The nurse admits a patient with a history of human immunodeficiency virus (HIV). Patient reports severe diarrhea, vomiting for the past 6 days. Which action will the nurse perform first?

Assess nutritional status with height, weight, blood urea nitrogen, transferrin, hemoglobin and hematocrit level.

Consult with dietitian to determine patient's nutritional needs.

Encourage patient to prepare simple meals or to obtain assistance with meal preparation if possible.

Encourage patient to eat meals with visitors or others when possible.

Answer and Explanation

The Correct Answer is C

A. Assess nutritional status with height, weight, blood urea nitrogen, transferrin, hemoglobin, and hematocrit level: This option focuses on assessing the patient's nutritional status, which is important for planning appropriate interventions. However, in a patient presenting with severe diarrhea and vomiting, the priority is to address immediate physiological needs and stabilize the patient's condition before conducting comprehensive assessments. While assessing nutritional status is important for long-term management, it is not the first action the nurse should take in this acute situation.

B. Consult with a dietitian to determine the patient's nutritional needs: Consulting with a dietitian is an important step in addressing the patient's nutritional needs, especially in cases of prolonged diarrhea and vomiting. However, in this scenario, the patient is experiencing severe symptoms that require immediate attention. Before consulting with a dietitian, the nurse should address the patient's acute symptoms and initiate interventions to manage fluid and electrolyte imbalances.

C. Encourage the patient to prepare simple meals or to obtain assistance with meal preparation if possible: This option addresses the immediate need to provide nutritional support to the patient. Encouraging the patient to consume simple, easily digestible meals or to seek assistance with meal preparation helps ensure that the patient receives adequate nutrition despite experiencing symptoms of diarrhea and vomiting. Providing practical advice on meal preparation empowers the patient to take control of their nutritional intake, which can be beneficial in managing symptoms and promoting recovery.

D. Encourage the patient to eat meals with visitors or others when possible: While social support and companionship can have a positive impact on the patient's overall well-being, including their nutritional intake, this option is not the first priority in this scenario. The patient's severe symptoms of diarrhea and vomiting require immediate attention to address fluid and electrolyte imbalances and prevent complications such as dehydration. Once the patient's condition stabilizes, encouraging social interaction during meals can be beneficial for promoting nutritional intake and emotional support.

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Correct Answer is A

Explanation

A. Reluctance to monitor blood pressure at home: One barrier to blood pressure management in patients newly diagnosed with hypertension is reluctance or resistance to monitor blood pressure at home. Home blood pressure monitoring is an essential component of hypertension management as it allows patients and healthcare providers to track blood pressure trends, assess the effectiveness of treatment, and make adjustments as needed. However, some patients may feel apprehensive about self-monitoring or may lack understanding of its importance, leading to reluctance to engage in this aspect of their care. Addressing this barrier requires patient education, encouragement, and support to promote the benefits of home blood pressure monitoring and empower patients to take an active role in managing their hypertension.

B. Reduction in work hours: While work-related stress and long working hours can contribute to hypertension, a reduction in work hours would not typically be considered a barrier to blood pressure management, especially if it allows for better stress management, lifestyle modifications, and adherence to treatment regimens.

C. Initiation of an exercise plan: Starting an exercise plan is generally considered a positive step in blood pressure management rather than a barrier. Regular physical activity helps lower blood pressure, improve cardiovascular health, and promote overall well-being. However, barriers related to exercise adherence, such as lack of time, motivation, or access to suitable facilities, could hinder effective blood pressure management.

D. Preference for a low sodium diet: Opting for a low sodium diet is beneficial for individuals with hypertension as it helps reduce blood pressure levels and lowers the risk of cardiovascular events. Therefore, a preference for a low sodium diet would not be considered a barrier to blood pressure management. However, barriers related to dietary adherence, such as taste preferences, cultural influences, or difficulty in meal planning, may need to be addressed to support long-term dietary changes and improve blood pressure control.

A. Monitors the patient's temperature, heart rate, respiratory rate and blood pressure. B. Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums. C. C Encourages the patient to perform cough, deep breathing, postural drainage every 2 to 4 hours. D. Provides nutritional support if patient is unable to take sufficient amounts by mouth.

Correct Answer is C

Explanation

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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The nurse admits a patient with a history of human immunodeficiency virus (HIV). Patient reports severe diarrhea, vomiting for the past 6 days. Which action will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient newly diagnosed with hypertension. What barrier to blood pressure management will the nurse identify?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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