Nursing Elites

1. What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS?

• A. Enlarged and tender cervical lymph nodes
• B. Presence of low-grade fever and sore throat
• C. Recent history of recurrent pneumonia
• D. CD4 blood cell count of 300

Correct answer: C

Rationale: The correct answer is C: 'Recent history of recurrent pneumonia.' Recurrent pneumonia is a hallmark indicator of progression to AIDS in clients with HIV infection. It signifies advanced immunosuppression when the body is unable to fight off infections effectively. Enlarged and tender cervical lymph nodes (Choice A) are more indicative of local infections or inflammation rather than AIDS progression. The presence of a low-grade fever and sore throat (Choice B) may be common in various infections and are not specific to AIDS progression. While a CD4 blood cell count of 300 (Choice D) is below the normal range and indicates immunosuppression, it alone may not be sufficient to suspect progression to AIDS without other supporting indicators like opportunistic infections such as recurrent pneumonia.

2. A female client tells the clinic nurse that she has doubts about binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia?

• A. Ask the client to complete a food diary for the last 3 days
• B. Review the client’s lab data to determine her TSH, T3, and T4 levels
• C. Interview the client about her use of laxatives and diuretics
• D. Encourage the client to describe her daily exercise regimen

Correct answer: C

Rationale: Inquiring about laxative and diuretic use helps confirm bulimia as these are common behaviors associated with the disorder. Asking the client to complete a food diary (Choice A) may provide information on eating patterns but does not directly support the diagnosis of bulimia. Reviewing lab data (Choice B) for thyroid function is not specific to bulimia. Encouraging the client to describe her exercise regimen (Choice D) may be relevant for overall health assessment but does not specifically address bulimia symptoms.

3. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent, and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, 'She says it is OK.' What action should the nurse take next?

• A. Clarify the client’s consent through the use of gestures and simple terms
• B. Have the interpreter co-sign the consent to validate the client's understanding
• C. Ask for a full explanation from the interpreter of the witnessed discussion
• D. Have the client sign the consent form and the nurse witness the signature

Correct answer: B

Rationale: Having the interpreter co-sign the consent form is the most appropriate action in this scenario. By having the interpreter co-sign, it ensures an additional layer of verification of the client's understanding and consent, which is crucial when language barriers exist. This step adds a level of confirmation to safeguard that the client's consent is both valid and well-informed. Option A is not sufficient as gestures and simple terms may not fully clarify the client's understanding, especially for complex medical procedures. Option C is unnecessary since the interpreter has already confirmed the client's consent. Option D does not involve the interpreter in validating the client's understanding, which is essential in this situation to ensure effective communication and comprehension between the client and the healthcare team.

4. A 10-month-old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the parent to assist in the diagnosis of cystic fibrosis (CF)?

• A. When you kiss her, does she taste salty?
• B. Do you notice if her urine has a musty odor?
• C. Has she been drinking cow's milk in her daily diet?
• D. How often does she have a normal bowel movement?

Correct answer: A

Rationale: The correct answer is A. Salty skin is a common sign of cystic fibrosis due to high levels of sodium in sweat. Asking about the taste of the child's skin provides valuable information related to the diagnosis of CF. Choices B, C, and D are not helpful in diagnosing cystic fibrosis. A musty odor in urine is not a typical symptom of CF. Drinking cow's milk or bowel movement frequency are not specific to CF diagnosis.

5. A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, 'Is my friend who was in the car with me ok?' What response is best for the nurse to provide?

• A. I am sorry, but your friend was killed in the accident.
• B. Right now you need to concentrate on getting well.
• C. Was the passenger in the car your friend?
• D. I think your friend is going to be all right.

Correct answer: A

Rationale: The correct answer is A: 'I am sorry, but your friend was killed in the accident.' In this situation, honesty and compassion are essential. The nurse should provide the client with truthful information, acknowledging the client's need to know the reality of the situation. Choice B is dismissive and does not address the client's inquiry directly. Choice C is a deflecting question and does not offer the direct information the client is seeking. Choice D provides false reassurance, which is not appropriate in this circumstance where the reality needs to be communicated.

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