MS2 FINAL EXAM PRACTICE QUESTIONS WITH
CORRECT ANSWERS WITH RATIONALES NEW
UPDATE GRADED A+
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?
• Perianal region and oral mucosa
• Sacral region and lower abdomen
• Scalp and skin over the scapulae
• Axillae and upper thorax --CORRECT ANSWER--Ans: A
Feedback:
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.
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for
Impaired Skin Integrity. What nursing intervention should be included in the
plan of care?
• Maximize the patients fluid intake.
• Provide total parenteral nutrition (TPN).
• Keep the patients bed linens free of wrinkles.
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,• Provide the patient with snug clothing at all times. --CORRECT ANSWER--
Ans: C
Feedback:
Skin surfaces are protected from friction and rubbing by keeping bed linens free
of wrinkles and avoiding tight or restrictive clothing. Fluid intake should be
adequate, and must be monitored, but maximizing fluid intake is not a goal.
TPN is a nutritional intervention of last resort.
A patient who has AIDS has been admitted for the treatment of Kaposis
sarcoma. What nursing diagnosis should the nurse associate with this
complication of AIDS?
• Risk for Disuse Syndrome Related to Kaposis Sarcoma
• Impaired Skin Integrity Related to Kaposis Sarcoma
• Diarrhea Related to Kaposis Sarcoma
• Impaired Swallowing Related to Kaposis Sarcoma --CORRECT ANSWER--
Ans: B
Feedback:
Kaposis sarcoma (KS) is a disease that involves the endothelial layer of blood
and lymphatic vessels. This malignancy does not directly affect swallowing or
bowel motility and it does not constitute a risk for disuse syndrome.
The nurse is caring for a patient who has been admitted for the treatment of
AIDS. In the morning, the patient tells the nurse that he experienced night
sweats and recently coughed up some blood. What is the nurses most
appropriate action?
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,• Assess the patient for additional signs and symptoms of Kaposi sarcoma.
• Review the patients most recent viral load and CD4+ count.
• Place the patient on respiratory isolation and inform the physician.
• Perform oral suctioning to reduce the patients risk for aspiration. --CORRECT
ANSWER--Ans: C Place the patient on respiratory isolation and inform the
physician.
Feedback:
These signs and symptoms are suggestive of tuberculosis, not Kaposi sarcoma;
prompt assessment and treatment is necessary. There is no indication of a need
for oral suctioning and the patients blood work will not reflect the onset of this
opportunistic infection.
A nurse is assessing a 28-year-old man with HIV who has been admitted with
pneumonia. In assessing the patient, which of the following observations takes
immediate priority?
• Oral temperature of 100F
• Tachypnea and restlessness
• Frequent loose stools
• Weight loss of 1 pound since yesterday --CORRECT ANSWER--Ans: B
Feedback:
In prioritizing care, the pneumonia would be assessed first by the nurse.
Tachypnea and restlessness are symptoms of altered respiratory status and need
immediate priority. Weight loss of 1 pound is probably fluid related; frequent
loose stools would not take short-term precedence over a temperature or
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, tachypnea and restlessness. An oral temperature of 100F is not considered a
fever and would not be the first issue addressed.
The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of
Risk for Impaired Skin Integrity Related to Candidiasis. What nursing
intervention best addresses this risk?
• Providing thorough oral care before and after meals
• Administering prophylactic antibiotics
• Promoting nutrition and adequate fluid intake
• Applying skin emollients as needed --CORRECT ANSWER--Ans: A
Feedback:
Thorough mouth care has the potential to prevent or limit the severity of this
infection. Antibiotics are irrelevant because of the fungal etiology. The patient
requires adequate food and fluids, but these do not necessarily prevent
candidiasis. Skin emollients are not appropriate because candidiasis is usually
oral.
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity.
What nursing intervention best addresses this risk?
• Utilize a pressure-reducing mattress.
• Limit the patients physical activity.
• Apply antibiotic ointment to dependent skin surfaces.
• Avoid contact with synthetic fabrics. --CORRECT ANSWER--Ans: A
Feedback:
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CORRECT ANSWERS WITH RATIONALES NEW
UPDATE GRADED A+
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?
