Human Immunodeficiency Virus Essay

Meet the Client: Jeff Smith Thirty-two-year-old Jeff Smith is admitted from his healthcare provider’s office to the acute care facility. Jeff was diagnosed HIV positive 2 years ago. His history includes fatigue, a productive cough, and weight loss. A tuberculosis (TB) skin test was administered in the healthcare provider’s office. Admission prescriptions include â€Å"isolation precautions for possible tuberculosis.† Admission Procedure The nurse welcomes Jeff to a private room at the end of the hall. According to hospital protocol, the nurse puts on a mask before starting the admission process. Jeff tells the nurse that his partner is downstairs and that he would like his partner to stay in the room with him. 1. How should the nurse respond? A) â€Å"Your healthcare provider wants you to get some rest.† INCORRECT Jeff is requesting an opportunity for psychosocial support, which should be honored by the nurse. B) â€Å"Your partner may stay, but only after we have the results of his tuberculin skin test.† INCORRECT Significant others may stay with appropriate protective equipment. C) â€Å"Your partner may stay, but he needs to wear a mask.† CORRECT Jeff’s partner may stay in the room, but he should wear a mask to help decrease the possibility of contracting the TB organism. D) â€Å"You don’t want to risk infecting your partner with TB, do you?† INCORRECT Jeff’s partner has already been exposed. In addition, this response denies Jeff the support he is requesting. Jeff’s partner, Anthony, arrives. Jeff wants to know why a mask is necessary for people entering his room. 2. What teaching should the nurse implement? A) Explain the use of a private room and mobile high-efficiency particle filters placed in the room. INCORRECT These are necessary precautions against infectious, airborne diseases such as TB. However, providing this information does not answer Jeff’s question. B) Explain that the tuberculosis organism is most often spread through the air. When an infected person coughs or sneezes, they produce infectious droplets that can be breathed in by another person. CORRECT This answer gives Jeff the scientific rationale for wearing a mask. C) Tell Jeff that tuberculosis will not be spread to others, and everything will be okay if the mask is worn. INCORRECT This is false information. Wearing a mask will not prevent the contraction of tuberculosis (TB), but it will reduce the risk of contracting the disease. D) Tell Jeff that masks are required for those persons who do not agree to be vaccinated with BCG vaccine. INCORRECT The BCG (Bacille Calmette-Guerin) vaccine is not generally recommended for use in the United States. It is only used here for very select persons who meet specific criteria. Isolation The unlicensed assistive personnel (UAP) asks why Jeff could not be in an empty semiprivate room closer to the nurse’s station so the staff would not have to walk so far to provide care. 3. What information should the nurse provide to the UAP on infection control practices? A) The client needs to be at the end of the hall because he requires privacy. INCORRECT This is not the reason for the location of Jeff’s room. B) The implementation of airborne precautions for possible TB requires a private, negative pressure room assignment. CORRECT According to the Center for Disease Control (CDC), in addition to isolating Jeff by using a private room, engineering controls can help to prevent the spread of TB. Controlling the direction of the airflow can prevent contamination of air in adjacent areas. C) A private room is required to implement contact precautions for possible TB. INCORRECT Airborne precautions, rather than contact precautions, are required to prevent the spread of TB. D) The client needs to be at the end of the hall for confidentiality. INCORRECT Confidentiality is provided for every client, regardless of the client’s room location. The nurse notices the UAP about to enter Jeff’s room to deliver a meal tray without wearing any protective apparel. 