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A patient is in the primary infection stage of HIV. What is true of this patients current health status?
- A. The patients HIV antibodies are successfully, but temporarily, killing the virus.
- B. The patient is infected with HIV but lacks HIV-specific antibodies.
- C. The patients risk for opportunistic infections is at its peak.
- D. The patient may or may not develop long-standing HIV infection.
Correct Answer: B
Rationale: During the primary infection stage of HIV, the patient is newly infected with the virus. At this stage, the patient's immune system has not yet produced HIV-specific antibodies, making it difficult to detect HIV infection using standard antibody tests. Instead, the virus can be detected by testing for the presence of HIV RNA or p24 antigen. The primary infection stage is characterized by a high level of viral replication and rapid spread of the virus throughout the body. In this early stage, the patient may experience flu-like symptoms such as fever, sore throat, muscle aches, and swollen lymph nodes. The absence of HIV-specific antibodies means that the patient is highly infectious and can easily transmit the virus to others. As the infection progresses, the patient will eventually develop HIV-specific antibodies, which can be detected through antibody tests.
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The nurse is describing theChooseMyPlateprogramto a patient. Which statement from the patient indicates successful learning?
- A. “I can use this to make healthy lifestyle food choices.”
- B. “I can use this to count specific calories of food.”
- C. “I can use this for my baby girl.”
- D. “I can use this when I am sick.”
Correct Answer: A
Rationale: This statement indicates successful learning because it acknowledges the main purpose of the ChooseMyPlate program, which is to help individuals make healthy food choices for a balanced diet and overall lifestyle. By understanding that ChooseMyPlate can guide them in making healthier food choices rather than just counting calories or using it for specific circumstances like sickness or infant care, the patient demonstrates a good grasp of the program's intended use and benefits.
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
- A. Page the physician and report this sign of infection.
- B. Reinforce the dressing and reassess in 1 to 2 hours.
- C. Reposition the patient to prevent further hemorrhage.
- D. Inform the surgeon of the possibility of a dural leak.
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when observing the surgical dressing saturated with serosanguineous drainage is to reinforce the dressing and reassess in 1 to 2 hours. Serosanguineous discharge is a common type of drainage following surgery, as it is a mixture of blood and serum. It is expected in the early stages of wound healing and does not necessarily indicate infection. By reinforcing the dressing and closely monitoring the drainage over the next couple of hours, the nurse can assess if the amount of drainage is decreasing or escalating. If there are any signs of infection, such as increasing redness, warmth, swelling, or excessive purulent discharge, then the nurse should notify the physician promptly. Until then, it is appropriate to continue observing and managing the drainage within the expected range.
The nurse is caring for a patient with an advanced stage of breast cancer and the patient has recently learned that her cancer has metastasized. The nurse enters the room and finds the patient struggling to breath and the nurses rapid assessment reveals that the patients jugular veins are distended. The nurse should suspect the development of what oncologic emergency?
- A. Increased intracranial pressure
- B. Superior vena cava syndrome (SVCS)
- C. Spinal cord compression
- D. Metastatic tumor of the neck
Correct Answer: B
Rationale: Superior vena cava syndrome (SVCS) is a medical emergency that can occur in patients with advanced cancer, such as breast cancer with metastasis. SVCS is caused by the obstruction or compression of the superior vena cava, a large vein that carries blood from the upper body back to the heart. When the superior vena cava is obstructed or compressed, it can lead to symptoms such as difficulty breathing (dyspnea) and distended jugular veins.
A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene?
- A. Custard
- B. Frozen yogurt
- C. Pureed vegetables
- D. Mashed potatoes and gravy
Correct Answer: D
Rationale: Mashed potatoes and gravy are not appropriate for a full liquid diet. A full liquid diet consists of foods that are liquid at room temperature or melt into liquid form at body temperature. Mashed potatoes and gravy are not in liquid form and therefore should not be consumed by a patient following a full liquid diet. The nurse should intervene and provide education about the correct food choices allowed on a full liquid diet, such as custard, frozen yogurt, and pureed vegetables.
A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patients lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. A nonmobile mass with irregular edges
- C. A mobile mass that is soft and easily delineated
- D. Nonpalpable right axillary lymph nodes
Correct Answer: B
Rationale: A nonmobile mass with irregular edges would most strongly suggest that the patient's lump is cancerous. Breast cancer lumps typically do not move easily and have irregular, poorly defined edges. These characteristics are concerning because they can indicate an invasive and aggressive growth pattern. Additionally, the fact that the lump is painless is another feature that raises suspicion for malignancy. It is important for the patient to undergo further evaluation, possibly including a mammogram, ultrasound, and biopsy, to determine the nature of the lump and provide appropriate treatment.