Test 2 Flashcards
A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, “I hate the way I look! I never go anyplace except here to the health clinic.” An appropriate nursing diagnosis for the patient is
a. activity intolerance related to fatigue and inactivity.
b. impaired skin integrity related to itching and skin sloughing.
c. social isolation related to embarrassment about the effects of SLE.
d. impaired social interaction related to lack of social skills.
c
Rationale: The patient’s statement about not going anyplace because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE.
A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care?
a. Institute seizure precautions.
b. Reorient to time and place PRN.
c. Monitor intake and output.
d. Place on cardiac monitor.
Answer: C
Rationale: Lupus nephritis is a common complication of SLE, and when the patient is taking corticosteroids, it is especially important to monitor renal function. There is no indication that the patient is experiencing any nervous system or cardiac problems with the SLE.
Following instruction for a patient with newly diagnosed systemic lupus erythematosus (SLE), the nurse determines that teaching about the disease has been effective when the patient says,
a. “I should expect to have a low fever all the time with this disease.”
b. “I need to restrict my exposure to sunlight to prevent an acute onset of symptoms.”
c. “I should try to ignore my symptoms as much as possible and have a positive outlook.”
d. “I can expect a temporary improvement in my symptoms if I become pregnant.”
Answer: B
Rationale: Sun exposure is associated with SLE exacerbation, and patients should use sunscreen with an SPF of at least 15 and stay out of the sun between 11:00 AM and 3:00 P
- vaccines are safe for people with SLE
- exception is the need to avoid live viruses with clients who are being treated with corticosteroids or cytotoxic agents
c
A patient who seeks health care for vague symptoms of fatigue and headaches has HIV testing and is found to have a positive enzyme immunoassay (EIA) for HIV antibodies. In discussing the test results with the patient, the nurse informs the patient that
a. the enzyme immunoassay test will need to be repeated to verify the results.
b. a viral culture will be done to determine the progress of the disease.
c. it will probably be 10 or more years before the patient develops AIDS.
d. the Western blot test will need to be done to determine whether AIDS has developed.
A
Rationale: After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not part of HIV testing. Because the nurse does not know how recently the patient was infected, it is not appropriate to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.
Four years after seroconversion, an HIV-infected patient has a CD4+ cell count of 800/µl and a low viral load. The nurse teaches the patient that
a. the patient is at risk for development of opportunistic infections because of CD4+
cell destruction.
b. the patient is in a clinical and biologic latent period, during which very few viruses are being replicated.
c. anti-HIV antibodies produced by B cells enter CD4+ cells infected with HIV to stop replication of viruses in the cells.
d. the body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity.
D
Rationale: The patient is the early chronic stage of infection, when the body is able to produce enough CD4+ cells to maintain the CD4+ count at a normal level. The risk for opportunistic infection is low because of the normal CD4+ count. Although the viral load in the blood is low, intracellular reproduction of virus still occurs. Anti-HIV antibodies produced by B cells attack the viruses in the blood, but not intracellular viruses.
A patient who tested positive for HIV 3 years ago is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP). Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), the patient is diagnosed as having
a. early chronic infection.
b. HIV infection.
c. AIDS.
d. intermediate chronic infection.
C
Rationale: Development of PCP pneumonia meets the diagnostic criterion for AIDS. The other responses indicate an earlier stage of HIV infection than is indicated by the PCP infection.
During posttest counseling for a patient who has positive testing for HIV, the patient is anxious and does not appear to hear what the nurse is saying. At this time, it is most important that the nurse
a. inform the patient how to protect sexual and needle-sharing partners.
b. teach the patient about the medications available for treatment.
c. ask the patient to notify individuals who have had risky contact with the patient.
d. remind the patient about the need to return for retesting to verify the results.
D
Rationale: After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals.
A patient who is diagnosed with AIDS and has developed Kaposi’s sarcoma tells the nurse, “I have lots of thoughts about dying. Do you think I am just being morbid?” Which response by the nurse is most appropriate?
a. “Thinking about dying will not improve the course of AIDS.”
b. “Although your diagnosis is serious, there are more treatments available now.”
c. “Try to focus on the good things in life because stress impairs the immune system.”
d. “Tell me what kind of thoughts you have about dying.”
