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Question 1 of 5

A client with AIDS has a viral load of 200 copies per mL. The nurse should interpret this finding as:

Correct Answer: C

Rationale: A viral load of 200 copies per mL is very low indicating effective antiretroviral therapy and minimal circulating virus. It does not directly assess opportunistic disease risk communicability or T-cell count.

Question 2 of 5

A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?

Correct Answer: B

Rationale: Normal infant attachment behaviors include responding to touch and wanting to be held. Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. Attachment behavior includes maintaining eye contact. Maternal deprivation behaviors include displeasure with touch and physical contact.

Question 3 of 5

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

Correct Answer: B

Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

Question 4 of 5

A six-month-old is receiving Lanoxin elixir (digoxin) following the repair of a VSD. Which finding should be reported to the physician?

Correct Answer: C

Rationale: A heart rate of 80 beats per minute in a six-month-old is low (normal range: 100-160 bpm) and may indicate digoxin toxicity or worsening cardiac function post-VSD repair. The other findings are within normal limits for an infant.

Question 5 of 5

A client with a history of pneumonia is admitted with complaints of dyspnea. The nurse should give priority to:

Correct Answer: A

Rationale: Dyspnea in pneumonia indicates impaired gas exchange, so administering oxygen is the priority to improve oxygenation.

Similar Questions

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A client with AIDS has a viral load of 200 copies per mL. The nurse should interpret this finding as:
The client at 28 weeks gestation is admitted with a diagnosis of preterm labor. The physician orders a non-stress test. The nurse should explain to the client that this test is used to:
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, 'I can't stay still at night. I toss and turn and can't fall asleep.' The nurse suspects that she may be experiencing:
Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:

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