4. What information should the nurse provide to the UAP? A) A mask is required for healthcare workers entering the room of someone suspected of having active TB. CORRECT TB is spread by airborne transmission of droplet nuclei. A well fitting, high-efficiency particulate air (HEPA) mask is necessary to filter the mycobacterium tuberculosis bacillus. B) Wearing a mask, gown, and gloves is required for healthcare workers entering Jeff’s room for any reason. INCORRECT The only protective apparel required when entering the room is a HEPA mask. C) The UAP will only be in the room for a brief moment to deliver the tray, so no intervention is needed by the nurse. INCORRECT Since TB is spread by airborne transmission of droplet nuclei, a HEPA mask is necessary for the UAP to wear. The nurse needs to inform the UAP of this and ensure that appropriate PPE is worn in Jeff’s room. D) Non-sterile gloves are necessary to deliver the meal and prevent the spread of TB. INCORRECT Gloves do not prevent the transmission of an airborne organism. Specimen Collection An acid-fast bacilli (AFB) stain is part of the initial admission prescriptions. Early morning sputum specimens will be collected for 3 consecutive days and sent to the lab. 5. Which task(s) may the nurse delegate to the UAP? (Select all that apply.) A) Tell Jeff that the specimen must be collected in the early morning. CORRECT This task may be delegated. B) Provide Jeff with 3 sterile specimen cups at his bedside. CORRECT This task may be delegated. C) Teach the client how to cough to obtain sputum from deep in the bronchi. INCORRECT Teaching is a responsibility of the nurse that cannot be delegated. Jeff needs to be taught to cough deeply, using the diaphragm to produce sputum from the bronchi instead of saliva from the oral cavity. D) Document the time and date that each sputum specimen was collected. CORRECT This task may be safely delegated. However, it is the nurse’s responsibility to ensure that the documentation is completed and sent with the specimen to the lab. E) Assess Jeff’s abilty to expectorate a sputum specimen. INCORRECT This task may not be delegated. Jeff is scheduled for several activities the following morning. 6. Which activity should Jeff perform first upon awakening? A) Eat a nutritionally dense, early morning snack sent from the food services department. INCORRECT While small, nutritionally dense meals and snacks are necessary for clients with HIV and/or TB, another action is of greater priority. B) Obtain the first of 3 sputum specimens for laboratory testing. CORRECT Because secretions collect during the night, Jeff should take the opportunity to cough and expectorate upon awakening before performing other morning activities. C) Take a shower and get ready to go to radiology for a chest X-ray. INCORRECT Another action is of greater priority. D) Weigh to determine if weight loss from the disease is continuing. INCORRECT Although daily weight monitoring may be done, another action is of greater priority. Legal/Ethical Concepts A female staff nurse tells the nursing supervisor that she does not want to be assigned to care for Jeff. She states, â€Å"I have never cared for a client with HIV and do not want to start now. I have babies at home that need me.† 7. The nursing supervisor should base her response on what information about the right of a nurse to refuse to care for clients with HIV? A) The registered nurse has the right and responsibility to protect the health of self and family and may therefore refuse to care for clients with contagious diseases. INCORRECT This answer does not meet the professional guidelines set forth by the ANA Code for Nurses that guide ethical nursing practice. B) The registered nurse may refuse to care for a client in circumstances where risk to the nurse outweighs the nurse’s responsibility to care for a client or if the assignment conflicts with the nurse’s ethical standards. CORRECT According to the ANA Code for Nurses, a nurse may morally refuse to participate in care, but only on the grounds of either client advocacy or moral objection to a specific type of intervention. Exceptions may be made when risk of harm outweighs the nurse’s responsibility to care for a given client. For example, an immunosuppressed nurse may refuse to care for clients with certain infectious processes. The pregnant nurse may refuse to care for the client with HIV who has secondary infections such as toxoplasmosis or cytomegalovirus, both of which can cause severe damage or death to the fetus. C) Refusal to treat or care for a person based on race, gender, or age is discrimination, which the federal government prohibits. INCORRECT The nurse in this case is not refusing to care for the client based on these  parameters. If the nurse did refuse, it would be illegal. D) The required staffing ratio of licensed personnel to client population does not allow for professional nurses to refuse to care for a client. INCORRECT Staffing ratio is a budgeting issue. Nurses in many states may claim â€Å"safe harbor† if they feel staffing is unsafe, but this is not the reason given for refusal in this case. 8.  