NUR 213 Health Exam

Correct Answer:

A) Utilize a pressure-reducing mattress.

Explanation:

Patients with HIV/AIDS are at risk for impaired skin integrity due to poor nutrition, diarrhea, opportunistic infections (e.g., Kaposi’s sarcoma, candidiasis), and prolonged bed rest. A pressure-reducing mattress helps prevent pressure ulcers and skin breakdown, especially for patients who are immobile or have muscle wasting. This is a proactive intervention to reduce pressure on bony prominences and improve circulation to the skin.

Why the Other Choices Are Incorrect:

• B) Limit the patient's physical activity:
  
  
  
  
  • Incorrect. Mobility helps prevent skin breakdown by reducing prolonged pressure on the skin and improving circulation. Instead of restricting activity, nurses should encourage repositioning, ambulation, or range-of-motion exercises as tolerated.
  
  
  
  


• C) Apply antibiotic ointment to dependent skin surfaces:
  
  
  
  • Incorrect. Antibiotic ointments are only needed if there is an active infection. Overuse of topical antibiotics can lead to resistance and is not a standard preventive measure for skin breakdown.
  
  
  
  


• D) Avoid contact with synthetic fabrics:
  
  
  
  • Incorrect. While natural fabrics like cotton may be more comfortable and breathable, avoiding synthetic fabrics does not significantly reduce the risk of impaired skin integrity. The primary focus should be on pressure relief, hydration, and proper hygiene.
  
  
  
  

Summary:

For HIV/AIDS patients at risk for skin breakdown, using a pressure-reducing mattress (A) is the best intervention to prevent pressure ulcers and maintain skin integrity. Mobility should be encouraged, antibiotic ointments should be used only if needed, and fabric choice is a minor concern compared to pressure relief and hygiene.

Correct Answer:

c. "What do you understand about what happened to you?"

Explanation:

The client’s statement about indigestion could indicate a lack of understanding of their condition. Clients who have experienced a myocardial infarction (MI) may sometimes mistake symptoms of a heart attack (e.g., chest discomfort, indigestion-like pain) for something less serious, like indigestion. By asking "What do you understand about what happened to you?", the nurse can assess the client’s knowledge of their condition and provide the necessary education about symptoms of a heart attack and the importance of managing their diet, risk factors, and overall heart health.

Why the Other Choices Are Incorrect:

a. "Chili is high in fat and calories; it would be a good idea to stop eating it."

While it is true that chili (especially with fatty meats or rich ingredients) may be high in fat and calories, which can affect heart health, simply telling the client to stop eating chili may not address the underlying issue. The nurse should first assess the client’s understanding of their condition and explain the relationship between diet and heart health in a more comprehensive manner.

b. "The provider has prescribed an antacid for you to take every morning."

If the client is experiencing gastrointestinal symptoms like indigestion, an antacid might help. However, the underlying concern is to ensure that the client is not confusing heart-related symptoms (such as chest discomfort) with gastrointestinal issues. This response could mislead the client into thinking that indigestion is the primary cause, rather than considering the potential link to their cardiac event.

d. "When did you start experiencing this indigestion?"

While it’s important to assess the client’s symptoms, this response does not address the client’s potential misunderstanding of their symptoms. It focuses only on the timing of symptoms without directly exploring the client’s understanding of the situation and their knowledge of MI-related symptoms.

Summary:

The correct answer is c. "What do you understand about what happened to you?" This response helps the nurse assess the client’s understanding of their myocardial infarction and provides an opportunity to educate the client about distinguishing between heart attack symptoms and other conditions like indigestion, as well as offering more detailed guidance on managing diet and heart health going forward.

Correct Answer: A. Medication Reconciliation

Why it is Correct

Medication reconciliation is the priority information that must be communicated to the home health nurse when discharging a client with a cardiac dysrhythmia. This process involves reviewing and verifying all medications the patient is taking, including prescription drugs, over-the-counter medications, and supplements. Patients with cardiac dysrhythmias are often prescribed antiarrhythmic drugs, anticoagulants, or beta-blockers, which require careful monitoring to prevent complications like arrhythmias, bleeding risks, or drug interactions. Ensuring medication accuracy reduces the risk of adverse drug events, medication errors, and hospital readmission.

Why the Other Options Are Incorrect

B. Immunization History

While immunization status is important, it is not the priority in managing a client with a cardiac dysrhythmia. Vaccines like the influenza or pneumococcal vaccine may be recommended for overall health, but they do not directly impact the immediate management of cardiac dysrhythmias or medication safety.

C. Religious Beliefs

A patient’s religious beliefs are important for holistic care and may influence healthcare decisions. However, they are not the priority when discharging a patient with a cardiac dysrhythmia. Religious considerations may come into play for decisions regarding advanced directives, dietary restrictions, or blood transfusions, but ensuring safe medication use is the most immediate concern.

