Question

The nurse is preparing a teaching plan for a group of well-educated clients who were found to be HIV positive within the last year. Members of the group express an interest in learning about the pathology of the AIDS virus. The nurse should explain that the human immunodeficiency virus (HIV) acts in which way to suppress the immune system?

Answer 1

Correct Answers:

Destruction of helper T-cells and CD4 cells.

Rationale :

🌸 HIV suppresses the immune system by infecting and destroying CD4 helper T-cells, which are essential for coordinating immune responses.

🌸 CD4 cells act as “command centers” of the immune system by activating other immune cells, including B cells and cytotoxic T cells.

🌸 HIV enters CD4 cells, uses them to replicate, and gradually reduces the number of functioning helper T-cells.

🌸 As CD4 levels decrease, the body becomes less able to fight infections and certain cancers, leading to the development of AIDS.

🌸 A weakened immune system increases the client’s risk for opportunistic infections such as Pneumocystis pneumonia, tuberculosis, and fungal infections.

🌸 Monitoring CD4 count helps evaluate the progression of HIV disease and the effectiveness of antiretroviral therapy.

🌸 Antiretroviral medications help slow HIV replication and preserve remaining immune function.

🌸 Therefore, HIV suppresses immunity primarily through destruction of helper T-cells and CD4 cells.

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Answer 2

Correct Answers:

Auscultate the client's bowel sounds.

Rationale :

🌸 Hydromorphone is an opioid analgesic that commonly causes decreased gastrointestinal motility, making bowel assessment a priority.

🌸 Opioids slow peristalsis by binding to opioid receptors in the gastrointestinal tract, which can lead to constipation, ileus, and abdominal discomfort.

🌸 After receiving hydromorphone for several days, the nurse should assess bowel function by auscultating bowel sounds and asking about bowel movements.

🌸 Decreased or absent bowel sounds may indicate reduced intestinal activity and possible opioid-induced constipation or ileus.

🌸 Early identification of gastrointestinal complications allows the nurse to implement interventions such as increasing fluids if appropriate, encouraging mobility, and administering prescribed stool softeners.

🌸 Constipation is one of the most common adverse effects of opioid therapy and should be monitored routinely.

🌸 Assessing bowel function is especially important when opioids are administered regularly over multiple days.

🌸 Therefore, auscultating bowel sounds is the most important assessment for a client receiving hydromorphone for four days.

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Answer 3

Correct Answers:

If I have sudden shortness of breath, I will use this inhaler.

Rationale :

🌸 Tiotropium is a long-acting anticholinergic bronchodilator used as a maintenance medication for COPD and should be taken daily as prescribed.

🌸 The HandiHaler device delivers tiotropium powder through inhalation and is intended for regular daily use, not occasional symptom relief.

🌸 Tiotropium works by blocking muscarinic receptors in the airways, causing bronchodilation and improved airflow.

🌸 Consistent daily use helps reduce COPD symptoms, decrease exacerbations, and improve breathing ability over time.

🌸 The client should understand that tiotropium is a maintenance medication, meaning it prevents symptoms rather than treating sudden episodes of respiratory distress.

🌸 Proper use of the HandiHaler includes loading the capsule, inhaling the medication as directed, and never swallowing the capsule.

🌸 The nurse should reinforce correct inhaler technique and encourage adherence to the prescribed schedule.

🌸 Therefore, stating “I should use this medication in its HandiHaler every day” demonstrates correct understanding of tiotropium therapy.

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Answer 4

Correct Answers:

Review food labels for sodium content.

Rationale :

🌸 Hypernatremia occurs when the sodium level in the blood is too high, often due to excessive sodium intake or insufficient water intake.

🌸 Teaching the client to review food labels helps reduce excessive sodium consumption from processed and packaged foods.

🌸 Foods such as canned soups, processed meats, chips, and frozen meals often contain high amounts of sodium that can worsen hypernatremia.

🌸 Sodium restriction helps restore fluid and electrolyte balance and prevents complications associated with elevated sodium levels.

🌸 The nurse should teach the client to choose fresh foods, limit high-sodium products, and follow any prescribed dietary restrictions.

🌸 Hypernatremia can cause neurologic symptoms such as thirst, confusion, weakness, irritability, and seizures when severe.

🌸 Dietary education is an important part of preventing recurrence after discharge.

🌸 Therefore, reviewing food labels for sodium content is an appropriate discharge teaching intervention for a client with hypernatremia.

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Answer 5

Correct Answers:

Decrease speaking speed.

Rationale :

🌸 Older adults with hearing impairment often have difficulty processing spoken information quickly, so slowing the rate of speech improves understanding.

🌸 Speaking slowly and clearly allows the client more time to interpret sounds and understand the message being communicated.

🌸 The nurse should face the client, maintain eye contact, and speak in a normal tone while reducing the speed of speech.

🌸 Many older adults experience age-related hearing changes (presbycusis), which commonly affects the ability to hear high-frequency sounds and distinguish words clearly.

🌸 Increasing clarity and allowing extra processing time improves communication without making the client feel embarrassed or uncomfortable.

🌸 Effective communication techniques help maintain the client’s independence, dignity, and participation in care decisions.

🌸 The nurse should avoid behaviors that may appear disrespectful, such as shouting or exaggerating movements.

🌸 Therefore, decreasing speaking speed is the best action to improve communication with an older adult who has difficulty hearing.

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Answer 6

Correct Answers:

Primes the inhaler with 7 pumps.

