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A client has a bone density score of 2.8. What action by the nurse is best?
a. Asking the client to complete a food diary
b. Planning to teach about bisphosphonates
c. Scheduling another scan in 2 years
d. Scheduling another scan in 6 months
- answer-b. Planning to teach about bisphosphonates
The nurse is caring for a client diagnosed with human immunodeficiency virus.
The clients CD4+ cell count is 399/mm3. What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence.
b. Encourage the client to abstain from alcohol.
c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d. Help the client plan high-protein/iron meals.
- answer-
The nurse is caring for a client diagnosed with human immunodeficiency virus.
The clients CD4+ cell count is 399/mm3. What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence.
b. Encourage the client to abstain from alcohol.
c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d. Help the client plan high-protein/iron meals.
- answer-a. Counsel the client on safer sex practices/abstinence.
This client is in the Centers for Disease Control and Prevention stage 2 case
definition group. He or she remains highly infectious and should be counseled on
either safer sex practices or abstinence. Abstaining from alcohol is healthy but not
required. Genetic testing is not commonly done, but an alteration on the
CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron
meals are important for people who are immunosuppressed, but helping to plan
them does not take priority over stopping the spread of the disease.
,The nurse is caring for a client diagnosed with human immunodeficiency virus.
The clients CD4+ cell count is 399/mm3. What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence.
b. Encourage the client to abstain from alcohol.
c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d. Help the client plan high-protein/iron meals.
- answer-a. Counsel the client on safer sex practices/abstinence.
This client is in the Centers for Disease Control and Prevention stage 2 case
definition group. He or she remains highly infectious and should be counseled on
either safer sex practices or abstinence. Abstaining from alcohol is healthy but not
required. Genetic testing is not commonly done, but an alteration on the
CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron
meals are important for people who are immunosuppressed, but helping to plan
them does not take priority over stopping the spread of the disease.
The nurse is caring for a client diagnosed with human immunodeficiency virus.
The clients CD4+ cell count is 399/mm3. What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence.
b. Encourage the client to abstain from alcohol.
c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d. Help the client plan high-protein/iron meals.
- answer-a. Counsel the client on safer sex practices/abstinence.
This client is in the Centers for Disease Control and Prevention stage 2 case
definition group. He or she remains highly infectious and should be counseled on
either safer sex practices or abstinence. Abstaining from alcohol is healthy but not
required. Genetic testing is not commonly done, but an alteration on the
CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron
meals are important for people who are immunosuppressed, but helping to plan
them does not take priority over stopping the spread of the disease.
The nurse is caring for a client diagnosed with human immunodeficiency virus.
The clients CD4+ cell count is 399/mm3. What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence.
b. Encourage the client to abstain from alcohol.
c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d. Help the client plan high-protein/iron meals.
- answer-a. Counsel the client on safer sex practices/abstinence.
,This client is in the Centers for Disease Control and Prevention stage 2 case
definition group. He or she remains highly infectious and should be counseled on
either safer sex practices or abstinence. Abstaining from alcohol is healthy but not
required. Genetic testing is not commonly done, but an alteration on the
CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron
meals are important for people who are immunosuppressed, but helping to plan
them does not take priority over stopping the spread of the disease.
The nurse is caring for a client during a sickle cell crisis. Which intervention does
the nurse implement for the client?
A. Administer acetaminophen as needed
B. Administer intravenous fluids to keep the vein open
C. Keep the room temperature at 80F
D. Transfuse red blood cells (RBCs)
- answer-C. Keep the room temperature at 80 F
A nurse plans care for a client who is recovering from open reduction and internal
fixation (ORIF) surgery for a right hip fracture. Which interventions should the
nurse include in this client's plan of care? (Select all that apply.)
a. Elevate heels off the bed with a pillow.
b. Ambulate the client on the first postoperative day.
c. Push the clients patient-controlled analgesia button.
d. Reposition the client every 2 hours.
e. Use pillows to encourage subluxation of the hip.
- answer-A,B,D
Postoperative care for a client who has ORIF of the hip includes elevating the
clients heels off the bed and repositioning every 2 hours to prevent pressure and
skin breakdown. ***It also includes ambulating the client on the first postoperative
day, and using pillows or an abduction pillow to prevent subluxation of the hip.***
The nurse should teach the client to use the patient-controlled analgesia pump, but
the nurse should never push the button for the client.
A nurse plans care for a client with a halo fixator. Which interventions should the
nurse include in this client's plan of care? (Select all that apply.)
a. Tape a halo wrench to the clients vest.
b. Assess the pin sites for signs of infection.
c. Loosen the pins when sleeping.
d. Decrease the clients oral fluid intake.
, e. Assess the chest and back for skin breakdown.
- answer-A,B,E
A special halo wrench should be taped to the clients vest in case of a
cardiopulmonary emergency. The nurse should assess the pin sites for signs of
infection or loose pins and for complications from the halo. The nurse should also
increase fluids and fiber to decrease bowel straining and assess the client's chest
and back for skin breakdown from the halo vest.
A nurse plans care for a client with lower back pain from a work-related injury.
Which intervention should the nurse include in this client's plan of care?
a. Encourage the client to stretch the back by reaching toward the toes.
b. Massage the affected area with ice twice a day.
c. Apply a heating pad for 20 minutes at least four times daily.
d. Advise the client to avoid warm baths or showers.
- answer-c. Apply a heating pad for 20 minutes at least four times daily.
Heat increases blood flow to the affected area and promotes healing of injured
nerves. Stretching and ice will not promote healing, and there is no need to avoid
warm baths or showers.
A nurse plans care for a client with Parkinson's disease. Which intervention should
the nurse include in this client's plan of care?
a. Ambulate the client in the hallway twice a day.
b. Ensure a fluid intake of at least 3 liters per day.
c. Teach the client pursed-lip breathing techniques.
d. Keep the head of the bed at 30 degrees or greater.
- answer-d. Keep the head of the bed at 30 degrees or greater.
Elevation of the head of the bed will help prevent aspiration. The other options will
not prevent aspiration, which is the greatest respiratory complication of Parkinson
disease, nor do these interventions address any of the complications of Parkinson's
disease. Ambulation in the hallway is usually implemented to prevent venous
thrombosis. Increased fluid intake flushes out toxins from the clients blood.
Pursed-lip breathing increases exhalation of carbon dioxide.
A nurse promotes the prevention of lower back pain by teaching clients at a
community center. Which instruction should the nurse include in this education?
a. Participate in an exercise program to strengthen muscles.