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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "It eliminates the clotting factors." - This statement suggests a misunderstanding of how enoxaparin works. Enoxaparin is a low molecular weight heparin that does not eliminate clotting factors but rather inhibits the activity of factor Xa, a key enzyme involved in the coagulation cascade. By inhibiting factor Xa, enoxaparin prevents the conversion of prothrombin to thrombin, thereby reducing the formation of fibrin clots. It does not eliminate existing clotting factors from the bloodstream.
B. "This medication will keep the blood clot from growing larger." - This statement demonstrates a correct understanding of enoxaparin's mechanism of action. Enoxaparin is an anticoagulant medication that works by preventing the enlargement of existing blood clots. By inhibiting the activity of factor Xa, enoxaparin prevents the conversion of prothrombin to thrombin, thereby reducing the formation of fibrin clots and preventing existing clots from growing larger.
C. "This medication will decrease my risk for bleeding." - This statement is incorrect. Enoxaparin, like other anticoagulants, actually increases the risk of bleeding due to its mechanism of action. By inhibiting the coagulation cascade, enoxaparin prolongs the time it takes for blood to clot, which can lead to an increased risk of bleeding, particularly in patients who are predisposed to bleeding or are taking other medications that affect clotting.
D. "I will get this medication in my veins." - This statement is incorrect. Enoxaparin is administered subcutaneously, not intravenously. It is usually injected into the fatty tissue of the abdomen or thigh using a prefilled syringe with a short, thin needle. The subcutaneous route of administration allows for slow absorption and sustained anticoagulant effects over time.
Correct Answer is C
Explanation
A. Injection of drugs:
Hepatitis E is not primarily spread through the injection of drugs. While injection drug use can increase the risk of hepatitis B and C transmission, hepatitis E is typically spread through the fecal-oral route, often via contaminated water or food.
B. Semen:
Hepatitis E is primarily transmitted via the fecal-oral route and is not commonly spread through semen. Sexual transmission of hepatitis E is rare compared to other types of viral hepatitis, and the primary mode of transmission is ingestion of contaminated food or water.
C. Fecal-oral:
The fecal-oral route is the primary mode of transmission for hepatitis E. This means that the virus is spread through ingestion of food or water contaminated with fecal matter containing the virus. Poor sanitation and hygiene practices are common risk factors for hepatitis E transmission.
D. Blood:
Unlike hepatitis B and C, hepatitis E is not primarily transmitted through blood exposure. While transmission through blood transfusions or organ transplants has been reported in some cases, the main mode of transmission for hepatitis E is ingestion of contaminated food or water.
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