D
Rationale: More assessment of the patient’s psychosocial status is needed before taking any other action. The statements, “Thinking about dying will not improve the course of AIDS” and “Try to focus on the good things in life …” discourage the patient from sharing any further information with the nurse and decrease the nurse’s ability to develop a trusting relationship with the patient. The statement, “Although your diagnosis is serious, there are more treatments available now” is correct, but without further assessment, it is impossible to know whether this responds to the patient’s concerns.
A pregnant woman with a history of asymptomatic HIV infection is seen at the clinic. Which information will the nurse include when teaching the patient?
a. Although infants of HIV-infected mothers always test positive for HIV antibodies, most infants are not infected with the virus.
b. Because she has not developed AIDS, the infant will not contract HIV during intrauterine life.
c. The infant will be started on zidovudine (AZT) after delivery to prevent HIV infection.
d. It is likely that her newborn will develop HIV infection unless she takes antiretroviral drugs during the pregnancy.
A
Rationale: Because antibodies are transmitted from the mother to the fetus during intrauterine life, all infants of HIV-positive mothers will test positive at birth. Ongoing antibody (or viral) testing is needed to determine whether the infant is infected with HI
Interventions such as promotion of nutrition, exercise, and stress reduction should be promoted by the nurse for patients who have HIV infection, primarily because these interventions will
a. promote a feeling of well-being in the patient.
b. prevent transmission of the virus to others.
c. improve the patient’s immune function.
d. increase the patient’s strength and self-care ability.
C
Rationale: The primary goal for the patient with HIV infection is to increase immune function, and these interventions will promote a healthy immune system
The occupational health nurse will teach the nursing staff that the highest risk of acquiring HIV from an HIV-infected patient is
a. a needlestick with a suture needle during a surgical procedure.
b. contamination of open skin lesions with vaginal secretions.
c. a needlestick with a needle and syringe used to draw blood.
d. splashing the eyes when emptying a bedpan containing stool.
C
Rationale: Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient’s blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.
Drug therapy is being considered for an HIV-infected patient who has a CD4+ cell count of 400/µl. The nursing assessment that is most important in determining whether therapy will be used is the patient’s
a. social support system offered by significant others and family.
b. socioeconomic status and availability of medical insurance.
c. understanding of the multiple side effects that the drugs may cause.
d. willingness and ability to comply with stringent medication schedules.
D
Rationale: Drug resistance develops quickly unless the patient takes multiple drugs on a stringent schedule, and this endangers both the patient and the community.
A patient has recently tested positive for HIV and asks the nurse about drug therapy for HIV infection. The nurse informs the patient that
a. drug therapy for HIV is indicated only for patients whose CD4+ cell counts indicate that AIDS has developed.
b. medication therapy is delayed as long as possible to prevent development of viral resistance to the drugs.
c. treatment is individualized based on CD4+ counts, the amount of virus in the blood, and the patient’s wishes.
d. ART is typically started soon after HIV diagnosis to prevent progression of the disease.
C
Rationale: ART is typically considered when the CD4+ count drops below normal levels or the viral load is high in patients who are appropriate for ART and desire ART. ART is used to prevent the progression to AIDS and is used in patients who have AIDS. ART is not delayed as long as possible but can be started when the CD4+ counts are relatively high in some patients. ART is not started soon after HIV diagnosis; rather, it is started when CD4+ count, viral load, or patient symptoms indicate that it will be beneficial.
Which of these patients will the nurse working in an HIV testing and treatment clinic anticipate teaching about ART?
a. A patient who is HIV negative but has unprotected sex with multiple partners
b. A patient who has been HIV positive for 5 years and has cytomegalovirus (CMV) retinitis
c. A patient who was infected with HIV 15 years ago and has a CD4 count of 740/µl
d. An HIV-positive patient with a CD4 count of 120/µl who drinks a fifth of whiskey daily
B
Rationale: CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not require ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.
When teaching a patient with HIV infection about ART, the nurse explains that these drugs
a. work in various ways to decrease viral replication in the blood.
b. boost the ability of the immune system to destroy the virus.
c. destroy intracellular virus as well as lowering the viral load.
d. increase the number of CD4+ cells available to fight the HIV.
A
Rationale: The three groups of antiretroviral drugs work in different ways to decrease the ability of the virus to replicate. The drugs do not work by boosting the ability of the immune system or CD4 cells to fight the virus. The viral load detected in the blood is decreased with effective therapy, but intracellular virus is still present.
To evaluate the effectiveness of ART, the nurse will schedule the patient for
a. viral load testing.
b. enzyme immunoassay.
c. rapid HIV antibody testing.
d. immunofluorescence assay.
