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<P> client who has tested positive for human immunodeficiency virus (HIV) now p

<Q>A
<TYPE>single</TYPE>
resents with a CD<sub>4</sub> count of < 200/microliter and invasive cervical ca
ncer. How would the nurse evaluate these findings in terms of current Centers fo
r Disease Control
<MC1>Client
<MC2>Client
<MC3>Client
<MC4>Client
<F>Rationale:
<CORRECT>4</CORRECT>
continues
is
hasThe
inacquired
seroconverted</MC1>
(CDC)case
latent
CDC todefinitions?</Q>
remain
period
immunodeficiency
definition
at the
of HIV-positive
ofdisease
AIDS
syndrome
for
process</MC3>
status</MC2>
adults
(AIDS)</MC4>
states that AIDS is pre
sent if the CD<sub>4</sub> count is below 200 and there is evidence of an infect
ion or disease process such as cancer (option 4). Seroconversion (option 1) can
occur up to one year after exposure. Once conversion occurs, the client has a po
sitive HIV status (option 2) until the conditions described above develop. The l
atent period is considered to be one in which the individual is asymptomatic (op
tion 3).Need:
Cognitive
Client
Integrated
Content
Strategy:Area:
Level:
Select
Process:
Physiological
Adult
Application
the Nursing
Health:
distractor
Integrity:
Process:
Immunological
that incorporates
Analysis
Physiologicalboth Adaptation
the CD<sub>4</sub> count
and the cervical
Reference: LeMone,cancer.
P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 351-352.</F>
diagnosed with an autoimmune disorder questions the nurse as to what
impact this may have on activities of daily living in the years to come. What i
s the bestchanges
<MC1>"The responsewillthatbethe
subtle
nurseatcan
firstgive?</Q>
so it won't be noticeable to others."<
<MC2>"It is hard to predict what the disease process has in store for any one in
/MC1>
<MC3>"I can hear the concern in your voice. Perhaps we can talk for a while and
dividual."</MC2>
discuss would
<MC4>"I some ofsuggest
your concerns."</MC3>
the use of any available remedy that might give you some c
<F>Rationale: A client diagnosed with an autoimmune disease is faced with a life
<CORRECT>3</CORRECT>
omfort."</MC4>
time of chronic illness and yet may not appear acutely ill because of the episod
ic nature of remissions and exacerbations. The nurse promotes a therapeutic rela
tionship by allowing the client to ventilate feelings (option 3). It is dismissi
ve to minimize any changes that a client may experience that are unnoticeable to
others as they may be quite unsettling to the individual (option 1). It is not
the role of the nurse to speculate how a disease process will progress (option 2
). Suggesting that the client use any "available remedy" may lead the client to
potential
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
harm
Level:
Consider
Process:
Psychosocial
Adult
orApplication
medical
that
Communication
Health:
a goal
quackery
Integrity
Immunological
of the
and
(option
Documentation
nurse-client
4). interaction is to encourage t
he client to verbalize concerns related to a diagnosis. Select the distracter th
at encourages
Reference: Berman,
the client
A., Snyder,
to continue
S., Kozier,
providing
B., &data
Erb,toG.the(2008).
nurse.<i>Fundamentals
of nursing: Concepts, process, and practice</i> (8th ed.). Upper Saddle River,
NJ: Pearson
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurseEducation,
determinespp. that467-471.</F>
which of the following nursing diagnoses has the hi
ghest priorityRheumatoid
<MC3>Ineffective
<MC2>Pain</MC2>
<MC1>Fatigue</MC1>
<MC4>Disturbed
<F>Rationale:
<CORRECT>2</CORRECT>
forrole
body aimage</MC4>
client
performance</MC3>
arthritis
who hascauses
rheumatoid
inflammation,
arthritis?</Q>
fluid accumulation in th
e joints, and degenerative changes in the joints. Pain and pain control are the
most important elements of care for this client (option 2). If the pain is well
controlled, the client will be able to function within his or her role (option 3
). If the inflammatory process is well controlled, joint deformity is lessened (
option Need:
Cognitive
Client
Integrated
Content
Strategy:
4).
Area:
Level:
Select
Fatigue
Process:
Physiological
Adult
Analysis
the
will
Nursing
Health:
distracter
alsoIntegrity:
Process:
Immunological
be that
lessened
Analysis
is
Physiological
most
withlikely
adequateAdaptation
to pain control
prevent the client
(optionfrom
1).l
iving independently
Reference: LeMone, P., and&being
Burke,functional.
