ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 19 Questions
Question 1 of 5
The nurse is caring for a client diagnosed with human immune deficiency virus. The client's CD4+ cell count is 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first?
Correct Answer: C
Rationale: Since this client's CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next, the nurse notifies the provider about the low CD4+ count and requests alternative testing for TB. Standard Precautions are not adequate in this case.
Question 2 of 5
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states, 'Whew! I was really worried about that result.' What action by the nurse is most important?
Correct Answer: A
Rationale: The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to developing antibodies to HIV. This period of time is known as the window period and can last up to 2 months. The nurse needs to assess the client's sexual behavior further to determine the proper response. Discussing safer sex practices is always appropriate, but assessing sexual activity is the priority to determine the risk of a false negative.
Question 3 of 5
A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?
Correct Answer: B
Rationale: Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this client's viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.
Question 4 of 5
A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?
Correct Answer: D
Rationale: This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client's activity.
Question 5 of 5
A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that the goals for this client problem have been met?
Correct Answer: D
Rationale: The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.