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NR 464 - Exam 3 (Saunders) Questions With Complete Solutions
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NR 464 - Exam 3 (Saunders) Questions With Complete Solutions
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NR 464 - Exam 3 (Saunders) Questions With CompleteSolutions
A CD4 T-cell count is measured in a client newly diagnosed
with human immunodeficiency virus (HIV). In planning care,
the nurse understands that which is accurate regarding the CD4
T-cell count? Select all that apply.
1. Falls in response to a declining viral load
2. Is a primary marker of immunocompetence
3. Plays a role in the cell-mediated immune response
4. Is a direct measure of the magnitude of HIV replication
5. Guides decision making regarding timing of initiation of
treatment Correct Answer 2. Is a primary marker of
immunocompetence
3. Plays a role in the cell-mediated immune response
5. Guides decision making regarding timing of initiation of
treatment
A CD4+ lymphocyte count is performed in a client with human
immunodeficiency virus (HIV) infection. When providing
education about the testing, what should the nurse tell the client?
1. "It establishes the stage of HIV infection."
,2. "It confirms the presence of HIV infection."
3. "It identifies the cell-associated proviral DNA."
4. "It determines the presence of HIV antibodies in the
bloodstream." Correct Answer 1. "It establishes the stage of
HIV infection."
A client admitted to the nursing unit from the hospital
emergency department has a C4 spinal cord injury. In
conducting the admission assessment, what is the nurse's priority
action?
1. Take the temperature.
2. Listen to breath sounds.
3. Observe for dyskinesias.
4. Assess extremity muscle strength. Correct Answer 2. Listen
to breath sounds.
A client arrives in the hospital emergency department with a
closed head injury to the right side of the head caused by an
assault with a baseball bat. The nurse assesses the client
neurologically, looking primarily for motor response deficits
that involve which area?
1. The left side of the body
2. The right side of the body
,3. Both sides of the body equally
4. Cranial nerves only, such as speech and pupillary response
Correct Answer 1. The left side of the body
A client asks the nurse about obtaining a home test kit to test for
human immunodeficiency virus (HIV) status. What should the
nurse tell the client?
1. Home test kits are not available for testing at this time.
2. Home test kits may not be as reliable as laboratory blood
tests.
3. Home test kits are most reliable immediately after a risk event
occurs.
4. Home test kits should not be used; rather, it is important to
contact the health care provider (HCP) with concerns about the
HIV status. Correct Answer 2. Home test kits may not be as
reliable as laboratory blood tests.
A client has a high level of carbon dioxide (CO2) in the
bloodstream, as measured by arterial blood gases. The nurse
anticipates that which underlying pathophysiology can occur as
a result of this elevated CO2?
1. It will cause arteriovenous shunting.
2. It will cause vasodilation of blood vessels in the brain.
, 3. It will cause blood vessels in the circle of Willis to collapse.
4. It will cause hyperresponsiveness of blood vessels in the
brain. Correct Answer 2. It will cause vasodilation of blood
vessels in the brain.
A client has clear fluid leaking from the nose following a basilar
skull fracture. Which finding would alert the nurse that
cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for
glucose. Correct Answer 4. Fluid separates into concentric
rings and tests positive for glucose.
A client has requested and undergone testing for human
immunodeficiency virus (HIV) infection. The client asks what
will be done next because the result of the enzyme-linked
immunosorbent assay (ELISA) has been positive. Which
diagnostic study should the nurse be aware of before responding
to the client?
1. No further diagnostic studies are needed.
2. A Western blot will be done to confirm these findings.
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