K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>fill</TYPE>
<P>
</P> 1468-1469.</F>
is leaving the room of a client following wound care for a large dr
aining pressure ulcer. Place the items in the correct numeric order for removing
isolation "clothing" when leaving the client's room. (Please enter your answers
separated by commas. For example, 1,2,3,4,5 or 1, 2, 3, 4, 5.)
<CORRECT>["1,3,4,6,5,2",
<F>Rationale:
1. Remove
2.
3.
4.
5.
6. Untie
Place
Everything
the
thegown
gown</Q>
waist
neck
maskbelow
gloves
"1,
ties
in
ties
the
3,on
the
on
4,biohazard
the
the
6, gown
waist
5,gown
2"]</CORRECT>
is can
considered contaminated, so the wais
t ties are undone first. The gloves are removed and disposed of before the neck
ties are undone because the neck ties are not considered contaminated. After the
neck ties are untied, the gown is removed by keeping the outside surfaces of th
e gown together and then discarding. The mask is then removed and discarded. As
a last step that is not included in the question, the nurse does handwashing or
other hand
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Differentiate
hygiene.
Process:
Safe,
Adult
Application
Effective
Nursing
Health:
the areas
Process:
Immunological
Care considered
Environment:
Implementation
contaminated
Safety and fromInfection
thoseControl
considered
not contaminated.
Reference: Smith, S.Remove
F., Duell,
the contaminated
D. J., & Martin,
items first.
B. C. (2007). <i>Clinical nursi
ng skills: Basic to advanced skills</i> (7th ed.). Upper Saddle River, NJ: Pears
on Education,
<Q>A
<TYPE>single</TYPE>
<P>
</P> client whop.is399.</F>
human immunodeficiency virus (HIV) positive and is taking ant
iretroviral medications asks why he was told that a change in medication might b
e needed during the course of treatment. Which of the following is the best expl
anation for the nursemedication
<MC1>"Antiretroviral to give theregimens
client?</Q>
must be changed to prevent expected tox
icity to major organs."</MC1>
<MC2>"Antiretroviral resistance is a major challenge to long-term management of
HIV infection, andisdrug
<MC3>"Monotherapy recommended
therapy may forchange
the treatment
based onofresearch
HIV andresults."</MC2>
must be adjusted."
<MC4>"Your treatment regimen will remain in place and is unlikely to change."</M
</MC3>
<F>Rationale: One of the most critical problems with regard to antiretroviral th
<CORRECT>2</CORRECT>
C4>
erapy is the emergence of antiretroviral resistance as the HIV virus continues t
o mutate (option 2). Should resistance develop, or research find a more effectiv
e drug, therapy will change (option 4). Combination therapies have been proven t
o be more effective in treating disease progression so monotherapy is no longer
used (option 3). Antiretroviral therapies, in proper dosage, do not cause specif
ic organNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
toxicity
Level:
This
Process:
Physiological
Adult
question
Analysis
(option
Nursing
Health:
targets
1),
Integrity:
Process:
Immunological
although
knowledge
Implementation
Reduction
theyofcanviral
cause
of Riskmyelosuppression.
mutation
Potential
and how it effects t
reatment. Select
Reference: LeMone,theP.,distracter
& Burke, K. that(2008).
best combines
<i>Medical-surgical
both contentnursing:
areas. Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 356-358.</F>
receives a polio vaccine during a clinic visit. The nurse explains t
hat this willartificial
<MC1>Active
<MC2>Active
<MC3>Passive
<MC4>Passive
<F>Rationale:
<CORRECT>2</CORRECT>
natural
natural
artificial
provideimmunity</MC1>
Vaccines immunity</MC3>
what
immunity</MC2>
are
immunity</MC4>
type of immunity
administered to client
to thetoclient?</Q>
promote the development of
specific antibodies to afford protection. This is an example of active artificia
l immunity (option 2). Active natural immunity implies the development of antibo
dies in response to a client who had an actual active infection (option 1). Pass
ive natural immunity implies the maternal and or placental transfer of antibodie
s (option 3). Passive artificial immunity implies the specific injection of an i
mmune serum
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Consider
Process:
(option
Health
Adult
Application
the
4).typesImmunological
Promotion
Nursing
Health: Process:
ofandpossible
Maintenance
Analysis
immunity and select the distracter that
Reference:
reflects theLeMone,
description
P., & Burke,
in theK.question.
