A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?

Correct Answer: B

Rationale: The correct answer is B: Tachypnea and restlessness. This observation takes immediate priority as it indicates potential respiratory distress, a common complication of pneumonia in HIV patients. Tachypnea can be a sign of hypoxia, while restlessness may indicate increased work of breathing. Prompt intervention is crucial to prevent respiratory failure. Choice A: Oral temperature of 100F is not an immediate priority as it is within normal range and may not directly impact the patient's immediate condition. Choice C: Frequent loose stools may suggest gastrointestinal issues but are not as urgent as respiratory distress in this scenario. Choice D: Weight loss of 1 pound since yesterday, while relevant in monitoring the patient's condition, does not require immediate intervention compared to respiratory distress.

Correct Answer: B

Rationale: The correct initial intervention for a chemical burn to the eye is to generously flush the affected eye with normal saline or water. Flushing helps to remove the chemical from the eye, preventing further damage. Antibiotic solution (choice A) is not the first intervention as the priority is to remove the chemical. Applying a patch (choice C) can trap the chemical against the eye, worsening the injury. Applying direct pressure (choice D) is not appropriate and can cause additional harm. Flushing with normal saline or water is the most effective and safest initial intervention to minimize damage from a chemical burn to the eye.

Correct Answer: B

Rationale: The correct answer is B: Stapes. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, causing the stapes bone to become fixed in place. This results in hearing loss due to the inability of the stapes to transmit sound vibrations to the inner ear. The malleus (choice A), incus (choice C), and tympanic membrane (choice D) are not primarily affected by otosclerosis. The malleus and incus are located in the middle ear but are not typically affected by otosclerosis. The tympanic membrane is part of the outer ear and is not directly involved in otosclerosis.

Correct Answer: B

Rationale: The correct answer is B: Recurrent pelvic infections. Pelvic infections can lead to scarring and blockage of the fallopian tubes, increasing the risk of ectopic pregnancy. Ovarian cysts and oral contraceptives are not directly linked to ectopic pregnancies. Heavy menstrual flow does not inherently increase the risk of ectopic pregnancy.

Correct Answer: C

Rationale: The correct answer is C: Formula intolerance. When a patient develops diarrhea shortly after starting enteral feeding, formula intolerance is the most likely cause. This can occur due to the patient's inability to tolerate certain ingredients in the formula, leading to gastrointestinal upset. Antibiotics (choice A) and Clostridium difficile (choice B) typically take longer to cause diarrhea. Bacterial contamination (choice D) would usually result in more severe symptoms beyond just diarrhea. In this scenario, formula intolerance is the most logical explanation for the immediate onset of diarrhea after starting enteral feeding.

Correct Answer: C

Rationale: The correct answer is C: Sudden cessation of output from the drainage device. This is crucial because it can indicate a potential complication like a blocked drain or infection, requiring immediate medical attention to prevent further issues. Other choices like fatigue (A) are common after surgery but not urgent. Temperature elevation (B) may indicate infection but is not as critical as sudden cessation of drainage. Gradual decline in output (D) is expected as the drainage decreases over time, so it doesn't require immediate reporting.

Correct Answer: B

Rationale: The correct answer is B: There is no noticeable decrease in the amount of ejaculate even though it contains no sperm. After a vasectomy, the vas deferens, the tube that carries sperm from the testicles, is cut or blocked. This prevents sperm from being ejaculated, but the seminal fluid produced by the prostate and other glands still makes up the majority of the ejaculate volume. Therefore, although the ejaculate does not contain sperm after a vasectomy, there is no significant change in the amount of fluid ejaculated. Choice A is incorrect because the absence of sperm does not impact the volume of ejaculate. Choice C is incorrect as there is no marked decrease in ejaculate volume. Choice D is incorrect as there is no evidence to suggest that the viscosity of ejaculate changes post-vasectomy.

Correct Answer: B

Rationale: The correct answer is B: The patient is likely to experience resolution of conductive hearing loss after the procedure. This information is crucial to include in the preoperative teaching because it directly addresses the patient's expected outcome, providing reassurance and setting appropriate expectations. Stapedectomy with prosthesis insertion is a well-established treatment for otosclerosis-related conductive hearing loss. Choices A, C, and D are incorrect because they either provide misleading information (A, D) or are not directly relevant to the procedure or the patient's immediate postoperative experience (C). It is important to focus on accurate and relevant information to prepare the patient effectively for the upcoming surgery and its expected outcomes.

Correct Answer: B

Rationale: The correct answer is B because an incisional biopsy is typically performed to confirm a diagnosis by obtaining a sample of the tissue in question. This allows for further analysis through special studies to determine the best course of treatment. The other choices are incorrect because: A: The reason for performing an incisional biopsy is not primarily based on pain or accuracy comparisons with other testing methods. C: An incisional biopsy is not done to assess potential recovery from a mastectomy but rather to diagnose the nature of the mass. D: Age and general health status are not sole criteria for determining the need for an incisional biopsy.