Question

The nurse is preparing a teaching plan for a group of well-educated clients who were found to be HIV positive within the last year. Members of the group express an interest in learning about the pathology of the AIDS virus. The nurse should explain that the human immunodeficiency virus (HIV) acts in which way to suppress the immune system?

Answer 1

Correct Answers:

Destruction of helper T-cells and CD4 cells.

Rationale :

🦠HIV primarily attacks helper T-cells, especially CD4 cells, which are essential in coordinating the body’s immune response.

🛡️When CD4 cells are progressively destroyed, the immune system loses its ability to activate other important defense mechanisms such as B-cell and cytotoxic T-cell responses.

🔬This decline in immune function makes the client more vulnerable to opportunistic infections and certain cancers that a healthy immune system would normally control.

📘Because the main pathologic action of HIV is the destruction of helper T-cells/CD4 cells, this option best explains how the virus suppresses immunity.

📌Core Message

HIV suppresses immunity mainly by destroying helper T-cells and CD4 cells, weakening the body’s coordinated immune defense.

Answer 2

Correct Answers:

Auscultate the client's bowel sounds.

Rationale :

💊Hydromorphone is an opioid analgesic, and one of its most common adverse effects is decreased gastrointestinal motility.

💁‍♂️With several days of regular opioid use, the client is at increased risk for constipation and possible ileus, so assessment of bowel sounds is especially important.

⚠️Although opioids can affect other body systems, prolonged suppression of bowel function is a very common and clinically significant complication that requires ongoing nursing assessment.

📘Because the client has been receiving hydromorphone for four days, auscultating bowel sounds is the most important assessment among the options provided.

📌Core Message

With ongoing hydromorphone therapy, the nurse should prioritize assessment of bowel sounds because opioids commonly reduce gastrointestinal motility.

Answer 3

Correct Answers:

I should use this medication in its HandiHaler every day.

Rationale :

💁‍♂️Tiotropium is a long-acting anticholinergic bronchodilator used for maintenance treatment in clients with COPD.

📅Because it is a maintenance medication, it must be taken every day as prescribed to help keep the airways open and reduce bronchospasm over time.

🚫Tiotropium is not a rescue inhaler, so it should not be relied on for sudden episodes of shortness of breath.

📘The statement showing correct understanding is that the client will use the medication in the HandiHaler every day, which reflects proper routine use of this maintenance drug.

📌Core Message

Tiotropium is a daily maintenance bronchodilator for COPD and should be used regularly in its HandiHaler.

Answer 4

Correct Answers:

Review food labels for sodium content.

Rationale :

🧂Hypernatremia means there is an elevated serum sodium level, so discharge teaching should include strategies to reduce excess sodium intake.

📦Reviewing food labels helps the client identify hidden dietary sodium sources, especially in processed and packaged foods.

💧Although adequate fluid intake is important, simply drinking when thirsty may not be enough teaching for correcting or preventing recurrent hypernatremia, particularly if high sodium intake continues.

📘Because lowering excess sodium consumption is a key part of prevention, the best discharge instruction is to review food labels for sodium content.

📌Core Message

For hypernatremia, discharge teaching should emphasize reducing dietary sodium, including checking food labels for sodium content.

Answer 5

Correct Answers:

Decrease speaking speed.

Rationale :

👂In an older adult with possible hearing impairment, the nurse should improve clarity of communication rather than simply making speech louder.

🗣️Decreasing speaking speed helps the client distinguish words more clearly, especially when age-related hearing loss affects the ability to process rapid speech.

⚠️Shouting or over-enunciating can distort normal speech sounds and may actually make understanding more difficult for the client.

📘Because slowing the rate of speech improves comprehension without distorting verbal messages, the best action is to decrease speaking speed.

📌Core Message

For an older client with hearing difficulty, the nurse should improve communication clarity by decreasing speaking speed rather than shouting.

Answer 6

Correct Answers:

Primes the inhaler with 7 pumps.