(2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 299-301.</F>
who is diagnosed with myasthenia gravis (MG) had not been compliant
with his medication regimen and has missed several doses of pyridostigmine (Mest
inon). For which
<MC1>Gastrointestinal
<MC4>Respiratory
<MC3>Bradycardia</MC3>
<MC2>Vertigo</MC2>
<F>Rationale:
<CORRECT>4</CORRECT>
MG causes
complication
distress</MC4>
symptoms</MC1>
a decrease
wouldinthemuscle
nursestrength
monitor?</Q>because of the unavailabil
ity of acetylcholine. If a client is insufficiently medicated, muscle weakness o
ccurs. The client should therefore be monitored for myasthenic crisis, as eviden
ced by respiratory distress, which is often a result of missed or undermedicatio
n (option 4). Gastrointestinal symptoms (option 1), vertigo (option 2), and brad
ycardia (option 3) are associated with cholinergic crisis. Cholinergic crisis is
usually the result of overmedication. Both complications are viewed as acute in
Cognitive
Client
Integrated
Content
Strategy:
nature.Need:
Area:
Level:
Differentiate
Process:
Physiological
Pharmacology
Analysis
Nursing
cholinergic
Integrity:
Process:and Assessment
Physiological
myasthenic crises.Adaptation
Select the distracter
Reference:
that best LeMone,
reflectsP.,the&description
Burke, K. (2008).
in the <i>Medical-surgical
stem. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 1649-1651.</F>
with tuberculosis is being admitted to the medical-surgical unit. Wh
ich type of precautions should the nurse institute to protect the client and sta
ff from possible
<MC1>Standard
<MC2>Contact
<MC3>Airborne
<MC4>Droplet
<F>Rationale:
<CORRECT>3</CORRECT>
precautions</MC2>
precautions</MC4>
precautions</MC1>
precautions</MC3>
Tuberculosis
exposure toisthis transmitted
infection?</Q>
to others via aerosolization. Airborne
precautions should be instituted for all clients being admitted with a diagnosi
s of tuberculosis (option 3). Standard precautions should be maintained for all
clients in the hospital setting (option 1). Contact precautions (option 2) and d
roplet Need:
Cognitive
Client
Integrated
Content
Strategy:
precautions
Area:
Level:
First
Process:
Safe
Adult
recall
Application
Effective
(option
Nursing
Health:
how tuberculosis
4)Immunological
Care:
Process:
do notSafety
apply
Implementation
isandtransmitted.
toInfection
this disease Control
Thenprocess.
select the distract
er that bestLeMone,
Reference: preventsP.,this
& Burke,
transmission.
K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1292-1293.</F>
has been asked to perform a home assessment on a client who has lon
gstanding rheumatoid arthritis (RA). Which one of the following findings should
receive the keeps
<MC1>Client
<MC2>Client
<MC3>Client
<MC4>Client
<F>Rationale:
<CORRECT>3</CORRECT>
highest
lives
hasIndividuals
installed
area
inpriority
medications
apartment
rugs handrail
scattered
withfor
inlong-standing
building
afollow-up
support
plastic
throughout
thatcase
teaching?</Q>
in has
RA
the
apartment</MC3>
onanbathroom</MC2>
have kitchen
elevator</MC1>
an increased
counter</MC4>
likelihood of
joint deformities and contractures that could increase risk of falls. Scattered
area rugs are a potential safety hazard (option 3). All of the other assessment
findings are considered to be supportive of this client with RA because they enh
ance mobility (option 1), safety (option 2), and medication compliance (option 3
Cognitive
).
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
This
Process:
Health
Adult
question
Analysis
Promotion
Nursing
Health:
is asking
Process:
Immunological
and you
Maintenance
Evaluation
to identify which of the four distracters
poses a risk to the client. Select the distracter that is most likely to cause i
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
njury.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 1468-1469.</F>
<Q>After
<TYPE>single</TYPE>
<P>
</P> a client is placed on droplet precautions, which of the following actio
ns by the nurse
<MC1>Using
<MC2>Washing
<MC3>Checking
<MC4>Changing
<F>Rationale:
<CORRECT>2</CORRECT>
strict
ofRegardless
sterile
intravenous
should
hands
aseptic
before
supplies
beoftubing
given
technique</MC1>
isolation
andfor
the
after
according
expiration
highest
precautions,
givingtopriority
clientthecare</MC2>
date</MC3>
hospital forbasic
policy</MC4>
infection
actioncontrol?</Q>
by the nurse
to prevent infection is hand washing (option 2). All of the other options shoul
d also be followed but hand washing establishes the first line of defense and is
Cognitive
Client
Integrated
Content
Strategy:
therefore
Need:
Area:
Level:
This
ofSafe
Process:
highest
Fundamentals
question
Application
Effective
Nursing
importance.
asksProcess:
Care
for prioritization
Environment:
Analysis Safety of theandmost
Infection
important
Control
item in re
ducing the spread of infection. Recall that hand washing is the most important b
ut also the most often neglected or underutilized measure; this will guide you t
o make the LeMone,
Reference: correct P.,
selection.
& Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 309.</F>
</P>