a nurse is assessing a client who reports a possible exposure to hiv which of the following findings should the nurse identify as an early manifestati

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A healthcare provider is assessing a client who reports a possible exposure to HIV. Which of the following findings should the healthcare provider identify as an early manifestation of HIV infection?

A. Stomatitis
B. Fatigue
C. Wasting syndrome
D. Lipodystrophy

Correct answer: B

Rationale: The correct answer is 'B: Fatigue.' Early manifestations of HIV infection often include symptoms like fatigue, fever, and rash, which are typical of viral infections. Stomatitis (choice A) refers to inflammation of the mouth and lips, which can occur in HIV but is not specific to early infection. Wasting syndrome (choice C) and lipodystrophy (choice D) are more commonly associated with later stages of HIV infection rather than early manifestations.

2. A client who has burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

A. It is okay to not want to touch the burned areas of your body.
B. Cosmetic surgery should be performed within the next year to be effective.
C. Reconstructive surgery can completely restore your previous appearance.
D. It could be helpful for you to attend a support group for people who have burn injuries.

Correct answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals who have burn injuries. Support groups can provide emotional support, shared experiences, and coping strategies for accepting their altered appearance. Choice A is not the best response as it does not offer proactive support. Choice B is not appropriate as the timing of cosmetic surgery should be determined by healthcare providers, not immediate. Choice C is misleading as reconstructive surgery may improve appearance but may not completely restore the previous look.

3. What should the healthcare provider do first when a patient is admitted with chest pain and possible acute coronary syndrome?

A. Administer sublingual nitroglycerin
B. Get IV access
C. Auscultate heart sounds
D. Obtain cardiac enzymes

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority intervention when a patient presents with chest pain and suspected acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. It is crucial to address the pain and potential ischemia promptly to prevent further cardiac tissue damage. Getting IV access, auscultating heart sounds, and obtaining cardiac enzymes are important assessments and interventions, but administering nitroglycerin takes precedence in managing acute coronary syndrome.

4. What are the priority lab values to monitor in a patient with HIV?

A. CD4 T-cell count below 180 cells/mm3
B. White blood cell count
C. Hemoglobin levels
D. Serum albumin levels

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A CD4 count below 180 cells/mm3 is considered severe immunocompromise and requires close monitoring and intervention. Choices B, C, and D are not the priority lab values to monitor in HIV patients. While white blood cell count, hemoglobin levels, and serum albumin levels can provide valuable information about the patient's health status, they are not as specific or indicative of HIV disease progression and management as the CD4 T-cell count.

5. What should a healthcare provider monitor for in a patient with hypokalemia?

A. Monitor for muscle weakness
B. Monitor for bradycardia
C. Check deep tendon reflexes
D. Monitor for hyperglycemia

Correct answer: A

Rationale: Corrected Rationale: Muscle weakness is a common symptom of hypokalemia and should be closely monitored in affected patients. Hypokalemia is a condition characterized by low potassium levels in the blood, which can lead to muscle weakness, cramps, and even paralysis. While bradycardia (slow heart rate) can be associated with severe hypokalemia, monitoring for muscle weakness is more specific to the condition. Checking deep tendon reflexes is not typically a primary monitoring parameter for hypokalemia. Monitoring for hyperglycemia is not directly related to hypokalemia, as hypokalemia is primarily associated with potassium levels in the blood.