A patient tests positive for HIV. Which statements should the nurse include in the patient’s education? (Select 3)
Answer Choices:
Headache, nausea, vomiting, anorexia are known side effects
Take ART with antacids
If you miss a dose, take two at once
ART causes insomnia, so take at night
There are no side effects of ART
ART medications will cause wasting syndrome
We will measure effectiveness by CD4+ T cell counts
These medications should keep the viral load suppressed
Answer: Headache, nausea, vomiting, anorexia are known side effects; We will measure effectiveness by CD4+ T cell counts; These medications should keep the viral load suppressed
Pressure injuries can occur due to pressure, shear, or friction. Which of the following reduce the incidence? (Select all that apply.)
Answer Choices:
Maintaining head of bed at 45°
Frequent turning and positioning
Frequent skin assessments
Inspect sacrum for blanching
Optimizing nutrition
Answer: Frequent turning and positioning, Frequent skin assessments, Inspect sacrum for blanching, Optimizing nutrition
The nurse is assessing a patient with peritonitis. What findings should they expect? (Select all that apply.)
Answer Choices:
Inability to pass stools
Rigid abdomen
Decreased urinary output
Frequent bowel movements
Hyperactive bowel sounds
Answer: Inability to pass stools, Rigid abdomen, Decreased urinary output
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer’s disease. Which of the following interventions should the nurse include?
Answer Choices:
Provide an activity schedule that changes from day to day.
Limit time for the client to perform activities.
Rotate assignment of daily caregivers.
Talk the client through tasks one step at a time.
Answer: Talk the client through tasks one step at a time.
A nurse is caring for a client who has moderate Alzheimer’s disease. During weekly home visits, the nurse notices that the client’s caregiver is tired, irritable, and impatient with the client. Which of the following actions should the nurse recommend to the caregiver?
Answer Choices:
Pursue local protective services.
Consider respite care services.
Contact hospice services for end-of-life care.
Take a nonprescription sleeping medication.
Answer: Consider respite care services.
A nurse is teaching a client with TB starting isoniazid, rifampin, pyrazinamide therapy. Which instruction should the nurse include?
Answer Choices:
Expect sputum cultures negative after 6 months
Provide sputum specimen every 2 weeks
Take isoniazid with an antacid
Drink at least 8 ounces of water with pyrazinamide
Answer: Expect sputum cultures to be negative after 6 months of therapy
A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
Answer Choices:
Full thickness skin loss with visible adipose tissue
Intact skin with localized erythema
Partial-thickness skin loss with red tissue in wound bed
Full thickness skin loss with visible bone
Answer: Partial-thickness skin loss with red tissue in wound bed
You are caring for a patient with a positive TB skin test (15mm), productive cough for two months, and unintentional weight loss. Which of the following orders will assist with the diagnosis of active tuberculosis? (Select all that apply.)
Answer Choices:
Vital signs every shift
CBC, BMP, HIV viral load, VDRL
Chest x-ray
Heart healthy diet
Collect specimen ×3 mornings for acid-fast bacilli
Admit to a negative pressure room
Answer: Chest x-ray, Collect specimen ×3 mornings for acid-fast bacilli, Admit to a negative pressure room
For each of the following assessment findings for the client with HIV, identify if the finding is consistent with HIV Stage I or HIV Stage III (AIDS).
Answer Choices:
Weight changes
Skin condition
Chest x-ray
Latest CD4 cell count
Answer: Weight changes – Both (seen early and in AIDS)
Skin condition – Both (rash early, worsens in AIDS)
Chest x-ray – Stage III (AIDS)
Latest CD4 cell count – Stage III (AIDS, <200)
A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 12 mm at the injection site. Which of the following instructions should the nurse provide to the client?
Answer Choices:
“You will need to follow up with your provider.”
“You will need to return in 48 hours for re-evaluation.”
“You will need to have the skin test annually.”
“Your test will need to be repeated at this time.”
Answer: “You will need to follow up with your provider.”