Answers
34. A nurse is assessing the skin integrity of a patient who has AIDS. When
performing this inspection, the nurse should prioritize assessment of what skin
surfaces?
A) Perianal region and oral mucosa
B) Sacral region and lower abdomen
C) Scalp and skin over the scapulae
D) Axillae and upper thorax Ans✓✓✓ A) Perianal region and oral mucosa
The nurse should inspect all the patients skin surfaces and mucous membranes,
but the oral mucosa and perianal region are particularly vulnerable to skin
breakdown and fungal infection.
A 16-year-old has been brought to the emergency department by his parents
after falling through the glass of a patio door, suffering a laceration. The nurse
caring for this patient knows that the site of the injury will have an invasion of
what?
A) Interferons
B) Phagocytic cells
C) Apoptosis
D) Cytokines Ans✓✓✓ B) Phagocytic cells
,Monocytes migrate to injury sites and function as phagocytic cells, engulfing,
ingesting, and destroying greater numbers and quantities of foreign bodies or
toxins than granulocytes. This occurs in response to the foreign bodies that have
invaded the laceration from the dirt on the broken glass.
A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the
teen what she needs and the teen responds that she has become sexually active
and is concerned about getting HIV. The teen asks the nurse what she can do keep
from getting HIV. What would be the nurses best response?
A) Theres no way to be sure you wont get HIV except to use condoms correctly.
B) Only the correct use of a female condom protects against the transmission of
HIV.
C) There are new ways of protecting yourself from HIV that are being discovered
every day.
D) Other than abstinence, only the consistent and correct use of condoms is
effective in preventing HIV. Ans✓✓✓ D) Other than abstinence, only the
consistent and correct use of condoms is effective in preventing HIV .
Other than abstinence, consistent and correct use of condoms is the only effective
method to decrease the risk of sexual transmission of HIV infection.
A 20-year-old man newly diagnosed with type 1 diabetes needs to learn how to
self-administer insulin. When planning the appropriate educational interventions
and considering variables that will affect his learning, the nurse should prioritize
which of the following factors?
,A) Patients expected lifespan
B) Patients gender
C) Patients occupation
D) Patients culture Ans✓✓✓ D) Patients culture
One of the major variables that influences a patients readiness to learn is the
patients culture, because it affects how a person learns and what information is
learned.
A 21-year-old male has just been diagnosed with a spondyloarthropathy. What
will be a priority nursing intervention for this patient?
A) Referral for assistive devices
B) Teaching about symptom management
C) Referral to classes to stop smoking
D) Setting up an exercise program Ans✓✓✓ B) Teaching about symptom
management
, Major nursing interventions in the spondyloarthropathies are related to symptom
management and maintenance of optimal functioning.
A 40-year-old woman was diagnosed with Raynauds phenomenon several years
earlier and has sought care because of a progressive worsening of her symptoms.
The patient also states that many of her skin surfaces are stiff, like the skin is
being stretched from all directions. The nurse should recognize the need for
medical referral for the assessment of what health problem?
A) Giant cell arteritis (GCA)
B) Fibromyalgia (FM)
C) Rheumatoid arthritis (RA)
D) Scleroderma Ans✓✓✓ D) Scleroderma
Scleroderma starts insidiously with Raynauds phenomenon and swelling in the
hands.
A 56-year-old patient has come to the clinic for his routine eye examination and is
told he needs bifocals. The patient asks the nurse what change in his eyes has
caused his need for bifocals. How should the nurse respond?
A) You know, you are getting older now and we change as we get older.
B) The parts of our eyes age, just like the rest of us, and this is nothing to cause
you to worry.