The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient?

Correct Answer: C

Rationale: When the patient expresses fear of dying, the best response from the nurse would be to address the patient's concerns directly by asking, "Can you tell me what concerns you most about dying?" This response shows empathy and allows the patient to express their fears and thoughts openly. By understanding the specific concerns, the nurse can provide appropriate support and guidance to help alleviate the patient's fears and anxieties. It also opens up a dialogue for the nurse to provide information and reassurance based on the patient's individual needs and feelings.

Correct Answer: A

Rationale: In the assessment of a patient with potential placenta previa or abruptio placentae, the nurse should pay close attention to the amount and characteristics of vaginal bleeding. Placenta previa typically presents with painless vaginal bleeding, which can be sudden and significant. Therefore, a saturated perineal pad within a short period of time (1 hour) is more indicative of placenta previa, as opposed to abruptio placentae which usually presents with painful vaginal bleeding and may not necessarily saturate a perineal pad quickly. Monitoring the amount of bleeding and keeping track of pad saturation over time can provide valuable information to differentiate between these two conditions.

Correct Answer: D

Rationale: Malignant disease processes transfer cells from one place to another primarily through the invasion of healthy host tissues. Cancer cells have the ability to break away from the primary tumor site and invade nearby healthy tissues. Once invasive cancer cells find their way into blood vessels or lymphatics, they can be carried to distant sites in the body where they can form new tumors, establish metastases, and spread the disease. This invasive property of cancer cells underlies the ability of cancer to spread throughout the body, a process known as metastasis. Commanding the cells to appear to adhere to primary tumor cells, inducing mutation of cells of another organ, or phagocytizing healthy cells are not mechanisms by which malignant disease processes transfer cells from one place to another.

Correct Answer: A

Rationale: The statement "If I get a blue color that means the test is negative" given by the patient indicates the need for further education. This is incorrect information because a blue color in the guaiac test indicates a positive result, which means the presence of fecal occult blood. The patient should be taught that a positive result indicates the need for further evaluation and follow-up with their healthcare provider. Proper understanding of the test results is vital to ensure accurate interpretation and appropriate management. Further clarification and education are necessary to correct this misconception and guide the patient towards understanding the significance of a positive result.

Correct Answer: B

Rationale: The nurse should prioritize educating the patient on the importance of keeping appointments for desensitization procedures. Immunotherapy involves gradually increasing exposure to allergens to build tolerance and reduce allergic reactions. Missing desensitization appointments can lead to interruptions in treatment and potentially decrease the effectiveness of the therapy. It is crucial for the patient to adhere to the scheduled appointments as prescribed by the healthcare provider to ensure the success of the immunotherapy treatment.

Correct Answer: A

Rationale: When planning care for an adolescent who plays sports, it is important to provide adequate nutrition to meet their increased energy needs. Carbohydrates are the main source of energy, providing fuel for physical activity. Adolescents engaged in sports require a higher carbohydrate intake and should aim for 55% to 60% of their total daily kilocalories to support their activity levels. Carbohydrates are essential for providing energy during exercise, building and repairing muscles, and promoting overall performance. Increasing carbohydrate intake in the diet is a key modification to support the energy demands of an active adolescent involved in sports.

Correct Answer: D

Rationale: Mashed potatoes and gravy are not appropriate for a full liquid diet. A full liquid diet consists of foods that are liquid at room temperature or melt into liquid form at body temperature. Mashed potatoes and gravy are not in liquid form and therefore should not be consumed by a patient following a full liquid diet. The nurse should intervene and provide education about the correct food choices allowed on a full liquid diet, such as custard, frozen yogurt, and pureed vegetables.

Correct Answer: B

Rationale: The preceptor would need to follow up with the new nurse for charting consecutively on every other line. This behavior is incorrect as it can lead to confusion and potential errors in documentation. Correct charting practice involves documenting consecutively, line by line without skipping lines in between. The preceptor should provide guidance and correction to ensure accurate and organized documentation for patient care.

Correct Answer: A

Rationale: Challenging communication situations in nursing care typically involve patients who exhibit behaviors that make communication difficult or complex. In the given options, a child who is developmentally delayed (Option A) and an older-adult patient who is demanding (Option B) are examples of patients who may have challenging communication issues.