Nursing Elites

1. The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?

• A. They must inform household members of their condition.
• B. They must take their medications exactly as prescribed.
• C. They must abstain from substance use.
• D. They must avoid large crowds.

Correct answer: B

Rationale: The correct answer is that clients with HIV must take their medications exactly as prescribed. Antiretrovirals need to be taken as directed to prevent the development of drug-resistant strains and maintain treatment effectiveness. Missing doses can compromise the effectiveness of future treatments. Choice A, informing household members, is important for social support but not the most critical aspect of managing the condition. Choice C, abstaining from substance use, is important but not as crucial as medication adherence. Choice D, avoiding large crowds, is not directly related to HIV management as long as the individual's immune system is not significantly compromised.

2. A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately?

• A. Abdominal distention
• B. A bruit near the epigastric area
• C. 3 episodes of vomiting in the last hour
• D. Blood pressure of 160/90

Correct answer: B

Rationale: A bruit near the epigastric area may indicate the presence of an aortic aneurysm, which is a life-threatening condition requiring immediate medical attention. Abdominal distention, while concerning, may not be as urgent as a potential aneurysm. Vomiting episodes may suggest underlying issues but do not present an immediate life-threatening situation. A blood pressure of 160/90, though elevated, does not pose the same level of immediate threat as a potential aortic aneurysm.

3. A man has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea. The nurse is concerned about which side effect of lisinopril?

• A. Vertigo
• B. Hypotension
• C. Palpitations
• D. Nagging, dry cough

Correct answer: B

Rationale: The correct answer is 'Hypotension.' Lisinopril, an ACE inhibitor commonly used for CHF, can cause hypotension as a side effect. Persistent diarrhea can lead to dehydration, increasing the risk of hypotension in this patient. Vertigo (choice A) is not a typical side effect of lisinopril. Palpitations (choice C) are not directly associated with lisinopril use. A nagging, dry cough (choice D) is a common side effect of ACE inhibitors like lisinopril, but in this case, the patient's presentation with persistent diarrhea would make hypotension a more immediate concern.

4. When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?

• A. Weak cough effort
• B. Barrel-shaped chest
• C. Dry mucous membranes
• D. Bilateral crackles at lung bases

Correct answer: D

Rationale: Bilateral crackles at lung bases indicate a potential acute issue like heart failure. Immediate action is necessary in this situation. The nurse should conduct further assessments such as oxygen saturation and inform the healthcare provider promptly. A barrel-shaped chest and hyperresonance to percussion are typical signs of aging and do not require immediate action. A weak cough effort is common in older patients due to age-related changes, and dry mucous membranes are also expected in older individuals. While these findings may warrant further evaluation, they do not demand immediate action like bilateral crackles at lung bases.

5. Which of the following factors may alter the level of consciousness in a patient?

• A. Alcohol
• B. Electrolytes
• C. Infection
• D. All of the above may cause altered level of consciousness

Correct answer: D

Rationale: Various factors can lead to altered levels of consciousness in a patient. Alcohol consumption can depress the central nervous system and cause changes in consciousness. Electrolyte imbalances, such as hyponatremia or hypernatremia, can disrupt brain function and affect consciousness. Infections, especially those affecting the brain like encephalitis, can also lead to alterations in consciousness. Therefore, all of the choices provided - Alcohol, Electrolytes, and Infection - can potentially cause changes in the level of consciousness. Remember the acronym AEIOU-TIPPS to recall common causes of decreased level of consciousness, including Alcohol, Electrolytes, and Infection, among others.

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