Rationale :

💁‍♂️Ipratropium is a bronchodilator used in COPD management, and correct inhaler technique is necessary for effective medication delivery.

📦The client may attach a spacer device, rinse the mouth after use, and store the medication at room temperature, all of which are appropriate practices depending on the inhaler type and routine care.

⚠️Priming an ipratropium inhaler with 7 pumps indicates incorrect technique because standard priming directions do not require that many sprays and excessive priming wastes medication.

📘Because incorrect priming reduces proper medication use and reflects misunderstanding of inhaler instructions, this action shows that additional teaching is needed.

📌Core Message

Incorrect priming technique with an ipratropium inhaler indicates the need for additional teaching about proper medication use.

Answer 7

Correct Answers:

Recent oral intake.

Rationale :

💊Pyridostigmine is an anticholinesterase medication used to improve muscle strength in clients with myasthenia gravis.

🍽️The timing of pyridostigmine is closely related to mealtimes because improved muscle strength is needed to support chewing and swallowing safely.

💁‍♂️Obtaining information about recent oral intake helps the nurse plan medication administration to maximize the client’s ability to eat and reduce the risk of aspiration.

📘Because effective scheduling of pyridostigmine is linked to food intake and swallowing function, the nurse should obtain information about recent oral intake before giving the medication.

📌Core Message

Before giving pyridostigmine, the nurse should assess recent oral intake so the medication can best support safe eating and swallowing.

Answer 8

Correct Answers:

Complete head to toe neurological assessment.

Rationale :

🧠The findings of confusion and projectile vomiting after a fall suggest possible increased intracranial pressure or an acute neurological injury.

⚠️The nurse must first perform a focused yet comprehensive neurological assessment to identify the client’s current status and detect urgent changes that may require immediate intervention.

📋Although a prior baseline is useful, the most urgent priority is assessing the client’s present neurological function so deterioration can be recognized promptly.

📘Because the client is showing signs of possible acute brain injury, the nurse should first complete a head-to-toe neurological assessment.

📌Core Message

After a fall with confusion and projectile vomiting, the nurse should first perform a neurological assessment to identify possible acute brain injury.

Answer 9

Correct Answers:

Obtain a pulse oximetry reading.

Rationale :

💁‍♂️When a client with COPD suddenly develops dyspnea, tachypnea, and coughing, the nurse should next assess the severity of the respiratory problem after positioning.

📟Obtaining a pulse oximetry reading provides immediate information about the client’s current oxygen saturation and helps guide further interventions.

⚖️Assessment should come before treatments such as humidification, coughing coaching, or a nebulizer unless there is evidence of severe distress requiring emergency action.

📘Because the nurse needs objective data about the client’s oxygenation status to direct safe care, the next action is to obtain a pulse oximetry reading.

📌Core Message

After positioning a client with COPD upright, the nurse should next assess oxygenation by obtaining a pulse oximetry reading.

Answer 10

Correct Answers:

Provide an eye shield to be worn while sleeping.

Rationale :

👁️After eye surgery, protecting the operative site from accidental trauma is an immediate postoperative priority.

🛡️An eye shield helps prevent the client from rubbing, bumping, or placing pressure on the affected eye, especially during sleep.

⚠️Activities such as coughing can increase intraocular pressure, so encouraging deep breathing with coughing is not the best immediate intervention after this procedure.

📘Because protection of the healing eye is essential right after surgery, the nurse should provide an eye shield to be worn while sleeping.

📌Core Message

After eye surgery, the nurse should immediately protect the operative eye with an eye shield during sleep.

2 :
The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

3 :
A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

4 :
Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

5 :
An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

6 :
A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

7 :
A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

8 :
A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

9 :
The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

10 :
A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

2 : The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

3 : A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

4 : Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

5 : An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

6 : A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

7 : A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

8 : A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

9 : The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

10 : A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

2 :
The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

3 :
A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

4 :
Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

5 :
An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

6 :
A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

7 :
A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

8 :
A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

9 :
The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

10 :
A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?