Nokea
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?
- A. Salmonella infection
- B. Mycobacterium tuberculosis
- C. Clostridium difficile
- D. Pneumocystis pneumonia
Correct Answer: D
Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.
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A 29-year-old patient has just been told that he has testicular cancer and needs to have surgery. During a presurgical appointment, the patient admits to feeling devastated that he requires surgery, stating that it will leave him emasculated and a shell of a man. The nurse should identify what nursing diagnosis when planning the patients subsequent care?
- A. Disturbed Body Image Related to Effects of Surgery
- B. Spiritual Distress Related to Effects of Cancer Surgery
- C. Social Isolation Related to Effects of Surgery
- D. Risk for Loneliness Related to Change in Self-Concept
Correct Answer: A
Rationale: The correct answer is A: Disturbed Body Image Related to Effects of Surgery. This nursing diagnosis is appropriate because the patient expresses concerns about feeling emasculated and a shell of a man after the surgery, indicating a disturbance in his body image. The patient's perception of how the surgery will affect his masculinity is a clear indication of body image disturbance.
Choice B is incorrect because there is no mention of spiritual distress in the patient's statements. Choice C is incorrect as there is no indication that the patient will experience social isolation specifically related to the surgery. Choice D is incorrect as the patient's concerns are primarily related to his body image and not loneliness.
A nurse is assessing the patient’s meaning ofillness. Which area of focus by the nurse ispriority?
- A. On the way a patient reacts to disease
- B. On the malfunctioning of biological processes
- C. On the malfunctioning of psychological processes
- D. On the way a patient reacts to family/social interactions
Correct Answer: A
Rationale: The correct answer is A because understanding how a patient perceives and reacts to their illness is crucial for providing holistic care. By focusing on the patient's perspective, the nurse can address their emotional, mental, and social needs. Choice B is incorrect as it only considers biological aspects. Choice C is incorrect as it only focuses on psychological processes. Choice D is incorrect as it does not directly address the patient's perspective on illness. A holistic approach that considers the patient's meaning of illness is essential for providing patient-centered care.
A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient?
- A. Sit or stand in front of the patient when speaking.
- B. Use exaggerated lip and mouth movements when talking.
- C. Stand in front of a light or window when speaking.
- D. Say the patients name loudly before starting to talk.
Correct Answer: A
Rationale: The correct answer is A: Sit or stand in front of the patient when speaking. This choice is correct because it allows the patient with otosclerosis to directly see the nurse's face and lip movements, aiding in lip-reading and understanding speech. Sitting or standing in front of the patient also ensures better eye contact and reduces background noise interference.
Choice B is incorrect because exaggerated lip and mouth movements may distort speech and make it harder for the patient to understand. Choice C is incorrect because standing in front of a light or window can create glare and make it difficult for the patient to see the nurse's face clearly. Choice D is incorrect because saying the patient's name loudly before starting to talk does not directly address the communication needs of a patient with otosclerosis.
A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear?
- A. Yellowish-white
- B. Pink
- C. Gray
- D. Bluish-white
Correct Answer: B
Rationale: The correct answer is B: Pink. In a healthy ear, the tympanic membrane should appear pink due to the rich blood supply. This color indicates good vascularization and normal functioning of the ear. Yellowish-white (choice A), gray (choice C), and bluish-white (choice D) are incorrect because they do not reflect the normal color of a healthy tympanic membrane. Yellowish-white may indicate fluid behind the eardrum, gray may suggest infection or inflammation, and bluish-white could indicate poor blood flow or trauma. Therefore, the pink color of the tympanic membrane is the most appropriate and indicative of a healthy ear in this case.
When assessing patient with nutritional needs, which patients will require follow-up from the nurse?(Select all that apply.)
- A. A patient with infection taking tetracycline with milk
- B. A patient with irritable bowel syndrome increasing fiber
- C. A patient with diverticulitis following a high-fiber diet daily
- D. A patient with an enteral feeding and 500 mL of gastric residual
Correct Answer: A
Rationale: The correct answer is A: A patient with infection taking tetracycline with milk. This is because tetracycline binds with the calcium in milk, reducing its absorption and effectiveness. The nurse should follow up to ensure the patient is not compromising the treatment.
Choices B and C are incorrect because increasing fiber for irritable bowel syndrome and following a high-fiber diet for diverticulitis are appropriate interventions that do not require immediate follow-up.
Choice D is incorrect because it is a routine part of managing enteral feedings to monitor gastric residuals, and does not necessarily require immediate follow-up unless there are specific concerns.