The nurse is evaluating the goal "Patient will remain free of opportunistic infections" for an HIV-positive pregnant patient
The nurse determines the goal was met when the patient: Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Has an absolute CD4+ T-lymphocyte count below 200.
2. Has no complaint of chills or fever during the pregnancy.
3. Has a weight gain of 30 lbs. during the pregnancy.
4. Has a white blood cell count of 2500 at 30 weeks' gestation.
5. Maintains a normal erythrocyte sedimentation rate during the pregnancy.
2,3,5
Rationale 1: The absolute CD4+ T-lymphocyte count must remain above 200 to protect against opportunistic infections.
Rationale 2: Not having chills, fever, or a sore throat throughout the pregnancy is an indication the patient did not have an infection.
Rationale 3: Twenty-five to thirty pounds in weight gain is normal for a pregnancy. This patient met the goal for nutrition and remaining infection-free.
Rationale 4: This is a low white blood cell count, and indicates the patient is at risk for developing an infection.
Rationale 5: Having a normal erythrocyte sedimentation rate during the pregnancy is an expected outcome.
You might also like to view...
A nurse cares for a pregnant client who has a family history of sickle cell disease. The client is unsure if she wants to participate in genetic testing. What action should the nurse take?
a. Provide information about the risks and benefits of genetic testing. b. Empathize with the client and share a personal story about a hereditary disorder. c. Teach the client that early detection can minimize transmission to the fetus. d. Advocate for the client and her baby by encouraging genetic testing.
A patient who is taking delavirdine (Rescriptor) as part of combination therapy for human im-munodeficiency virus (HIV) complains of rash, fever, and headache. Which of the following in-terpretations is accurate regarding this patient's symptoms?
a. This patient's symptoms are most compatible with a frequent adverse drug effect. b. This patient's symptoms are most compatible with lack of adherence to dosing schedule. c. This patient's symptoms are most compatible with a hypersensitivity reaction to the drug. d. This patient's symptoms are most compatible with worsening of the HIV infec-tion.
Which of the following changes in functioning of the gastrointestinal tract occurs with aging?
a. increased sensitivity to taste c. increased peristalsis b. increased saliva pro-duction d. increased likelihood for constipation
A patient had an epidural inserted 2 hours ago. It is functioning well, the patient is stable, and labor is progressing
Which parts of the assessment have the highest priority? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess blood pressure every hour. 2. Assess the pulse rate every hour. 3. Palpate the bladder. 4. Auscultate the lungs. 5. Assess the reflexes.