How should the nursing supervisor respond to the staff nurse who does not want to care for Jeff? A) â€Å"I understand. I will assign you to a different client and give Jeff to one of the other nurses.† INCORRECT This response does not provide an opportunity to assess if something else is needed. B) â€Å"I understand you are concerned, but I am concerned about you losing your job over this.† INCORRECT Not only is addressing possible dismissal of the nurse premature, this response does not provide an opportunity to assess whether something else is needed. C) â€Å"I understand your fears, but do you realize this will cause a hardship on your fellow staff members?† INCORRECT This response does not help develop the nurse as a team member, nor does it provide an opportunity to assess if something else is needed. D) â€Å"I understand you want to protect your children. Please tell me your concerns regarding caring for a client with HIV.† CORRECT This response by the nurse supervisor demonstrates compassion and provides an opportunity to discover if education of the staff nurse is needed. Client Education The nurse checks on Jeff and finds him reading a brochure about TB. 9. Which statement by Jeff indicates that he understands why he is at risk for TB? A) â€Å"I realize my helper T cells are diminished from HIV. Those are the cells needed to fight TB.† CORRECT HIV attacks the CD4 receptors on the helper T cells that help the body fight off diseases such as TB. B) â€Å"I may get tuberculosis because my viral load count is diminished.† INCORRECT An increased HIV viral load indicates disease progression and puts the client  at risk for opportunistic infections. A decreased viral load count is desirable. It is a goal of anti-HIV therapy. C) â€Å"I am at risk for developing TB because I was born with a low number of helper T cells.† INCORRECT This may indicate Jeff is in denial or lacks correct information. The human immunodeficiency virus is acquired rather than genetic in origin. D) â€Å"I realize I am at risk for acquiring TB because I used intravenous drugs in the past.† INCORRECT Jeff could have been exposed to HIV and hepatitis virus from a contaminated needle. However, the mode of transmission of the mycobacterium tuberculosis bacilli is through respiratory secretions, not blood-borne routes. After 3 days, the nurse receives the results from Jeff’s tuberculin skin test that was administered at his healthcare provider’s office. Even though Jeff’s reaction to the tuberculin skin test measures only 5 mm in diameter, the healthcare provider documents a positive test result. A new graduate nurse finds this confusing. She tells her preceptor that she thought a 10 mm induration was the minimum size for a positive reading. 10. How should the nurse-preceptor respond? A) â€Å"This confuses me, too. I think we need to consult with the healthcare provider.† INCORRECT The nurse-preceptor should be able to explain the tuberculin skin test result. B) â€Å"That is not always true. A 5 mm induration is considered positive for TB in a person with HIV.† CORRECT The person with HIV has diminished T cell immunity, which compromises their ability to react to skin tests. Therefore, an induration of 5 mm is considered a positive reaction, rather than the standard of 10 to 15 mm for other groups. C) â€Å"It may be that you are confusing induration with inflammation in skin testing results.† INCORRECT The hardened, raised area of induration at the site of the skin test is measured. Any flat, reddened area of inflammation is not measured. The graduate nurse did not indicate confusion between the two. D) â€Å"Let’s ask the nurse-practitioner who specializes in caring for clients who are HIV  positive.† INCORRECT Although the practitioner is an excellent resource, the nurse-preceptor should be able to explain the tuberculin skin test result. Pharmacotherapeutics/Medication Administration Before breakfast, the nurse brings Jeff the HIV medicines that are due. Jeff inquires about his other medications, stating, â€Å"I take all my HIV pills at once before breakfast. I don’t want to bother with this disease all day long!† 11.  How should the nurse reply? A) â€Å"To be most effective, HIV medications are prescribed on different schedules.