A patient with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the patient about this treatment?

Correct Answer: B

Rationale: Step 1: Immunotherapy injections can cause allergic reactions. Step 2: Monitoring post-injection is crucial to detect and manage any potential adverse reactions promptly. Step 3: Staying in the clinic for 30 minutes allows for immediate intervention if needed. Step 4: This ensures patient safety and reduces the risk of severe reactions. Summary: A: Epinephrine is not typically given before immunotherapy injections. C: Therapeutic response may take longer than 3 months to show. D: Immunotherapy is usually given via subcutaneous route, not intravenous.

Correct Answer: B

Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.

Correct Answer: D

Rationale: The correct answer is D: Reports to third-party payers. In home health care, it is essential to document and report patient care to third-party payers for reimbursement purposes. This includes detailed reports on the services provided, patient progress, and any changes in the care plan. This information is crucial for ensuring that the patient receives appropriate reimbursement for the care received. Incorrect choices: A: Nursing process form - While a nursing process form is important for documenting patient care, it is not specifically related to reporting to third-party payers. B: Step-by-step skills manual - While a skills manual may be helpful for guiding care provision, it is not typically included in the patient's medical record. C: A list of possible procedures - While a list of procedures may be useful for reference, it is not a formal part of the patient's medical record for home care documentation.

Correct Answer: D

Rationale: The correct answer is D: Ensuring patient privacy. In the PLISSIT model, ensuring patient privacy is crucial as it creates a safe and confidential environment for discussing sensitive topics like sexual health. This step helps build trust and allows the patient to feel comfortable sharing intimate details. Briefly teaching about normal sexual physiology (A) may come later in the assessment process. Assuring confidentiality (B) is important but doesn't address the immediate need for privacy. Asking if the patient is willing to discuss sexual functioning (C) assumes patient readiness without first establishing a private setting.

Correct Answer: B

Rationale: Correct Answer: B - Urge urinary incontinence Rationale: 1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence. 2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage. Incorrect Choices: A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void. C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis. D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.

Correct Answer: A

Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.

Correct Answer: C

Rationale: The correct answer is C. When a patient's level of consciousness declines and becomes unresponsive, it may indicate a potential overdose of analgesics. To ensure patient safety, IV analgesics should be withheld and replaced with transdermal analgesics, which provide a more controlled and gradual release of medication. This switch helps prevent further overdose and adverse effects. Continuing the current pain control regimen (Choice A) may worsen the situation. Placing the pain control regimen on hold (Choice B) may lead to inadequate pain management. Reducing analgesic dosages (Choice D) may not be sufficient in addressing the overdose issue.

Correct Answer: A

Rationale: The correct answer is A because macular degeneration is a leading cause of blindness in older adults. The macula is responsible for central vision, crucial for tasks like reading and driving. Macular degeneration can lead to permanent vision loss if not managed promptly. The other choices are less likely to result in blindness: astigmatism, hyperopia, and myopia are refractive errors that can be corrected with glasses or contacts, and they do not typically lead to blindness. The age and condition of the patient are important factors in determining the risk of blindness.

Correct Answer: C

Rationale: The correct answer is C: "You are anxious about the surgery. Do you see smoking as helping?" This response acknowledges the patient's anxiety and invites him to explore his reasons for wanting to smoke, opening up a dialogue and potentially uncovering underlying issues. It also avoids judgment or direct orders, fostering a therapeutic nurse-patient relationship. Explanation of why the other choices are incorrect: A: "Smoking is the reason you are here." - This response is blaming and may increase the patient's guilt or anxiety, hindering effective communication. B: "The doctor left orders for you not to smoke." - This response is authoritative and may lead to resistance or defensiveness from the patient, rather than addressing his concerns. D: "Smoking is OK right now, but after your surgery it is contraindicated." - This response is unclear and may send mixed messages to the patient, potentially leading to confusion or misunderstanding.