A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority?

Correct Answer: B

Rationale: The correct answer is B, tachypnea and restlessness. This is the immediate priority because it indicates respiratory distress, a potentially life-threatening complication in a client with pneumonia and HIV. Tachypnea suggests inadequate oxygenation, while restlessness may indicate hypoxia. Prompt intervention is crucial to prevent respiratory failure. Choice A, oral temperature, is important but not as urgent as addressing respiratory distress. Choice C, frequent loose stools, could be a concern but is not an immediate priority compared to respiratory distress. Choice D, weight loss, is relevant but does not require immediate intervention like tachypnea and restlessness.

Correct Answer: C

Rationale: The correct answer is C: Follow-up testing will be promptly performed to confirm the result. This is the most appropriate next step as a positive result on an antibody test does not confirm HIV infection. Follow-up testing, such as a confirmatory test like Western blot or PCR, is needed to confirm the diagnosis. This step is crucial to avoid unnecessary anxiety or premature treatment initiation. Explanation for incorrect choices: A: The client will be started on fluoxetine in 1 month - This choice is incorrect because fluoxetine is an antidepressant and not a treatment for HIV. B: Antiretroviral therapy will begin within 3 months - This choice is incorrect because starting antiretroviral therapy should be based on confirmed diagnosis, not just a positive antibody test result. D: The client will be monitored for signs and symptoms of HIV to determine the need for treatment - This choice is incorrect because monitoring signs and symptoms alone is not sufficient to confirm HIV infection or determine the need for treatment.

Correct Answer: B

Rationale: Step 1: Anemia is a condition characterized by a decrease in red blood cells or hemoglobin levels. Step 2: Lisinopril is an ACE inhibitor commonly used to treat hypertension, but it can cause anemia as a side effect. Step 3: Administering Lisinopril to a client with anemia can worsen the condition by further reducing red blood cell production. Step 4: Therefore, the nurse should question administering Lisinopril to a client with anemia to avoid exacerbating the condition. Summary: - A (Cipro): An antibiotic, not typically contraindicated in anemia. - C (Acetaminophen): A pain reliever, not directly related to anemia. - D (Ferrous sulfate): Iron supplement, actually used to treat anemia.

Correct Answer: B

Rationale: The correct answer is B because pernicious anemia is typically caused by the absence of intrinsic factor, a protein necessary for the absorption of vitamin B12. Without intrinsic factor, the body cannot properly absorb vitamin B12, leading to anemia. The other choices are incorrect because: A: Schilling's test is used to diagnose pernicious anemia, but an elevated result is not a distinguishing laboratory finding. C: Sedimentation rate is a nonspecific test for inflammation and is not specific to pernicious anemia. D: RBC count of 5.0 million is within the normal range and is not a distinguishing feature of pernicious anemia.

Correct Answer: C

Rationale: Step 1: Drinking coffee or tea with meals can inhibit iron absorption due to the presence of tannins and polyphenols. Step 2: Tannins bind to iron, making it less available for absorption in the body. Step 3: Polyphenols in coffee and tea also interfere with iron absorption. Step 4: Therefore, by drinking coffee or tea with meals, the client is hindering the absorption of iron from their diet. Summary: A: Adding dried fruit provides iron and is beneficial for anemia. B: Cooking in iron pots can increase dietary iron intake. D: Adding vitamin C enhances iron absorption, indicating understanding of nutritional counseling. C: Drinking coffee or tea with meals limits iron absorption, indicating a lack of understanding.