral numbers rise c. CD4+ T cell counts rise and viral numbers fall d. CD4+ T cell counts and viral numbers rise
b. CD4+ T cell counts fall and viral numbers rise
A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action? a. Perform a comprehensive pain assessment. b. Discontinue the infusion of the drug. c. Conduct a neurologic assessment. d. Administer an antihypertensive drug
b. Discontinue the infusion of the drug.
According to the CDC laboratory classifications, which class of HIV is marked by CD4+ T-cell count greater than 500 cells/mm^3 or a percentage of 29% or greater? a. class 0 b. class 1 c. class 2 d. class 3
b. class 1 class 0 - normal range class 1 - greater than 500 class 2 - 200-499 class 3 - less than 200
The nurse recognizes that which patient assessment finding is consistent with a stroke in the right hemisphere? a. slowness b. unawareness of deficit c. anger and frustration d. deficit in the right visual field
b. unawareness of deficit
The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke? a. Age greater than or equal to 75 b. Blood pressure greater than or equal to 160/95 c. Unilateral weakness during a TIA d. TIA symptoms lasting less than a minute
c. Unilateral weakness during a TIA
The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue
c. Visual disturbances
Which defines the concept known as Treatment As Prevention (TAP) of the human immune deficiency virus? a. written consent for including HIV screening as part of routine testing is not required b. the use of HIV-specific antiretroviral drugs in an HIV-uninfected adult serves the purpose of preventing HIV infection c. the use of combination antiretroviral therapy (cART) reduces the viral load to undetectable levels, thereby reducing the risk for HIV transmission d. expanding screening recommendations include a one-time screen for all adults age 15 to 65, annual screening of those at heightened risk, routine prenatal screening, and frequent testing in adults with repeated high-risk exposures.
c. the use of combination antiretroviral therapy (cART) reduces the viral load to undetectable levels, thereby reducing the risk for HIV transmission
A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates thatgoals have been met for this client problem? a. Chooses high-protein food. b. Has decreased oral discomfort. c. Eats 90% of meals and snacks. d. Has a weight gain of 2 lb (1 kg)/1 mo.
d
After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? a. "His masklike face makes it difficult to communicate, so I will use a white board." b. "He should not socialize outside of the house due to uncontrollable drooling." c. "This disease is associated with anxiety causing increased perspiration." d. "He may have trouble chewing, so I will offer bite-sized portions."
d. "He may have trouble chewing, so I will offer bite-sized portions."
A nurse assesses clients at a community center. Which client is at greatest risk for low back pain? a. A 24-year-old female who is 25 weeks pregnant. b. A 36-year-old male who uses ergonomic techniques. c. A 53-year-old female who uses a walker. d. A 65-year-old female with osteoarthritis.
d. A 65-year-old female with osteoarthritis.
The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client's plan of care? a. Restrain the client to prevent falling. b. Ensure that the client uses incentive spirometry. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.
d. Keep the head of the bed at 30 degrees or greater.
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset
d. Time of symptom onset
A client continues to have persistent low back pain even after using a number of nonpharmacologic pain management strategies. Which prescribed drug would the nurse anticipate that the client might need to manage the pain? a. Oxycontin b. Gabapentin c. Lorazepam d. Tramadol
d. Tramadol
For a patient with Parkinson disease, which prescribed intervention would the nurse anticipate when the patient develops a medication tolerance? a. increase the prescribed medication dosage b. change the route of medication administration c. provide a medication holiday that lasts up to 20 days d. change the medication or its frequency of administration
d. change the medication or its frequency of administration
Which factor is the distinction between HIV infection and AIDS? a. viral load b. course of treatment c. duration of infection d. Number of CD4+ T cells
d. number of CD4+ T cells
The nurse expects which symptom(s) in an adult with an acute infection that has occurred within 4 weeks of first being infected with HIV? Select all that apply. a. fever b. night sweats c. memory loss d. muscle aches e. purplish lesions
fever night sweats muscle aches
