During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?

Correct Answer: D

Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.

Correct Answer: C

Rationale: The correct answer is C: Reduce environmental noise and distractions before communicating. This intervention is most likely to facilitate effective communication with a hearing-impaired patient because it creates an optimal environment for the patient to better focus on the communication. By reducing noise and distractions, the patient can more easily concentrate on the conversation and lip reading, if needed. This approach demonstrates sensitivity to the patient's needs and enhances the chances of successful communication. The other choices are incorrect because: A: Asking the patient to repeat what was said may cause frustration and does not address the environmental factors that can hinder communication. B: Standing directly in front of the patient to facilitate lip reading may help, but it does not address the impact of environmental noise and distractions on communication. D: Raising the voice to project sound at a higher frequency is not effective as it can distort speech and may not necessarily improve understanding for a hearing-impaired patient.

Correct Answer: C

Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance. A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain. B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss. D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.

Correct Answer: A

Rationale: The correct initial action for the school nurse is to assess for signs and symptoms of anaphylaxis (Choice A). This is crucial as anaphylaxis is a severe allergic reaction that can be life-threatening and requires immediate intervention. Assessing for anaphylaxis symptoms such as difficulty breathing, swelling of the face or throat, and a rapid pulse helps the nurse quickly identify the severity of the situation. Administering OTC antihistamines (Choice C) or epinephrine (Choice D) should only be done after confirming the presence of anaphylaxis. Assessing for erythema and urticaria (Choice B) is important but not as immediate as assessing for signs of anaphylaxis in this scenario.

Correct Answer: A

Rationale: The correct answer is A. Recording times when the patient is incontinent is crucial in identifying patterns and establishing a structured bowel training program. This data helps in determining the optimal timing for toileting. Choices B, C, and D are incorrect. Choice B is not specific to bowel training and may not address the patient's individual needs. Choice C is not a recommended posture for effective bowel elimination. Choice D, while important for overall health, is not directly related to bowel training.

Correct Answer: C

Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.

Correct Answer: C

Rationale: The correct answer is C: Anaphylaxis due to a latex allergy. Anaphylaxis is a severe allergic reaction that can be triggered by exposure to latex products such as gloves in the operating room. The symptoms of swelling of the eyes and difficulty breathing are classic signs of anaphylaxis. Rationale: 1. Swelling of the eyes and difficulty breathing are hallmark symptoms of anaphylaxis. 2. Latex is a common allergen that can cause severe allergic reactions like anaphylaxis. 3. The student's symptoms are occurring shortly after entering the operating room, suggesting an acute allergic reaction. 4. The other choices (A, B, D) do not align with the symptoms presented and are less likely in this scenario.

Correct Answer: C

Rationale: The correct answer is C: A barrier to hospice care for this patient. The lack of knowledge about hospice care can be perceived as a barrier to accessing this type of care for the patient and her family. Understanding hospice care is crucial in making informed decisions about end-of-life care options. This lack of knowledge does not necessarily indicate lack of education (choice A), language barrier (choice B), or inability to grasp American concepts of health care (choice D), as hospice care is a universal concept that transcends cultural and educational backgrounds.

Correct Answer: D

Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.