In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:

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Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet Questions

Question 1 of 9

In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:

Correct Answer: B

Rationale: Step-by-step rationale: 1. CD4+ cells are a type of white blood cell crucial for immune function. 2. HIV targets and destroys CD4+ cells, leading to immune system damage. 3. Measuring CD4+ levels helps determine the extent of this damage. 4. Therefore, the correct answer is B. Summary: A: Presence of opportunistic infections - CD4+ levels indirectly affect susceptibility, but not measured for this purpose. C: Level of the viral load - Measured separately from CD4+ levels. D: Resistance to antigens - CD4+ levels do not directly indicate resistance.

Question 2 of 9

A home care nurse assesses for disease complications in a client with bone cancer. The nurse knows that bone cancer may cause which electrolyte disturbance?

Correct Answer: C

Rationale: The correct answer is C: Hypercalcemia. In bone cancer, there can be excessive release of calcium from the bones, leading to elevated blood calcium levels. This can result in various complications such as kidney stones, cardiac arrhythmias, and weakness. Hyperkalemia (choice A) is not commonly associated with bone cancer. Hyponatremia (choice B) is more commonly seen in conditions like heart failure or kidney disease. Hypomagnesemia (choice D) is not a common electrolyte disturbance in bone cancer.

Question 3 of 9

After a 3- month trail of dietary therapy, a client with type2 diabetes mellitus still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:

Correct Answer: A

Rationale: The correct answer is A: 30 minutes before breakfast. Glyburide is a sulfonylurea medication that stimulates insulin release from the pancreas, enhancing glucose uptake. Taking it before breakfast ensures peak insulin levels coincide with the postprandial glucose spike, aiding in glucose control throughout the day. Option B is incorrect as taking it after dinner may lead to hypoglycemia during sleep. Option C is incorrect as midmorning is not an optimal time for a sulfonylurea dose. Option D is incorrect as taking it at bedtime may also increase the risk of hypoglycemia overnight.

Question 4 of 9

A patient who was walking in the woods disturbed a beehive, was stung, and was taken to the emergency department immediately due to allergies to bee stings. Which of the ff. symptoms would the nurse expect to see upon admission of this patient? i.Pallor around the sting bites iv. Retinal hemorrhage ii.Numbness and tingling in the extremities v. Tachycardia iii.Respiratory stridor vi. Dyspnea

Correct Answer: D

Rationale: The correct answer is D: 4, 5, 2006. Upon admission, a patient with allergies to bee stings may exhibit tachycardia (increased heart rate) due to an allergic reaction. Respiratory stridor (high-pitched wheezing) may occur as a sign of airway inflammation. Retinal hemorrhage and dyspnea (difficulty breathing) are not typically associated with bee sting allergies. Pallor and numbness/tingling are also not common symptoms in this scenario. Therefore, choices A, B, and C are incorrect.

Question 5 of 9

A 32 y.o. male patient is admitted to a medical unit with a diagnosis of Guillain-Barre Syndrome. His legs are weak, and he is unable to walk without assistance. Which of the ff. is most likely responsible for this syndrome?

Correct Answer: D

Rationale: The correct answer is D: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.

Question 6 of 9

Appropriate nursing interventions for J.E. would be

Correct Answer: A

Rationale: The correct answer is A because it addresses the specific nursing interventions needed for a patient with head injuries like J.E. Skin care and repositioning every 2 hours help prevent pressure ulcers. Maintaining extremity alignment prevents contractures. Respiratory exercises aid in lung expansion and prevent complications. The other choices are incorrect because they either lack essential interventions (B) or include unnecessary or inappropriate interventions (C, D). Teaching the use of an overhead trapeze is not necessary for head injuries, and intermittent positive pressure breathing therapy may not be indicated. Choice A provides a comprehensive and targeted approach to address the specific needs of a patient with head injuries.

Question 7 of 9

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?

Correct Answer: D

Rationale: The correct answer is D: “You must avoid hyperextending your neck after surgery.” This is because hyperextending the neck can put strain on the surgical incision site and increase the risk of complications. A: Incorrect, as the head of the bed should be elevated to reduce swelling and promote drainage. B: Incorrect, as deep breathing and coughing are important to prevent pneumonia and promote lung expansion. C: Incorrect, as swallowing may be difficult initially but should improve gradually.

Question 8 of 9

Nurse Amy teaches a group of nursing students about the factors that cuses biliary cirrhosis. Which factor is associated with the condition?

Correct Answer: C

Rationale: The correct answer is C: chronic biliary inflammation or obstruction. Biliary cirrhosis is a condition characterized by scarring of the liver due to long-term damage to the bile ducts. Chronic biliary inflammation or obstruction can lead to the build-up of bile in the liver, causing damage over time. Acute viral hepatitis (choice A) typically does not directly cause biliary cirrhosis. Alcohol hepatotoxicity (choice B) is more commonly associated with alcoholic liver disease rather than biliary cirrhosis. Hepatic failure with prolonged venous hepatic congestion (choice D) may lead to liver cirrhosis, but it is not specific to biliary cirrhosis.

Question 9 of 9

Deaths have occurred when potassium chloride has been used incorrectly to flush a lock or central venous catheter. Which of the ff precautions should a nurse take to minimize this risk?

Correct Answer: C

Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used. Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly. Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride. Summary: - Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration. - Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride. - Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.

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