Nursing Elites

1. What lab value should be prioritized in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. White blood cell count
• C. Serum albumin levels
• D. Hemoglobin 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 count below 180 cells/mm3 signifies severe immunocompromise and an increased risk of opportunistic infections. Choices B, C, and D are not the priority lab values in HIV management. While white blood cell count, serum albumin levels, and hemoglobin levels are important, they do not directly reflect the immune status and progression of HIV as the CD4 T-cell count does.

2. What are the signs and symptoms of a hemorrhagic stroke?

• A. Sudden severe headache, decreased level of consciousness, and seizures
• B. Loss of consciousness and weakness
• C. Temporary vision loss
• D. Severe chest pain and shortness of breath

Correct answer: A

Rationale: The correct answer is A. A hemorrhagic stroke often presents with a sudden severe headache, decreased level of consciousness, and seizures due to bleeding in the brain. Choice B, loss of consciousness and weakness, is more indicative of an ischemic stroke where a clot blocks blood flow to the brain. Choice C, temporary vision loss, is more commonly seen in conditions like transient ischemic attacks (TIAs) or retinal migraines. Choice D, severe chest pain and shortness of breath, are symptoms more associated with cardiac issues like a heart attack.

3. What are the early signs of increased intracranial pressure (IICP)?

• A. Restlessness, irritability, and confusion
• B. Sudden onset of seizures
• C. Decreased heart rate and pupillary response
• D. Loss of consciousness

Correct answer: A

Rationale: The correct answer is A: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These signs indicate that the brain is starting to experience pressure, often due to conditions such as trauma, tumors, or hemorrhage. Sudden onset of seizures (choice B) is not typically an early sign of IICP but can occur later as the pressure increases. Decreased heart rate and pupillary response (choice C) are more indicative of late-stage IICP as the brainstem becomes compromised. Loss of consciousness (choice D) is a late sign of IICP when the pressure has significantly increased and is causing significant brain dysfunction.

4. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?

• A. Immunosuppressant medications need to be taken for up to 1 year
• B. Shortness of breath might be an indication of transplant rejection
• C. The surgical site will heal in 3 to 4 weeks after surgery
• D. Begin 45 minutes of moderate aerobic exercise per day following discharge

Correct answer: B

Rationale: The correct answer is B. Shortness of breath is an important sign of transplant rejection. Other manifestations of rejection include fatigue, edema, bradycardia, and hypotension. Choices A, C, and D are incorrect because: A) Immunosuppressant medications are typically required for life, not just up to 1 year. C) The surgical site healing time can vary and may take longer than 3 to 4 weeks. D) Starting a specific exercise regimen should be individualized and guided by healthcare providers; a general recommendation like 45 minutes of exercise per day may not be suitable for all heart transplant recipients.

5. What should be monitored in a patient receiving insulin who is at risk for hypoglycemia?

• A. Monitor blood glucose levels
• B. Monitor for respiratory distress
• C. Monitor for hypertension
• D. Monitor for hyperkalemia

Correct answer: A

Rationale: Corrected Question: In a patient receiving insulin who is at risk for hypoglycemia, monitoring blood glucose levels is crucial. This helps in preventing and identifying hypoglycemia promptly. Choice B, monitoring for respiratory distress, is not directly related to hypoglycemia caused by insulin. Choice C, monitoring for hypertension, is not typically associated with hypoglycemia. Choice D, monitoring for hyperkalemia, is not a common concern in patients receiving insulin who are at risk for hypoglycemia.

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