• Perianal region and oral mucosa
• Sacral region and lower abdomen
• Scalp and skin over the scapulae
• Axillae and upper thorax --CORRECT ANSWER--Ans: A
Feedback:
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.
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for
Impaired Skin Integrity. What nursing intervention should be included in the
plan of care?
• Maximize the patients fluid intake.
• Provide total parenteral nutrition (TPN).
• Keep the patients bed linens free of wrinkles.
Page 1 of 68
,• Provide the patient with snug clothing at all times. --CORRECT ANSWER--
Ans: C
Feedback:
Skin surfaces are protected from friction and rubbing by keeping bed linens free
of wrinkles and avoiding tight or restrictive clothing. Fluid intake should be
adequate, and must be monitored, but maximizing fluid intake is not a goal.
TPN is a nutritional intervention of last resort.
A patient who has AIDS has been admitted for the treatment of Kaposis
sarcoma. What nursing diagnosis should the nurse associate with this
complication of AIDS?
• Risk for Disuse Syndrome Related to Kaposis Sarcoma
• Impaired Skin Integrity Related to Kaposis Sarcoma
• Diarrhea Related to Kaposis Sarcoma
• Impaired Swallowing Related to Kaposis Sarcoma --CORRECT ANSWER--
Ans: B
Feedback:
Kaposis sarcoma (KS) is a disease that involves the endothelial layer of blood
and lymphatic vessels. This malignancy does not directly affect swallowing or
bowel motility and it does not constitute a risk for disuse syndrome.
The nurse is caring for a patient who has been admitted for the treatment of
AIDS. In the morning, the patient tells the nurse that he experienced night
sweats and recently coughed up some blood. What is the nurses most
appropriate action?
Page 2 of 68
,• Assess the patient for additional signs and symptoms of Kaposi sarcoma.
• Review the patients most recent viral load and CD4+ count.
• Place the patient on respiratory isolation and inform the physician.
• Perform oral suctioning to reduce the patients risk for aspiration. --CORRECT
ANSWER--Ans: C Place the patient on respiratory isolation and inform the
physician.
Feedback:
These signs and symptoms are suggestive of tuberculosis, not Kaposi sarcoma;
prompt assessment and treatment is necessary. There is no indication of a need
for oral suctioning and the patients blood work will not reflect the onset of this
opportunistic infection.
A nurse is assessing a 28-year-old man with HIV who has been admitted with
pneumonia. In assessing the patient, which of the following observations takes
immediate priority?
• Oral temperature of 100F
• Tachypnea and restlessness
• Frequent loose stools
• Weight loss of 1 pound since yesterday --CORRECT ANSWER--Ans: B
Feedback:
In prioritizing care, the pneumonia would be assessed first by the nurse.
Tachypnea and restlessness are symptoms of altered respiratory status and need
immediate priority. Weight loss of 1 pound is probably fluid related; frequent
loose stools would not take short-term precedence over a temperature or
Page 3 of 68
, tachypnea and restlessness. An oral temperature of 100F is not considered a
fever and would not be the first issue addressed.
The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of
Risk for Impaired Skin Integrity Related to Candidiasis. What nursing
intervention best addresses this risk?
• Providing thorough oral care before and after meals
• Administering prophylactic antibiotics
• Promoting nutrition and adequate fluid intake
• Applying skin emollients as needed --CORRECT ANSWER--Ans: A
Feedback:
Thorough mouth care has the potential to prevent or limit the severity of this
infection. Antibiotics are irrelevant because of the fungal etiology. The patient
requires adequate food and fluids, but these do not necessarily prevent
candidiasis. Skin emollients are not appropriate because candidiasis is usually
oral.
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity.
What nursing intervention best addresses this risk?
• Utilize a pressure-reducing mattress.
• Limit the patients physical activity.
• Apply antibiotic ointment to dependent skin surfaces.
• Avoid contact with synthetic fabrics. --CORRECT ANSWER--Ans: A
Feedback:
Page 4 of 68