† CORRECT Some HIV inhibitors need to be given on an empty stomach and some need to be given with food for best effectiveness. Many need to be taken around the clock, even if sleep is disrupted, to ensure drug efficacy. B) â€Å"All right. I will give the rest to the UAP to bring in as soon as possible.† INCORRECT This is not the correct way for Jeff to take his medication, nor is it within the UAP’s scope of practice to give medications. C) â€Å"We are just trying to provide you with the best nursing care possible on this unit.† INCORRECT That is a defensive reply, which does not contribute to educating Jeff. D) â€Å"We need your cooperation to help fight this disease.† INCORRECT This reply is judgmental and implies that Jeff is uncooperative, which he is not. Jeff responds by agreeing to take his medications as prescribed. He then states, â€Å"However, I don’t know what good they will do. Do you?† 12.  How should the nurse respond? A) â€Å"I honestly do not know, but I would give it a try. What is there to lose?† INCORRECT This response does not educate Jeff about the purpose of the HIV meds. B) â€Å"The main purpose of these medicines is to block the replication of the HIV virus.† CORRECT The purpose of the antiretroviral and inhibitor medicines is to block the replication of the HIV virus and prevent opportunistic diseases. C) â€Å"You should talk to your healthcare provider about your medications.† INCORRECT The nurse should be able to answer Jeff’s question about his medications. D) â€Å"Tell me about the experiences your friends have had with these medicines.† INCORRECT Exploration of how Jeff formed his opinion would be better if left until after the nurse answers Jeff’s question. Jeff’s healthcare provider has also prescribed the antibiotic Rifater. This drug is a combination of isoniazid, rifampin, and pyrazinamide. 13.  What information is important to teach Jeff about the use of Rifater? (Select all that apply.) A) Rifampin stains urine, stool, saliva, sweat, and tears reddish-orange. CORRECT This teaching can help Jeff prepare for this side effect without anxiety. B) Liver function tests should be routinely conducted and monitored. CORRECT The major side effect of isoniazid, rifampin, and pyrazinamide is drug-induced hepatitis. Therefore, Jeff must be taught the importance of having blood samples drawn to monitor his liver function. C) There is no need to wear sunscreen when exposed to sunlight while taking Rifater. INCORRECT Pyrazinamide may make the skin sensitive to sunlight, and this should be taught to the client. D) Supplemental Vitamin B6 may be prescribed. CORRECT Jeff may be prescribed Vitamin B6 to prevent peripheral neuritis, a side effect of isoniazid (INH). E) Rifater has been known to cure HIV within a few months of taking it. INCORRECT Rifater is a first-line anti-tubeculin drug Nursing Diagnosis Jeff has been diagnosed with the opportunistic disease TB. He has experienced weight loss and has a CD4 cell count of 240 cells/mm3. The healthcare provider moves Jeff from the HIV asymptomatic stage (CDC HIV Infection Stage 1) to the HIV Infection Stage 3 (AIDS). 14. What is the priority nursing diagnosis for Jeff at this time? A) Risk for new opportunistic infections related to decreased immune function. CORRECT Since Jeff’s immune system is no longer competent, he is at risk for additional opportunistic infections. Immune problems start when the CD4 cell count drops below 500 cells/mm3. Preventing infections is a basic need and is a high priority in the immunocompromised client. B) Social isolation related to worsening of condition. INCORRECT Social isolation should be addressed, but there is a higher priority nursing diagnosis. C) Imbalanced nutrition, less than body requirements related to medication side effects. INCORRECT Although this is frequently a side effect of taking HIV and TB medications, there is a higher priority nursing diagnosis. D) Fatigue related to altered body chemistry. INCORRECT Although the client initially complained of fatigue, there is a nursing diagnosis with a higher priority. Infection Control One of the unlicensed assistive personnel (UAP) says, â€Å"Now that Jeff’s condition has worsened and he has been moved to the HIV Symptomatic stage, shouldn’t added precautions be posted on Jeff’s door to protect staff members?