A client who abused intravenous drugs was diagnosed with the human Immunodeficiency virus (HIV) several years ago.
The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client:
Develops an acute retroviral syndrome
Has a CD4+ T lymphocyte level of less than 200 cells/mm
Is capable of transmitting the virus to others
Contracts HIV-specific antibodies A nurse is caring for a client who has been diagnosed as HIV positive.
The Correct Answer is B
Choice A rationale:
Acute retroviral syndrome (ARS) is an early stage of HIV infection that often presents with flu-like symptoms. It does not determine AIDS diagnosis.
Choice B rationale:
A CD4+ T lymphocyte level of less than 200 cells/mm is a defining criterion for AIDS diagnosis. This low count indicates a severely weakened immune system, leading to susceptibility to opportunistic infections and other AIDS-defining illnesses.
Choice C rationale:
A person with HIV can transmit the virus to others regardless of their CD4+ T cell count. Transmission risk is not a diagnostic criterion for AIDS.
Choice D rationale:
HIV-specific antibodies are produced by the immune system in response to HIV infection but their presence does not signify AIDS progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Losing 2 pounds in 2 weeks is not a significant weight loss and may not be a cause for concern in this context. It's important to monitor weight trends over time, but this isolated statement doesn't necessarily require immediate discussion.
Choice B rationale:
Engaging in physical activity like swimming is generally beneficial for individuals with rheumatoid arthritis. It can help improve joint mobility, reduce pain, and enhance overall well-being. The nurse might encourage the client to discuss any specific concerns or limitations with their healthcare provider, but the activity itself is not alarming.
Choice C rationale:
Taking an antibiotic concurrently with naproxen can potentially increase the risk of adverse effects. Some antibiotics, like those in the fluoroquinolone class (e.g., ciprofloxacin, levofloxacin), can interact with naproxen and increase the risk of tendonitis or tendon rupture. This interaction warrants further discussion to ensure the client is aware of potential risks and to explore alternative medications if necessary.
Choice D rationale:
Using applesauce to facilitate medication intake is a common and acceptable practice. It does not affect the absorption or efficacy of naproxen.
Correct Answer is A
Explanation
Choice A rationale:
Coughing and deep breathing are essential for mobilizing and removing secretions from the airways, which is crucial for improving airway clearance in patients with pneumonia. These techniques help to loosen mucus and bring it up from the lungs, allowing it to be expelled through coughing.
Hydration maintenance is also critical because it helps to thin secretions, making them easier to cough up. Adequate hydration helps to keep mucus moist and less sticky, which promotes easier expectoration.
Choice B rationale:
Keeping the head of the bed elevated can help to improve oxygenation and reduce the work of breathing, but it does not directly address the issue of airway clearance. It may be a helpful adjunct intervention, but it's not the priority for this specific nursing diagnosis.
Choice C rationale:
Preparation for insertion of a tracheostomy tube is a more invasive intervention that may be necessary in severe cases of airway obstruction, but it is not the first-line intervention for ineffective airway clearance related to pneumonia. It would be considered if other measures fail to maintain adequate ventilation.
Choice D rationale:
Providing supplemental oxygen can help to improve oxygenation in patients with pneumonia, but it does not directly address the issue of airway clearance. It's important to support oxygenation, but it's not the primary intervention to clear secretions.
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