Rationale :

🌸 Priming an ipratropium inhaler with 7 pumps indicates the client needs additional teaching because the number of priming sprays depends on the specific inhaler device.

🌸 Many ipratropium metered-dose inhalers require priming before first use or after a period of nonuse, but the client should follow the manufacturer’s instructions rather than automatically using a specific number of pumps.

🌸 Incorrect priming can result in receiving an inaccurate medication dose, which may reduce the effectiveness of COPD symptom control.

🌸 The nurse should teach the client to review the medication instructions and prime the inhaler only as directed.

🌸 Proper inhaler preparation ensures the medication is delivered correctly into the lungs.

🌸 Ipratropium is an anticholinergic bronchodilator that helps relax airway smooth muscle and improve airflow in clients with COPD.

🌸 Correct inhaler technique is essential because poor technique can lead to inadequate symptom relief and worsening respiratory problems.

🌸 Therefore, stating that the inhaler should be primed with 7 pumps requires further teaching.

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Answer 7

Correct Answers:

Recent oral intake.

Rationale :

🌸 The nurse should assess the client’s recent oral intake before administering pyridostigmine because the medication improves muscle strength involved in swallowing and should be timed with meals.

🌸 Pyridostigmine is an acetylcholinesterase inhibitor used to increase acetylcholine availability at neuromuscular junctions in clients with myasthenia gravis.

🌸 Myasthenia gravis commonly causes weakness of skeletal muscles, including muscles involved in chewing and swallowing.

🌸 Administering pyridostigmine before meals can improve swallowing ability and reduce the risk of dysphagia and aspiration during eating.

🌸 Knowing when the client last ate helps the nurse determine the best timing for medication administration and ensure adequate nutritional intake.

🌸 Clients with myasthenia gravis are at increased risk for aspiration due to weakened pharyngeal muscles.

🌸 Proper timing of pyridostigmine helps maximize muscle strength when the client needs it most, especially during meals and activities.

🌸 Therefore, obtaining information about recent oral intake is the priority before administering pyridostigmine.

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Answer 8

Correct Answers:

Complete head to toe neurological assessment.

Rationale :

🌸 A client with multiple sclerosis who experiences a fall followed by confusion and projectile vomiting may have an acute neurological complication, such as increased intracranial pressure or head injury.

🌸 A neurological assessment is the priority because changes in level of consciousness and projectile vomiting are concerning signs of possible brain injury.

🌸 The nurse should assess level of consciousness, pupil response, motor function, sensation, speech, and vital signs to identify neurological deterioration.

🌸 Early recognition of neurological changes allows rapid intervention and prevents further complications.

🌸 Although knowing the client’s baseline neurological status is important, the nurse must first assess the client’s current neurological condition.

🌸 Projectile vomiting without nausea and sudden confusion are red-flag findings that require immediate evaluation.

🌸 A comprehensive neurological assessment provides critical information for determining the severity of the client’s condition and guiding treatment.

🌸 Therefore, completing a head-to-toe neurological assessment is the first priority intervention.

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Answer 9

Correct Answers:

Obtain a pulse oximetry reading.

Rationale :

🌸 After positioning a client with COPD upright for sudden dyspnea and tachypnea, the next priority is to assess oxygenation status using pulse oximetry.

🌸 Positioning the client upright helps improve lung expansion and decreases pressure on the diaphragm, but the nurse must next determine the severity of the respiratory problem.

🌸 Pulse oximetry provides information about the client’s oxygen saturation (SpO₂) and helps identify possible hypoxemia.

🌸 COPD clients may experience worsening airway obstruction, mucus retention, or impaired gas exchange during episodes of increased respiratory distress.

🌸 Obtaining an oxygen saturation level helps guide further interventions, such as oxygen therapy, bronchodilator treatments, or provider notification.

🌸 The nurse should always assess the client’s respiratory status before initiating additional treatments.

🌸 Rapid assessment of oxygenation is essential because respiratory compromise can quickly become life-threatening.

🌸 Therefore, obtaining a pulse oximetry reading is the next priority action after positioning the client upright.

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Answer 10

Correct Answers:

Provide an eye shield to be worn while sleeping.

Rationale :

🌸 After eye surgery involving removal of a foreign object such as glass, protecting the surgical eye from accidental injury is the priority intervention.

🌸 An eye shield worn during sleep prevents the client from accidentally rubbing, pressing, or injuring the affected eye while unconscious or unaware.

🌸 The eye is vulnerable after surgery because healing tissues can be disrupted by pressure or trauma.

🌸 Protecting the eye helps prevent complications such as wound disruption, increased intraocular pressure, bleeding, or delayed healing.

🌸 The nurse should teach the client to avoid rubbing the eye and follow activity restrictions prescribed by the provider.

🌸 Eye protection is especially important during sleep because the client cannot consciously control movements that may harm the eye.

🌸 Maintaining surgical site protection promotes healing and reduces the risk of postoperative complications.

🌸 Therefore, providing an eye shield to wear while sleeping is the immediate postoperative intervention.

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QLexNursing

2 :
The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

3 :
A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

4 :
Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

5 :
An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

6 :
A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

7 :
A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

8 :
A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

9 :
The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

10 :
A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

QLexNursing

2 : The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

3 : A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

4 : Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

5 : An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

6 : A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

7 : A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

8 : A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

9 : The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

10 : A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

2 :
The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

3 :
A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

4 :
Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

5 :
An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

6 :
A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

7 :
A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

8 :
A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

9 :
The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

10 :
A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?