† 15. What information should the nurse give the UAP? A) Following standard precautions will minimize the exposure to blood and body fluids. CORRECT Standard precautions are designed to prevent contact with blood or body fluids, which are the mode of transmission for HIV, and are used no matter what the stage classification of the disease. B) Reverse isolation procedures should be implemented to protect the staff. INCORRECT Reverse isolation protects the immune-compromised client, not the staff. C) Respiratory precautions are all that are needed, and those are already posted on the door. INCORRECT This does not address the UAP’s concerns about prevention of HIV transmission from client to staff. D) Staff members caring for Jeff should begin prophylaxis medications. INCORRECT Unless HIV exposure occurs, staff should not begin the postexposure prophylacis regimen. The UAP has been assigned to help Jeff bathe. As the UAP prepares to enter Jeff’s room, the nurse observes her putting on a gown, gloves, mask, and goggles. 16. What should the nurse say to the UAP? A) â€Å"I see you are putting on a gown, gloves, mask, and goggles to go into the client’s room. Help me understand this choice.† CORRECT This type of open-ended statement seeks clarification and invites the UAP into a dialog where teaching can take place. The nurse can then educate the UAP concerning the proper use of equipment. Standard precautions (for HIV) require that gloves be worn, and respiratory precautions (for TB) require that a mask be worn. Goggles and a gown are not necessary. B) â€Å"Don’t you know all that equipment is not necessary?† INCORRECT This statement is overly aggressive and may seem demeaning to the UAP. C) â€Å"Wearing all that equipment is a waste of hospital supplies.† INCORRECT While it is important to ensure effective use of resources, this statement is critical and negative and may cause the UAP to become defensive. D) â€Å"Wearing all that equipment may frighten Jeff.† INCORRECT While the excessive equipment may frighten Jeff, there is a better response. Oral Candidiasis The nurse notices that Jeff has left most of his dinner untouched. The nurse offers to order something different for Jeff, but he replies that his mouth is sore and he just doesn’t feel like eating. 17. Which assessment finding by the nurse would be indicative of oral candidiasis, a common secondary infection in persons with compromised immune systems? A) Blisters on the tongue or oral mucosa. INCORRECT This is a sign of herpes simplex type virus 1 (HSV-1) infection. B) Inflammation of the gums. INCORRECT This is a symptom of gingivitis. C) Painless white lesions on the lateral surface of the tongue. INCORRECT This is a description of leukoplakia. D) White-yellow patches on the tongue or oral mucosa. CORRECT This sign is indicative of a Candida albicans infection. It is a common finding in people with HIV, and it frequently occurs with a falling CD4 cell count. The nurse notifies the healthcare provider, who prescribes nystatin (Mycostatin) 6 ml PO 4 times per day. 18. What instruction should the nurse give Jeff about the use of liquid Mycostatin? A) Place all of the suspension in the mouth, then swish and swallow immediately. INCORRECT This is not the proper way to take liquid Mycostatin. B) Sip the suspension over 5 minutes, swishing and swallowing after each sip. INCORRECT This is not the proper way to take liquid Mycostatin. C) Place the suspension in the mouth, then swish for several minutes before swallowing. CORRECT This â€Å"swish and swallow† technique is the proper way to take liquid Mycostatin. Providers also recommend gargling, as well as swishing, prior to swallowing. D) Use the applicator to paint the medication on the infected sites and swallow the remaining dose. INCORRECT This describes the recommended procedure for young children or infants taking Mycostatin. Nutritional Interventions Jeff Smith is 5 feet, 11 inches tall. He has a large frame and weighs 152 pounds. His current BMI (body mass index) is 17.4. Jeff says he realizes he should eat, but he does not have the energy or the appetite, even when he has no oral pain. The nurse identifies the nursing diagnosis of, â€Å"Imbalanced Nutrition: less than body requirements.† 19.  