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A patient with AIDS-related wasting syndrome is very weak, lies listlessly in bed, has an intravenous (IV) drip, and receives antiretroviral medications via injection. What should be the priority nursing diagnosis for this patient?
- A. Pain related to immobility
- B. Ineffective Individual Coping due to terminal stage of HIV
- C. Risk for Injury due to impaired mobility, weakness, and weight loss
- D. Risk for Infection due to weak immune system and parenteral therapy
Correct Answer: D
Rationale: The correct answer is D: Risk for Infection due to weak immune system and parenteral therapy. This is the priority nursing diagnosis because a patient with AIDS-related wasting syndrome is at high risk for infections due to their weak immune system and parenteral therapy, which can introduce pathogens into the body. Addressing the risk for infection is crucial in preventing further complications and promoting the patient's overall well-being.
Choice A (Pain related to immobility) is not the priority as the patient's immobility is not the immediate concern compared to the risk of infection.
Choice B (Ineffective Individual Coping due to terminal stage of HIV) may be a valid concern, but ensuring the patient's physical health and preventing infections take precedence.
Choice C (Risk for Injury due to impaired mobility, weakness, and weight loss) is important but does not address the immediate threat of infection that the patient faces.
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A 16-year-old wants to drive, but the parents will not allow it. A 14-year-old sibling was invited to several sleepovers, but the parents found reasons to deny permission. Both teens are annoyed because the parents buy clothes for them that are more suitable for younger children. The parents say, We dont want our kids to grow up too fast. Which term best describes this familys boundaries?
- A. Rigid
- B. Clear
- C. Enmeshed
- D. Differentiated
Correct Answer: A
Rationale: Rigid boundaries are those that do not change or flex with changing circumstances, as indicated here by parents who are reluctant to revise their roles and expectations about their children as the children mature. Enmeshed boundaries are those that have failed to differentiate or develop individually; the family shares roles and thoughts to an excessive degree, without a healthy degree of individuality. Clear boundaries are not enmeshed; they are appropriate and well maintained.
A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, Ive considered leaving, but I made a vow and I must keep it no matter what happens. Which outcome should be met before discharge? The patient will:
- A. facilitate counseling for the abuser.
- B. name two community resources for help.
- C. demonstrate insight into the abusive relationship.
- D. reexamine cultural beliefs about marital commitment.
Correct Answer: B
Rationale: The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abusers counseling may require weeks or months.
ne domestic roles of women as a housekeeper tend to be
- A. Under valued
- B. reversed
- C. Over paid
- D. appreciated
Correct Answer: A
Rationale: Women's housekeeping roles are historically undervalued, lacking recognition or compensation.
A client is questioning why she was told that the nausea she is experiencing with this new antidepressant medication will subside once her medication is regulated. Based on the pharmacologic principle of steady state, the nurse explains that:
- A. When her body reaches a steady point where introduction and elimination of the medication are constant the nausea will stop.
- B. Blood work can be done to determine the appropriate time her body will reach a steady state when the new medication will not cause the nausea.
- C. Antidepressants commonly cause nausea for the first 10 doses and once her body can steady the absorption of the medication the side effect will stop.
- D. Antidepressants have a relatively short half life that will allow for the blood serum's steady state to occur within a few days and then the nausea will stop.
Correct Answer: A
Rationale: The correct answer is A because steady state refers to the point where drug intake equals drug elimination in the body, leading to a constant drug concentration. This equilibrium is reached after approximately 4-5 half-lives of the medication. Once the body reaches steady state, the drug's effects, including nausea, become more predictable and stable.
Choice B is incorrect because blood work cannot determine the exact time it takes for the body to reach steady state.
Choice C is incorrect because the number of doses is not a reliable indicator for when steady state is reached, as it depends on the drug's half-life and individual factors.
Choice D is incorrect because stating that antidepressants have a relatively short half-life is not universally true, and the time to reach steady state can vary depending on the specific medication and individual factors.
In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)?
- A. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided.
- B. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained.
- C. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided.
- D. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.
Correct Answer: A
Rationale: The correct answer is A because for a patient who has ingested LSD, it is important to have someone stay with them and provide verbal support due to the potential for anxiety and panic attacks. This helps in grounding the patient and providing reassurance. On the other hand, for a patient who has ingested PCP, a regimen of limited contact with staff members is maintained to prevent potential aggression or unpredictable behavior. Continual visual monitoring is provided to ensure safety without directly engaging with the patient.
Choice B is incorrect because placing a patient on one-on-one intensive supervision for PCP ingestion may escalate the situation due to potential paranoia or aggression. Choice C is incorrect because LSD ingestion may lead to sensory overload, so providing moderate sensory stimulation is more appropriate. Choice D is incorrect because restraints for LSD ingestion are not necessary and seizure precautions are not typically needed for PCP ingestion.