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Prioritization Delegation and Assignment 4th Edition Test Bank

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Prioritization Delegation and Assignment 4th Edition Test Bank 1.A pregnant client diagnosed with human immunodeficiency virus (HIV) is asking about her babys risk of infection. Which of the following does put the newborn at risk? 1. Bottle-feeding 2. Changing diapers 3. Kissing the baby 4. Vaginal birth ANS: 4 Breastfeeding and vaginal birth put the newborn at risk for HIV. HIV cannot be transmitted by changing diapers (feces) or kissing the baby (saliva). PTS:1DIF:Apply REF: Human Immunodeficiency Virus Infection: Etiology 2.A health care provider has accidentally been stuck with a used needle. The health care provider is going to be tested for human immunodeficiency virus (HIV). Which of the following would be the testing schedule for the health care provider? 1. Tested at 2 months, 4 months, and then at 6 months 2. Tested immediately and then again at 2 months 3. Tested immediately and then again at 6 months 4. Tested in 6 months and then again in 1 year ANS: 3 The health care provider should be tested immediately to show if any preexisting infection exists. Seroconversion usually occurs in 1 to 3 months but can take up to 6 months. Testing at 2 months is too late to discover a preexisting infection and can be too early to detect a new infection. Testing at 6 months or 1 year would not detect a preexisting infection. PTS:1DIF:Apply REF: Human Immunodeficiency Virus Infection: Etiology 3. Which of the following CD4+ count would be used to confirm the diagnosis of acquired immunodeficiency syndrome (AIDS)? 1. 155 cells/mcL 2. 255 cells/mcL 3. 455 cells/mcL 4. 755 cells/mcL ANS: 1 A CD4+ count of less than 200 cells/mcL is used as a criterion to establish the diagnosis of AIDS. In cell counts less than 500 to 600 cells/mcL, antiviral therapy should be initiated. Cell counts greater than 600 cells/mcL are in the normal range. PTS:1DIF:Analyze REF:Human Immunodeficiency Virus Infection: Pathophysiology 4. The nurse, planning care for a client diagnosed with human immunodeficiency virus, realizes that the most common infection that occurs in clients with this health problem is: 1. cytomegalovirus infection. 2. Mycobacterium tuberculosis. 3. Pneumocystis carinii pneumonia. 4. Streptococcus pneumoniae. ANS: 3 As the immune system becomes overpowered, opportunistic infections can occur. The most common infection is Pneumocystis carinii pneumonia. The other infections can also occur, but they occur less frequently. PTS:1DIF:Analyze REF: Human Immunodeficiency Virus Infection: Assessment with Clinical Manifestations 5.A client diagnosed with acquired immunodeficiency syndrome (AIDS) 6 years ago has a purple lesion located on the inner thigh. This lesion is most likely to be: 1. AIDS-related syndrome. 2. Burkitts lymphoma. 3. cachexia. 4. Kaposis sarcoma. ANS: 4 Kaposis sarcoma presents as abnormal lesions that appear purple or blue-red in color. They can be found anywhere but are common on the feet, arms, thighs, perineal area, and face. Cachexia is tissue wasting. Burkitts lymphoma is characterized by enlarged lymph nodes. AIDS-related syndrome is a collection of symptoms and infections resulting from the specific damage to the immune system caused by the HIV virus. PTS:1DIF:Analyze REF: Human Immunodeficiency Virus Infection: Assessment with Clinical Manifestations 6.The nurse realizes that which of the following tests can be used to initially identify the presence of human immunodeficiency virus (HIV) antibodies in a client? 1. Enzyme-linked immunosorbent assay (ELISA) 2. Platelet count 3. Red blood cell count 4. Western blot ANS: 1 The ELISA test detects HIV antibodies. The Western blot is used as a confirmatory test to a positive ELISA test. Red blood cell counts and platelet counts are part of standard blood studies. PTS:1DIF:Analyze REF:Human Immunodeficiency Virus Infection: Diagnostic Tests 7.A client diagnosed with acquired immunodeficiency syndrome (AIDS) is sitting alone crying. Which of the following is an appropriate response for the nurse to give? 1. Everything will be okay. 2. Let me call your doctor about your depression. 3. Whats wrong now? 4. Would you like to talk? ANS: 4 Asking the client if he would like to talk allows the client an opportunity to express his feelings. The other responses give the client false reassurance or put off the client. PTS:1DIF:Apply REF: Human Immunodeficiency Virus Infection: Planning and Implementation 8. The nurse is instructing a client on ways to reduce the risk of exposure to the human immunodeficiency virus. Which of the following activities would present the least risk of exposure to this virus

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Prioritization Delegation and
Assignment 4th Edition
LaCharity Test Bank

,Prioritization Delegation and Assignment 4th Edition Test Bank



Chapter 1. Pain MULTIPLE CHOICE

1.A client tells the nurse that she rarely experiences pain, but when she does, she seeks medical
attention. The nurse realizes this client understands that pain is important because it:



1. is a protective system.

