The nurse is reviewing the laboratory results of studies on a 4-month-old infant and notes that the human immunodeficiency virus (HIV) antibody test is positive. The nurse determines that this test result indicates which of the following?
1. The infant has HIV.
2. The infant is infected with the HIV virus.
3. The mother is infected with the HIV virus.
4. This is a significant result, indicating a repeat test in 1 month.
3
Rationale: A positive HIV antibody test result in a child younger than 18 months indicates only that the mother is infected, because maternal IgG antibodies persist in infants for 6 to 9 months and, in some cases, as long as 18 months. "The infant has HIV," "the infant is infected with the HIV virus," and "this is a significant result, indicating a repeat test in 1 month" are incorrect in-terpretations of this laboratory result.
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The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord?
A) Coccyx B) Second lumbar vertebrae C) Eleventh thoracic vertebrae D) Fifth lumbar vertebrae
The nurse is caring for a client with cardiac compromise related to mitral valve impairment. Which outcome of the eroding of the mitral valve is most significant?
A) Presence of a heart murmur B) Heart failure C) Activity intolerance D) Pulmonary congestion
Immediately prior to placing the client on a gurney for surgery, the nurse asks the client to remove the partial plate dentures. The client becomes upset and states, "No one can see me without my teeth. I am so embarrassed by the way I look without them." What is the nurse's best response to the client?
A. "I realize this is hard for you to do. I will ask the nurse in surgery to remove them for you after you go to sleep." B. "Why don't you take them out and drape this washcloth over your face so no one can see you without your teeth?" C. "Leaving your teeth in during surgery may cause injury to you or your teeth. Here is the cup for your dentures. Take them out right before surgery and then you can place them back in your mouth as soon as you wake up." D. "This is just something you have to put up with when you have surgery. No one knows you here so it won't be that embarrassing."
About an hour after the patient has ECT, he complains of having a headache. The nurse should:
a. Notify the physician stat. b. Administer an as needed (prn) dose of acetaminophen. c. Take the patient through a progressive relaxation sequence. d. Advise going to activities to expend energy and relieve tension.