ATI RN
Core Concepts of Family Centered Care Questions
Question 1 of 5
A patient asks, 'What is the main purpose of these medications I take for my HIV?' Which response should the nurse make?
Correct Answer: D
Rationale: The correct answer is D because antiretroviral medications used for HIV treatment work by inhibiting enzymes essential for viral replication, thus interfering with viral production. This prevents the virus from multiplying and spreading in the body. Option A is incorrect as medications do not encapsulate virus-infected cells. Option B is incorrect as the medications do not mark the virus for natural killer cells. Option C is incorrect as medications do not attract macrophages to the cells.
Question 2 of 5
A patient who has AIDS has been instructed on foods to eat to reduce the risk of infection. Which foods should the patient select that indicates correct understanding of this teaching? (Select all that apply.)
Correct Answer: D
Rationale: The correct answer is D: Pasteurized milk. This is because pasteurization kills harmful bacteria, making it safe for consumption by individuals with weakened immune systems like AIDS patients. A: Rare meat and B: Raw seafood may contain harmful bacteria that can pose a risk of infection for AIDS patients. C: Soft egg yolks may also contain harmful bacteria if not fully cooked, which can be dangerous for individuals with compromised immune systems. In summary, pasteurized milk is the safest option as it eliminates the risk of bacterial contamination, while the other choices may increase the risk of infection for a patient with AIDS.
Question 3 of 5
A patient with AIDS is prescribed the nucleoside reverse transcriptase inhibitor lamivudine (Epivir). What information should the nurse ensure that the patient receives about this medication? (Select all that apply.)
Correct Answer: B
Rationale: Step 1: Lamivudine (Epivir) can cause hepatotoxicity, leading to yellowing of the skin (jaundice). Step 2: Yellowing of the skin is a serious side effect that should be reported immediately to prevent further liver damage. Step 3: Reporting yellowing of the skin promptly allows for timely evaluation and necessary interventions. Summary: Reporting bleeding, change in urine output, or flu-like symptoms are not specific to lamivudine and are not directly related to its side effects. Yellowing of the skin is a critical side effect that requires immediate attention.
Question 4 of 5
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, 'Bugs are crawling on my bed. I’ve got to get out of here.' What is the most accurate assessment of the situation? The patient:
Correct Answer: C
Rationale: The correct answer is C: The patient has symptoms of alcohol withdrawal delirium. The presentation of shakiness, irritability, anxiety, diaphoresis, elevated heart rate, and hallucinations ('bugs are crawling on my bed') are classic signs of alcohol withdrawal delirium. Delirium tremens, a severe form of alcohol withdrawal, typically occurs 48-72 hours after the last drink and can be life-threatening. This patient's symptoms are consistent with the timeline and manifestations of alcohol withdrawal, requiring immediate medical intervention. Incorrect answers: A: Manipulating staff for attention is unlikely given the severity of the symptoms and the potential life-threatening nature of alcohol withdrawal delirium. B: Head injury would not typically present with these specific symptoms and timeline. D: Acute psychosis would not typically manifest with these specific symptoms in the context of alcohol intoxication and withdrawal.
Question 5 of 5
Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient:
Correct Answer: B
Rationale: The correct answer is B: the patient has a high tolerance to alcohol. At a blood alcohol level of 400 mg/dl, most individuals would exhibit severe symptoms such as unconsciousness or coma. However, this patient only shows mild symptoms of ataxia, slurred speech, and confusion, indicating a high tolerance to alcohol. This high tolerance suggests that the patient regularly consumes large amounts of alcohol, leading to an adaptation in the body's response to alcohol. Choice A is incorrect because a blood alcohol level of 400 mg/dl is indicative of significant alcohol consumption, contradicting the statement that the patient rarely drinks alcohol. Choice C is incorrect as disulfiram is used to treat alcohol dependence, not tolerance. Choice D is incorrect since sedative drugs would exacerbate the effects of alcohol, causing more severe symptoms than what is observed in this case.