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Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 53-2
Question 24Type: SEQWhen considering guidelines for teaching about safer sex, how would the nurse rank the risk for HIV transmission from highest to lowest?Standard Text: Click and drag the options below to move them up or down.Choice 1. Heterosexual intercourse between partners using latex condomsChoice 2. AbstinenceChoice 3. Monogamous sex between partners who are both EIA and Western Blot negativeChoice 4. Anal intercourse between partners using latex condomsCorrect Answer: 4,1,3,2Rationale 1: Heterosexual intercourse between partners using latex condoms is the second riskiest behavior of these choices.Rationale 2: Abstinence carries the lowest risk and is the safest practice.Rationale 3: Monogamous sex between partners who are both EIA and Western Blot negative still carries some small risk.Rationale 4: Anal intercourse is damaging to sensitive tissues, increasing trauma and the risk of transmission.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Reduction of Risk PotentialNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 53-3Question 25Type: MCMAA patient had no skin reaction to a purified protein derivative (PPD) screen. When discussing this result, the patient tells the nurse that she is HIV positive. What information should the nurse provide?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. “As this is the first PPD you have ever had, you should have it repeated in 2 weeks.”
2. “You have not contracted TB.”3. “Your skin test may not be valid.”4. “You should have a chest X-ray.”5. “Additional laboratory tests are indicated.”Correct Answer: 3,4,5Rationale 1: Two-step PPD tests are commonly done but are not indicated for this patient.Rationale 2: In a patient diagnosed with HIV, the PPD test will likely be negative. The immune system must be intact for the classic response to occur.Rationale 3: The patient’s immune system is involved in the response to a PPD. Patients diagnosed with HIV may not respond.Rationale 4: A screening chest X-ray should be done for patients who are HIV positive and who are exposed to TB.Rationale 5: Acid-fast bacillus testing or sputum, blood, or cerebral spinal fluid may be used to diagnose the presence of TB.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 53-4