To achieve the goal of improving Jeff’s nutrition, which nursing intervention should the nurse perform? A) Consult with Jeff to assess his food preferences. CORRECT Determining Jeff’s food preferences is a good first step. It is essential that Jeff be an active participant in his care so he has some control. If a favorite food is not on the menu, it can be requested. B) Request a prescription for total parenteral nutrition (TPN). INCORRECT While this may eventually be needed, it is not the best intervention at this point. C) Inform Jeff that adequate nutrition is essential. INCORRECT Jeff has already indicated he understands the need to eat. D) Instruct Jeff to focus on breakfast, the most important meal of the day. INCORRECT It is not necessary to focus on breakfast. Adequate nutrition can be achieved from meals eaten throughout the day. 20.  Since Jeff now has thrush, in addition to fatigue and anorexia, which food best contributes to improving Jeff’s nutrition? A) Broiled steak. INCORRECT Although steak is a good source of protein, it requires energy to chew, and it may be irritating to Jeff’s mouth. B) Milk shake. CORRECT A milk shake is a nutrient-dense food. It provides needed calories, calcium, and protein. Jeff can drink the nutritious snack without using the energy it would take to eat a full meal. Jeff may find the cool liquid is soothing to his sore mouth. C) Tomato soup. INCORRECT Although liquid soup is not difficult to eat, (note, the warmth could be soothing), the acidity of the tomato soup may be irritating to Jeff’s mouth. D) Lettuce salad with raw vegetables. INCORRECT Although a salad with raw vegetables is a good source of vitamins, it  requires energy to chew, and it may be irritating to Jeff’s mouth. A Complication Occurs Jeff develops severe diarrhea with occasional incontinence that could be caused by an opportunistic gastrointestinal infection or by one of his medications. While stool cultures are pending, other interventions can be initiated. 21.  Which task(s) should be delegated to the UAP? (Select all that apply.) A) Weigh Jeff each morning before breakfast. CORRECT Weights can be obtained by the UAP. B) Measure the urine output. CORRECT Measurement of the urine output can be delegated to the UAP, then reported to the RN. C) Count and record the number of watery stools. CORRECT The UAP can legally count and record the number of watery stools. However, it is the nurse’s responsibility to be aware of the client’s condition and promptly report any significant changes to the healthcare provider. D) Evaluate the rate and quality of Jeff’s pulse. INCORRECT The nurse must evaluate the quality and rate of Jeff’s pulse because this requires judgment and expertise beyond the scope of practice of unlicensed personnel. E) Check Jeff’s skin turgor to determine if he is dehydrated. INCORRECT The nurse conducts physical exam procedures, including assessing for alterations in skin turgor, to determine hydration status. This expertise is not within the scope of practice for the UAP. When performing Jeff’s morning physical assessment, the nurse discovers that he has a weak, rapid pulse. He also has decreased skin turgor and dry, sticky, oral mucous membranes. His weight is 2 pounds less than it was yesterday morning. 22.  What is the priority nursing diagnosis? A) Fatigue. INCORRECT Fatigue may be present with diarrhea, but it is not the priority nursing diagnosis. B) Disturbed sleep pattern. INCORRECT While diarrhea may certainly disrupt sleep, this is not the priority diagnosis. C) Deficit Fluid Volume. CORRECT A weak, rapid pulse; decreased skin turgor; dry, sticky, oral mucous membranes; and weight loss are signs of dehydration. D) Situational low self-esteem. INCORRECT Incontinence of stool may lead to low self-esteem, but this is not the priority diagnosis. 23.  Which action should the nurse take first? A) Hold Jeff’s breakfast tray to provide bowel rest. INCORRECT While clear liquids or another diet that promotes bowel rest may be prescribed, another action should be performed first. B) Perform oral care and moisten mucous membranes. INCORRECT Another action should be performed first. C) Take Jeff’s blood pressure to assess for postural hypotension. CORRECT Postural hypotension can result from dehydration. Therefore, it is important for the nurse to obtain this vital information because it directly impacts Jeff’s safety. D) Notify the healthcare provider of Jeff’s weak, rapid pulse. INCORRECT Another action should be performed before notifying the healthcare provider. 24.  The health care provider is notified of Jeff’s physical exam findings indicating possible dehydration and vital signs, including a blood pressure of 100/50. It is determined that Jeff could use a bolus of IV fluids. The HCP prescribes 1000 cc of normal saline to run over 6 hours. The drop factor tubing set is 15 drops/ml. How many drops/minute will the IV run? (Enter the  numerical value only. If rounding is required, round to the whole number.) 