D. Nutrition Preferences

While diet plays a role in cardiovascular health (e.g., low sodium, heart-healthy diets), nutritional preferences are not as urgent as medication reconciliation in preventing medication-related complications in a patient with a cardiac dysrhythmia. Dietary factors can be addressed during home visits but do not require immediate communication upon discharge.

Summary

The priority information to communicate upon discharge is medication reconciliation because it ensures the accuracy and safety of prescribed drugs, reducing the risk of medication errors and complications. While immunization history, religious beliefs, and nutrition preferences are relevant for comprehensive care, they are not as critical as medication reconciliation in managing a cardiac dysrhythmia.

Priority Orders (Select 4)

1️⃣ Cefepime 2 grams IV every 12 hours ✅

• Rationale: Broad-spectrum IV antibiotics should be initiated as soon as sepsis is suspected. Early antibiotic administration is critical in preventing worsening infection and sepsis-related complications.

2️⃣ Stat lactate level ✅

• Rationale: Elevated lactate levels indicate tissue hypoxia and worsening sepsis. A lactate level >2 mmol/L suggests possible sepsis, and >4 mmol/L indicates septic shock, requiring immediate intervention.

3️⃣ Obtain a set of blood cultures ✅

• Rationale: Before starting antibiotics, blood cultures must be obtained to identify the causative organism and ensure appropriate antibiotic therapy.

4️⃣ Discontinue indwelling catheter ✅

• Rationale: The catheter is a likely source of infection, and removal helps reduce bacterial colonization and prevent further complications.

Non-Priority Orders (Not Selected)

Fingerstick glucose every 6 hours

• Rationale: Hyperglycemia can occur in stress responses, but glucose monitoring is not a primary intervention in suspected sepsis.

Discontinue Furosemide

• Rationale: Stopping diuretics abruptly in a CHF patient could lead to fluid overload. The provider should reassess fluid balance first.

1000mL Lactated Ringer's at 170mL/hr

• Rationale: Aggressive fluid resuscitation must be carefully considered in a CHF patient, as excess fluids may worsen heart failure. A more cautious approach with monitoring would be preferred.

Final Priorities

✅ Administer IV Cefepime

✅ Obtain stat lactate level

✅ Draw blood cultures

✅ Discontinue the indwelling catheter

💡 These actions align with the Surviving Sepsis Campaign and focus on infection control, identifying severity, and initiating treatment

Correct Answer: b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg

Explanation:

This client is the highest priority because hypertension after a coronary artery bypass graft (CABG) can put excessive pressure on the new grafts, increasing the risk of graft failure, bleeding, or even myocardial infarction. The nurse should intervene immediately to prevent complications such as suture line rupture or stroke.

Why the other options are incorrect:

a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours

While nitroglycerin is used to manage chest pain and hypertension, a stable dose with no recent titration suggests the client is stable. This client does not require immediate attention compared to option b.

c. Client who is 1 day post percutaneous coronary intervention (PCI), going home this morning

A discharge-ready client is not a priority, as they are stable and do not require urgent intervention.

d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

Dizziness is concerning, but it is not as critical as uncontrolled hypertension in a CABG patient. The nurse can assess this client after addressing the immediate risk of complications in option b.

Summary:

The hypertensive client post-CABG is at the highest risk for serious complications, making them the nurse’s first priority.

Correct Answer: A) HIV encephalopathy

Explanation:

HIV encephalopathy, also known as AIDS dementia complex, is a progressive neurological disorder caused by HIV infection affecting the brain. It leads to cognitive decline, behavioral changes, and motor dysfunction, which matches the symptoms described in the question. The virus directly damages the brain's white matter, leading to neurocognitive impairments.

Why the Other Choices Are Incorrect:

B) B-cell lymphoma:

B-cell lymphoma is a type of cancer affecting the lymphatic system, which is common in patients with AIDS due to immune system suppression. However, it primarily presents with symptoms such as lymph node enlargement, fever, night sweats, and weight loss, rather than cognitive, behavioral, and motor decline.

C) Kaposi's sarcoma:

Kaposi’s sarcoma is a cancer that develops from the endothelial cells lining blood vessels and is associated with human herpesvirus-8 (HHV-8). It presents as purple, red, or brown skin lesions, and though it can be systemic, it does not primarily cause cognitive decline or motor dysfunction.

D) Wasting syndrome:

Wasting syndrome is characterized by involuntary weight loss of more than 10% of body weight along with chronic diarrhea or weakness and fever. While it is a severe complication of AIDS, it does not primarily manifest with neurological symptoms.

Summary:

The correct answer is HIV encephalopathy (A) because it directly causes the cognitive, behavioral, and motor impairments described. Other choices—B-cell lymphoma, Kaposi’s sarcoma, and wasting syndrome—are complications of AIDS but do not primarily cause progressive neurological decline.