A
Rationale: The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect for HIV antibodies, which remain positive even with effective ART.
When assessing an individual who has been diagnosed with early chronic HIV infection and has a normal CD4+ count, the nurse will
a. ask about problems with diarrhea.
b. examine the oral mucosa for lesions.
c. check neurologic orientation.
d. palpate the regional lymph nodes.
D
Rationale: Persistent generalized lymphadenopathy is common in the early stage of chronic infection.
A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what “type 2” means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes
a. the patient is totally dependent on an outside source of insulin.
b. there is decreased insulin secretion and cellular resistance to insulin that is produced.
c. the immune system destroys the pancreatic insulin-producing cells.
d. the insulin precursor that is secreted by the pancreas is not activated by the liver.
B
Rationale: In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body’s needs or the cells do not respond to the insulin appropriatel
A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dl (6.7 mmol/L). The nurse will plan to teach the patient about
a. use of low doses of regular insulin.
b. self-monitoring of blood glucose.
c. oral hypoglycemic medications.
d. maintenance of a healthy weight.
D
Rationale: The patient’s impaired fasting glucose indicates prediabetes and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabete
During a diabetes screening program, a patient tells the nurse, “My mother died of complications of type 2 diabetes. Can I inherit diabetes?” The nurse explains that
a. as long as the patient maintains normal weight and exercises, type 2 diabetes can be prevented.
b. the patient is at a higher than normal risk for type 2 diabetes and should have periodic blood glucose level testing.
c. there is a greater risk for children developing type 2 diabetes when the father has type 2 diabetes.
d. although there is a tendency for children of people with type 2 diabetes to develop diabetes, the risk is higher for those with type 1 diabetes.
B
Rationale: Offspring of people with type 2 diabetes are at higher risk for developing type 2 diabetes. The risk can be decreased, but not prevented, by maintenance of normal weight and exercisin
When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask?
a. “Have you lost any weight lately?”
b. “Do you crave fluids containing sugar?”
c. “How long have you felt anorexic?”
d. “Is your urine unusually dark-colored?”
A
Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar- containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.
During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will plan to obtain a(n)
a. fasting blood glucose level.
b. urine dipstick for glucose.
c. glycosylated hemoglobin level.
d. oral glucose tolerance test.
C
Rationale: The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days.
The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the
a. thigh.
b. buttock.
c. arm.
d. abdomen.
D
Rationale: Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.
A newly diagnosed type 1 diabetic patient likes to run 3 miles several mornings a week. Which teaching will the nurse implement about exercise for this patient?
a. “You should not take the morning NPH insulin before you run.”
b. “Plan to eat breakfast about an hour before your run.”
c. “Afternoon running is less likely to cause hypoglycemia.”
d. “You may want to run a little farther if your glucose is very high.”
B
Rationale: Blood sugar increases after meals, so this will be the best time to exercise
A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The patient tells the nurse, “I hate to exercise! Can’t I just follow the diet to keep my glucose under control?” The nurse teaches the patient that the major purpose of exercise for diabetics is to
a. increase energy and sense of well-being, which will help with body image.
b. facilitate weight loss, which will decrease peripheral insulin resistance.
c. improve cardiovascular endurance, which is important for diabetics.
d. set a successful pattern, which will help in making other needed changes.
B
Rationale: Exercise is essential to decrease insulin resistance and improve blood glucose control.
A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:00 PM. The clinic nurse teaches the patient to
a. delay eating the noon meal until after the swimming class.
b. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class.
c. time the morning insulin injection so that the peak occurs while swimming.
d. check glucose level before, during, and after swimming.
D
Rationale: The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.
A program of weight loss and exercise is recommended for a patient with impaired fasting glucose (IFG). When teaching the patient about the reason for these lifestyle changes, the nurse will tell the patient that
a. the high insulin levels associated with this syndrome damage the lining of blood vessels, leading to vascular disease.
b. although the fasting plasma glucose levels do not currently indicate diabetes, the glycosylated hemoglobin will be elevated.
c. the liver is producing excessive glucose, which will eventually exhaust the ability of the pancreas to produce insulin, and exercise will normalize glucose production.
d. the onset of diabetes and the associated cardiovascular risks can be delayed or prevented by weight loss and exercise.