42  CORRECT 1000/360 X 15 = 41.66 = 42 gtts/minute Jeff’s stool cultures are negative. After treatment with fluids and diet modification, his diarrhea resolves in 24 hours. Jeff’s fluid balance is restored and his oral candidiasis is resolving. Discharge Instructions Before Jeff is discharged home, it is important that he understands how to prevent the spread of HIV. When discussing infection control practices with the nurse, Jeff says, â€Å"I have heard that condoms don’t always prevent HIV.† 25.  How should the nurse respond? A) â€Å"If used correctly and consistently, latex condoms are highly effective in preventing the transmission of HIV.† CORRECT Jeff’s misinformation and misunderstanding is a common myth regarding the effectiveness of latex condoms. Studies prove that condoms work. B) â€Å"I know you would feel terrible if you passed HIV to someone because you did not use a condom.† INCORRECT Not only is this statement judgmental, the nurse also presumes to know how Jeff will feel. C) â€Å"I will have an AIDS educator discuss condom use with you.† INCORRECT The nurse has the knowledge to respond to Jeff’s question. D) â€Å"What is your source of information about condom failure?† INCORRECT While it may be helpful to know where Jeff got his information, this response does not answer Jeff’s question. Jeff assures the nurse that he will use a condom with each sexual encounter. He also expresses concern that he may become dehydrated again. 26.  What resource can be provided for Jeff in the event this complication occurs? A) Meals on Wheels. INCORRECT Meals on Wheels is a national nonprofit organization that delivers food to the elderly, the disabled, and the homebound. Jeff would not be a candidate to receive help from Meals on Wheels. B) HIV/AIDS support group. INCORRECT Although an HIV/AIDS support group can be a valuable resource, it cannot prevent Jeff from getting diarrhea or becoming dehydrated. C) Access to the services of a registered dietitian. CORRECT It is essential that the nurse arrange a consult for Jeff with a registered dietitian before he is discharged home. The dietitian will give Jeff specific information on suggested foods and liquids to include in his diet to help prevent dehydration if diarrhea occurs at home. The clinical dietitian will provide Jeff with resources, such as a phone number, that will give him access to the dietitian on an outpatient basis. Breast cancer Evolve Case Study Breast Cancer – Patient: Sandra Williams 1) â€Å"Select whatever day you can best remember to perform BSE consistently every month.† 2) â€Å"When lying down, your arm should be positioned over your head.† 3) The combination of yearly CBE and monthly BSE is the best approach for early detection.† 4) Teach Barb that even women with no identified risk factors are at risk 5) â€Å"You may experience some discomfort, but only for a few minutes.† 6) â€Å"It’s hard to believe that this is happening, isn’t it?† 7) â€Å"Are you saying that you do not want to have surgery?† 8) Anticipatory grieving 9) â€Å"To ensure your safety, I need to notify the surgeon of the snack you ate.† 10) Nonmaleficence 11) Notify the surgeon that further explanation of the procedure is necessary 12) Observe the Jackson-Pratt drainage device, Administer a PRN dose of prescribed analgesic, Monitor vital signs and pulse oximetry 13) Encourage Sandra to continue performing these exercises 14) Advise the UAP to immediately stop and obtain a larger cuff so the BP reading can be taken in the leg 15) Both the GN and UAP are at fault for the incorrect action of the UAP. 16) Ask Sandra to clarify how she learned this information so  that a plan for further teaching can be developed 17) Blood clots 18) â€Å"The medication decreases estrogen levels, which is what also causes the symptoms of menopause 19) Diarrhea, Alopecia 20) Label the two lumens as non-functional, and use one of the remaining lumens 21) Oral temperature of 99.5 ° F 22) Altered tissue perfusion 23) Apply a sequential compression device, Elevate the affected arm. 24) Fifteen minutes prior to administration of the next dose of the drug. 25) 63 26) Candida superinfection 27) A 65-year-old woman, who is a retired teacher and who never married or had children. 28) Younger sister 29) Unusual skin texture. 30) Hard, irregular, and does not move freely