A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?

Correct Answer: A

Rationale: The most appropriate nursing intervention for a patient with AIDS experiencing extreme anxiety is to teach the patient guided imagery. Guided imagery is a relaxation technique that can help the patient reduce anxiety levels, promote a sense of calm, and improve overall well-being. By teaching the patient how to use guided imagery, the nurse empowers the patient to manage her anxiety in a non-pharmacological way. This intervention promotes self-care and allows the patient to have a tool to use independently beyond the hospital setting. Giving the patient more control of her antiretroviral regimen may be beneficial for adherence but does not directly address the anxiety symptoms. Increasing the patient's activity level may be helpful for overall well-being but may not specifically target the extreme anxiety. Collaborating with the patient's physician to obtain an order for hydromorphone, a potent opioid medication, is not appropriate unless it is indicated for severe pain management, not anxiety.

Correct Answer: B

Rationale: In this situation, the nurse needs to obtain a telephone order because the patient's condition has changed significantly. The drop in blood pressure from 120/80 to 90/50 along with the saturated incision dressing indicates a potential complication or need for immediate intervention. The nurse must act quickly to address the situation and may require additional orders from the primary care provider over the phone to manage the patient's condition effectively. The urgency and critical nature of the situation necessitate obtaining a telephone order promptly to ensure the best outcome for the patient.

Correct Answer: C

Rationale: This response shows empathy and allows the patient to express their thoughts and feelings without feeling rushed or pressured. By asking the patient if there is anything they want to say, you are showing that you are there to listen and support them during this difficult time. It is important to give the patient the space and opportunity to communicate their emotions and concerns. Offering advice or making assumptions about the patient's feelings may not be as helpful as simply providing a listening ear.

Correct Answer: B

Rationale: The primary aim when transitioning a patient with rapid cancer metastases from active treatment to palliative care is to prevent and relieve suffering. Palliative care focuses on enhancing quality of life, managing symptoms, and addressing physical, emotional, and spiritual needs. By prioritizing the prevention and relief of suffering, healthcare providers can work towards improving the patient's comfort and overall well-being during this difficult time. This approach aligns with the goals of palliative care, which aim to provide holistic support and care for patients facing serious illnesses like cancer.

Correct Answer: B

Rationale: Superior vena cava syndrome (SVCS) is a medical emergency that can occur in patients with advanced cancer, such as breast cancer with metastasis. SVCS is caused by the obstruction or compression of the superior vena cava, a large vein that carries blood from the upper body back to the heart. When the superior vena cava is obstructed or compressed, it can lead to symptoms such as difficulty breathing (dyspnea) and distended jugular veins.

Correct Answer: D

Rationale: Immunotherapy, also known as allergy shots, is a form of treatment that can help reduce symptoms for individuals with severe allergies to substances such as pollen, dust mites, or pet dander. This treatment involves exposing the patient to small, increasing doses of the allergen over time to help the immune system gradually build up a tolerance. Patients with severe allergies to grass and tree pollen would most likely benefit from immunotherapy as it can help reduce their allergy symptoms and improve their quality of life. On the other hand, individuals with anaphylactic reactions to insect stings (Choice A), allergies to eggs and dairy (Choice B), or a positive tuberculin skin test (Choice C) are not typically candidates for immunotherapy as their conditions are not related to the type of allergies that are commonly treated with this method.

Correct Answer: B

Rationale: Redness of the eye after cataract surgery can be a sign of infection or inflammation, which are serious complications that require immediate medical attention. Redness may be accompanied by pain, swelling, or discharge, and if left untreated, it can lead to complications that may affect the surgical outcome and the patient's vision. Therefore, it is crucial for the patient to contact the office immediately if they notice any redness in their eye following cataract surgery.

Correct Answer: A

Rationale: The nurse's best response should be to provide accurate information and manage the patient's expectations realistically. Tamoxifen is known to have a slight protective effect in reducing the risk of developing breast cancer in high-risk individuals like the patient in the scenario. However, it is not a guarantee against developing breast cancer. It is essential for the nurse to convey this information to the patient to ensure that she understands the benefits and limitations of Tamoxifen therapy. Additionally, discussing potential side effects and risks associated with Tamoxifen, such as an increased risk of osteoporosis, is important for the patient to make an informed decision about her health care.

Correct Answer: B

Rationale: When admitting a pregnant patient who has experienced a bleeding episode in late pregnancy, the top priority nursing intervention is to assess fetal heart rate (FHR) and maternal vital signs. This assessment will help the nurse determine the extent of the blood loss and its impact on both the mother and the fetus. Monitoring uterine contractions is important as well, but not the priority in this situation. Placing clean disposable pads to collect any drainage is important for ongoing assessment and management but can be done after assessing the FHR and vital signs. Performing a venipuncture for hemoglobin and hematocrit levels is necessary for further evaluation but can be done after the initial assessment of FHR and vital signs. Checking the patient and fetal well-being is crucial in situations of bleeding in late pregnancy to ensure timely and appropriate intervention.