A nurse is counseling a client who is to undergo enzyme-linked immunosorbent assay (ELISA) testing for HIV. Which of the following information should the nurse include?
The test monitors the progression of the disease
The test measures antibodies to the virus
The test results are accurate 24 hours after exposure to the virus
A positive result requires initiating immunoglobulin administration
The Correct Answer is B
Choice A reason: The test does not monitor the progression of the disease, as it only detects the presence of antibodies to HIV, not the amount of virus or the damage to the immune system. Other tests, such as viral load and CD4 count, are used to monitor the progression of HIV infection and the response to treatment.
Choice B reason: The test measures antibodies to the virus, which are produced by the immune system in response to HIV infection. The test is used to screen for HIV infection and to confirm the diagnosis. A positive result indicates that the person has been exposed to HIV and has developed antibodies to the virus.
Choice C reason: The test results are not accurate 24 hours after exposure to the virus, as it takes time for the body to produce enough antibodies to be detected by the test. The window period, which is the time between exposure to HIV and a positive test result, varies from person to person, but it can range from 3 weeks to 3 months. Therefore, a negative result does not necessarily rule out HIV infection, and a repeat test may be needed after the window period.
Choice D reason: A positive result does not require initiating immunoglobulin administration, as immunoglobulin is not a treatment for HIV infection. Immunoglobulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not affect HIV. A positive result requires further confirmation by a more specific test, such as the Western blot, and referral to a specialist for treatment and counseling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Asking the client if they have been thinking about harming themselves is not the best response, as it may sound accusatory or judgmental. It may also make the client defensive or reluctant to share their feelings. The nurse should assess the client's suicide risk later, after establishing rapport and trust.
Choice B reason: Asking the client how long they have been feeling this way is not the most appropriate response, as it may imply that the nurse is more interested in the duration of the problem than the client's current situation. It may also suggest that the nurse expects the client to have a clear timeline of their feelings, which may not be the case.
Choice C reason: Telling the client to share what is going on with them right now is the best response, as it shows empathy and genuine interest in the client's perspective. It also invites the client to express their thoughts and emotions, and helps the nurse identify the factors that contribute to the client's sense of meaninglessness.
Choice D reason: Asking the client if they really think their life has no purpose is not a helpful response, as it may sound dismissive or sarcastic. It may also make the client feel invalidated or misunderstood, and reinforce their negative beliefs. The nurse should avoid challenging the client's statements, and instead explore the reasons behind them.
Correct Answer is D
Explanation
Choice A reason: A child who has a BMI of 18 is not the highest priority, as it is within the normal range for children. BMI, or body mass index, is a measure of weight relative to height. A BMI of 18 is considered healthy for children aged 2 to 20 years, according to the Centers for Disease Control and Prevention (CDC). The nurse should monitor the child's growth and development and provide nutrition education as needed.
Choice B reason: An adolescent who has scoliosis is not the highest priority, as it is a common and usually mild condition. Scoliosis is a sideways curvature of the spine that affects about 3% of adolescents. Most cases of scoliosis are mild and do not require treatment, although some may need braces or surgery. The nurse should refer the adolescent to a specialist for further evaluation and management.
Choice C reason: An adolescent who has psoriasis is not the highest priority, as it is a chronic and non-contagious condition. Psoriasis is a skin disorder that causes red, scaly patches on the skin that may itch or burn. Psoriasis is not curable, but it can be controlled with medications, creams, or light therapy. The nurse should provide education and support to the adolescent and encourage them to seek medical care as needed.
Choice D reason: A child who has nits is the highest priority, as it indicates a parasitic infestation that can spread to others. Nits are the eggs of head lice, which are tiny insects that live on the scalp and feed on blood. Head lice can cause itching, irritation, and infection of the scalp. The nurse should isolate the child and notify the parents and the school staff. The nurse should also provide instructions on how to treat the infestation and prevent reinfestation.
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