A client is tested for human immunodeficiency virus (HIV) infection with an enzyme- linked immunosorbent assay (ELISA), and the test result & positive. What would the nurse tell the client?

You probably have a gastrointestinal infection*

"You are confirmed to be infected with the HIV virus.

This is a good result, which means you do not have HIV."

Your result will need to be confirmed with a Western blot test."

Answer and Explanation

The Correct Answer is D

A. "You probably have a gastrointestinal infection":
This statement is incorrect. A positive result on the enzyme-linked immunosorbent assay (ELISA) indicates the presence of antibodies to HIV, which suggests exposure to the virus. It does not point to a gastrointestinal infection. HIV is a viral infection that primarily affects the immune system, not the gastrointestinal system. Misleading the client in this way would delay proper care and understanding of their health status.

B. "You are confirmed to be infected with the HIV virus.":
A positive ELISA test result does not automatically confirm an HIV diagnosis. ELISA is a screening test that detects HIV antibodies, but it can sometimes produce false-positive results. A positive ELISA result must be confirmed with a more specific confirmatory test, such as the Western blot test. Therefore, it would be premature to tell the client that they are "confirmed" to be infected with HIV without further confirmatory testing.

C. "This is a good result, which means you do not have HIV.":
This statement is also incorrect. A positive ELISA test result does not mean that the client does not have HIV. In fact, it indicates potential exposure to the virus. However, because the result is a screening test, it must be followed up with confirmatory testing. Telling the client that this is a "good result" would be misleading and could cause confusion or delay in appropriate care.

D. "Your result will need to be confirmed with a Western blot test.":
This is the correct response. The Western blot test is the confirmatory test used to verify a positive result from the ELISA. If the ELISA result is positive, the client should be informed that further testing, such as the Western blot, is needed to confirm the diagnosis of HIV infection. It is important to explain that the ELISA is a screening tool, and a positive result does not mean a definitive diagnosis without confirmation. This helps to set realistic expectations and ensures the client receives the appropriate follow-up care.

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Correct Answer is B

Explanation

A) Simvastatin: Simvastatin is a medication used to lower cholesterol levels and does not typically require monitoring of blood pressure before or after administration. While statins may have some indirect cardiovascular benefits, blood pressure is not directly affected by this medication, so it is not necessary to assess blood pressure before or after administering simvastatin.

B) Metoprolol: This is the correct answer. Metoprolol is a beta-blocker commonly used to treat hypertension and other cardiovascular conditions. It works by reducing heart rate and blood pressure. Therefore, it is important to assess the client's blood pressure both before and after administering metoprolol to ensure the medication is having the desired effect and to detect any adverse changes, such as hypotension or bradycardia.

C) Acetylsalicylic Acid (Aspirin): Aspirin is primarily used for its antiplatelet effect, such as for preventing heart attacks or strokes, and it does not have a significant direct impact on blood pressure. While aspirin can have side effects, such as gastrointestinal irritation or bleeding, blood pressure monitoring is generally not necessary before or after administering aspirin.

D) Metformin: Metformin is used to manage type 2 diabetes by helping control blood glucose levels. It does not directly affect blood pressure, so routine blood pressure assessment is not required before or after giving metformin. However, monitoring for side effects like gastrointestinal distress or lactic acidosis is important, but blood pressure is not a priority for this medication.

A. Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain B. Urine output of 40 mL/hr and clear yellow after having their Foley catheter removed C. Patient ambulating short distances and performing range of motion exercises alter pain is controlled D. Hypoactive bowel sounds 2 hours post-operative.

Correct Answer is A

Explanation

A) Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain:
The patient’s refusal to perform these respiratory exercises could lead to serious complications such as atelectasis, pneumonia, and other respiratory issues. Coughing, deep breathing, and using the incentive spirometer are essential to prevent postoperative respiratory complications, especially if the patient is at higher risk for lung issues due to immobility or anesthesia. This needs immediate intervention to ensure the patient understands the importance of these activities and to address the pain issue, potentially with additional pain management or support.

B) Urine output of 40 mL/hr and clear yellow after having their Foley catheter removed:
A urine output of 40 mL/hr is within normal limits for a post-operative patient, and the clear yellow color indicates that the urine is not concentrated or indicative of infection. While monitoring urine output is important postoperatively, this finding suggests adequate renal function and does not indicate an immediate risk for long-term complications.

C) Patient ambulating short distances and performing range of motion exercises after pain is controlled:
Early ambulation and range of motion exercises are encouraged after surgery to promote circulation, prevent blood clots, and support overall recovery. It indicates that the patient is progressing in their recovery and actively participating in post-operative rehabilitation, which is a positive sign and does not need urgent intervention.

D) Hypoactive bowel sounds 2 hours post-operatively:
This is expected immediately after surgery, especially if the patient underwent abdominal surgery or received general anesthesia, which can temporarily reduce bowel motility. Hypoactive bowel sounds within the first few hours post-surgery are a normal response to anesthesia and do not require urgent intervention. The nurse should continue to monitor the patient’s bowel function, but this finding is not a priority in the immediate postoperative period.

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A client is tested for human immunodeficiency virus (HIV) infection with an enzyme- linked immunosorbent assay (ELISA), and the test result & positive. What would the nurse tell the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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