Nursing Elites

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?

• A. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
• B. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
• C. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
• D. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.

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. A client with deep vein thrombosis (DVT) is being treated with warfarin. Which dietary instruction should the nurse provide?

• A. Avoid foods high in vitamin C
• B. Increase intake of green leafy vegetables
• C. Limit intake of foods high in vitamin K
• D. Avoid dairy products

Correct answer: C

Rationale: The correct answer is C: 'Limit intake of foods high in vitamin K'. Vitamin K can interfere with the effectiveness of warfarin, an anticoagulant medication commonly used to treat conditions like deep vein thrombosis (DVT). Patients on warfarin should maintain a consistent intake of vitamin K-rich foods and be monitored closely. Choices A, B, and D are incorrect because avoiding foods high in vitamin C, increasing intake of green leafy vegetables, and avoiding dairy products are not essential dietary instructions for a client on warfarin therapy for DVT.

3. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

• A. Administer antihypertensive medication as prescribed.
• B. Place the client in a supine position.
• C. Obtain a detailed health history.
• D. Monitor urine output.

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

4. The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?

• A. Chest pain
• B. Sudden confusion and difficulty speaking
• C. Gradual onset of weakness in the legs
• D. Nausea and vomiting

Correct answer: B

Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.

5. How should the nurse measure urinary output for an infant with dehydration?

• A. Attaching a urine collecting bag
• B. Wringing out the diaper
• C. Weighing the diaper
• D. Inserting a catheter

Correct answer: C

Rationale: The correct way to measure urinary output for an infant with dehydration is by weighing the diaper. Wet diapers are weighed to assess the amount of output accurately. Attaching a urine collecting bag and inserting a catheter are invasive methods not typically used for routine measurement of urinary output in infants. Wringing out the diaper can lead to inaccurate measurements and is not a recommended method for assessing urinary output.

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