Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Lymphangitis is an inflammation of lymphatic vessels. 2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection. 3. Nurse should notify the physician for further evaluation and treatment. 4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification. 5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification. 6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.

Correct Answer: A

Rationale: The correct answer is A. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process. B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully. C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood. D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.

Correct Answer: C

Rationale: The correct answer is C because Neomycin is given preoperatively to decrease and retard the growth of normal bacteria in the intestines. This helps reduce the risk of infection during surgery by minimizing the number of bacteria present in the colon. Options A, B, and D are incorrect because Neomycin is not given to prevent infection postoperatively, eliminate the need for preoperative enemas, or treat cancer of the colon. The main purpose of administering Neomycin in this scenario is to create a sterile surgical field by reducing the normal flora in the intestines.

Correct Answer: B

Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for their health care. By focusing on the patient's expectations, the nurse can establish a therapeutic relationship, provide patient-centered care, and tailor the care plan accordingly. A: Nurse's concerns - Incorrect. The nursing health history should prioritize the patient's perspective and needs over the nurse's concerns. C: Current treatment orders - Incorrect. While important, this component focuses on the medical treatment plan rather than the patient's expectations. D: Nurse's goals for the patient - Incorrect. The nurse should collaborate with the patient to set goals that align with the patient's needs and preferences, not impose their own goals.

Correct Answer: B

Rationale: The correct answer is B: Patient expectations. During a nursing health history, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because: A: Nurse's concerns are not the primary focus of a nursing health history. C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care. D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.

Correct Answer: B

Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for care. By focusing on the patient's expectations, the nurse can provide patient-centered care and tailor interventions to meet the patient's specific needs. A: Nurse's concerns - While it is important for the nurse to consider their own concerns, the primary focus should be on the patient's needs and expectations. C: Current treatment orders - This is important information to gather, but it does not directly address the patient's expectations or preferences. D: Nurse's goals for the patient - The nurse should work collaboratively with the patient to establish goals that align with the patient's expectations and preferences, rather than imposing their own goals.

Correct Answer: B

Rationale: The correct answer is B: 45-year old woman who has never been pregnant. This client has the highest risk of ovarian cancer due to nulliparity, which is a known risk factor. Women who have never been pregnant have a higher risk of developing ovarian cancer compared to those who have had children. Other choices are incorrect because contraceptives actually reduce the risk of ovarian cancer, having children can slightly decrease the risk, and having a child at a young age does not increase the risk significantly.

Correct Answer: A

Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.

Correct Answer: A

Rationale: The correct answer is A: Decreased serum sodium level. In SIADH, there is an excessive release of ADH, causing water retention and dilution of sodium in the blood. This leads to hyponatremia. B: Increased blood urea nitrogen and C: Decreased serum creatinine level are not typically associated with SIADH. D: Increased hematocrit is not a typical finding in SIADH, as it is more related to dehydration. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level due to dilutional hyponatremia.