D
Rationale: The patient with IFG is at risk for developing type 2 diabetes, but this risk can be decreased with lifestyle change
When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask?
a. “Have you lost any weight lately?”
b. “Do you crave fluids containing sugar?”
c. “How long have you felt anorexic?”
d. “Is your urine unusually dark-colored?”
A
Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar- containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.
During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will plan to obtain a(n)
a. fasting blood glucose level.
b. urine dipstick for glucose.
c. glycosylated hemoglobin level.
d. oral glucose tolerance test.
C
Rationale: The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed.
A patient who has just been diagnosed with type 2 diabetes is 5 ft 4 in (160 cm) tall and weighs 182 pounds (82 kg). A nursing diagnosis of imbalanced nutrition: more than body requirements is developed. Which patient outcome is most important for this patient?
a. The patient will have a diet and exercise plan that results in weight loss.
b. The patient will state the reasons for eliminating simple sugars in the diet.
c. The patient will have a glycosylated hemoglobin level of less than 7%.
d. The patient will choose a diet that distributes calories throughout the day.
C
Rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels.
A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says,
a. “I may have an occasional alcoholic drink if I include it in my meal plan.”
b. “I will need a bedtime snack because I take an evening dose of NPH insulin.”
c. “I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia.”
d. “I may eat whatever I want, as long as I use enough insulin to cover the calories.”
D
Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol.
A patient using a split mixed-dose insulin regimen asks the nurse about the use of intensive insulin therapy to achieve tighter glucose control. The nurse should teach the patient that
a. intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin.
b. intensive insulin therapy is indicated only for newly diagnosed type 1 diabetics who have never experienced ketoacidosis.
c. studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes.
d. an insulin pump provides the best glucose control and requires about the same amount of attention as intensive insulin therapy.
A
Rationale: Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly
A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis (RA). During an acute exacerbation of the patient’s arthritis, the health care provider prescribes prednisone (Deltasone) to control inflammation. The nurse will anticipate that the patient may
a. require administration of insulin while taking prednisone.
b. develop acute hypoglycemia during the RA exacerbation.
c. have rashes caused by metformin-prednisone interactions.
d. need a diet higher in calories while receiving prednisone.
A
Rationale: Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucos
A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. During evaluation of the patient’s technique of SMBG, the nurse identifies a need for additional teaching when the patient
a. chooses a puncture site in the center of the finger pad.
b. washes the puncture site using soap and water.
c. says the result of 130 mg indicates good blood sugar control.
d. hangs the arm down for a minute before puncturing the site.
A
Rationale: The patient is taught to choose a puncture site at the side of the finger pad
A diabetic patient is admitted with ketoacidosis and the health care provider writes all of the following orders. Which order should the nurse implement first?
a. Start an infusion of regular insulin at 50 U/hr.
b. Give sodium bicarbonate 50 mEq IV push.
c. Infuse 1 liter of normal saline per hour.
d. Administer regular IV insulin 30 U.
C
Rationale: The most urgent patient problem is the hypovolemia associated with DKA, and the priority is to infuse IV fluids.
A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNC) is made for a patient with type 2 diabetes who is brought to the emergency department in an unresponsive state. The nurse will anticipate the need to
a. administer glargine (Lantus) insulin.
b. initiate oxygen by nasal cannula.
c. insert a large-bore IV catheter.
d. give 50% dextrose as a bolus.
C
Rationale: HHNC is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient’s blood glucose and would be contraindicated.
A patient receives a daily injection of 70/30 NPH/regular insulin premix at 7:00 AM. The nurse expects that a hypoglycemic reaction is most likely to occur between
a. 8:00 and 10:00 AM.
b. 4:00 and 6:00 PM.
c. 7:00 and 9:00 PM.
d. 10:00 PM and 12:00 AM.
B
Rationale: The greatest insulin effect with this combination occurs mid afternoon. The patient is not at a high risk at the other listed times, although hypoglycemia may occur.
Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient?
a. Fasting blood glucose of 130 mg/dl
b. Noon blood glucose of 52 mg/dl
c. Glycosylated hemoglobin of 6.9%
d. Hemoglobin A1C of 5.8%
B
Rationale: The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient.
Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness?
a. Give the patient a snack of cheese and crackers.
b. Have the patient drink a glass of orange juice or nonfat milk.
c. Administer a continuous infusion of 5% dextrose for 24 hours.
d. Assess the patient for symptoms of hyperglycemia.
A
Rationale: Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar.
