ATI MED SURG EXAM WITH RATIONALE %PASS
human immunodeficiency virus (HIV) - retrovirus that causes immunosuppression making person more susceptible
... [Show More] to infections
How can HIV be transmitted? - through contact with certain body fluids
-blood
-semen
-vaginal secretions
-breast milk
Name the MOST common mode of transmission of HIV. - unprotected sex with an HIV-infected partner
How can HIV be transmitted perinatally? - during pregnancy, delivery or breastfeeding
name the target cells for HIV - CD4+T cells
When a persons CD4+T cell count drops to <500 cells/uL, what will happen? - immune problems begin
The normal CD4+T cell range - 800-1,200 cells/uL
When a persons CD4+T cell count reaches <200 what will happen? - severe problems develop
AIDS
When the body cannot regulate immune responses, what can happen? - it allows for opportunistic diseases to develop
How will a pt present if they have HIV? - FLULIKE SYMPTOMS
-fever
-swollen lymph nodes
-sore throat
-headache
-malaise
-nausea
-muscle and join pain
-diarrhea
If a pt has pneumocystis jiroveci pneumonia what can you diagnose them with? - AIDS
How is HIV progression monitored? - 1. CD4+T counts
2. Viral load
-lower viral load the less active the disease
Goals of HIV - (1) monitoring HIV disease progression and immune function
(2) initiating and monitoring antiretroviral therapy (ART)
(3) preventing the development of opportunistic diseases
(4) detecting and treating opportunistic diseases
(5) managing symptoms
(6) preventing or decreasing complications of treatment
(7) preventing further transmission of HIV
Testing for HIV is the only.... - sure method of determining HIV infection
ART can significantly slow HIV progression, but it... - -is complex
-has side effects
-does not work for everyone
-is expensive
A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The pt states "I am very nervous about making my baby sick." which info will the nurse include when teaching the pt?
a) The antiretroviral medications used to treat HIV infections are teratogenic
b) Most infants born to HIV-positive mother are not infected with the virus
c) Because it is an early stage of HIV infection, the infant will not contract HIV
d) Her newborn will be born with HIV unless he uses ART therapy - b) Most infants born to HIV-positive mother are not infected with the virus
A diagnosis of AIDS can be made for a pt with HIV with:
a) A CD4+T cell count <500/uL
b) A WBC count <3000/uL
c) Development of oral candidiasis (thrush)
d) Onset of Pneumocystis jiroveci pneumonia - d) Onset of Pneumocystis jiroveci pneumonia
The nurse is teaching a newly diagnosed 34-year-old male about his HIV infection. Which statement by the pt would indicate the pt needs additional education?
a) I will need to take my HIV meds daily for the rest of my life
b) Although I only take one pill, it has multiple medications combined into a single tab
c) I should notify my HIV provider if I get fevers that do not go away with Tylenol or Aspirin
d) Once my viral load is undetectable, I don't have to worry about taking my meds every day - d) Once my viral load is undetectable, I don't have to worry about taking my meds every day
The nurse is caring for a pt who is receiving antiretroviral therapy (ART) for treatment of AIDS. Which assessment BEST indicates that the pts condition is improving?
a) Decreased viral load
b) Increased drug resistance
c) Decreased CD4+T cell count
d) Increased aminotransferase levels - a) Decreased viral load
Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.
A nurse is providing discharge teaching to a client who is postop following a rhinoplasty. Which of the following instructions should the nurse include?
a) apply warm compresses to the face
b) take aspirin 650 milligrams by mouth for mild pain
c) close your mouth when sneezing
d) lie on your back with your head elevated 30 degrees when resting - d) lie on your back with your head elevated 30 degrees when resting
The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.
A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?
a) eat high calorie foods first
b) increase intake of water at meal times
c) perform active range of motion exercises before meals
d) keep saltine crackers nearby for snacking - a) eat high calorie foods first
The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first.
A nurse is assessing a client who has fluid overload from a cardiovascular disorder. which of the following manifestations should the nurse expect? (select all that apply)
a) jugular vein distension
b) moist crackles
c) postural hypotension
d) increased heart rate
e) fever - a) jugular vein distension
b) moist crackles
d) increased heart rate
The increase in venous pressure due to excessive circulating blood volume results in neck vein distension.
This is an indicator of pulmonary edema that can quickly lead to death.
Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses.
A nurse is planning care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. the nurse should plan to prepare the client for which of the following procedures?
a) curettage
b) external radiation therapy
c) regional chemotherapy
d) surgical excision - d) surgical excision
The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, followed by skin grafting.
A nurse is caring for a client who has a lesion on the back of his right hand. the client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate?
a) basal cell carcinomas
b) melanomas
c) actinic keratoses
d) squamous cell carcinomas - b) melanomas
Melanomas are malignant neoplasms with atypical melanocytes in both the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases in the bone, liver, lungs, spleen, the CNS, and lymph nodes.
A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of malignant melanoma?
a) rough, dry, scaly lesion
b) firm nodule with crust
c) pearly papule with ulcerated center
d) irregular shaped lesion with blue tones - d) irregular shaped lesion with blue tones
Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on the client's upper back and lower legs.
A community health nurse is providing teaching about malignant melanoma to a group of clients. the nurse should inform the group that which of the following traits places a client at risk for developing malignant melanoma?
a) brown eyes
b) light skin
c) black hair
d) dark skin - b) light skin
A nurse is providing discharge instructions to a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of following findings should the nurse include as a indication of a potential malignancy of a mole?
a) ulceration
b) blanching of surrounding skin
c) dimpling
d) fading of color - a) ulceration
Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.
A nurse is teaching a group of young adults client about health promoting techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include?
a) apply a broad spectrum sunscreen 5 minutes before sun expose
b) wear a sun visor instead of a hat when outside in the sun
c) avoid exposure to the midday sun
d) use a tanning booth instead of sunbathing outdoors - c) avoid exposure to the midday sun
The nurse should instruct clients to avoid skin exposure to the sun, especially during the midday hours of 1000 to 1600 because sun rays are the strongest at that time.
A nurse is caring of a client who has HIV. The client asks the nurse, "should I tell my partner that I am HIV positive?" Which of the following statements should the nurse give?
a) that is your decision
b) I would if I were you
c) it sounds like you are unsure what to say to your partner
d) your provider is required by law to notify your partner - c) it sounds like you are unsure what to say to your partner
A nurse is teaching a client who has HIV about how the virus is transmitted. Which of the following statements should the nurse include the teaching?
a) HIV can be transmitted as soon a person develops manifestations
b) HIV can be transmitted to anyone who has contact with the infected blood
c) HIV is transmitted through the respiratory route through droplets
d) HIV is transmitted only during the active phase of the virus - b) HIV can be transmitted to anyone who has contact with the infected blood [Show Less]