41. The three components of cushing's response (triad) are which of the following? Select all that
apply
a. decreased blood pressure
b. widened pulse pressure
c. Bradycardia
d. increased systolic blood pressure e. uncontrolled thermal regulation
EXAM 4
The nurse working in the emergency department (ED) has triaged a client who presented with
chest pain, shortness of breath, a productive cough, and reports of night sweats. The client’s
health history includes the presence of acquired immune deficiency syndrome (AIDS) and a
recent laboratory result that reveals a low CD4+ count. Which of the following actions should
the nurse take next?
Answer Text
Initiate airborne precautions.
Check the client’s temperature
Assess the client for shingles
Obtain a throat culture
Question 2
The newly hired nurse is developing a plan of care for a client who has acquired immune
deficiency syndrome (AIDS) and was just diagnosed with Pneumocystis jiroveci pneumonia
(PJP). Which of the following interventions should the nurse preceptor question?
, Answer Text
Offering the client foods high in calories and protein
Instructing the client to drink at least 2 to 3 liters of fluid throughout the day
Wearing a surgical mask when standing within 3 feet of the client.
Auscultating the client’s breath sounds for crackles at least once per shift
Question 3
The nurse is caring for a client who has acquired immune deficiency syndrome (AIDS) and has
just been diagnosed with toxoplasmosis encephalitis. Which of the following actions should the
nurse take?
Answer Text
Thicken the client’s liquids to honey consistency
Initiate airborne precautions for the next 72 hours
Ask the client if they ingested undercooked meat
Monitor the client’s level of orientation.
Question 4
The nurse working in a community health center has instructed a group of clients who have
acquired immune deficiency syndrome (AIDS) about ways to prevent infection. Which of the
following statements by a client indicates the need for additional teaching?
Answer Text
“I should clean my toothbrush by running it through the dishwasher once a week.”-N
“I will avoid eating uncooked fruits and vegetables.”-N
, Answer Text
“I will notify my primary health care provider if my temperature is greater than 101° F.”.-
Y
“I will avoid drinking water that has been standing for longer than 1 hour.”-Y
Question 5
The nurse is admitting a client who has acquired immune deficiency syndrome (AIDS) and has
developed an infection caused by Cryptosporidium. Which of the following client statements is
consistent with this diagnosis?
Answer Text
“I have lost 5 pounds this past week.”
“I have developed a persistent dry cough.”
“I have noticed that my speech has become slurred.”
“I have noticed that my food does not taste the same.”
Question 6
The nurse is caring for a client who had a heart transplant 10 days ago. Which findings from the
box below require follow-up by the nurse??
1. Prolonged prothrombin time (PT).
2. Activity intolerance.
3. Weight gain of 3 lb.
4. Shortness of breath.
5. Hypotension.
6. Irritability.
Answer Text
1, 2, 3, 4
apply
a. decreased blood pressure
b. widened pulse pressure
c. Bradycardia
d. increased systolic blood pressure e. uncontrolled thermal regulation
EXAM 4
The nurse working in the emergency department (ED) has triaged a client who presented with
chest pain, shortness of breath, a productive cough, and reports of night sweats. The client’s
health history includes the presence of acquired immune deficiency syndrome (AIDS) and a
recent laboratory result that reveals a low CD4+ count. Which of the following actions should
the nurse take next?
Answer Text
Initiate airborne precautions.
Check the client’s temperature
Assess the client for shingles
Obtain a throat culture
Question 2
The newly hired nurse is developing a plan of care for a client who has acquired immune
deficiency syndrome (AIDS) and was just diagnosed with Pneumocystis jiroveci pneumonia
(PJP). Which of the following interventions should the nurse preceptor question?
, Answer Text
Offering the client foods high in calories and protein
Instructing the client to drink at least 2 to 3 liters of fluid throughout the day
Wearing a surgical mask when standing within 3 feet of the client.
Auscultating the client’s breath sounds for crackles at least once per shift
Question 3
The nurse is caring for a client who has acquired immune deficiency syndrome (AIDS) and has
just been diagnosed with toxoplasmosis encephalitis. Which of the following actions should the
nurse take?
Answer Text
Thicken the client’s liquids to honey consistency
Initiate airborne precautions for the next 72 hours
Ask the client if they ingested undercooked meat
Monitor the client’s level of orientation.
Question 4
The nurse working in a community health center has instructed a group of clients who have
acquired immune deficiency syndrome (AIDS) about ways to prevent infection. Which of the
following statements by a client indicates the need for additional teaching?
Answer Text
“I should clean my toothbrush by running it through the dishwasher once a week.”-N
“I will avoid eating uncooked fruits and vegetables.”-N
, Answer Text
“I will notify my primary health care provider if my temperature is greater than 101° F.”.-
Y
“I will avoid drinking water that has been standing for longer than 1 hour.”-Y
Question 5
The nurse is admitting a client who has acquired immune deficiency syndrome (AIDS) and has
developed an infection caused by Cryptosporidium. Which of the following client statements is
consistent with this diagnosis?
Answer Text
“I have lost 5 pounds this past week.”
“I have developed a persistent dry cough.”
“I have noticed that my speech has become slurred.”
“I have noticed that my food does not taste the same.”
Question 6
The nurse is caring for a client who had a heart transplant 10 days ago. Which findings from the
box below require follow-up by the nurse??
1. Prolonged prothrombin time (PT).
2. Activity intolerance.
3. Weight gain of 3 lb.
4. Shortness of breath.
5. Hypotension.
6. Irritability.
Answer Text
1, 2, 3, 4
