A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

Monitors the patient's temperature, heart rate, respiratory rate and blood pressure.

Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums.

C Encourages the patient to perform cough, deep breathing, postural drainage every 2 to 4 hours.

Provides nutritional support if patient is unable to take sufficient amounts by mouth.

Answer and Explanation

The Correct Answer is C

A. Monitors the patient's temperature, heart rate, respiratory rate, and blood pressure:
Monitoring vital signs is crucial for assessing the patient's overall condition, including respiratory status. However, while changes in vital signs may indicate respiratory distress, they do not directly address the need to ensure clear breath sounds. This intervention alone does not actively promote airway clearance or improve breath sounds.

B. Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums:
This intervention focuses on reducing the risk of exposure to potential pathogens that could worsen the patient's respiratory condition. While important for infection control, it does not directly address the need to ensure clear breath sounds. Environmental precautions, although necessary, do not actively promote airway clearance or improve breath sounds.

C. Encourages the patient to perform cough, deep breathing, and postural drainage every 2 to 4 hours:
This intervention directly targets promoting airway clearance and improving breath sounds in a patient with pneumonia. Coughing helps mobilize secretions, deep breathing promotes lung expansion and ventilation, and postural drainage assists in the drainage of secretions from different lung segments. Regular performance of these interventions prevents secretion accumulation, thereby improving breath sounds and respiratory function.

D. Provides nutritional support if the patient is unable to take sufficient amounts by mouth:
While nutritional support is important for overall patient care, especially during illness or compromised nutritional intake, it does not directly address the need to ensure clear breath sounds in a patient with pneumonia. Although adequate nutrition supports immune function and overall recovery, it does not directly impact respiratory clearance or breath sounds.

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Correct Answer is C

Explanation

A. "I should avoid bowel irritants such as fatty or fried foods": This statement demonstrates an understanding of dietary modifications to help manage recurrent diarrhea in someone with AIDS. Avoiding bowel irritants such as fatty or fried foods can help reduce gastrointestinal distress and improve symptoms.

B. "I should eat BRAT diet such as bananas, rice, applesauce, tea, and toast": The BRAT diet (bananas, rice, applesauce, tea, and toast) is a bland diet often recommended for individuals with diarrhea because it is easy to digest and can help firm up stools. This statement indicates appropriate understanding of dietary recommendations for managing diarrhea.

C. "I should avoid foods high in calories and proteins": This statement is incorrect and requires further clarification. Individuals with AIDS, especially those experiencing recurrent diarrhea, often have increased nutritional needs due to malabsorption, increased metabolism, and the body's increased energy requirements to fight infection. Avoiding foods high in calories and proteins can lead to malnutrition and worsen the patient's condition. Therefore, this statement requires correction.

D. "I should stop smoking and keep myself hydrated": This statement is appropriate and indicates understanding of important lifestyle modifications to manage diarrhea in someone with AIDS. Smoking cessation can improve overall health, while staying hydrated is essential to prevent dehydration associated with diarrhea.

A. Has anyone in your family ever experienced symptoms similar to yours?" B. "How many alcoholic drinks do you typically consume in a weak?" C. To the best of your knowledge, are your immunizations up to date?" D. "Have you recently had unprotected Intercourse with a new partner?"

Correct Answer is D

Explanation

A. "Has anyone in your family ever experienced symptoms similar to yours?":
This question aims to gather information about potential familial illnesses or infections but does not specifically address the possible etiology of human immunodeficiency virus (HIV). While HIV can be transmitted vertically from mother to child, asking about family members' symptoms is less directly relevant to the assessment of HIV exposure.

B. "How many alcoholic drinks do you typically consume in a week?":
This question assesses the patient's alcohol consumption habits and is important for evaluating overall health and potential risk factors for various conditions. However, it does not directly address the possible etiology of human immunodeficiency virus (HIV). Alcohol consumption may affect immune function but is not a primary indicator of HIV exposure.

C. "To the best of your knowledge, are your immunizations up to date?":
This question is aimed at assessing the patient's immunization status and is essential for preventive healthcare. However, it does not directly address the possible etiology of human immunodeficiency virus (HIV). Immunizations primarily protect against infectious diseases caused by bacteria or viruses other than HIV.

D. "Have you recently had unprotected intercourse with a new partner?":
This question directly addresses behaviors that could lead to HIV transmission. Unprotected sexual intercourse with a new partner is a significant risk factor for acquiring HIV, as the virus can be transmitted through sexual contact with an infected individual. Asking about recent sexual activity helps identify potential exposure to HIV and informs appropriate testing and counseling.

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A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

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Naxlex Comprehensive Predictor Exams

The nurse has given nutritional instructions to a patient with acquired immune deficiency syndrome (AIDS) who has recurrent diarrhea. Which statement by the patient requires further instructions?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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