Correct Answer:

A) Atelectasis

Explanation:

Postoperative atelectasis (collapse of the alveoli in the lungs) is a common complication when patients remain immobile after surgery. Transurethral prostate resection (TUPR) patients, like all post-surgical patients, are at risk for decreased lung expansion and mucus accumulation, leading to:

• Impaired gas exchange


• Shallow breathing due to pain


• Increased risk of pneumonia

Early ambulation is crucial because it:

• Encourages deep breathing and lung expansion


• Mobilizes secretions, reducing the risk of pneumonia


• Improves circulation to prevent complications like DVT

Why the Other Choices Are Incorrect:

• B) Anemia:
  
  
  
  
  • Incorrect. While blood loss can occur during a TUPR, it is not the most immediate concern from bed rest. Anemia is typically managed through monitoring hemoglobin levels and not primarily affected by early ambulation.
  
  
  
  


• C) Dehydration:
  
  
  
  • Incorrect. Dehydration is a risk postoperatively, especially with continuous bladder irrigation (CBI) after a TUPR. However, it is more related to fluid balance and intake rather than immobility.
  
  
  
  


• D) Peripheral edema:
  
  
  
  • Incorrect. While immobility can contribute to fluid retention, peripheral edema is not the primary risk in this scenario. The biggest immediate concern post-TUPR is pulmonary complications like atelectasis.
  
  
  
  

Summary:

The primary complication from postoperative immobility is atelectasis (A), which can lead to pneumonia if untreated. Encouraging early ambulation and deep breathing exercises helps prevent lung complications and promotes overall recovery.

Correct Answers:

• Admit to a negative pressure room


• Chest x-ray


• Collect specimen x3 mornings for acid-fast bacilli

Explanation of Correct Answers:

1. Admit to a negative pressure room

• The patient has symptoms of active TB (positive TB skin test, productive cough for 2 months, and weight loss).


• Active TB is airborne, so the patient must be placed in airborne precautions in a negative pressure room to prevent transmission.


• N95 masks should be worn by healthcare staff.

2. Chest X-ray

• A chest x-ray (CXR) helps identify lung involvement in active tuberculosis.


• Findings may include cavitary lesions, infiltrates, or nodules in the upper lobes.

3. Collect specimen x3 mornings for acid-fast bacilli (AFB) testing

• The gold standard for diagnosing active TB is sputum smear microscopy and culture for Mycobacterium tuberculosis.


• Three consecutive early morning sputum samples should be collected since bacteria are most concentrated in the morning.

Explanation of Incorrect Answers:

1. Vital signs every shift

• Monitoring vital signs is important but does NOT confirm the diagnosis of active TB.


• TB patients may have low-grade fever and tachycardia, but these are non-specific.

2. CBC, BMP, HIV viral load, VDRL

• These tests are useful but do not directly confirm active TB.


• HIV viral load may be relevant since HIV increases TB risk, but it does not diagnose TB.


• CBC may show mild anemia or leukocytosis, but it is not specific for TB.


• VDRL (syphilis test) is unrelated to TB diagnosis.

3. Heart-healthy diet

• A proper diet is important for overall health but does NOT assist in diagnosing active TB.

Summary:

To diagnose active tuberculosis, the key orders are:

✅ Negative pressure isolation (airborne precautions)

✅ Chest X-ray (to check for lung involvement)

✅ AFB sputum smear and culture (gold standard for TB diagnosis)

Other tests (vital signs, CBC, HIV viral load, and diet changes) may be important for overall patient management but do not directly confirm TB.

Correct Answer:

C) Pulmonary embolism

Explanation:

• External pneumatic compression stockings (also called sequential compression devices, or SCDs) help prevent deep vein thrombosis (DVT) by promoting venous blood flow in the legs.


• Postoperative patients, especially elderly individuals and those who are immobile, are at a high risk of developing blood clots in their deep veins due to venous stasis (slow blood flow).


• If a DVT forms and dislodges, it can travel to the lungs, causing a pulmonary embolism (PE)—a life-threatening condition.

Why the Other Choices Are Incorrect:

A) Sepsis

• Incorrect because sepsis is a systemic infection, typically resulting from surgical site infections, pneumonia, or urinary tract infections.


• Not wearing compression stockings does not directly increase the risk of sepsis.

B) Infection

• Incorrect because infections are primarily related to surgical wounds, invasive devices (e.g., catheters), or poor hygiene.


• While prolonged immobility can weaken the immune response, it does not directly cause infections.

D) Hematoma

• Incorrect because a hematoma is a localized collection of blood outside the blood vessels, usually caused by surgical trauma or injury.


• Not wearing compression stockings does not increase the risk of hematoma formation.

Summary:

Refusing to wear external pneumatic compression stockings significantly increases the risk of deep vein thrombosis (DVT), which can lead to a pulmonary embolism (PE). PE is a serious, potentially fatal complication, making patient education and compliance with compression therapy essential in postoperative care.