For your patient with a CD4 count, less than 200, the most important nursing assessment would include

Correct Answer: C

Rationale: In the context of a patient with a CD4 count less than 200, which indicates severe immunosuppression typically seen in advanced HIV/AIDS, the most crucial nursing assessment would be monitoring for fever (Option C). This is because a low CD4 count puts the patient at high risk for opportunistic infections. Fever is often the first sign of an infection in these patients and can indicate a serious systemic response. Option A, bowel movements, while important for overall health assessment, is not the priority in this case as it does not directly correlate with the patient's immunosuppressed status and infection risk. Option B, urinary output, is also important but does not take precedence over monitoring for signs of infection in a patient with such a low CD4 count. Option D, blood pressure, is not the priority in this situation unless the patient is showing signs of sepsis, which would typically present with a fever. Understanding the priority assessments based on the patient's condition is crucial in providing effective and targeted care in medical-surgical settings, especially in patients with complex health conditions like advanced HIV/AIDS.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) The left side of your heart is weakened and is losing the capability to pump blood to your lungs. This is because congestive heart failure typically involves the left side of the heart being unable to effectively pump blood to the rest of the body, causing fluid to back up into the lungs. Option A is incorrect because fluid accumulation in the lungs is not primarily due to the volume of IV fluid administered but rather to the heart's inability to pump effectively. Option B is incorrect as it mentions the right side of the heart, which is not typically associated with fluid accumulation in the lungs in congestive heart failure. Option C is unrelated to the pathophysiology of congestive heart failure and is therefore incorrect. Educationally, understanding the underlying pathophysiology of congestive heart failure is crucial for providing appropriate care and education to patients. By knowing why fluid accumulates in the lungs, healthcare providers can better explain the condition to patients like Tom and help them manage their symptoms effectively. This knowledge also aids in delivering patient-centered care and promoting patient compliance with treatment plans.

Correct Answer: B

Rationale: In a patient with peritonitis, the correct assessment findings would include rebound tenderness and guarding. Rebound tenderness refers to pain felt upon the sudden release of pressure on the abdomen, indicating peritoneal irritation. Guarding is the involuntary contraction of the abdominal muscles in response to pain, which is a protective mechanism. These signs suggest inflammation of the peritoneum, a key feature of peritonitis. Option A is incorrect because a soft abdomen with normal bowel sounds is not indicative of peritonitis. Option C is incorrect because hyperactive bowel sounds are not typically associated with peritonitis; instead, bowel sounds may be diminished. Option D is incorrect as ascites and increased vascular pattern on the skin are not specific to peritonitis. Educationally, understanding these assessment findings is crucial for nurses and healthcare providers to recognize peritonitis promptly and initiate appropriate interventions. This knowledge is vital for patient safety and optimal outcomes, highlighting the importance of clinical assessment skills in the medical-surgical setting.

Correct Answer: B

Rationale: The correct answer is option B: "Symptoms usually appear between the ages of 30 and 50; however, you may want to ask your physician about genetic testing that can detect if your son has the gene that is associated with Huntington's disease." This response is correct because it provides accurate information about the typical age range for the onset of Huntington's disease symptoms and suggests genetic testing for the son to determine if he carries the gene associated with the disease. This proactive approach aligns with best practices in managing genetic conditions and seeking early intervention if necessary. Option A is incorrect because it inaccurately states that symptoms usually appear before the age of 30, which is not always the case with Huntington's disease. Option C is also incorrect as it provides a generalization that symptoms usually appear before the age of 30 without considering the variability in age of onset for the disease. Option D is incorrect as it simply states a fact about the genetic transmission of Huntington's disease without providing concrete guidance or information to address Bob's specific concern about his son. In an educational context, it is crucial for healthcare professionals to have a deep understanding of genetic conditions like Huntington's disease and be able to offer accurate information and guidance to individuals and families affected by such conditions. By recommending genetic testing and providing relevant information, healthcare providers can support informed decision-making and early intervention strategies for individuals at risk of genetic diseases.

Correct Answer: D

Rationale: The correct answer is D) One or more arteries that supply blood to your heart are blocked, thereby preventing blood from flowing to your cardiac muscles. This response is accurate because a myocardial infarction, commonly known as a heart attack, occurs when there is a blockage in the coronary arteries leading to a lack of blood flow to the heart muscle, resulting in tissue damage or cell death. Option A is incorrect because it simply restates the patient's condition without providing any explanation. Option B is incorrect as it describes a congenital heart defect, not a myocardial infarction. Option C is incorrect and stigmatizing as it inaccurately links weight to the risk of a heart attack, disregarding the multifactorial nature of cardiovascular diseases. In an educational context, it is crucial to provide accurate and clear information to patients to enhance their understanding of their health condition. By explaining the cause of a myocardial infarction, patients like Sam can better comprehend the importance of lifestyle modifications and adherence to treatment plans to prevent future cardiac events. This empowers patients to actively participate in their care and make informed decisions regarding their health.