When administering azoles in the home setting, the home health nurse should prioritize educational interventions that address what nursing diagnosis?
- A. Risk for injury related to antifungal therapy
- B. Risk for acute confusion related to antifungal therapy
- C. Risk for infection related to antifungal therapy
- D. Risk for falls related to antifungal therapy
Correct Answer: A
Rationale: The correct answer is A: Risk for injury related to antifungal therapy. When administering azoles, the priority is to educate patients and caregivers about potential side effects that could lead to injury, such as hepatotoxicity or allergic reactions. Choices B, C, and D are incorrect because acute confusion, infection, and falls are not typically associated with azole therapy.
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Right-sided heart failure is characterized by:
- A. Immunosuppression
- B. Pulmonary edema
- C. Peripheral edema
- D. Coughing
Correct Answer: C
Rationale: Right-sided heart failure is characterized by peripheral edema, which results from the buildup of fluid in the body. This fluid accumulates in the extremities due to the heart's inability to effectively pump blood forward. Choices A, B, and D are incorrect. Immunosuppression is not a typical feature of right-sided heart failure. Pulmonary edema is more commonly associated with left-sided heart failure, where fluid accumulates in the lungs. Coughing is a symptom that can be present in various conditions but is not a defining characteristic of right-sided heart failure.
A patient with a history of venous thromboembolism is prescribed hormone replacement therapy (HRT). What should the nurse discuss with the patient regarding the risks of HRT?
- A. HRT is associated with an increased risk of venous thromboembolism, so the patient should be aware of the signs and symptoms of blood clots.
- B. HRT can decrease the risk of osteoporosis, but the patient should also be aware of the increased risk of venous thromboembolism.
- C. HRT may increase the risk of breast cancer, so the patient should undergo regular breast exams.
- D. HRT can improve mood and energy levels, but it also carries a risk of cardiovascular events.
Correct Answer: A
Rationale: The correct answer is A. Hormone replacement therapy (HRT) is indeed associated with an increased risk of venous thromboembolism. Therefore, patients should be educated about the signs and symptoms of blood clots and advised to seek immediate medical attention if they occur. Choice B is incorrect because although HRT may decrease the risk of osteoporosis, the focus of concern in this case is the increased risk of venous thromboembolism. Choice C is incorrect as it mentions the risk of breast cancer, which is not the primary concern when discussing HRT with a patient with a history of venous thromboembolism. Choice D is also incorrect as it mentions cardiovascular events, which are not the main focus of risk associated with HRT in this scenario.
A child with a serious fungal infection is receiving amphotericin B parenterally. Which of the following minerals will the patient most likely be required to receive?
- A. Chloride
- B. Magnesium
- C. Glucose
- D. Sodium
Correct Answer: B
Rationale: When a patient is receiving amphotericin B, which is known to cause renal toxicity, they are most likely to require magnesium supplementation. Amphotericin B can lead to renal loss of magnesium, potassium, and calcium. Magnesium is an essential mineral that plays a vital role in various physiological functions, and its levels need to be monitored and supplemented when necessary. Chloride, glucose, and sodium are not typically supplemented in the context of amphotericin B therapy for a serious fungal infection.
As you are walking in the park, a huge black Labrador runs up to you and places his paws on your shoulders. Immediately your heart starts racing, you feel palpitations, anxiety, and your hands become a little shaky. The nurse knows that this response is primarily caused by:
- A. cerebral cortex.
- B. somatic nervous system.
- C. limbic system.
- D. autonomic nervous system.
Correct Answer: D
Rationale: The autonomic nervous system controls involuntary bodily functions like heart rate, respiration, and sweating. In the given scenario, the 'fight or flight' response is activated, leading to increased heart rate, palpitations, anxiety, and shaky hands. The cerebral cortex is involved in conscious thought processes and decision-making, not the immediate physiological response observed here. The somatic nervous system regulates voluntary movements, while the limbic system is responsible for emotions and memory, but the autonomic nervous system is primarily responsible for the physiological responses seen in this situation.
An infant is being administered an immunization. Which of the following provides an accurate description of an immunization?
- A. It should be administered to a pregnant woman prior to the infant's birth.
- B. It is the administration of an antigen to stimulate an antibody response.
- C. It produces many adverse reactions, particularly autism, in the infant.
- D. It protects the infant from exposure to infectious antibodies.
Correct Answer: B
Rationale: The correct answer is B. Immunization involves administering an antigen, such as a weakened or killed microorganism, to stimulate the immune system to produce an antibody response. This process helps the body recognize and remember specific pathogens, providing immunity against future infections. Choice A is incorrect because immunizations are administered to the infant directly, not to the pregnant woman before birth. Choice C is incorrect as there is no scientific evidence linking immunizations to autism. Choice D is incorrect as immunizations protect against infectious agents, not antibodies.