2. includes the automatic withdrawal reflex.

3. creates sensitivity to pain.

4. helps with healing.

ANS: 1

Pain is a protective system that includes protection from unsafe behaviors by use of reflexes, memory,
and avoidance. Even though the automatic withdrawal reflex is a part of the pain response, it does not
explain why pain is important. Pain does not create sensitivity to pain. Pain does not help with healing.

PTS: 1 DIF: Analyze REF: Definitions and Implications of Pain

2.A client complains that the bed sheets touching his skin are extremely painful. The nurse realizes this
client is experiencing:



1. allodynia.

2. modulation.

3. kinesthesia.

4. proprioception.

ANS: 1

Allodynia or hyperalgesia is a state where a slight or nonpainful stimulus is interpreted as very painful.
Kinesthesia is the awareness of movement. Proprioception is the awareness of body position.
Modulation is an influencing factor in the perception of pain.

PTS: 1 DIF: Analyze REF: Peripheral Nervous System

3.A client is complaining of severe abdomen pain. The nurse realizes this client is experiencing which
type of pain?



1. Neuralgia

,2. Pathological

3. Somatic

4. Visceral

ANS: 4

Visceral pain is pain arising from the body organs or gastrointestinal tract. Somatic pain is pain that
originates from the bone, joints, muscles, skin, or connective pain. Neuralgia and



pathological pain are both types of pain that result from injury to a nerve or malfunction of the neuronal
transmission process or due to impaired regulation.

PTS:1DIF:AnalyzeREF:Types of Pain

4.A client, diagnosed with acute appendicitis, is experiencing abdominal pain. The best way for the nurse
to describe this clients pain would be:



1. chronic.

2. neuropathic.

3. referred.

4. acute.

ANS: 4

Acute pain onset is sudden and of short duration. Chronic pain is a sudden or slow onset of mild to
severe pain that lasts longer than 6 months. Referred pain is the result of the transfer of visceral pain
sensations to a body surface at a distance from the actual origin. Neuropathic pain is paroxysmal pain
that occurs along the branches of a nerve.

PTS:1DIF:ApplyREF:Types of Pain

5.A client is observed holding a pillow over the abdominal region with both knees flexed in a side-lying
position. Vital signs assessment reveals an elevated blood pressure and heart rate. Which of the
following should the nurse say to this client?



1. Can I get you anything?

2. Would you like something for pain?

3. You look comfortable.

4. Your blood pressure is up.

ANS: 2

, Sympathetic responses to pain include elevated blood pressure and heart rate. And since the client is
hugging a pillow over the abdominal region with both knees flexed in a side-lying position, the best thing
for the nurse to say to this client is Would you like something for pain? The other responses are
incorrect because they do not acknowledge that the client is experiencing pain.

PTS: 1 DIF: Apply REF: Assessing the Clinical Manifestations of Pain

6.A client experiencing chronic pain asks the nurse why she is not prescribed Demerol like she received
when she had a total knee replacement. Which of the following should the nurse respond to this client?



1. You dont need something that strong.

2. That medication does not exist anymore.

3. That medication does not last very long.

4. It can cause you have high blood pressure.



ANS: 3

Meperidine is no longer a major drug for acute or chronic pain due to its short analgesic duration of 2 to
3 hours and the potential for accumulative toxic effects of its metabolite, normeperidine. The best
response for the nurse to make to the client would be that medication does not last very long. The other
responses are inaccurate.

PTS:1DIF:ApplyREF:Opioid Analgesics

7.A client is informed that a tricyclic antidepressant medication is going to help control his chronic pain.
The nurse would expect the physician to prescribe:



1. Amitriptyline.

2. Baclofen.

3. Gabapentin.

4. Diazepam.

ANS: 1

Amitriptyline is an antidepressant. Gabapentin is an anticonvulsant. Baclofen is a muscle relaxant.
Diazepam is a benzodiazepine.

PTS: 1 DIF: Analyze REF: Adjuvant Medications

8.A client receiving around-the-clock medication for terminal cancer experiences additional pain when
performing activities of daily living. The nurse realizes this client is experiencing:

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