a male client with acquired immune deficiency syndrome aids and pneumocystis carinii pneumonia has a cd4 t cell count of 200 cellsmicroliter the clien
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Nursing Elites

HESI LPN

Medical Surgical Assignment Exam HESI

1. A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question?

Correct answer: D

Rationale: With a CD4+ T cell count of 200 cells/microliter, the client's immune system is severely compromised, leading to opportunistic infections.

2. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red, and the client reports a burning sensation. What action should the nurse take?

Correct answer: D

Rationale: In primary Raynaud phenomenon, the fingers go through a color sequence of pallor, cyanosis, and then redness when warmed. The burning sensation reported by the client indicates reperfusion. Continuing to monitor the fingers until the color returns to normal is appropriate in this situation as it ensures that the symptoms are resolving without the need for further intervention. Applying a cool compress could exacerbate the symptoms by causing vasoconstriction. Securing a pulse oximeter to monitor oxygen saturation is not necessary in this case as the issue is related to vasospasm rather than oxygenation. Reporting the finding to the healthcare provider is not urgent unless there are signs of complications or the symptoms do not improve with warming.

3. Parents of a 5-year-old child diagnosed with cognitive impairment have come to the nurse to discuss different approaches to the ongoing care of their child. The nurse should suggest focusing on what activity?

Correct answer: C

Rationale: The correct answer is C: Performing self-care activities. For a 5-year-old child diagnosed with cognitive impairment, it is crucial to focus on teaching them basic self-care skills. This includes activities like dressing themselves, feeding, and personal hygiene. These skills are fundamental for their daily living and independence. Choices A, B, and D are not appropriate for a young child with cognitive impairment. Acquiring job skills is not developmentally suitable at this age, making decisions may be challenging due to cognitive limitations, and reading and doing simple math may be too advanced for their current cognitive abilities.

4. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

Correct answer: A

Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.

5. The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat Gout?

Correct answer: B

Rationale: Taking allopurinol every day helps to prevent gout flare-ups by reducing uric acid levels.

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