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The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
- A. Maximize the patients fluid intake.
- B. Provide total parenteral nutrition (TPN).
- C. Keep the patients bed linens free of wrinkles.
- D. Provide the patient with snug clothing at all times.
Correct Answer: C
Rationale: The correct answer is C: Keep the patient's bed linens free of wrinkles. This intervention is important in preventing pressure ulcers, a common complication in patients with impaired skin integrity. Wrinkles in bed linens can create pressure points on the skin, leading to skin breakdown. By keeping the bed linens smooth and wrinkle-free, the patient's skin is protected from excessive pressure, reducing the risk of impaired skin integrity.
A: Maximizing fluid intake is important for overall health but is not directly related to preventing impaired skin integrity.
B: Providing total parenteral nutrition may support the patient's nutritional needs but does not specifically address the risk of impaired skin integrity.
D: Providing snug clothing can increase friction and pressure on the skin, potentially worsening the risk of impaired skin integrity.
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The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk?
- A. Providing thorough oral care before and after meals
- B. Administering prophylactic antibiotics
- C. Promoting nutrition and adequate fluid intake
- D. Applying skin emollients as needed
Correct Answer: A
Rationale: The correct answer is A: Providing thorough oral care before and after meals. This addresses the risk for impaired skin integrity related to Candidiasis in patients with stage 3 HIV by preventing oral Candidiasis, a common fungal infection. Poor oral hygiene can lead to Candidiasis, which can spread to the skin. Thorough oral care reduces the risk of oral Candidiasis, thereby preventing skin integrity issues. Administering prophylactic antibiotics (B) is not indicated for preventing Candidiasis. Promoting nutrition and fluid intake (C) is important for overall health but does not directly address the risk of impaired skin integrity. Applying skin emollients (D) may help with skin dryness but does not directly address the underlying cause of Candidiasis.
The clinic nurse is performing a prenatal assessment on a pregnant patient at risk for preeclampsia. Which clinical sign would not present as a symptom of preeclampsia?
- A. Edema
- B. Proteinuria
- C. Glucosuria
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C, Glucosuria. Preeclampsia is characterized by hypertension, proteinuria, and edema. Glucosuria is not a typical symptom of preeclampsia. Glucosuria is more commonly associated with gestational diabetes, which is a separate condition from preeclampsia. Therefore, in a pregnant patient at risk for preeclampsia, the presence of glucosuria would not be indicative of preeclampsia. The other choices, edema, proteinuria, and hypertension, are all common clinical signs seen in patients with preeclampsia.
A male patient presents at the free clinic with complaints of impotency. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect?
- A. Prolactinoma
- B. Angioma
- C. Glioma
- D. Adrenocorticotropic hormone (ACTH)producing adenoma
Correct Answer: A
Rationale: The correct answer is A: Prolactinoma. Hypogonadism is often associated with decreased testosterone levels, which can be caused by excessive prolactin secretion from a prolactinoma. Prolactin inhibits the secretion of gonadotropin-releasing hormone (GnRH), leading to decreased production of testosterone. Angioma, glioma, and ACTH-producing adenoma are not typically associated with hypogonadism. Angiomas are benign tumors of blood vessels, gliomas are tumors of the brain or spinal cord, and ACTH-producing adenomas are associated with Cushing's disease, not hypogonadism.
A hospice nurse is well aware of how difficult it is to deal with others pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome?
- A. Inefficiency in the provision of care
- B. Excessive weight gain
- C. Emotional exhaustion
- D. Social withdrawal
Correct Answer: C
Rationale: The correct answer is C: Emotional exhaustion. Dealing with others' pain daily can lead to burnout and emotional exhaustion for the nurse. This can result in decreased empathy and effectiveness in providing care. Healthy practices such as self-care, setting boundaries, and seeking support can help prevent emotional exhaustion.
Choice A: Inefficiency in the provision of care is incorrect because emotional exhaustion may affect the quality of care but does not necessarily lead to inefficiency.
Choice B: Excessive weight gain is incorrect as it is not directly related to the emotional toll of dealing with others' pain.
Choice D: Social withdrawal is incorrect as it is a potential outcome of emotional exhaustion but not the primary concern in this scenario.
A patient has lost most of her vision as a result of macular degeneration. When attempting to meet this patients psychosocial needs, what nursing action is most appropriate?
- A. Encourage the patient to focus on her use of her other senses.
- B. Assess and promote the patients coping skills during interactions with the patient.
- C. Emphasize that her lifestyle will be unchanged once she adapts to her vision loss.
- D. Promote the patients hope for recovery.
Correct Answer: B
Rationale: The correct answer is B because assessing and promoting the patient's coping skills is essential in addressing the psychosocial needs of a patient with macular degeneration. By understanding how the patient is coping with the vision loss, the nurse can tailor interventions to support the patient effectively. This approach acknowledges the patient's emotional responses and helps them navigate the challenges associated with the condition.
Choice A is incorrect as solely focusing on other senses may not address the psychological impact of vision loss. Choice C is incorrect as it dismisses the significant lifestyle changes the patient may experience. Choice D is incorrect as promoting hope for recovery may not be realistic in the case of irreversible conditions like macular degeneration.