A 10-month-old infant has been confirmed with HIV. The nurse knows that:
The infant should be immediately placed on antiretroviral therapy (ART).
The infant should begin ART after turning 12 months old.
Once the infant has a clinical manifestation of AIDS, then ART should begin.
The mother must be mandatorily tested.
The Correct Answer is A
Choice A reason: This statement is correct, as ART is the standard treatment for HIV infection in infants and children, regardless of their age, clinical status, or CD4 count. ART can suppress the viral load, improve the immune function, prevent opportunistic infections, and prolong the survival and quality of life of the infant.
Choice B reason: This statement is incorrect, as delaying ART until the infant turns 12 months old can increase the risk of disease progression, mortality, and drug resistance. The nurse should explain to the parents that early initiation of ART is recommended for all infants with HIV, as they have a high viral load and a rapid decline of CD4 cells.
Choice C reason: This statement is incorrect, as waiting for the infant to have a clinical manifestation of AIDS before starting ART can be too late and ineffective. The nurse should inform the parents that AIDS is the most advanced stage of HIV infection, characterized by severe immunosuppression and life-threatening opportunistic infections. The nurse should emphasize the importance of early diagnosis and treatment of HIV to prevent the development of AIDS.
Choice D reason: This statement is incorrect, as the mother's HIV status is not mandatory to be tested, but voluntary and confidential. The nurse should respect the mother's right to privacy and autonomy, and offer her counseling and testing services if she agrees. The nurse should also educate the mother about the modes of transmission, prevention, and treatment of HIV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Increased stroke volume is not a correct answer as it means that the heart pumps more blood with each contraction. This would result in increased blood pressure and perfusion, not cool extremities, weak pulses, and low urine output.
Choice B reason: Cardiac arrhythmia is not a correct answer as it means that the heart beats irregularly or abnormally. This can cause palpitations, chest pain, or fainting, but not necessarily cool extremities, weak pulses, and low urine output.
Choice C reason: Decreased cardiac output is a correct answer as it means that the heart pumps less blood than the body needs. This can result from a ventricular septal defect, which causes blood to shunt from the left ventricle to the right ventricle, reducing the amount of oxygenated blood that reaches the tissues. This can cause cool extremities, weak pulses, and low urine output, as well as fatigue, poor growth, and shortness of breath.
Choice D reason: Cyanosis is not a correct answer as it means that the skin, lips, or nails turn blue due to low oxygen levels in the blood. This can occur in some cases of ventricular septal defect, especially if there is pulmonary hypertension or a reversal of the shunt. However, cyanosis is not a direct cause of cool extremities, weak pulses, and low urine output.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as sodium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Sodium excess, or hypernatremia, is a condition where the blood sodium level is too high, which can result from excessive intake or loss of water. The symptoms of sodium excess may include thirst, dry mouth, confusion, seizures, or coma.
Choice B reason: This statement is incorrect, as overhydration is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Overhydration, or hypervolemia, is a condition where the body has too much fluid, which can result from excessive intake or retention of water. The symptoms of overhydration may include edema, weight gain, shortness of breath, or crackles in the lungs.
Choice C reason: This statement is correct, as dehydration is the most likely cause of the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Dehydration is a condition where the body loses more fluid than it takes in, which can result from vomiting, diarrhea, fever, or inadequate intake of water. The symptoms of dehydration may include dry skin, sunken eyes, decreased urine output, or lethargy.
Choice D reason: This statement is incorrect, as calcium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Calcium excess, or hypercalcemia, is a condition where the blood calcium level is too high, which can result from hyperparathyroidism, malignancy, or excessive intake of vitamin D or calcium. The symptoms of calcium excess may include nausea, constipation, muscle weakness, or kidney stones.
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